Sunday, September 20, 2009

Meaningful Health Care Reform Will Happen When Unicorns Fly High and Free

Last week's presidential address to a joint session of Congress was a veritable clinic in public speaking. It has become trite to lavish praise upon Barack Obama for his mellifluous eloquence, but the speech had everything: policy details, emotion, grace, a steadfast tone, a twinge of ferocity, and a heartfelt homage to Edward Kennedy - the modern-day Congressional watchdog for the poor and dispossessed.

Despite the fact that Dixie-can Rep. Joe Wilson missed the memo about not turning the House floor into a Yuma town hall meeting - sans firearms and ankle holsters - while the President's speaking, Obama's speech may go down as one of the most consequential Congressional addresses of the past half-century. Or it will completely sink into obscurity, alongside George H.W. Bush's scintillating 1989 joint session address in which the then-commander-in-chief ramped up the heat by tagging Dan Quayle to head a "Task Force on Competitiveness." We'll check back later to see how that one's working out.

But despite Obama's dogged assertions during his speech that a health care reform bill will be brought to full fruition on his watch, I sincerely doubt that it will significantly improve a shattered system, for several big reasons:

First and foremost, our country's biggest impediment toward real reform of any kind is political inertia.

Politicians are notoriously skittish souls, constantly straining to justify their existence by pandering to their ill-informed, reactionary, or just plain change-averse constituencies. Some deem this set-up thoroughly acceptable and argue that political leaders adhering to the people's wills and whims is paramount for a healthy democracy. Somehow, though, I don't think Thomas Jefferson had this in mind.

(By watching many of these gatherings on Youtube, I think I've discovered the modern right-wing permutation of the Jedi Mind Trick, otherwise known as: "What ______ is doing right now is exactly what Hitler did. The evidence is out there. Go ahead and read up on it, and you'll see it's true.")

Okay, so let me just get this straight: you get to make the psychotic claim, and then I have to do the research? Great. Totally unfair, especially since these lunatics never once tell you where one can find all the copies of Hitler and Obama: Basically the Same. By the way, don't try Costco - out of stock.

Based on the existing constructs of our government, there's actually every reason to believe that the framers of the Constitution were at best ambivalent about the masses' ability to lead themselves. The fact of the matter is, we Americans often do not know what's best for us in a political context, all too frequently granting our emotions primacy over our own best interests. I submit to you Exhibit A. And in Louisiana, a place where much of the population goes without health insurance, guess who public enemy number one is? You guessed it: That commie bastard from the country of Hawaii who's lobbying for universal coverage. From The New York Times:
Though nearly 22 percent of the state's adult residents have no health insurance - one of the highest rates in the nation - pollsters and political experts say voters in the state are overwhelmingly against Mr. Obama's health care proposals.
As individuals, whenever politics is concerned, our judgement can't ever be completely trusted; in large groups, even less so. When election time rolls around, we frequently vote for the wrong candidates. We vote for people we "trust," the ones who aren't too pedantic or professorial - people we want to have beers, catch ball games, or hit "juice bars" with, as opposed to policy wonks like Al Gore, John Kerry, Bill Bradley, or even Hillary Clinton, whose wild fantasies would no doubt entail a 24-hour all-access pass to the Library of Congress archives.

Lawmakers, in their slavish devotion to our childish whims, pander to mechanisms known as tracking polls, which doesn't exactly make for creative problem solving or visionary lawmaking. So, that a full-fledged discussion regarding alternative methods of solving the health care crises - such as adopting a more preventive approach - is completely absent from the current debate should come as no surprise.

Still, this was supposed to be different. With a champion of social responsibility (right-wing translation: fascist) and progressive values (homos, baby-killers) in the White House and clear majorities in the House and Senate, this bill would be The One: A landmark piece of legislation that would pass in a timely manner while maintaining its overall integrity, as submitting to the GOP's political whims, whose unwavering support of the health insurance and pharmaceutical industries would render any bill virtually useless, would be largely avoidable.

So that even a modicum of dialogue regarding preventive care, single-payer, or any other progressive approach is absent from any of the pending legislation is further testament to Democratic ineptitude - as if anyone alive during the W. Bush administration needed more proof.

Think about it. As recently as this past March, journalists and pundits were writing the epitaph for the GOP, implying that its self-imposed Crazy Uncle Joe-Mumbling-in-the-corner-about-how-they're-all-taking-over image was effectively rotting the party from the edges inward, rendering it irrelevant in a new age of post-racial post-partisanship.

But then we discovered something else: Much like their Republican rivals, many centrists in the Democratic party seemed to possess a strange affinity for the always warm, fuzzy, and fluffy health insurance and pharmaceutical industries. Why might that ever be?

Top Democratic party recipients of health insurance industry donations (2005-2008):
  • Senator Max Baucus (Mont.)..........$413,000.00
  • Rep. Earl Pomeroy (N.D.)...............$104,000.00
  • Rep. John Dingell (Mich.)...............$180,000.00
Baucus' situation is especially horror-inducing, since he chairs the Senate Finance Committee, which is responsible for producing the Senate's version of a health care bill. So you probably don't have to rack your brain wondering what his stance on a public option might be.
Nor was there much evidence that establishing non-profit cooperatives - Baucus' alternative to the public option in legislation proposed by the House and by the Senate health committee - would work to compete with private insurers and bring costs under control.

The cooperatives "seem unlikely to establish a significant market presence in many areas of the country," the nonpartisan budget office concluded.
Baucus - with his predilection for acting, looking, and legislating exactly like a Reagan Republican - may be a problem, but he's far from the biggest. Enter the serial parasites of politics, the GOP, and their largest recipients:
  • Sen. John McCain (AZ.)..................$546,000.00
  • Sen. Mitch McConnell (Ky.)...........$425,000.00
  • Rep. John Boehner (Ohio).............$257,000.00
  • Rep. Eric Cantor (N.D.)..................$249,000.00

McCain vehemently opposes a public option of any kind, as does McConnell, the Senate Minority Leader, and Boehner, the House Minority Leader, and House Minority Whip Eric Cantor. Cantor's the GOP's rising star for this week, at least until he's either a. caught on tape soliciting a hooker in downtown Bismark or b. discovered to be a practicing Jew.

And then there's Washington Senator Olympia Snowe, a moderate Republican, which is sort of like saying she's the one in her party least likely to scream "I AM THE LIZARD KING!" before dousing herself in pig's blood and, finally, taking a dump in the middle of the Senate Chamber during a heated floor debate. A backhanded compliment, to say the least.

Snowe has the distinction of receiving over a million bones in campaign contributions from the health care industry throughout her career, which is even more cringe-worthy if you know that she's the swing vote on the Senate Finance Committee.

In other words, if you believe money talks in politics (and what evidence exists to suggest otherwise?), now would be a good time to bid farewell to a public option (beyond the existing and thoroughly socialist medicaid and medicare programs), unless, of course, you foresee Obama and his coterie of timid allies ramming a bill through both Houses - which, considering the stakes, would be wholly appropriate at this point. But, again, it won't happen. From Matt Taibbi's Rolling Stone piece "Sick and Wrong":
The president and the Democrats decided not to press for the only plan that makes sense for everyone, in order to preserve an industry that is not only cruel and stupid and dysfunctional, but through its rank inefficiency has necessitated the very reforms now being debated. Even though the Democrats enjoy a political monopoly and could have started from a very strong bargaining position, they chose instead to concede at least half the battle before it even began.
Now about preventive care...

...Designing policy around challenging individuals to exercise self-discipline and restraint remains politically unfeasible. You may as well call Americans a bunch of pork-fried fat-asses, which is exactly what we are. Over the past decade, obesity rates have skyrocketed, accompanied by across-the-board increases in Type-2 adult onset diabetes (which, alarmingly, is increasingly plaguing young children), hypertension, heart disease, colorectal cancer, and liver, kidney, and pancreatic failure. Why? Because we are a nation of lard-lusting sugar junkies. To hell with the pundits who claim that America has lost its zeal for producing anything of import. Where else but in the good ol' U.S.A. can you find - and find someone willing to eat - one of these?

In a country with such an historically over-the-top contempt for the perils of "street drugs," is there any question that regularly indulging in things like ham dogs can be as dangerous as mainlining black tar heroin? It's probably more addictive, too. Oh, I've seen my share of indy movies in which gaunt hipsters shoot up in grimy bathroom stalls, but not once have I ever had the impulse to do so myself. And it has nothing to do with the "Just Say No" skit put on at my former Hebrew School (which was, quite disappointingly, performed in English).

How many of us - myself included - would take a massive chomp out of that Ham Dog goodness if it were sitting on a plate in front of us right this second, all warm and steamy and meaty? Uh, Alex, what is one-hundred percent?

As humans, we have yet to evolve beyond our proclivity for overeating - especially foods that are typically high in sugars and fats. Five thousand years ago, this made sense. We were subsisting off the bounties - or lack thereof - that the natural world had to offer, and the ability to store fat was a boon, enabling us to survive lean times. When available, we gorged on fruits, as they contain massive amounts of disease fighting vitamins and minerals. From David Zinczenko, author of The Abs Diet:
Since he first stood upright, man has also had a craving for sweets...Without our sweet tooth, we would have been happy to eat nothing but wooly mammoth and buffalo meat - the original Atkins program. But nature saw to it that we craved the foods that would make us healthy.
Sadly for us, the same biological rules still apply. Except now we're drowning in mass quantities of fatty, sugary, and synthetic foods, overproduced by agribusiness, over-processed by the food industry, and conveniently packaged in super-sized portions for our consumption. From Paul Roberts' 2008 The End of Food:
Food companies, although they no longer deny that larger portions are a key marketing strategy, vigorously resist any suggestion that these larger portion sizes actually encourage consumers to eat or drink more - a denial that has to qualify as one of the most laughable claims in the entire obesity debate. Not only have numerous studies shown that large portions always induce greater consumption, but it would be hard to understand why else the food industry would offer them. Given that consumers register the value of food primarily by eating it, if bigger portions didn't increase consumption and thus cause consumer to feel they were getting greater value for their dollars, no food company would bother offering larger portions in the first place.
Some of Obama's more lucid opponents (not the ones breaking into unbridled sobbing fits or threatening to douse themselves in kerosene) claim that all of the current proposals lack a deficit neutrality, meaning any of the health care plans, as currently proposed, would further burden the nation's ballooning federal deficit.

Perhaps. But, according to Berkley professor Michael Pollan, author of the groundbreaking An Omnivore's Dilemma, who penned this op-ed in Thursday's Times:
We're spending $147 billion to treat obesity, $116 billion to treat diabetes, and hundreds of billions more to treat cardiovascular disease and the many types of cancer that have been linked to the so-called Western diet. One recent study estimated that 30 percent of the increase in health care spending over the past 20 years could be attributed to the soaring rate of obesity, a condition that now accounts for nearly a tenth of all spending on health care.
That's a shitload of Ham Dog eatin'.

So it seems logical to me that eliminating the obesity epidemic by incentivizing Americans into adopting healthier, more active lifestyles would keep any of the current Congressional proposals financially solvent.

But for an assortment of reasons, this isn't an option. While Pollan and Roberts maintain that both agribusiness and the food industry are the main culprits responsible for thwarting a meaningful shift to a healthier America, I often wonder if maybe we're just victims of our own obstinance and rapacious excess, too set in our ways to significantly modify our atrocious eating habits and too lazy to elevate our heart rates for 30 sustained minutes a day. In other words, the average American is Jabba The Hutt with a gun rack.

And would corporations continue to market and sell this and this and these if millions of Americans weren't slobbering all over their double-butts to devour them? Living in a so-called progressive enclave myself, I'm frequently confronted with restaurant waiters who blanch upon my ordering of a side of mixed veggies without the melted butter drizzle and Subway sandwich makers who pause to steel themselves after I order my turkey sandwich, no mayo on top.

"So, you want it beneath the meat?"
"No, just hold it altogether."
"And put it on the side?"
"No. Eliminate it."
"And substitute Russian dressing?"
"No. Hold the Russian dressing, too."
"And put it on the side?"

That's when I wonder: am I the only person who's made this request all day? All week? Ever? Am I that guy? Am I an annoying healthy food extremist, or has the rest of the of the world just collectively surrendered to their inner fat kid?

And let me just clarify that the response I typically receive from food service employees, such as the young woman at Baja Fresh who paused dramatically upon my request of a fish taco, sans aioli sauce (which is code for chile powder, ketchup, and a base of full-test mayonnaise - and nothing says vive Mexico quite like tilapia slathered in Helmann's), suggested not a peevish dismissal in the form of an eye roll, exaggerated sigh, or bitch slap, but rather a sense of utter panic, the type of which, hypothetically, might envelop a candidate for the second highest office in the world upon being asked which newspapers she reads - when in fact she's never read one. Deep, profound panic.

(IMPORTANT NOTE: Alaska isn't a foreign country. But, apparently, Hawaii is.)

(IMPORTANT NOTE PART II: Mike Campbell's dry swallow at the 1:39 mark of the video is epic.)

And suggesting to Americans that they should do both would probably amount to political suicide for the poor sap who proposed it, opening the flood gates to further allegations of fascism, naziism, and giving rise to an angry network of Twinkie brigades that would descend upon each state's Capitol in protest of their God-given civil right to morbid obesity.

Which is tantamount to that chain smoker, sitting on the outside patio of the coffee shop getting indignant over the fact that someone nearby has just politely asked for him to extinguish his cigarette: They just can't see past the fact that their self-indulgence has immediate adverse effects on the lives of others. And, remember, regardless of whether you're for or against a public health insurance option, at this moment, those of us who make an effort to live healthy lifestyles are paying the freight on the fattest Americans in the land. Remember, when a diabetic has his leg amputated, the physician gets to sing this little ditty while policy holders across the country watch as their premiums skyrocket. From the June 25th edition of The Economist:
Most doctors in America work on a fee-for-service basis; the more pills they prescribe, or tests they order, or procedures they perform, the more money they get - even though there is abundant clinical evidence that more spending does not reliably lead to better outcomes. Private providers everywhere are vulnerable to this perverse incentive, but in America, where most health care is delivered by the private sector rather than by salaried public-sector staff, the problem is worse than anywhere else.
Although I don't have a fundamental problem with sharing the wealth and pain when it comes to taxes and costs, why not give individuals financial incentives to live healthier lifestyles, rather than waiting for their blood-glucose levels to shoot into orbit? The following is my proposal from a previous post:
The feds would disburse a series of tax rebates to individuals doing their diligence to improve their health. Join and attend a gym at least three times a week? Tax break. Improve your BMI? Tax break. Sustain a healthy BMI for a year? Tax break. Lower your blood pressure or bad cholesterol? Tax break. Etcetera. And each of these actions would be eminently measurable when linked to a national database.
But because patients who are at risk of contracting serious diseases are seldom dealt with until their ailments have reached critical proportions, more invasive - and expensive - procedures and longer hospital stays become necessary, adding further financial strain to individuals, taxpayers, and the overall health care system.

Which brings us to yet another seemingly inexorable burden on the health care system: over-treatment. Again, from The Economist:
The trouble is that many Americans are understandably happy with all-you-can-eat health care, which allows them to see any doctor they like and get any test that they are talked into thinking they need. Forcing people into "managed" health schemes, where some species of bureaucrat decides which treatments are cost-effective, is politically toxic; it was the central tenet of Hillary Clinton's disastrous failed reform of 1994.

But to some extent it will have to be done. There is solid evidence to suggest that by cutting back on unnecessarily expensive procedures and prescriptions, anything from 10% to 30% of health costs could be saved; a gigantic sum.
But don't blame the doctors for this; blame the system. Like every other industry that employs human beings - be it law enforcement, education, firefighting, sales, politics, diamond mining, or custodial arts - there will always be a segment that egregiously exploits their status, sometimes using the most immoral methods imaginable. Whether or not a significant number of physicians are consciously trying to game the system is immaterial to the real problem, which is that such a system of fee for service exists in the first place. From Dr. Atul Gawande's lauded New Yorker piece "The Cost Conundrum":
Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later?
Gawande would certainly know, as he's tethered to such an irreparably flawed system, witnessing much of the waste and mismanagement firsthand.

During a recent office visit, my own general practitioner disclosed to me about the incessant expectation to order more scans and procedures. In the past, he said, doctors often took a wait-and-see approach in dealing with a patient's burgeoning symptoms. But now, because of the lure of compensation, the prospect of legal reprisals from patients (settle down conservatives - medical liability lawsuits comprise only 0.5 percent of overall health care spending), and the fear that they will be ostracized by colleagues for taking the ethical high road (as apparently even the medical field is rife with bullying and douchebaggery), physicians are inclined to order superfluous MRIs and CT scans and to recommend expensive, invasive treatment procedures that ultimately prove ineffectual or even harmful to the patient.

And then, as I was getting up to leave, ol' Doc dropped the bomb on me (I'm paraphrasing): Why wouldn't I order an MRI every single time, he asked, if there's absolutely no downside in doing so?

Ponder them apples for a moment. Think about all the general practitioners throughout the nation. Now, assuming they all share a common mindset, how many hundreds of millions are being wasted on excessive MRIs alone? From The New York Times:
Even when doctors order costly treatments with serious side effects and little evidence of their being effective, as studies find is common, patients are loath to question the decision. Instead of blaming such treatments for the rising cost of medicine, many people are inclined to blame forces that health economists say are far less important, like greedy insurance companies or onerous malpractice laws.
Which is all the more reason to remove the burden - and temptation - that's inherent in the current system from the physicians' domain. Doctors are rigorously trained and highly skilled in the art of medical diagnoses and treatment; but they've yet to evolve past the rest of us when it comes to the nature of temptation. Also, in the gap of time that exists between my annual office visits, I want my doctor sharpening his talents - training his focus on new treatments, studies, and applications - rather than filling out hours of Byzantine paperwork, haggling with Aetna bureaucrats, or cutting lucrative kickback deals with Pfizer reps. Again, from Matt Taibbi's "Sick and Wrong":
There are currently 1,300 private insurers in this country, forcing doctors to fill out different forms and follow different reimbursement procedures for each and every one. This drowns medical facilities in idiotic paperwork and jacks up prices. Nearly a third of all health care costs in America are associated with wasteful administration. Fully $350 billion a year could be saved on paperwork alone if the U.S. went to a single-payer system - more than enough to pay the whole goddamned thing, if anyone had the balls to stand up and say so.
Furthermore, Americans seem just a tad too eager to project blame in this crises, be it unto the food industry for flooding the market with chin-proliferating eating options, the fat cats in Washington for feeding at the insurance companies' money trough, the pharmaceutical companies for profiteering at the expense of the sick and infirm, and the socialists for abducting and indoctrinating our president so that he could do their eternal bidding for evermore. But at what point should we ask ourselves what we're doing wrong - or, at the very least, question what we, as patrons of a wasteful system, can do to help trim costs so that there's room for everyone under the health care umbrella?

Problem is, at this point, there's simply no way a card carrying Democrat can make a case for frugal management and distribution of health care services, a la the Mayo Clinic, without piercing allegations from the right of care rationing - yet another jaunty Republican-recycled term from the Cold War era that evokes endless lines of defeated, stoop-shouldered, woolen-clad families, in sub-zero temperatures, awaiting a pair of rusty garden sheers so that they can take care of Uncle Yuri's growth before it grows to the size of a basketball.

(Judging from their growing reputation for intransigence and inaction, for most Republicans, no health care reform at all would be eminently preferable to what they dub "rationing.")

These are the nuts and bolts questions that need to be addressed and discussed in a controlled public forum, but they won't be because of all the piercing noise emanating from the right-wing lunatic fringe, which has controlled the tone, tenor, and yes, content of the health care discussion since mid-July. A 55-year-old redneck who bursts into rage-fueled tears, while standing two feet away from a prominent senator, makes for a much better TV news lead-in as well.

And by right-wing lunatic fringe, I'm referring to the preponderance of the entire Republican party: the sound and fury signifying nothing leadership; and the incendiary right-wing radio carny barkers, preying on the simple minds and base emotions of an ever-expanding sea of gullible reactionaries who have been waiting for this very moment so that they could have a reason - regardless of how misinformed, distorted, or flat-out wrong that reason may be - to channel their simmering rage at a young, black Constitutional Law professor with the audacity to assert his agenda.

And, yes, Jimmy Carter was more right than we'll ever know or want to admit.

The few moderate voices remaining within a party that was once noted for its proud patrician swagger have been muted by scores of paranoid lunatics. Crackpots like Sarah Palin, Mike Pence (the number 3 GOP House leader), Jim DeMint, Joe Wilson, and Chuck Grassley have eagerly assumed the mantle of screaming assassins in a party formerly known for its stolid, calculating persona. Pence, whom I can only hope was just thinking out loud when he said this, was quoted in the L.A. Times this past Sunday:
How we as conservatives respond to these challenges could determine whether America retains her place in the world as a beacon of freedom, or whether we slip into the abyss that has swallowed much of Europe in an avalanche of socialism.
Mr. Pence, you receive zero points for being both unoriginal and clinically insane. And, if you're not insane, then you're just being a total demagogue d-bag - take your pick. (You know, it must be real nice to have a job where you can say whatever random asinine shit that pops into your head at a given moment...SOCIALIST! NAZI! TOAST! GUMMY BEARS!)

And, of course, let's not forget the verbal Abstract Expressionism of the lovely Ms. Palin:
Is it any wonder that many of the sick and elderly are concerned that Democrat proposals will ultimately lead to rationing of their health care by - dare I say it - death panels? Establishment voices dismissed that phrased, but it rang true for many Americans.
By the way, new rule (with apologies to Bill Maher): Goys are no longer allowed to reference death panels, extermination camps, or Nazis every again. If you want to play the victim, you or your people actually have to be victimized at some point. And taking a hard tumbler off your ATV while chasing after thumper doesn't count. Nor are you a victim when the town issues you a cease and desist for when you and your buddies forge a makeshift Octagon out of 2x4's, deflowered bed mattresses, Gorilla Glue, and chicken wire - and engage in late-night Pabst-fueled mixed martial arts set to a pulsing backdrop of Billy Squier and Jackyl.

But I wouldn't be surprised if Palin's right about the term "death panels" resonating with many Americans, as we live in a country where Bill O'Reilly and his nightly adventures in shit flinging average five million viewers a night.

Ultimately, the denizens of big, square states are easily manipulated by whomever on the right barks the loudest, regardless if whether the message ever actually makes sense or not. Sprinkle a few catchy, anxiety-provoking buzz words into the equation and you instantaneously have yourself hoards of fear zombies, awaiting their marching orders. For old pros like O'Reilly, Rush Limbaugh, Michael Savage, and Glen Beck, it's literally easier to do this than to hatch Sea Monkeys.

And it's unfortunate. Most of us have absolutely no idea how dire our situation can become at less than a moment's notice. We think we have sufficient health coverage, and that it'll be enough to weather the storm of illness or disease. But more than likely, it won't be. According to James Surowiecki, we "overvalue" what we already have, hence the reluctance to change. In other words, we humans are anxious little creatures with a predisposition for settling for the devil we know. From Surowiecki's piece in The New Yorker:
Behavioral economists have established that we feel the pain of losses more than we enjoy the pleasure of gains. So when we think about change, we focus more on what we might lose rather than on what we might get. Even people who aren't all that happy with the current system, then, are still likely to feel anxious about whatever will replace it.
It's a tragic flaw that we are seemingly so thoroughly possessed by our reptilian brain - by our fears, immediate desires, and anxieties - and so easily given over to mob and bunker mentalities.

Because, if right this moment, millions of Americans flooded the streets and, instead of withering under a sea of right-wing mendacity, demanded that health care in the U.S. become inherent to our civil rights, as much as voting, schooling, and getting a fair shake in a job interview, it would happen next week. But we won't. Because what if we get arrested during the protest and miss several days of work - and, as a result, get fired? Then we lose our health coverage, right?

Oh, shit...

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Stop the Inanity. by Brock Cohen is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.
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