Essentially Contested America

How can profit be the driving force in the health care industry? The contrast between human health and making money is as stark as human safety and making money.  Imagine if police departments or fire departments were privatized and unregulated by government. Suppose further they were paid by how many crimes they prevented or criminals they caught. Such private entities would have an enormous incentive to directly or indirectly encourage crime. Similarly, private hospitals make their living from the number of beds they fill. There’s not much incentive to increase wellness just to treat illness.  As illness decreases these hospitals lose profits. The analogy is far from complete, but the point nevertheless is this. Absent socialized medicine profit will exist in medicine, but profits for doctors and other health care providers and profit for health care corporations are vastly different entities. It is Wall Street that keeps costs rising and prevents universal care. The public option is a minimal attempt to counteract the devastating effects of shareholders, who must be fed with the health and wealth of the nation, on the health care system. Yet Americans have been so brain-washed against this option that it is unlikely to succeed unless President Obama realizes this is a battle he can’t afford to lose.

From Media Matters:

Media Matters: Storming Camelot: Sen. Kennedy’s death brings out worst from the right

Following Wednesday’s early-morning news that Sen. Edward M. Kennedy had lost his battle with brain cancer, Media Matters posted the following statement from president Eric Burns at 3:51 a.m. ET on the County Fair blog:

“Ted Kennedy was a true American statesman. The values that he so eloquently and tirelessly championed represent the best of our American ideals. He reached across the aisle to get hard work done but never sacrificed principle. Though he is gone, the dream will forever live on. Our thoughts and prayers go out to Vicki Kennedy, the Senator’s family, his loyal staff and the millions of lives he touched throughout his historic life and career.”

Far from letting Kennedy rest in peace, many media conservatives savagely attacked the Senate’s last liberal lion. Leading the charge was radio host Rush Limbaugh, who began his broadcast Wednesday morning eulogizing Kennedy by calling him “the lion of the Senate” before noting that “we were his prey.” Hardly finished, El Rushbo would go on to say that “Kennedy screwed up everything he touched.” He said Kennedy’s opposition to Robert Bork’s Supreme Court nomination was “the beginning of the dawn of the age of the current hate.” He claimed Kennedy “used the government to take money from people that work to give it to people that don’t work” and that “most of Senator Kennedy’s plans ended up damaging the people he seeks to help.” Finally, Limbaugh marveled at the fact that “the Constitution is still there, even after Ted Kennedy in the Senate for 52 [sic] years.” All that and more led MSNBC’s Joe Scarborough and Politico’s Patrick Gavin to agree that “Limbaugh showed great restraint” in discussing Kennedy’s death. Can you imagine what Rush would have said had it not been for such “restraint?”

Limbaugh was hardly alone in his disgusting attacks on Kennedy. Radio host and Fox News political analyst Tammy Bruce kept it classy, claiming on Twitter that Fox News Sunday’s Chris “Wallace noted the last great act of Kennedy’s career was to endorse [President] Obama. I agree: he left a woman to drown and now he’s left us to drown.”

Eric Sanger, a director at Premiere Radio Networks, ABC Radio/Citadel Media and The Sean Hannity Show, said on Facebook (emphasis added), “The irony is that the media is already positioning Ted as a champion for the little man against wealth and privilege. This piece of garbage was the poster child for wealth and privilege. Hopefully, this event will mark the end of this repugnant family and all the endless crap, entitlement, personal indulgences and collateral damage (Kopechne, Bessette, Bowman, Moxely, etc.).”

Wesley Pruden, a Washington Times columnist, wrote that Kennedy’s death was “a good career move” and that Democrats “are smiling through their tears,” while Andrew Breitbart, a fellow Times columnist, called Kennedy a “villain,” a “duplicitous bastard,” and a “prick” on Twitter, as noted by Politico. Riehl World View, a right-wing blog, came to Breitbart’s defense, claiming that liberals criticizing him were “hypocrites” because when Dick Cheney dies, they’re going to do the exact same thing. That’s right, liberals today are hypocrites because of what they might do in the future. Now that’s some crazy fortune-telling.

Fox News host Sean Hannity told his audience that “out of respect for his family,” he had decided not to “bring up Mary Jo Kopechne” or Kennedy’s “radical socialism.” Seriously.

When they weren’t busy attacking Kennedy’s legacy, media conservatives — like Fox News’ Laura Ingraham — were attacking Democrats for purportedly attempting to use his passing to stifle debate and enact health care reform legislation, repeatedly calling this supposed tactic the “death card.” In a true episode of pot meets kettle, conservative media figures — like health care serial misinformer Betsy McCaughey — have used Kennedy’s death to attack health care reform, some even baselessly suggesting that if reform passes, elderly cancer patients — as Kennedy was — will be “denied” treatments or that their treatments will be “rationed.” Limbaugh said that “Ted Kennedy didn’t have to read a death book,” while Tom Marr, guest-hosting Lou Dobbs’ radio show, said under a public option, a “bureaucrat” would have told Kennedy, “77, brain tumor, bye-bye.”

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While Pattrick Buchanan intones about the “truce of God” on MSNBC pertaining to political quietude and respect for the passing of Senator Kennedy, the Radical Rights’ media savages haven’t the sense to postpone attacking the Senator until he is at least interred.  Is it the quest for fame, position, money, or downright meanness that motivates this hatred?  Whatever it is, it debases us all.

Listen to some more. Finally, Canadians are fighting the slanderous characterizations of the Canadian health care system by U.S. insurance companies and other ideologues. As stated, medical care is a human right, not an economic product to be evaluated simply in terms of the bottom line.  We, Americans, would do well to heed the advice of out northern cousins.  But we also need more help from Canada in setting the record straight about its own system and pointing out the systematic attempt on the part of those Americans opposing health insurance reform to distort, obscure, and simply lie about the Canadian system.  Click here for more.

From the Canadian Medical Association Journal

EDITORIAL
August 24, 2009

America, embrace health care reform

If power, wealth and talent alone determined how a nation serves the needs of its people, the United States would be second to none in health care. Yet America’s health care system clearly ranks behind those of Canada and most other developed countries. The precious opportunity that US President Barack Obama’s health care reform proposals offer to Americans is currently threatened by partisan disunity, which could once again deny Americans the quality and accessibility of health care that they should receive.

Canada’s “socialist” health system is the favourite whipping boy of antireform lobbyists, who employ fear-mongering and myths about rationing, waiting lists and lack of choice to persuade the American public to accept their status quo as better. As Canadians, we agree that Canada’s health system is not perfect. We have said so many times in CMAJ. Nevertheless, it takes only a few comparisons to show how much better Canada’s health system is than that of the United States — and how much Americans could hope to gain from embracing reform.

Consider the following statistics, taken from the Organisation for Economic Co-operation and Development’s health data for 2006.1 We start with the most basic outcomes any health care system is supposed to optimize: life and death. The life expectancy of an average American is nearly three years shorter than that of an average Canadian (78.1 vs. 80.7 years). That survival gap starts from the moment of birth: infant mortality is higher in the US than in Canada (6.7 vs. 5.0 deaths per thousand live births). Yet the US economy spends — or increasingly, borrows — more than half again as much for health care as does Canada’s (16% vs. 10.1% of the economy). And despite spending so much more, Americans get to see their doctors a third less often than Canadians (3.8 vs. 5.8 doctor visits a year).

While these differences result from many factors, the inescapable truth is that, compared to Canada, America is achieving poor value for money from its health care system, and that is killing Americans. The potency of that truth is the reason why antireform lobbyists are now turning to attack Canada’s system.

As Republican strategist Dr. Frank Luntz puts it, the opposition’s strategy rests on “health care denial horror stories from Canada.”2 Yet the attacks are so absurd and full of fantasy that they would be laughable — if not for the fact that many Americans believe them. Canadians do not, in fact, conduct euthanasia on our elderly; If we did, then Canadian life expectancy would hardly be longer than American.  There is no such thing as a “death panel,” neither in Canada’s health care system, nor President Obama’s reform proposal.  Nor is it true that in Canada, the system imposes a government bureaucrat between a patient and their doctor to decide what care to provide.  On the contrary, that is a routine feature in America’s system, where doctors and patients struggle endlessly with insurance company “bureaucrats” for payment.

The only accusation that has even a shred of evidence, albeit heavily misrepresented, is that Canadians face waiting lists for health care.  But that does not mean Canadians routinely die waiting for tests and operations, because the lists are for elective procedures, such as joint replacement surgery, and not for emergency or life-saving care.  Prioritizing actually helps ensure the serious cases are seen first.

We cannot condemn strongly enough the intellectual dishonesty of the lobbyists and politicians whose distortions of Canada’s health system camouflage their appalling rejection of reform for uninsured and underinsured Americans. All 32 million Canadians are insured. To be sure, some are unhappy to wait and some are denied treatments it would be better they had; no system is perfect or pleases everyone.  But even the least fortunate Canadian is better off than the 47 million uninsured Americans, for whom no treatments are covered and for whom the wait is forever, unless they can afford to pay the health care bills.

If America wants to improve its citizens’ health — as it must — then some negative attitudes need to be turned around.  Here are some.

First, the US$1 trillion that the Obama administration says it will cost to cover America’s uninsured over 10 years is not a burden; per capita, it is a screaming bargain. Canada spends about US$156 billion each year to cover fewer people than America’s uninsured. For Congress to hesitate at the outlay is penny-wise and pound foolish, when economic studies suggest that the cost of not investing could be greater still, owing to lost productivity and lost jobs, provided that expanded coverage goes hand-in-hand with cost-containment measures.3,4 Still, when Congress last year dropped US$700 billion at a sitting to bail out Wall Street, it is hard to understand why a lesser amount for public health insurance provokes so much anxiety.

Second, all health care systems ration care — including the US system. The only cruelty in rationing health care comes in doing it the wrong way. When America’s private insurers routinely refuse to cover persons having pre-existing health conditions, that is the worst kind of rationing, aimed mercilessly at those who need medical care most. In Canada, nobody is denied coverage for pre-existing conditions, and there is no cut-off age. Instead, Canada aims to ration medically futile treatments. Where we occasionally make mistakes is in rationing new treatments that in hindsight prove to be useful, not futile. In Canada’s deferential culture, we correct such mistakes slowly by pressuring the public insurer. In America’s litigious culture, suing the public insurer is likely to correct such mistakes more rapidly. That difference, we believe, is likely to make rationing fairer in American than Canadian hands.

Third, certain members of Congress need to get over the bogeyman of “socialist” medicine. Thinking about the military may help. All of America’s closest NATO allies, including those, like Canada, who fight alongside the US in Afghanistan, receive “socialist” medicine back home. Furthermore, when Americans join the military, they qualify for public, government-run health insurance that provides access to care at Veterans Administration hospitals. When Texas Republican Congressman Louie Gohmert described Canadian health care as “a bureaucratic, socialistic piece of crap,”5 was he also implying that America’s soldiers are getting bureaucratic, crappy care?

Fourth, freedom-loving Americans who value making their own medical and economic choices ought to be outraged at how the status quo restricts their choice and freedoms. Because private insurance plans are usually provided through one’s employer, changing jobs often means losing existing coverage and having to re-qualify for new coverage (if one can) under a new plan — a risky move.  Private insurance has become the freedom-destroying leash that ties Americans and their families to jobs with less pay or satisfaction than other opportunities that might exist. Canadians, in contrast, can change jobs in our universal, portable public system and stay insured throughout.

Fifth, and perhaps most importantly, America has reached an economic tipping point where the “public option” is inevitable, if only because households (read: voters) find the current system’s costs unsustainable. Canada’s first meaningful foray into public insurance happened in 1940s Saskatchewan, when public anger boiled over as health bills forced families — including many in the middle class — into bankruptcy. That same tragedy is replaying in America, where more than half of personal bankruptcies are medically related.6 This number will only worsen as health costs rise in America, as the population ages and as the US dollar loses ground as a reserve currency. Even if Congress and President Obama fail to achieve a public insurance option this year, in the long term the smart money is against any political party whose name becomes attached to these personal medical bankruptcies.

If Americans find the courage to embrace change, they could enjoy health care that is second to none. Canada’s example has many positive lessons — and a few negative ones — to teach reformers. Lamentably, in the current partisan circus playing out on Capitol Hill, analysis is short and sophistry of the Louie Gohmert variety is long. America must move beyond this if it ever hopes to be able to provide the best care for all its people.

Amir Attaran LLB DPhil
Associate Editor, Editorials

Matthew B. Stanbrook MD PhD
Deputy Editor, Scientific

Paul Hébert MD MHSc
Editor-in-Chief
CMAJ
With the Editorial-Writing Team (Ken Flegel MDCM MSc, Noni MacDonald MD MSc and Laura Eggertson BA)

Cite as CMAJ 2009. DOI:10.1503/cmaj.09-1511

REFERENCES (Omitted)

Ted Kennedy is gone.  Now is the time for Congress to enact meaningful health care reform, including a public option, as a tribute to the “Lion of the Senate.”  Last year, Senator Kennedy referred to health care reform as “the cause of my life.”  This was no exaggeration.  Kennedy ran on the issue of affordable health care in 1962, in his first run for the Senate.  Kennedy was instrumental in the passage of Medicare and Medicaid programs, both controversial programs that faced considerable Republican opposition at the time which have now become highly popular.  In 1980, in his famous “the dream will never die” speech at the Democratic National Convention, Kennedy announced that he would “continue to stand for national health insurance” because “the state of a family’s health should never depend on a family’s wealth.”  There would be no better tribute to a man who gave over 45 years of his life to championing the cause of the poor, the middle class and the disenfranchised, than for Congress to enact health care reform in Ted Kennedy’s name.

There is precedent for enacting major human rights legislation to honor a fallen senatorial comrade.  In 1875, Kennedy’s Bay State predecessor, the great anti-slavery advocate Senator Charles Sumner, lay on his death bed as he pleaded with his Senate colleagues to “enact my civil rights bill.”  Sumner’s colleagues in Congress responded by enacting the 1875 Civil Rights Act as a tribute to his lifelong battle against slavery and on behalf of civil rights.  The 1875 Act prohibited race discrimination in privately owned places of public accommodation.  (Historical note: The Supreme Court struck the 1875 Act down, necessitating the 1964 Civil Rights Act (which also passed with Ted Kennedy’s support)).

Like Sumner, Ted Kennedy worried about his life’s cause while on his death bed. From home, he continued to advocate for health care reform with his staff and colleagues. The week before he died, Kennedy repeated his request to the Massachusetts legislature to authorize the governor to appoint his successor instead of waiting until a special election filled his spot. Ted Kennedy knew that every vote would count in the Senate battle for health care reform.

So, members of Congress, it is up to you to realize Senator Ted Kennedy’s lifelong dream.  He deserves it, and so do we.

Sen. Edward M. Kennedy has died.  He had already been re-elected as a senator from Massachusetts before I was born.  For me, he has always been a lion of the Senate.  He made some terrible decisions and some brilliant decisions in both his personal and political lives.  He dealt with great tragedy and great joy both in public and in private.  He caused great happiness for many and caused great pain for some.  Nonetheless, words are indequate to express the gratitude that America should feel for what Ted Kennedy did for this country, for how he made us think about how to make our country more perfect and for how he pushed us to be better.  Lord knows he had his flaws, but I always liked and admired Ted Kennedy.  May he rest in peace.

What is “reasonableness” and what role should it play in American democracy?  A casual description of “reasonableness” is the commitment to gather and balance as much information and evidence as one can about social and political issues as well as challenging and scrutinizing one’s own view as forcefully as one does the views of others.  Are Americans reasonable? Certainly some are, but it seems to many are not. For example, the large percentage of Americans who dismiss global warming or who still believe that Saddam Hussein was involved in 9/11, not to mention the so-called “birthers” who insist that President Obama is not a natural born citizen.  What accounts for such unreasonableness?  It is almost as if certain segments of the society valorize unreasonableness, assuming that it is somehow beneficial to be unreasonable, feeling no need to respond to charges of unreasonableness in a manner likely to convince those making the charges. What is it about our culture as well as many different groups and individuals who populate this culture that permits us to believe despite the evidence in all sorts of propositions that will eventually be abandoned?  It is not at all clear that democracy can thrive without an answer to this question.

On Anderson Cooper’s CNN on healthcare yesterday, August 23rd, David Gergen insisted the American people would never embrace a single payer system. We’re too unlike Europeans and Canadians in simply not trusting government enough to run such a healthcare system.  We’re too rebelliousness and anti-authoritarian to tolerate such government control.  Maybe so.  But how then did Americans tolerate the virtual constitutional dictatorship of the Bush-Cheney administration in spying on Americans and in President Bush’s extraordinary use of signing statements turning that practice into a virtual line-item-veto.  Americans will never accept governmental control of healthcare, but will gladly embrace a soft dictatorship concerning governmental control of privacy. Something doesn’t compute here.

Try, as I may, it’s difficult figuring out President Obama’s approach to the health care battle. He continues to praise Senator Grassley’s attempt at “bipartisanship” when the “good” Senator keeps making outrageous remarks suggesting otherwise.  The latest in a round of comments is his suggestion (requirement?) that health care reform should receive at least 80 votes in the Senate.  Thank about it. That’s 20 Republicans. Name one certain Republican vote. What’s going on? Does the President watch television? Has he heard Grassley’s “death panel” remarks? Is there a secret agreement between the President and the Senator that Grassley will make negative comments designed to assure his reelection, but vote for the bill anyway? That’s not a likely strategy for his reelection or the bill. So just what is going go? Supporters of the public option need to know. Please Mr. President talk to us. The point is President Obama introduced the idea of a public option to many of us, explained its importance in significantly reducing costs, and arguing for its effectiveness in offering Americans a choice. He, above anyone else, cannot be the one to waver or capitulate. Mr. President you must come out forcefully for the public option now. Your transformative, defining moment as a president is at your door step.  Take the step boldly.

I am hoping, beyond hope perhaps, that my co-blogger, Hank Chambers, is right about how President Obama’s health care plan will play out. Among other important elements, President Obama must keep his original promise to include a public option which, among other things, is necessary to contain costs. Bravo, Hank. Author!