Reflections from Denver - Guest post by Skylanda

I had meant to throw up a couple more posts from the stands at the Democratic National Convention, but (hey, who knew?!) typing on a PDA is harder than it looks. So instead I’ll finish out with a couple days’ retrospect, a reasonably sized keyboard, and a little more sleep than I’ve had in a week.

I’m not a flag-waving sort, but Thursday night in Denver I waved a flag. In general I don’t believe in the sort of thoughtless, jingoistic patriotism it takes to go swinging any nation‘s cloth around in a crowd. And over the last seven years (two weeks out from the seventh anniversary of 9/11, we are), the idea of patriotism and the act of flag-waving has been so usurped by reactionary idealogues in America that any time I see red bars and white stars on a field of blue, my gut tightens with the heavy anticipation of what hatred or hawkishness is coming down the road.

But they were passing out flags Thursday, before the sun went down, so I took one and dutifully pinholed it on the seat back in front of me in a spot usually reserved for Broncos sports paraphenalia.

The afternoon was long and hot and some of those speeches could have been a might bit shorter (though I can’t help but smirk that the afternoon’s entertainment opened with the Yonder Mountain String Band, a collection of bluegrass-picking stoners from just up the road in Boulder…in a venue just a tad larger than the last outdoor bar I saw them play in). The crowd built throughout the afternoon as the hours-long line outside the stadium (which we had the good foresight to hit up in the early afternoon when it was less than 45 minutes long) slowly poured in to fill the seats. The lesser-knowns spoke first - state party officials and campaign managers, House representatives from Midwestern states, a token panel of undersung war heroes. Then the better-knowns - Howard Dean, the New Mexico governor who keeps pretending toward a presidential bid despite that atrocious semi-mullet he insists on sporting, a local member of venerable Udall political clan. Then Al Gore, who comes off as so terribly more presidential that he ever did during his run for office. Then the six American Voices - men and women from across the country telling their own stories of life under the Bush years - who proved that people you would never expect to have a public voice can talk like elder statesmen and stateswomen in front of eighty-thousand live and another how many millions over the airwaves.

And then, the man himself: Barack Obama. And a thunder of applause that could have brought down mountains. He speaks with the intonation of an old-time preacher and the rhetoric of a classical civil rights leader - more electrifying in person than television or YouTube could ever capture - even to a crowd of tens of thousands and under the watchful eye of snipers that roamed the high points of the perimeter. He commands crowds in a manner that Kerry or Gore never could, and even Clinton (the ex-president, not the ex-candidate) never did until the retrospect of the Bush years made him look a whole lot better than he ever did on his own.

He spoke of hard times in America, and how it speaks to the soul of a nation how we face down, put down, or help up those enduring tough times. He spoke of pragmatics like oil independence, educational investment, and covering the uninsured with health care. He spoke of hope, and of renewal, and of a kind of conciliation that understands political opposition as a force not of mal intent, but a force of those who just don’t get it.

His conciliatory stance is sometimes frustrating, and his command of the issues doesn’t line up precisely with the farther left side of the left wing. He put the word “abortion” out of the spotlight, offering up that eternal thorn in the side of pro-choice rights, the safe, legal, and rare clause: “We may not agree on abortion, but we can agree on reducing the number of unwanted pregnancies in this country.” One has to read between lines to understand that it’s not that Obama may disagree with the right wing on the abortion issue, it’s that he does disagree, with 100% score from NARAL on his pro-choice voting records for 2005, 2006, and 2007. The recent change in the Democratic platform both emphasizes the prevention model and staunchly support Roe v. Wade all at one time - a move designed to make the tent bigger, include a greater constituency, please the breadth of the masses.

Which is all a very mixed blessing. On one hand, I would like to see a candidate who is unafraid to stand up for pro-choice rights without this nebulous couching of the issue in a candy wrapper of palatable concession. On the other hand, losing this election by forcing the abortion issue to the front and center - for a candidate who is palpable and provably pro-choice - does not seem like a wise move for anyone interested in preserving a woman’s right to choose. Perhaps this sort of tactic will widen the door of the democratic party to what is probably a quiet majority in the anti-choice movement - those who would like to see fewer abortions, but who are not so bat-shit crazy as to oppose comprehensive sex education and accessible birth control. Pro-choice services and preventing the need for abortions go well together in every-day practice (just go ask your local Planned Parenthood what they have on the table if you don’t believe me); it is only in politics where they make uncomfortable bedfellows, and maybe an alliance between them can go a ways toward actually solving concrete problems rather than miring us down in ideology and battlefield damage control.

Other topics too got a glossing over; environmental protection got a four-word nod to clean water alone…though in a line-up where Obama was preceded almost directly by resident Democratic party environmental guru Al Gore, it is easy to see why this might have already been said better and more thoroughly that Obama had time for.

But the sustaining issues that drew the party to Obama remained the focus.

Front and center: “For the sake of our economy, our security, and the future of our planet, I will set a clear goal as president: in ten years, we will finally end our dependence on oil from the Middle East.”

Front and center: “As commander-in-chief, I will never hesitate to defend this nation, but I will only send our troops into harm’s way with a clear mission and a sacred commitment to give them the equipment they need and the care and benefits they deserve when they come home.”

Front and center: “Now is the time to keep the promise of affordable, accessible healthcare for every single American.”

Front and center: “Now is the time to finally meet our moral obligation to provide every child a world-class education.”

Front and center: “Now is the time to keep the promise of equal pay for an equal day’s work, because I want my daughters to have exactly the same opportunities as your son.”

Front and center: “America, now is not the time for small plans.”

I looked up to find that flag in my hand, waving among the tens of thousands of others like it. It’s kind of pretty, you know. All primary colors against the midnight black of a moonless summer sky, backlit by the glow of a thousand stadium spotlights, washed in the populist flash of 80,000 Americans and their digital cameras and cell phone cameras, hoping to capture a moment in history.

Promises are just promises, and they are harder to keep than virginity on prom night, but still. This is the kind of America I could wave a flag about. This is the kind of nation that might make me pick up those colors and believe again.

It will take more than showing up on November 4th to make this happen. It will require will, and effort, and the movement of thousands of people to force a new vision of America into being. Especially in the wake of McCain’s half-hearted, media-grabbing nod to putting a woman on the ballot, it is vital that every American who desires something other than four more years of the same put in the time, here and now. Whether Obama lines up perfectly with your ideals or not (and whether you pressed for a Clinton candidacy, as did I), if you’re reading this blog, chances are he’s a hundred-eighty degrees closer to your place on the spectrum than McCain. Between now and election day, promise yourself that you will do just one thing to put Obama and the litany of progressive candidates in office: Register at least one new voter before the October 4th deadline (later in some states). Skip a latte once a week and send the money it would have bought to the coffers of an activist organization - NARAL, even the Democratic party itself, what have you - working to put progressive women and men in national and local office. Call your local precinct and ask them how you can join up and be a part of the effort. Talk to wavering independents in your family; write a letter to your local newspaper.

Be a part of the process. Make your voice heard. The next four years of this nation’s history depends on us.

Cross-posted at my blog, Loose Chicks Sink Ships.

Fifteen days of blogging for health care reform: Where do we go from here?

Guest post by Skylanda.

If you’re still with me, fifteen wordy days later, you may feel buried beneath an avalanche of priorities and issues and complexities. Out of a whole heap of information, there is always the lingering question: where do we go from here? What conclusions can we make from all this quagmire of complication and controversy?

So here’s the post-game, the recap, the proverbial twelve steps to health care reform, not so humbly opined from the dozen-plus posts above. Without rehashing the minutiae of detail from every post over the last two weeks, these are the overarching priorities that I believe could make substantative, transformative health care reform a reality in this decade, in this country.

* Single payer health care. Health care is a public good, like roads or schools or national defense, with a unique requirement of portability; it is the obligation of every soul living on our soil to pay into it in the proportion to which he or she is able, in order that he or she may draw out what is needed for the maintenance of their health.

* Structuring reimbursement to best motivate service without compromising quality, with an eye toward equalizing procedural and non-procedural reimbursement and drawing quality providers into the field of primary care.

* Prioritizing funding and services toward maximum gain per dollar spent (especially in considering preventive care versus heroic end-of-life interventions), with the caveat that this does not release us of any obligation to care for the most vulnerable populations among us.

* Minimizing barriers to care for the most at-risk populations in order to prevent costly delays in service associated with neglect of care in those groups.

* Market-based and legislative pressure to bring pharmaceutical research & development in line with the goals of social good, with an emphasis on innovation over continued production of me-too drugs.

* Using evidence-based medicine as a means of exerting cost-control measures. We have the means to know what works, and to know what works at the most efficient price: time to put this to work for us at the individual, system-based, and legislative levels.

* Reforming medical education to emphasize clinical over theoretical focus, humane treatment of trainees, and capping student debt in return for expectation the physicians will make generous but not unreasonable incomes throughout their career.

* Reforming the medical malpractice to systematically emphasize patient safety and create a means of compensating patients harmed by medicine without resorting to the bad-luck lottery of the lawsuit.

* Drawing on the immense portion of the governmental budget and national GDP already dedicated toward health care to reformulate a fifty- to one hundred-year plan to fund, streamline, and maintain a sustainable health care system at a per head investment comparable to that of other developed nations.

* And finally, understanding that health care insecurity is an untenable impingement on the freedom that Americans value so highly, and that health care security divorced from private employment-based insurance is a key to maintaining a healthy, open market for small-scale capitalism to flourish in.

The work of today’s generations - the generations that opt out of health care through their twenties, that shoulder the tab for the nation’s health through their productive years, and that will very likely live to see the useful end of that nested safety blanket known Social Security if we do not steer this ship in a very different direction - the work of this generation is to meld the brilliance of American innovation and ingenuity with the pragmatics of the collective good to form a health care system that none other can parallel. We can do this. It has been eons in coming, and the shoulders of giants are ripe and ready for you to stand on.

You may have been tinkering on this issue for years, or you may new to the playing field. If you have been involved in the push for health care reform for weeks or months or decades: good on you, keeping fighting the good fight. If you step gingerly around the questions of whence to start and who will pay for this and whether you really know enough to put that first toe in the water, understand this: as a famous person once said (and many have since quoted) - if not now, then when? If not you, then who?

It starts with November 4th and every day that comes between now and then. It starts the next time you see your doctor and ask whether he or she considers cost control when prescribing your medications. It starts with a letter to the editor, a call to your state representative next time a health care bill arises. It starts when you tell your story, when you speak up, when you talk out.

It starts now, today, here. With you. Let the work begin.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Buying Locally by Anthony McCarthy

For Phila

A dusty Saturday morning in August,
The music store in the dilapidated building on Sixth Street,
Looking for the kid’s new instrument,
She’s heard of one there.

Good lord, guitars.
All shapes, ages, some
configurations you can’t believe could work.

You see sparks in her eyes ,
dream colors of post-war chemistry,
and you almost have to pinch yourself awake.
Strange, ancient electrics,
Safe?
The risk of death modulating the frisson of stage fright?
Talk about your performance edge.
Even you, who curse the too-too-solid body,
have got to admit,
they’re really something.

Ancient sliders,
Spirit mediums conjure Commodore Bing in a lea
exiled in a decaying New Hampshire mill town,
depression winter escapes to “Havaii”.
Another points to Opree
A cursive text in red glitter worn.
unreadable, unrestored, Road Show unwashed.
A Nashville palimpsest, though Bangor is closer.
And a ‘one-string’,
Not so designated, but a complete outfit,
with beater and bottle.
The can resonator, sprayed leftover opalescent blue,
like an old pickup by, you hope, a craftsman-scholar-bodywork guy,
Is that Bondo?
“Can’t out funk that,”
You tell the owner.
But he can, he’s got the LP!

Alas, to business.
“This one’s on consignment”, he tells her,
“adjusted the action myself.”
She waits your advice,
That’s why you’re here.
Look down the neck,
“Who can tell in this joint,
nothing straight or level?”
He offers a meter stick,
swallowing your pride,
adjusting your bifocals,
you take it.

“Yeah, looks good.
Only way you can tell is to play it.”
She tries a Sor study, one in A,
Good. Then the Bb,
Bb, the test of all flaws, the limits of resonance.
The bar chords tell all.
She does all right. The action’s good.

She still, wants you to decide,
“’s your money”, you say.
She vacillates,
“Return policy?”,
Flexible, trusts his stock,
and makes the money back on strings and service.
Better to have a customer than a sale
She takes it.

You find an ocarina,
clay, tenth up from about G with chromatics.
Filthy, she can’t believe you put it in your mouth.
“Been here forever, five bucks.”
You can’t top it.


“One-string” : A beaten monochord played with a slide, as recorded on only a couple of legendary dates with the mysterious LA street musician Eddie “One-string” Jones.

What The Media Would Say If Sarah Palin Had Been Barack Obama’s VP Pick by Anthony McCarthy

If Barack Obama had crossed party lines and chosen Palin as his VP pick, by now the corporate media would have:

- Gone wild over her Troopergate scandal. They would have said it was an illegal abuse of power that exposed her as a power hungry woman bent on using the power of her office to destroy her ex-brother in law at the behest of her husband who would also be being revealed to be a danger to the republic by his part in it.

This would have revealed her to be:

- A power mad cop hater who ruined the decades long career of Walter Monegan, a dedicated public servant, when he wouldn’t do her bidding in violation of his legal obligations and his code of honor.

- A hypocritical “reformer” engaged in a major cover up of unethical if not illegal abuse of power through Bush-Cheney style attempts to keep evidence from being investigated. Only the names of Bush and Cheney wouldn’t be used to describe it.

- A jumped up, small town mayor who climbed to power over the political corpses of more experienced politicians. They might mention Lady Macbeth. The public relations stock of many discredited Alaskan Republicans would be rescued in the process, their crimes would all but become unmentionable in the cabloid babble and Sunday morning BS sessions.

- Her children’s names and the number of them would be an issue. They would be proof of at the least terminal ickiness if not some serious mental defect. Dowd, alone, would get at least a half dozen of her instantly produced columns from it. Yes, the one with downs syndrome would be fully used against her. Proof of irresponsibility (late parenthood) etc. Her pursuing a career while having and “neglecting” a disabled child would be a major ‘issue’. Though the more august media would report those as a "it's being said" story.

- Obama would be slammed non-stop for putting the United States a heart beat away from the inexperienced hands a flawed, green, small-town mayor. Handing the nuclear codes to the likes of her would be considered treasonable. The media would suddenly rediscover that it really matters who is president.

- Obama would be accused of going for the Jerry Springer vote. Every effort would be made to turn his choice into proof of irresponsibility, negligence, malfeasance and most damaging of all, tackiness. They would call it proof that his reputation as a reformer, a maverick an advocate of women’s rights etc. was a sham.

- Alaska would be as ‘exotic’ as Hawaii. It would go from the rugged frontier to being marginal and dangerous. It’s entire cultural history would be mined to show that having the president’s understudy come from there would endanger the entire world.

- Getting back to her husband. He would be revealed to be the male equivalent of that Hillary Clinton monster created by the media and Jerry Falwell among others. He would be accused of every possible crime up to and including murder of a close friend for political gain. There would be a complete investigation of his and her sexual histories, those would be created for them if nothing concrete was found.

- Every yahoo they could dig up with any connection to her and her family would be put on national TV to make their charge. C-Span would have their representatives on, this would be the US-BS stamp of approval for the legit media to run with every single story they could invent. How much do you want to bet that some oil billionaire wouldn’t start funding that one immediately.

- Oh, they also would say she only got anywhere because she was a woman. They might mention Lady Macbeth.

And that’s only what I can come up with on short notice. You can take any of the Democratic “scandals” of the past thirty years, change the names, make a few minor modifications and I can just about guarantee you’ll see exactly how the media WON’T be covering McCain's Palin choice. They won't even mention his history with younger women.

.

McCain/Palin: A Bad Choice For Women

The divine Snake Goddess asked me to cross-post this, which I put up at my place in response to queries:

I've gotten quite a few e-mails asking what I think of John McCain's choice of Governor Palin for his VP. Here are my initial thoughts.

First, Barack Obama gave an historic speech last night. It was soaring, it was grounded, it was inspirational, it was lethal to the Bush junta, and I was feeling very honored to have lived long enough to get to hear it. And, second, no woman should vote for McCain/Palin. He and she are anti-choice, anti-woman, anti-polar bear, anti-Social Security, neo-cons. They'll give us 16 more years of Bush policies and we can't take even 16 more months.

That said, I disagree with the majority of liberal bloggers (whom I've been able to read so far) who think Palin was a dumb choice. I think she was a smart choice and one that points out that, as I've maintained all along, Biden was a dumb choice. (She was on my short list until she gave birth a few months ago to a child with Downs Syndrome, which I assumed meant that she wouldn't be interested in the job.)

Palin's young, attractive, middle class, a sympathetic figure as the new mother of a child with Downs Syndrome and the mother of an 18 year-old son about to be shipped to Iraq. She hunts and fishes and is married to her childhood sweetheart. She's going to suck up a huge amount of media attention and comparisons to Geraldine Ferraro are going to keep opening wounds in the Democratic Party and give Ferraro, who's had almost as big a problem running off her mouth as does Biden, more air time. Lots of rural, Southern, and working class voters -- the one group that has yet to really warm up to Obama -- are going to like her. I include men from those groups; the large population in the racist and sexist overlap of that Venn Diagram will pick the anti-woman pretty woman over the black man. She undoes some of the damage that being married to a millionairess with a jillion houses has done to McCain. Elections aren't won or lost based on the VP debate, but Biden's going to have a tough time debating her and, if he mistreats her or patronizes her, that could have larger ramifications. Let's hope he's learned something since the days when he treated Anita Hill like the dirt on the bottom of his shoes.

Will she attract some votes from women because she's a woman? As I said above, women should not vote for her. But consider this. If the situation were reversed and Clinton had won after a long and emotional primary battle against Obama and had then chosen Biden for her VP, indicating that she didn't see any need to give African Americans the VP slot, and then McCain had picked an African American VP, would you expect some African Americans to be tempted to vote against Clinton/Biden? I would.

Obama made this problem for himself. If he'd picked Clinton or Siebelius or McCaskill or any of a dozen other good Democratic women for VP, McCain would have picked Romney or Lieberman or some other man. So, once again, if I were advising the Obama campaign, and, Goddess knows, they never listen to me, I'd advise them to find some new and important ways to reach out to women. Endorse the ERA. Announce some early cabinet picks and make them women. Democrats always count on the "women's vote" -- they can't win without it. The difference this time is, they shouldn't continue to take it for granted.

Fifteen days of blogging for health care reform: The bridge to EPT

Guest post by Skylanda.

Where the dusty border town of Juarez butts up against the jutting mountains to the north, there is a bridge. On one side of this bridge lies Mexico, and on the other lies the city of El Paso, Texas. A place whose name itself invokes journey, transition, a throughway to greater things: The Passage.

Women on the south side of the river that divides the wealth of the north from the churning poverty and violence of Ciudad Juarez gather to watch and wait. These women walk heavily, bellies swollen with child, often in the night, often alone. When labor pains come fast and hard and strong enough to promise imminent delivery, these women make for the bridge. Border patrol will pick up most of them; if they are picked up short of the bridge, they are transported to a hospital back on the Mexico side to birth their children. If they make the bridge, they are transported to the north side and the babies born of them - born on American ground - become American citizens by right of birth.

This is something of an apocryphal tale. I have never seen this bridge, or met these women, nor can I verify for certain the veracity of these stories. I only hear tell of them from the residents who rotate through the labor & delivery floor there in El Paso. But it is a useful tale, one that silhouettes race and class and gender against the background of globalization as clearly as a nine-month gravid belly silhouettes out, against the desert heat of the borderlands under a moonless August night like tonight, back-lit by a Border Patrol spotlight.

In 1981 a cadre of radical feminist women of color published the anthology titled This Bridge Called My Back. It’s an aptly titled book, and the name came to mind when I first heard about the bridge to EPT. On the backs of these women, the layered complications of globalization are played out. These women bridge nations for their families; their flight during the pain of labor is a valiant attempt (from one perspective; a sneaky ploy from the other perspective) to drag their families into a relative sort of wealth in a manner that their men cannot, nor would they likely be asked to. On their backs intersect every complication of their gender, their minority race, their humanity-defying poverty. In the pangs of labor, outside, on the run, they become the reflection of everything unjust about a stratified world of haves and have-nots, and a mirrored view into the never-dead but ever-ephemeral hope that one day, somehow, life can be better.

The story of these women, when I first heard it, gave me pause to remember what the fight for universal care is about, and what it is not about - what it means to merely operate a universal payment system versus what it means to institute a social movement that pushes toward real social change. It is difficult to imagine - never mind articulate - how universal health care can be a part of that move toward equality and justice, so I’ll take on an easier task: the task of defining the things that universal health care cannot be if it is to play any role in the universalization of human rights.

And so, these are the things that universal health care is not:

Universal health care is not a system that claims to cover every person, but with a benefits package that circumvents one of the single most common services needed by half the adult population. This is why I will not get behind any pro-life candidate who talks out one side of his mouth about abstinence-only education and out of the other about covering the uninsured; if you’re not covering reproductive health services, you are not offering universal coverage.

Universal health care is not a system that reimburses for its covered citizens but leaves hospitals and clinics out in the cold for care of undocumented patients. It’s hard to advocate that the US government pay unlimited health care costs for people crossing borders illegally, but care for people who pick your grapes, clean your office building, and mow your lawn without benefit of legal status has to be covered in some measure. The most marginalized people are also some of the least likely to be able to pay, and the infrastructure that cares for them needs to be maintained as well as the infrastructure for legal, documented workers.

Universal health care is not a system that tackles the price tag of health care without at least some nod to the radical health disparities increasingly apparent in our nation today - why African American women and their babies die in the peripartum period at a rate that stands out like a sore toe compared to the rest of the nation. Why decades of increasing life span has suddenly reversed for women in the poorest mountain states of the south and east. And what the system needs to do to produce equitable care - toward equitable outcomes - for the people most affected by the disparities.

Universal health care is not an excuse to promote nationalism, exclusionary stances, an us-for-us and them-alone policy. If we didn’t want to cope with an influx of undocumented people, we should not have set up the border region as our own personal sweatshop, and we should not have built our agrarian and light-industrial economies on the backs of immigrant labor. The price we pay for being wealthy and well-funded is that our services are desired by those whose resources are so minimal as to be non-existent; we either accept a certain price tag on that privilege, or we decide to drop our care standards to the lowest denominator common to both sides of the border region so that people stop coming across. I would like to suggest that the latter is not an idea any of us would choose to live with.

Universal health care is not a foundation on which to build a healthy class of cannon fodder for the next military incursion into the next hotspot of global tension.

Universal health care is not a means to reinforce a global norm of inequality.

Universal health care is not simply another means to prop up wealth in the world’s core economies on the backs of the poor, the children, and the women of the peripheral economies.

It is up to the ambition of our collective conscience - and the hard work of concrete planning - to imagine up what universal health care can help make of America. I’ll keep my thoughts to myself on this one, and let yours do the work of imagining where a profound move toward taking care of our own might take us.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Friday Critter Blogging (by Suzie)

This is a photo of Elle. Previously, when I posted a photo of a Chihuahua in a bee costume, I had no idea there was a site dedicated to dogs in bee costumes. "Beedogs.com is the premier online repository for pictures of dogs in bee costumes." My favorite part is the verbiage about clicking on the next page, such as: "Your daily intake of beedogs has been critically low. Click here or you will die."

Gay men & sexism (by Suzie)

         Like a lot of feminists, I don’t think we’ll ever end discrimination against gay people until we end sexism. For that reason, I’d love to see every LGBT organization educate members about sexism. We need some good old consciousness-raising.
         A lot of gay men are squeamish about behavior marked “feminine.” When one refers to another as Mary or a diva or a girl, it’s usually a putdown, even if a very gentle or humorous one. This reinforces ideas about the proper behavior for men and women.
         Gay culture that elevates muscular, “masculine” men hurts men who are considered effeminate. But it also harms women by once again making the “masculine” superior.
          It’s not enough for gay men to tell me how much they like women since plenty of straight guys say the same thing. As a political ally with gay men, I want them to question their own sexism.

Fine Music From Minneapolis, Decorah, Cincinnati, Hales Corners, NYC, Independence, Rochester, Dallas, Kirkland, .... by Anthony McCarthy

The Public Radio radio program Pipe Dreams, which features organ music played in a lot of different places by a lot of different organists, is one of the most reliable opportunities to hear fine performances of unusual music, much of it very new. Since it’s based in Minnesota a lot of the performances are recorded in the middle of the country, a continuing revelation to someone based on the infamously insular East Coast. You can listen to it and find yourself grinning happily to hear the evidence of great musical culture from cities and even states which are associated with high art in no other part of the media.

A good pipe organ and a good player can go a long way towards taking the place of an orchestra in a town. And good, well maintained, organs are more common than you might think. They are certainly less expensive, and so more common, than good orchestras. The culture of organ playing tends towards having good habits of musicianship. I’d imagine it’s due to all that Bach and the historically informed performance practices a concentration in his music tends to foster. It’s a question of honesty and integrity. Once you learn to try and find how one composer said they wanted their music played, you feel an obligation to try and find out how other composers wanted it done. Organists also tend to have a much better ability to control the rhythm of their playing than other instrumentalists, though this isn’t a universally practiced virtue. Anyway, for whatever reason, organists are often very good.

In this program of Pipe Dreams which contains performances of all four books of his “Gospel Preludes” William Bolcom points out that organists, unlike some other instrumentalists, tend to buy new music at impressive volume. He said that when one of his Gospel Prelude books would come out his publisher would rush it into print, expecting that music directors at churches would buy them up. He suspected that it was a combination of musical curiosity and adventurousness along with having a budget that needed to be used or it would be cut the next year. The 2007 program presented all of his Gospel Preludes, unless he’s written more since then. The performances on different organs and different organists are excellent and evidence of the geographic dispersal of high art mentioned above.

If you were raised with these hymns you might have pleasant or unpleasant associations with them. I don’t, with a few exceptions. Having been raised an Irish Catholic in a French parish, the hymns aren’t the ones I grew up with. A few I associate with cloying religiosity as presented in movies, though that’s not really a reason to condemn them out of hand. It’s interesting, in the interview with Bolcom that’s interspersed with the pieces, he addresses those associations and his trying to do something with them.

One, probably the most famous one, I hate due to having lived next to an impossible person who played a famous recording of someone crooning it every single day for a year. It was a penitential experience. You’ve heard it a million times yourself. That’s the Gospel Prelude that gives me the most trouble in the way of extraneous associations. Though I think Bolcom’s setting could turn it around for me. His most explicit presentation of the melody, minus the annoying grace notes introduced into the singing tradition, perhaps by that famous recording, is probably the best rendition I’ve heard. The others move me in ways ranging from being knocked off balance and having to find my footing to excitement to wondrous raw experience that escapes reflection. Say what you will, these are not demure, well behaved pieces representing the uptight, self-righteous tradition of protestant hymnody.

The one which made the biggest impression is the last one, the Free Fantasia on O Zion Haste and How Firm a Foundation - if you want to find that one, it starts at about 1:14:00. Listing the technical features that are so marvelous might not help you get more of it, so I won’t go into those. Just say that when Bolcom constructs one of his enormous chords you don’t know what direction they’re going to take off in. The last part when he combines the two melodies, after what I’ll just say is an amazing chord, is stirring.

Perhaps most audacious of all is Bolcom’s citation of Black gospel performance traditions, which he was familiar with from his attendance at an AME church in Seattle in his youth. That took real guts for a white composer in the years he was writing these. It is done with such respect and observance of the dignity and validity of the tradition, with such respect for the substance of its intentions, that I don’t see how anyone could honestly fault it. It’s clear that he loved what he heard enough to really understand its techniques and purpose. Other traditions are cited but not, to my hearing, as often or with such strength. At times I suspect I can hear reference to one of his teachers, Darius Mihaud as well as the culture of the organ in general. With Bolcom, you get worlds, many of them, all in one sitting.

In reference to some of the other pieces posted during this brief return from hiatus, listen to Bolcom talking about the jobs he had while he was a student. Listening to one of the world’s finest living classical composers talking about some of the jobs he’s worked might come as a surprise to some. Musicians won’t be surprised, though.

As I said, Pipe Dreams is one of the few reliable broadcast sources for hearing new and exciting music and old music in fresh, informed performances on the radio. Luckily, they’ve got an archive of past programs and a few CD recordings for sale. I’d recommend sampling quite a bit of it if you are interested. Note that some newer Preludes Bolcom has written on Jewish melodies are included in the program as well as pieces by Virgil Thomson and the rarely heard Gardener Read.

Fifteen days of blogging for health care reform: The Road to Denver

Guest post by Skylanda.

Today’s the day. The speech-givers have speechified, the spinners have had done their spun, the pundits have spoken their punditry. Tonight the man of the hour takes the stage in front of some 70,000 some-odd live and some millions more by television and internet to accept the Democratic nomination.

Like thousands of others, I am in Denver among the revelers and the protesters and the bloggers and the masses and the elite. I come here with a group called Healthcare United and their website is worth a look if health care reform is up your alley. Sponsored by the two million-strong Service Employees International Union (the largest health care employee union in America), Healthcare United is a newly-formed organization designed to bring together people from all branches of the healthcare field - nurses, pharmacists, psychologists, nursing aides, doctors, and everything in between - to bridge the gap between these workers, start a mutual conversation on how health care reform might look that would account for every level of care, and work toward national goals of reform. The SEIU is the umbrella organization that oversees the Committee of Interns and Residents (CIR) - the union that stepped up when the administration at my residency decided unilaterally to double or triple individual contribution to medical coverage a couple of years ago. The residents unionized; the move to dump increasing costs on one of the most underpaid programs in the western US was halted. Among the points negotiated in the first union contract - alongside the first pay raise in years and caps on insurance premium increases - was a $25,000 patient care fund for the residents to collectively distribute to projects that benefited patients in a system that chronically underfunds hospitals, providers, and patients alike. In so many ways, unionization of the residency program has worked toward improving patient care in my state - though the small but symbolic patient care fund, to the renewed ability to attract quality trainees to a region underserved by every medical specialty from primary care to the most sub-specialized service.

We caravanned two vehicles up to Denver from my neck of the woods - one of the CIR residents and one of the Healthcare United volunteers. Since I got on at the last stop, I hopped on with the nurses and staff of Healthcare United. Between naps (I had been up all night - a crash c-section, a couple of peds admissions…not a terrible night, but no more than an hour of sleep either), I chatted with and quietly talk of what healthcare looks like from their end of the short stick. These stories are always three-pronged: one prong is the patients they see harmed from the stunning holes in the system; another prong is the staff they see the harmed from the gaps in safety, in pay, in benefits; and the third prong is the families - usually their own - that inevitably suffer a story or two of harm from underinsurance, the gap between insurance and the required cash contribution to one's care, or lack of access to care altogether. Their tales sounded eerily similar to mine, and I am struck by how little difference there is in our plights despite how different our jobs sometimes our. We did not get to talking about solutions, but I wonder how similar or different those might be too.

In Denver we attended a rally where SEIU advocacy groups - single payer players, health care for all fighers - gathered from all across the nation to speak for health care reform. The afternoon was MC'd by none other than Chuck D (yeah, that Chuck D), and if anyone can tell me how to upload a wave file from my phone to the web, I can stream a live version of Fight the Power - 2008-style - here on this site. It was a surprisingly small (but enthusiastic) crowd for a free concert that also included an appearance by Death Cab for Cutie (are they the living image of Flight of the Conchords, or what?) and local phenomenon Devotchka...but hey, it's a Wednesday afternoon, apparently some people have to work. The speakers ran the range from health care workers to local organizers, and the diversity of speakers spoke to the broad-reaching appeal that Obama brings to the table.
In the evening we gathered at a local watering hole for a standing-room only viewing of the goings on just down the way. The crowd cheered and jeered on cue as if we were front row at the event itself. Much merriment was made, many optimistic views of the future were offered up for hope. The crowd broke up happy and inebriated on the drunken brew of hope. In the back of my mind the words of one of the afternoon's speakers rang through again. On the millions without insurance, children without coverage, elders without access to care, his voice called clear and true...

It is not only wrong, it is a sin, and it is a shame. Wrong, sin, and a shame. Wrong, sin, and a shame...

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals. Please excuse any technical difficulties...I'm writing from a pda from the stands of Invesco stadium - more to come!

Being Such an Elitist You Won’t be Satisfied Until Everyone is Elite. by Anthony McCarthy

One of the more irrational ideas that has become commonplace is that a passionate interest in what’s called classical music is a sign of snobbish elitism. Even when someone is advocating the wider encouragement of all classes of people to try classical music, the charge of “elitism” will follow. It’s a funny kind of elitism which insists on the right of all people to have access to high art. You’d think it would be obvious that it represents the exact opposite, radical populism.

Maybe its because there is, in fact, a snob audience for classical music who consider it their property, or at least their exclusive franchise. Anyone who has worked in classical music will have run into them. Some who aren’t musicians imagine that one of the greatest pleasures of being a musician, practicing, is the worst part of it. Actually, speaking for myself, it is the after concert reception that is the most brutal form of torture inflicted on musicians. The snobs who frequent and often are the reason for those events can be some of the most trying and obnoxious people in the world and you have to experience them at a time you are absolutely demolished by the experience of performance.

And there have been artistic snobs within classical music, though almost never have they represented the greatest figures of all, the great composers. Just about every really great composer was familiar with folk and popular music around them. They clearly listened to it and many of them explicitly incorporated it into their music. It’s always been that way, from Dufay to today. Jazz, even before it was jazz, absorbed the attention of composers from Brahms through Schoenberg. Stravinsky would never have composed the music he did if he hadn’t been aware of jazz and there are not many American composers who haven’t been thoroughly immersed in jazz. I’ve hardly ever met a good classical musician who didn’t have the highest respect for the great jazz composers and performers. Jazz composers have also composed very fine “classical” music.

And artists in other genres of music have certainly been interested in classical music, which has often stretched the limits of musical resources farther than their own idioms. Even many pop musicians, sometimes even the most banal of those, have enriched their music by borrowing or stealing from what classical composers have invented. The borrowing back and forth in what is called “country” music goes to the start and finds some of it’s clearest traces in the familiar suites of Bach and other baroque era composers and fiddle tune collections.

Just about to a person, the people I’ve known who have worked in classical music have been from the middle and upper middle class and just about every one has been on the populist side of the left. Some excellent classical musicians have had parents who worked in what would be considered menial jobs, a lot of them worked menial jobs themselves. The disadvantages of not starting out with good teachers due to lack of money is the real limiting factor for many people who would like to work in classical music. Unless people without money have parents interested in music and able to sacrifice and an unusual amount of drive, the disadvantages to them will be a roadblock to their achievement. But advocating that children be provided as good a basic musical education as possible will get you the “elitist” label faster than advocating the use of public money for a kitschy ornament for a little used venue. Isn’t it interesting that advocating tax breaks for the wealthy is unlikely to get someone called an elitist by the media.

You get the feeling that a lot of the pegging of classical music to elitism is done through the ignorance of people who don’t know the first thing about classical music, a lot of whom seem to be in charge of programming at public radio and TV stations. Since most of those I’ve met have been social climbers it’s possible that they deeply want to believe that “serious” classical music is beyond their audience’s attention span.

Or maybe they rely on those marketing surveys which should be banned by statute and charter for any public broadcasting medium. There was one I read about which seems to be responsible for the reduction of public broadcasting’s classical music programing into a manifestation of what Virgil Thomson called “the music appreciation racket”. The results are eternally repeated chestnuts and banal alternative offerings that are offensive because they achieve bathos through boring inoffensiveness. I’ve heard rumors that the disappearance of vocal and original instrument performances from some public radio stations are due to this kind of survey. When’s the last time you heard Bach that wasn’t played on a piano on your local radio station?

I once heard a program director who was outraged when someone said that the purpose of his station was to educate, something that is explicitly stated in their mission statement and, I’d guess, the excuse for the deductibility of donations to them. God help us if someone should learn something new from listing to public radio. Like just about all of what passes as contemporary culture, it’s practice is to confirm existing experiences and stereotypes, not to challenge or overturn them. But that will get me on the pathetic state of the “avant guard” again. “Posterior poseurs in pursuit of patronage”, would be more accurate. So you see that is a topic relevant to a discussion of American public broadcasting.

The descent of the news programming in public broadcasting into establishment babble has matched the destruction of its music programming. I don’t think it’s just a coincidence.

Maybe it’s because I was forced to go to so many of those after concert receptions. I’ve had my elbow rubbed by rich snobs, I’ve had my ear chewed by them. I’ve had to smile and answer them without having heard what they were saying. With few exceptions, I’d rather practice music with a rowdy bunch of public school students. You’re more likely to find someone who’s listening for the first time and having their imagination kindled. The experience I got as a teenager hearing, my first hearing Schoenberg’s Chamber Symphony, the clarinet after the introduction the non-stop compulsion to listen and pay attention to the very end, the amazing audacity and daring of it. The memory of that still raises my hair and makes me know life is worth the effort after more than four decades. It has dragged me out of low spots any number of times. That kind of experience is the birthright of every human being.

Fifteen days of blogging for health care reform: A Primer on the Obama Healthcare Platform

Guest post by Skylanda.

Tomorrow, in Denver, Barak Obama will take the stage to accept the nomination for the Democratic ticket for presidency. I will be there along with Americans from all over the nation, converging on a mile-high city that could not be more dead center of the country. Not a bad metaphor for Obama: a man who sometimes seems to walk so far above petty politics that even the swift-boaters haven’t had the juice to knee-cap him yet, and who seems to so thoroughly occupy middle-of-the-road America that the progressive left may be wondering - like I am - what exactly happened between his solemn promises of change and renewal.

So it might be a good time to take a moment to look at Obama’s health care platform through the lens of the issues and reforms I’ve brought up over the last two weeks. A thorough but sound-byte summary of the platform is available here, and if you really want to want knock yourself out cold, you can read the whole document in all its multi-page PDF glory here.

First, let’s examine the overarching, definitive issues.

Does he propose a single-payer system? No, frankly, he does not. But he cracks the door to some intriguing possibilities. His opening proposal is for a new national health plan available for all Americans to buy into (yeah, I know - if you could afford it, you’d have bought already). It includes clauses for subsidies to folks who cannot pay outright for this option, and promises affordable premiums, copays, and deductibles. Who would provide this insurance plan? Well, this is a little nebulous, but if you read the finer print, it appears that it would be administered via private insurers who contract to federal government. So: more access, still through individual contributions to private corporations. It has a certain ring to it - you get a certain sense that this might be a slow move toward a central, national system that could evolve into a single payer - and yet it lacks moxie. And it does nothing to address the question of why federal money should be going to private insurers in the first place.

Does he use the magic p-word? “Portability” makes a prominent (double-size header font!) appearance in the language of the Obama platform. Specifically mentioned is the problem of moving job to job, and the proposed answer is that through this new national health plan, you could keep your insurance through those transitions. Not mentioned are any other moments of salient relevance to portability: moving states, turning eighteen, getting divorced, suddenly making enough money to get booted off the Medicaid rolls, or, saying, losing a job altogether. I like that the word has entered the common vocabulary on a national platform; I’m not terribly pleased that the Obama platform would be satisfied with a “portability” that applies to only a fraction of cases in which it is required. A publicly funded system without full portability will incur all the taxpayer cost of a subsidized system without the streamlining benefit of single-payer sourcing - and I fear that this will end up costing more over the long haul than its own benefits are worth.

Does his platform include a provision for free small business from the yoke of paying for employee health insurance? Yes and no. Tax breaks are proposed for those that kick in for their employees health coverage, and small businesses would be exempt from a proposed requirement to tax commercial enterprises that do not offer employee health care. This is a move in a good direction, but it radically fails the fundamental task at hand: firmly and permanently extricating health benefits from employment.

Does he emphasize patient safety as a means of increasing patient confidence and reducing malpractice suits? Yes, and he proposes a steep investment into electronic medical records (though as a separate, not adjunctive, issue to the question of patient safety).

Does he acknowledge the role of prevention and public health? Yes: “Too little is spent on prevention and public health.” Good enough for me.

And then there’s some interesting details…

Investment into “Comparative effectiveness research.” You can read the detail on your own, but the content of what is proposed here already exists in several form - the most well-respected of which is the Cochrane collaboration. If the Obama camp failed to notice its existence (or thinks it can outdo Cochrane), it has another think coming.

“Millions of Americans are uninsured or underinsured because of rising medical costs.” I suppose one does not need a macro-economics lecture wrapped up in campaign promotional material, but statements like this belie a naïvete about the root causes of lack of access - things like a private insurance industry which relies on stock market investment and high interest rates for profitability and raises premiums when those do not come through; a growing disparity between rich and poor; monopolistic practices and obscuring of cost which disallow free choice (that whole “free market“ thing that we love so much in this country) in choosing providers and products; and a whole host of other complications.

Requiring that “providers that participate in the [federally supported plans] utilize proven disease management programs.” Though this sounds like a good, solid prop for evidence-based medicine, the wording raises some hairs on the back of my neck. Proven protocols exist for common and quotidian diseases like diabetes, high blood pressure, and cholesterol. Treatment algorithms are far less established for diseases like cancer (especially the rarer types). Some diseases simply require far more flexibility, ingenuity, and nuance - not a federal mandate that straitjackets them into narrow protocols with compliance enforced by the threat of yanking reimbursement.

And then there’s a few red flags…

Demanding “mandatory coverage of children” without explaining how he plans to enforce that mandate. The paragraph following this edict notes an emphasis on expanding S-CHIP and Medicaid (which both disproportionately cover children) as “critical safety net(s),” but fails to make anything other than a threatening overtures in answering the question of how to mandate insurance for a majority children. What plans do they have for the uninsured child - turn the case over to CYFD, throw the parents in jail for lack of compliance? It is not clear what “mandatory” means in this context. Aaah, the great unfunded mandate: the same no child that was left behind under the Bush education plan would be left behind once again with the Obama health care plan.

Promising comprehensive benefits by citing “maternity health” as one of the covered aspects of the proposed national health care plan. Why not just go and call it what most providers call this sort of stuff: reproductive health. Ah yes, because that might imply that we are going to cover birth control and abortion - two words which make absolutely no appearance on the Obama platform‘s exhaustive leading page. *sigh*

In summary, the Obama platform on health care reform is ambitious and far-reaching, but still far from aligned with the vast majority of points made here over the last couple of weeks. Will I vote for him? Yeah, I will. He’s our man, whether we want him or not, and his vision for health care reform at least leans in a tenable direction. This platform is a starting gate, a flawed and imperfect one, but a place we can work from nonetheless.

As for McCain - because you might be wondering - you can sum up his proposed health care policy in four words, and so I will:

More. of. the. same.

On to Denver…

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Beauty contest for nuns (by Suzie)

       I hope to publish a calendar called "Priests: Straight From the Heart," with photos of priests looking as heterosexual as possible. I want to counter the stereotype that they're all gay. I won't dictate what they wear; I just want ones who look like models. 

      I got my inspiration from an Italian priest who is organizing a beauty pageant for nuns to prove they aren't all old and ugly. 

      Update: The priest has scrapped his plans. 

Fifteen days of blogging for health care reform: Paying the piper

Guest post by Skylanda.

Today, you’re going to hear something new and different. Today you are going to hear this bleeding heart, tree-hugging, west-coast, San Francisco-born, ivory-tower progressive make a neo-conservative argument. Free market, pay-your-own way, private enterprising, classical neo-liberalism. Hold on to your wallets, we’re going for a ride.

This argument concerns the question that underlies everyone’s hesitation with heath care, no matter what your political orientation: how are we going to pay for it. Covering every child, woman, and man in America is an expensive proposition, and paying for it is the key stumbling block between dreamy idealism and real movement forward toward universal health coverage.

Anyone who wants to answer this question - from the most laissez-faire neo-liberal to the farthest left socialist - needs to understand one thing, and one thing alone: we already are paying for it. No health care economist disputes this one common understanding: Americans pay more - per capita and as a percentage of our gross national product - for health care services than any other industrialized nation. And for that sacrifice, we cover less of our people, we live with the gripping national fear of health care insecurity, we measure out at some piss-poor rankings on standard outcomes measures like infant mortality and childhood nutrition. We pay more money for the great privilege of getting less health.

In other words, Americans are getting the rawest health deal on the block.

That is the bad news. But that bad news is also the seedling that sprouts the sapling of good news on the horizon. The good news is that if dozens of nations with similar wealth profiles to ours are able to squeeze better outcomes out of lesser health investments, that means that there is slack in the system, that we have already dedicated the resources and the means to the accomplish the task, and that providing America with a first-class health care system is merely a means of rearranging that system to fit the circumstance at hand. Simple, yes?

God, however, is in the details, as they say. So here are some of the nuance it behooves us to understand in tackling the dizzying problem of paying for universal health care.

Rationing. If you’re my age, the word might bring to mind propaganda shots of little old Russian ladies standing in line to buy bread just before the fall of the Iron Curtain, with a Reaganesque voiceover decrying the evils of Communism. A little older and you might remember the oil crisis and the self-rationing feat of standing in line for hours to pay for gas. If you’re my parents age, you might remember stamps that gave you the right to buy tires and butter and other household products that were scarce during the war.

Rationing is the hobgoblin under the bed, the Commie in the closet, that is yanked out to be puppetted around every time the prospect of a national health care plan arises. Do you know how long it takes to get an MRI scan in Canada?! - it threatens (and actually, I have no idea at all how long it takes to get an MRI in Canada; I suspect it depends on the same variables that drive wait times here: distance from nearest tertiary care center, relative wealth of the region, staffing issues, and the like). Because in America we use rationing as a strawman to promote the glories of capitalism over the evils of…well, just about everything else, we tend to be blind to the fact that there are actually two forms of rationing - one of which terrifies us to our very core (Commie plot that it is, of course), and one of which we live with so commonly that we fail to notice its sinister existence, the way we forget to notice the sky is blue after too many sunny days.

The first form of rationing - the one that invokes such terror - is rationing by wait time. These are the communist breadlines of old Russia, the gas lines of the 1970s, the apocryphal wait times to get that MRI scan in Canada (it also explains the way you have to put your name on the list now if you want to get a private permit to run the Grand Canyon by river raft some ten to fifteen years into the future - even in the good ol’ USofA, rationing by time has its well-worn time and place). If you stand there long enough, you’ll get your goods. The goods aren’t even necessarily any more expensive for your troubles; you just have to wait for them.

The other means of rationing is by cost - that is, you just raise the price until the right number of buyers drops out, and there you have your trade. This is the absolute fundament of free-market capitalism; a certain quantity of goods is out there, a certain demand is placed on that supply, and the winners are those whose cash and values come into best alignment with the available quantity of desired stuff. This is also what you see modeled in simple Cartesian form in every freshman econ class, with the supply on one axis, the demand on the other axis, and economic efficiency at that magical price where the two meet in the middle (I never saw rationing by time modeled on a two-axis graph - I suppose it‘s possible, but not so much the subject of talk in countries where the free market is the order of the day). This functions well for goods like luxury cars, designer jeans, concert tickets hawked on the day of the show, and artwork; it falters clumsily in the face of health care products which are not optional, and have great social consequence if they are not distributed with some efficiency of manner.

In America, we ration by cost so frequently and so thoroughly that we do not consider it rationing and we get very huffy when anyone implies that it might not be the best means out there to distribute goods like health care. And if we do complain - about, say, the cost of health care - it is not looked on as a reaction to rationing; it is looked on as the free market in action (which it is; it is also a formalized and highly regulated form of distributing limited supplies of goods…that is, rationing). Conversely, we recoil at the very thought of rationing by time, even though rationing by time may actually get services sooner for a large number of people than rationing by cost, because so many people can simply never mount the resources pay for something like an MRI.

The question of rationing by time versus cost is heavily reliant on regional values, and it speaks to the soul of America whether we would rather to continue rationing by cost - which allows quick access for the ever-shrinking numbers of those who can pony up cash (or bill their insurer) - or whether we might start to thinking about rationing by wait time, which equalizes the playing field across a wider socio-economic spectrum. The fact that those making policy usually have insurance (and the quick access it entitles) throws a wrench in any attempt to change this status quo (though insured individuals should remember that this is not a permanent status, rather an ephemeral notion of security that could evaporate tomorrow). Rationing by time does not necessarily mean that every cancer patient is going to wait eight months to see a specialist; a good health care rationing system uses effective triage to work in emergent cases first, then urgent, then routine, with preventive services tracked along a different route. These sorts of systems take planning and rational forethought (as well as continuous adjustment to feedback) to work effectively, but consider the alternative that we have now: a haphazard system where your entry into specialty care is wholly predicated on where you live, what emergency room your ambulance screamed into the night you first got sick, what providers happen to accept what insurance, who your primary doctor happens to know that she or he can pull strings with when time gets alarmingly short, and the like. Rationing by time provides a means to more efficiently utilize services that are today placed without overall regional planning for needs, often with a waste of investment inherent in that sort of decentralized system.

Which brings me to the second point that is vital to understand in the financing of health care:

The inevitability of decreasing returns on investment. Health care is like chocolate cake. The first bite of that cake is good, even fabulous. It satisfies that place in the belly that only chocolate cake can satisfy, it fires off a few dopamine receptors, and for a moment, life ain‘t so bad. The second bite? Also very good, but not quite as fulfilling as the first. By the fourth or fifth bite you’re getting kind of bored, and by the end of the plate, you wish you had stopped a few bites back.

Such is the investment in things like health care (and other public goods like education). If you had been uninsured and get, say, a sudden windfall of $2,000, the first thing you might do is spend a chunk of that money catching up on the pressing health issues that have been bothering you. A hundred fifty bucks to go to the dentist to take care of an aching tooth - money well spent, like that first bite of cake. After that you focus a little more on that gnawing feeling you get in your stomach after you eat, so you go to the doctor, who tells you it’s just severe heartburn and gives you a prescription. You feel better - not quite as much better as when you knocked that first burning priority off your list, but still, better. Next you’re wondering if that ugly twisted toenail could be fixed; it doesn’t really bother you, it’s just unsightly, and it turns out that it costs lots of time and money to fix something like that. You decide to forgo it, because you’ve already blown about five hundred bucks, and you want to spend the rest on a vacation you’ve been putting off, a contribution to your retirement account, and a new bike to replace the one that is breaking down in your garage. The toenail is the middle of that cake, the part you’re still enjoying but not really getting too much out of anymore. On the other hand, you might take that money and hit up a cosmetic dermatologist, who gives you an expensive cream to remedy that embarrassing adult acne and talks you into lasering the hair off your legs (or chest, or back…let’s not discriminate against the boys here) for $350 a shot. It sounds like a good idea at the time, but once the bill comes, you realize that not only is your entire $2000 gone, you now owe another $200 on top of that, and that‘s the end of your vacation and your retirement contribution and your new bike. This is that last bite of cake, the one you kind of wish you’d never eaten.

This model can be extrapolated to nation-wide health expenditure. There are pressing matters that can give great relief if funded: vaccines for children, primary care access, care for life-threatening illnesses, those kinds of things. Then there are secondary matters that are best addressed once those primary matters are covered - advanced care for professional sports injuries, cosmetic issues like acne and braces, etc. The primary issues tend to be (though are not always) mass, cheap interventions; after that, things usually become more costly and individualized. But if you go far enough on down the line, you can continue paying more and more money for incrementally smaller outcomes (let’s call those outcomes “health”) until you are paying so much cash for so little gain in health that it is questionable whether that is still something you want to spend your hard-earned dough on - or, more accurately, what we as a nation want to spend our hard-earned dough on. Not because health isn’t important, but because there are other important things too - roads, schools, social security, clean air and water, national defense - and the national budget (or GDP, or whatever your source of cash) is always going to be a limited resource.

For that reason, it is not necessary nor desirable to purchase an unlimited amount of health, nor does it make sense to spend unlimited funds on health care. It behooves us to plan what portion of our collective wealth we want to spend on this thing called “health” - or what sort of health we want to achieve given the limits of our wealth - and then to determine the most efficient way to reaching that end. Setting open-ended financial boundaries, on the other hand, does not make for sound planning and is not a sustainable means of establishing universal health care.

The year that I moved to Oregon, citizens of the state voted on a ballot measure to provide universal health care for every person within the state borders. It was a lovely thought - it would have paid for everything, for everybody. It set no limits on what would be covered, when, or for whom. It included things like aromatherapy as a covered medical service, despite the dubious benefit of that particular modality for any other purpose than making your nose happy. It was voted down by a resounding margin, something like 70-30 on the nay side. This was a wise move on the part of the voters. The measure included no cost estimates, but pundits and analysts on both sides noted that this kind of coverage for that number of people would exceed the entire state budget every year; no new funding source had been built into the proposed program. Had it passed, it would have failed with the thud of a thousand lead bricks hitting the ground, and it would have been hailed by opponents nationwide as a failure of universal coverage - a nail in the coffin of single-payer health care. For that reason, I can look back and say that I am very glad that, in this case, single-payer coverage did not pass muster.

Which brings me to the third point that I advocate everyone understand about health care financing:

Understanding that good business sense and the profit-making motive are two different things. That there is a very big difference between divorcing the profit motive from the health care industry, and removing good financial sense from the health care industry. Under no circumstances can I advocate the breezy, never-can-care idea that medicine should not be about money. Medicine is about money. Everything is about money. The last time that medical providers acted like they could work without a thought to the financial consequences of their actions, we ended up with a system of capitated HMOs...please, please let us not do that again.

On the other hand, prying our health care system back from profit-making ventures is not going to be an easy maneuver. The health insurance industry is a large and powerful lobbying force, one that gets its digs in every time a state or region starts tinkering around with the idea of single-payer coverage. And whereas pharmaceutical outfits have at least some mutual role in which profit motive operates toward the benefit of people who eventually receive their drugs, I am not sure I can come up with a solid social good provided by for-profit insurers that could not be equally provided by a well-funded single-payer system (aside from providing employment for a literal legion of administrators and bureaucrats along the way).

This is not to say that the free market has no place in health care - on the contrary, single-payer coverage may actually open up choice for consumers by unshackling the lock-down on preferred providers, formularies bargained for convenience instead of efficacy or cost-effectiveness, and regional limits that insurers tend to have over their patients. Moreover, ancillary services (such as imaging centers, laboratories, even clinics themselves) can still operate in the free market under single-payer coverage by providing competitive advantages over each other to attract business in the same manner they do currently. This is one of the main reasons I support single-payer sourcing but not an entire system of government-employed providers: by hybridizing socialism and capitalism, you can squeeze the best out of both without losing the aspects that makes each of them attractive.

So in the context of these three principles (rationing, decreasing returns per increased investment, and good financial planning with or without the profit motive), where is the American health care system now? One, we ration by cost, not by time, for almost every service…though some regions are so strapped for specialty care that we ration by both cost and time - a particularly potent recipe for disaster. Two, we are hugely overspending on health care and yet not even getting that first delicious, satisfying bite of cake out to the entire population. And three, we consistently emphasize profit over any kind of good business sense at all.

Pulling these three forces into alignment is - in this one opinion - key to founding a sustainable, affordable version of universal coverage that Americans can live with and thrive on. And here is the sinking realization that should haunt every American when it comes to health care: we already pay too much for too little. We are getting the rawest end of the deal in the developed world. We now have a choice: we can continue to bury our heads in a very expensive sort of sand and believe that a fractured system with ever-increasing premiums is working to our advantage, or we can start to wonder what would happen if we took all that cash - that enormous chunk of the GDP now wrapped up in health care - set it all into one collective system, redistributed without the skimming of profit or the redundancy of hundreds of parallel systems, and set about planning a rational health system for the next fifty years. Could we do it? It would be one of the toughest, most contentious enterprises America could take on…just a hair less tough and contentious than our current health care system, I would wager.

But, you say, would I have to pay higher taxes?

Well, that’s a good question. I submit that if you are paying insurance premiums in America today, you are subjecting yourself to one of the most ludicrously progressive tax schemes on the planet. You may consider yourself middle class (or otherwise), but the public good known as the nation’s health is resting on your shoulders - not only are you contributing directly to the private pooled premium fund, you are also paying federal taxes to support others on the Medicare-Medicaid axis and a variety of other programs. And if you are not paying health insurance premiums, it’s time to buck up and do your share - in the proportion to which you are able, so that you may draw resources that you require. There is only one way to accomplish this: taxes.

If you worry that only the wealthy, the documented, or the honest will pay their fair share? Well then heck, make it a sales tax - no one walks the American soil without buying something. If you want to ensure that every person stepping foot on American earth deserves their fair share of the health care pie because they contributed their piece, sales tax is probably the most thorough (though probably not the most equitable) way to do it.

And if we paid for single-payer health care out of an increased tax, what would that buy you to make it worth your trouble? You could do away with your health care premiums. Stop wondering if Blue Cross is going to double your deductible this year just for the heck of it, or triple your premium because you just found out that persistent nagging cough is severe asthma, or deny your coverage because you had that condition before your employer switched plans last month. You would buy portability, security, and predictability - ratcheting the stochastic impact of health care costs out of your emergency budget. And if you get what you expect out of a single-payer system, you actually have a voting say in who stays in office to guide the system - unlike your coverage today, where you only have a voice in Blue Cross’ policies if you are a major stockholder. And remember, head for head, every other developed nation in the world - by controlling the profit motive and the redundancy issue - has managed to pull off some form of access that covers more of the population for less cost than we have. We are already paying the piper; now is the time we demand that the piper hand over the goods.

And how do we go about demanding those goods, forcing a system wracked by inertia to start a free-wheeled move in the direction of universal coverage? First there is the regional approach - county by county, city by city, state by state. State-wide universal coverage has been tried to varying degrees of success in a number of territories; New Mexico is among those currently wrestling (thus far unsuccessfully) with how to cover its total (albeit rather small) population within the bounds of a notoriously cash-strapped budget. On a smaller scale, cities like San Francisco and Albuquerque have made grand efforts to carve out havens of access within their boundaries. The pitfall of this approach is obvious: it creates a system more finely fractured than Yugoslavia after the fall of the Iron Curtain. You move ten miles down the road and lose your insurance.

A second tactic is to attempt grand sweeping reform at the national level. This might result in the best outcomes should it succeed, but please remember this was recently tried at the highest levels of power - during the Clinton years - and the plan was killed by political manhandling before it even got a chance to stretch its wings.

Another strategy - this one sneakier and designed to make an end-run around such organized resistance - is to simply pick the most successful federal program and quietly fund and expand its scope until it covers a larger and larger portion of the population. What the free-marketeers fail to mention so often is that we are have an enormous sector of America already on federally funded health insurance. Start adding up the numbers from these programs, and go from there: Medicare. Medicaid (alongside its state-by-state contribution). The VA system. The Indian Health Service. S-CHIP. (If you add every county and local coverage scheme across the nation, you might start to guess that we already have a heavily socialized, but very poorly planned, medical system - but that‘s a digression for another time.) Medicaid is fractured by state, the IHS is limited to tribal members only, and S-CHIP is for childhood coverage. But then there’s Medicare - a nationwide, full-spectrum insurer that (so long as its budget stays on an even keel) doesn’t do such a bad job of funding care for a large number of Americans, albeit usually of a particular age group. If one could slowly expand its population coverage (maybe even combine it with the contribution of the VA’s remarkable system of health care informatics), it is possible to build a system of universal coverage without ever having to do national battle on the gladiatorial field of the congressional floor. The infrastructure is already in place, the bureaucracy already pushing those papers; all we need is the will and the cash.

And now to bring it all back around to the place where I started, the neoliberal argument for universal health care. So far, this probably sounds pretty far to the opposite side - all kinds of people-taking-care-of-people, feel-good socialist talk. And it is. But flip it over for a second and take a look at what the burden of the providing insurance does to the free market in America:

Providing private health care benefits to employees saddles businesses - especially small businesses - with a burden so unpredictable, expensive, and bureaucratically top-heavy that it severely impinges the ability of the free market to operate in America today. The current health coverage system does its part to kill the entrepreneurial spirit as people feel locked into secure jobs purely for the health benefits. It imposes a legitimate but ultimately defeat-ist fear of going out and taking the risks needed to start a business, become self-employed, go out on one’s own - all those things that go along with free-style invention and innovation. It restricts the market for labor as people become geographically bounded by their need to maintain a particular insurance policy due to a pre-existing condition, or because one state has more sympathetic laws regarding repossession of personal property in medical bankruptcies (ironically, Texas - a bastion of neo-liberalism - has been repeated cited as a state with laws friendly toward individuals in crisis from the hit of medical bills on their finances…go figure), or because they are afraid to temporarily lose Medicaid coverage for a serious illness in the interim. I defy you to find another force in America that so deeply impinges in the entrepreneurial spirit for so little gain in social good.

It is a strange sort of backwardness in America that we are defiantly against government-sponsored socialism (at least on the surface: I‘d like a show of hands of how many neo-cons are on the Medicare or VA rolls), but we are quite happy to saddle commerce - especially small businesses - with what largely amounts to a social good obligation. I believe the reverse should be true. I believe that the free market should be unburdened of the heavy load of providing health benefits, and that once so unburdened, we may see a re-flowering of what Adam Smith envisioned when we first spoke of the capitalism and the invisible hand a couple centuries ago: a multitude of players, easy entry and exit from the market (a key component of “perfect competition”), a society of self-motivated self-sustaining players who can equally sell their labor to others or work it for themselves, as they so choose. That is capitalism, old-style, old-school, the way the game was meant to be played.

Single payer health care. Socialized medicine. It’s the new capitalism.

Moreover, health care security on the individual level is about that most American value of all: personal freedom. It is about the ability to choose a job that fits your interests and your skills, not your medical needs. It is about being able to quit that job and not worry that you‘re also quitting your best shot at health. It’s about being able to work hard and get that raise without worrying that it will be the straw that breaks the Medicaid threshold without offering any new benefits in return. It is about being able to divorce your spouse and not worry that you are also divorcing your right to be seen by a doctor for your health problems. It is about being able to cross state lines for a better job without leaving your benefits behind. It is about sleeping well at night knowing that a mis-step in front of a bus or a few cancer cells growing in your bones will not mean the capping out of your meager private benefits, repossession of your house, or the long road to permanent poverty.

Universal coverage is about security. It’s about freedom. It’s about time.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.