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On Healthcare... The Silence of the Blogs

One other observation about the healthcare reform moment we're in: yesterday's developments, which played out fairly fast and furious (by the time I finished my post, it was clear the Medicaid piece of expansion to 150% was actually DOA), reminded me of another problem we have, that there's precious little good blogging going on around healthcare, reform, and understanding more fully what is and isn't happening.

I've worked this observation from the reverse angle of saying we don't have a good, informative conversation about healthcare in this country... but it's important to understand why that is, and why it's hard to undo. I think a couple of things are in play: one is that, for a number of reasons, healthcare professionals, especially doctors but really a wide swath of the professions, are not online in quite the way others are (like writers, lawyers, educators, etc). This is part of the big hurdle to computerizing and standardizing medical records, in that even now, most doctors use paper for medical notes, and train their support personnel in similar methods. Ever notice that your doc's office has a huge collection of paper files? Ever notice that it's growing and not shrinking? That's the medical records problem... and it's enormous.

And it's indicative of how little daily interaction medical professionals have online; it's just not folded into the daily rhythm of many offices, care centers, or hospitals. Sure, there are exceptions... but many of them underscore that same divide: the medical professionals who do blog tend to be outside of practice (docs who write columns, do TV reporting, write books, and such). Some are working in nonprofits and other groups and are, indeed, working on reforms... but the point is, those people are outside of the practicing mainstream, and their views reflect, often, a narrow subset of the full professional insight on reform and its impact on actual care.

Feeding that narrow range of views is the fact, as I've pointed out before, that much of the energy around reform and thinking ceatively about changing healthcare is happening among liberlas and progressives. There is little activity on health reform on the right - a symptom and an illustration of the conservative malaise right now that there is so little interest in such a key issue - and the lack of knowledgeable opposing views hinders broad, thoughtful debate. Too often, you get panels and discussions among people who all agree, who share very similar backgrounds, exposure to similar data and ideas, and who see solutions in much the same way. It's hard, for many people in the think of things, to understand that there's things that they're missing, important, valuable things that might challenge worldviews and easy conclusions.

And finally, as healthcare reform has moved to the center of political discussions and gained media attention, what's become clear is how many people either don't understand or are only recently getting up to speed on the healthcare systems in this country, and tend to repeat the word of others when caught uninformed, or less than fully aware. I have little or no use for bloggers - many prominent ones - who blog about healthcare by repeating snips of coverage, usually from Ezra Klein and/or Jon Cohn. Both men are doing good (though not great) work covering the day-to-day twists and turns in Congress... but both have limitations and biases that tend to get lost in repetition. And few bloggers are doing, or seem to want to do, the hard work of questing further for more information, or looking deeper at prevailing views to ask if they make sense, or are supported by all the data. Hence, the need for a public option - which should have been a small piece of a number of other, much more significant changes to insurance - became by repetition and general agreement and lack of investigation... a be-all, end-all political chip that distorted the whole debate.

In the end, all of this reminds me that I ought to do more to write about these things, because I do have information to share, insights to challenge the status quo, and the ability to write persuasively. And I don;'t mean to leave anyone high and dry when it comes to looking for other, alternative places for insight. Myself, I'f recommend these in relative order of insight, usefulness and alternative ideas:

• The Healthcare blog - where you will find medical professionals with a variety of experiences sharing a broad range of ideas
• Karen Tumulty - who's been doing some of the best straight reporting I've seen that is both thorough and informative
• Talk Left - where Big Tent Democrat doesn't buy into all the hype of the progressives
• The Daily Dose at Washington Post - the Wa Po's more through (and more thoroughly reported) blog on healthcare, which makes you wonder why they need Ezra separately.
• Firedoglake - not my favorite site, but Jane Hamsher and company are very up to speed on both the politics and a number of the larger issues
• The Prescriptions blog at the New York Times, which occasionally breaks new news, and can be very insightful (but can also be very much the voice of The Establishment, as the Times likes to do)
• The healthcare blog at Change.org - a little likely to rehash the same Ezra Klein/Jon Cohn boilerplate, but with lively discussion threads. For that matter, if you do read Ezra, I highly recommend following his comment threads; a number of his commenters are very good for pointing out the weaknesses in his arguments, theories and political stances.

As I find more, I'll pass them along. I'm always on the lookout, and I appreciate any others you can share.

Still, the lack of anything but repetition of the same ideas, the same political thinking, and the same laundry list of expectations is tiring. As long as healthcare reform is a narrow conversation, among (fairly) informed people with similar poltical and worldviews who reach the same if not similar conclusions... we're not likely to have the good, healthy discussion we need... the one which, I think, would have made the current bill in Congress either a dead issue, or a significantly different, better piece of legislation than it is shaping up to be. The prmoise of blogs is that they offer the potential to challenge the status quo and offer fresh ideas; the challenge is that to do that requires the different thinking, different voices and fresh ideas of outsiders. And we don't have that... instead we have silence. And repetition.

Getting Down To The Real Public Options

While I've been following the health care "reform" developments in Congress closely, I've written little about it, because I don't think there's much to say, and much of what there is to argue about... is air. Even the "official House version" that passed didn't settle the question, because the Senate's version looked basically nothing like it. To the extent I've tried to weigh in, I've tried to stick to more concrete issues, like the horrifying Stupak Amendment.

And still doesn't. As the Senate lurches along, debating and attempting to pull together a 60 vote winning compromise position, the actual shape of the reforms - if one can call them reforms - continues to shift.

I've been dismayed, most, by the fetsh of the "public option" which progressive and liberal activists glommed onto as the proposal began to take shape, and which has become the "make or break" inclusion item for some lefty support. The shrill, one note approach taken by a number of groups and individuals to this is indicative of how partcipation in the health care debate does not, necessarily, indicate a great depth of understanding or reflect a real commitment to some seriously progressive needs; instead it tends to show how the instinct to score a political win can overshadow the need for good policy, or trump common sense and concern for more than the hot buzzword of the moment.

Even if I was keen on a public option - and, frankly, I think in the context of the ideas under discussion it's a "nice to have" that shouldn't be the most crucial element - I think one has to admit that, as much of the bill has, the idea of a public option health plan has been distorted beyond any useful purpose. The option of offering a government run health plan to individuals who might not otherwise find insurance has always been needed to secure full insurance. But making sure every single, solitary person has health insurance may, itself, be an unnecessary, or unwise goal. Getting to 96% or so insured in this country would, generally, solve a number of problems. Especially if we focused more thoroughly on that 96% getting good coverage that provided access to necessary, quality care.

But more fundamentally, one reason I've been puzzled by the "public option fetish" is because we already have "public options" - namely the government run plans of Medicare, Medicaid and the Veterans Administration. And more than anything, those who claim an overarching need for a fourth "public option" tend to show a fairly basic lack of familiarity with what we already have... again, which is why I think we should have done more, and still need to do more, to create an informed general public that can really understand what reform is about. And what it's not.

The Soft Bigotry Of... Well, Soft Bigotry.

It's a rough end of year for The Gays.

When election day passed and we faced another loss on gay marriage, this one an especially cruel result in Maine, I debated what to say. And while I waited ("dithered" now belongs to Obama, apparently), there started a harangue from the right about intolerant gay activists.

And still I struggled. But this week, the icing arrived when the New York state Senate voted down a marriage equality bill that had already passed the Assembly.

When Prop 8 failed, I was one who noted the failure of gay marriage to find support in the black community; I take that back: the problem, apparently is finding enough of anyone - at least anyone's who not gay or one of our friends.

The failure of gay marriage in Maine and New York has many angles, but all come down to proving why "I'm not intolerant" types like Rod Dreher and Jeff Jacoby - who both accused gay advocates of negativity and namecalling - have it backwards. Those who accuse the gay marriage opponents of intolerance and bigotry have it right... the challenge is making such bigotry both socially less acceptable and to make clearer why that is. Until then... treating gay people badly... well, that's just what happens. And it's hard not to be angry about it.

The Case Against Bernanke

As I move - finally - to shake off the current doldrums, I've been tooling around the blogosphere, checking out the latest political thoughts (generally... not much new or especially enlightening). One that did catch my eye was over at My DD (still the "organized left" progressive political blog I prefer to Open Left or Daily Kos), where they posted Jim Bunning's harsh assessment of Ben Bernanke. If you want a concise, effective laying out of both the economic crisis and a case against Bernanke, this is it:

I have been kind of lukewarm on Bernanke's reappointment; like many Obama decisions, it doesn't seem to match his rep as especially bold in his thinking. Reappointing Bernanke is safe, establishment... and questionable on many levels. Bunning may not be right on everything... but his counterweight to prevailing economic talk is bracing, and welcome. Someone needs to say it.

When Your Academic Exercise Leaves You With Military Buildup

It was a nice speech.

And yes, we should be willing to admit that, even now, it's nice to have a President who gives thoughtful, coherent speeches that actually explain things, and even use impressive rhetorical devices.

The problem has not been, and will not be, the speeches.

The problem, illustrated again tonight in the speech and in the aftermath, has to do with matching rhetoric to action, ideas to process, higher purpose to practical realities. The problem of what to do in Afghanistan isn't about an idea; it's about a set of complicated, practical challenges. And what was proposed tonight - again, a plan, not the actual actions - is not sounding like enough of anything to get us, or Afghanistan, where we need to be.

The contradictions, really, leapt out out of the speech itself - after admitting that Afghans have a government elected under fraudulent circumstance, President Obama called them partners who would have to deliver on progress. That's nice... but they can't even seem to conduct a legitimate election. Their government does nothing about an economy reliant on growing and selling hashish and opium and heroin. This is sure to be a problem. Oh wait... it already is.

Then there was the attempt to overcome objections - which amounted to "because I said so" defenses not much better than the sort of thing other leaders on the defensive come up with. It's not Vietnam... cause it's not. People complain that it's expensive... and it is, but at least we're going to be honest about it. The candor is refreshing; the explanations, still, are wanting.

Choosing and Choices and The Choice We're Stuck With

Of all the problematic aspects of the healthcare bill still (still!) not fully decided in Congress, none I think is as far reaching as the Stupak Amendment on coverage of abortion. And as much as it is revealing the complexities of applying the idea of "no federal funding of abortions" to health insurance, I think the bigger problem it's revealed is a deeper, more systemic question: is the left really as unified on abortion as we've been arguing for years?

One of the more popular lines people have been using in the new millenium is that abortion is "settled" - there's a left-right divide, easily labeled "pro-life and "pro-choice", never the twain shall meet, and almost all of the rest of anyone's politics can be determined by the simple test of picking a side on abortion.

It was never that simple, and it never quite will be... but I think up until about 2006, it was easy to mask internal tensions on the left while the Republicans were self destructing.

Blame it on the first President Bush and his "big tent" philosophizing, but for whatever reason, the drama around abortion for the past 15 years or so had been on the right. As much as religious conservatives were clearly anti-abortion absolutists and just as clearly had the power to dictate policy, the far right didn't have a lot to show for control of the Republican aganeda on abortion. For all the talk about "sanctity of life", the anti-abortion agenda of repealing Roe v. Wade, passing some sort of Human Life Amendment banning abortion, or even extensively altering laws at the state level never quite developed into much in the way of success. And many, myself included, would conclude that the problem, simply, was that anti-abortion forces were a vocal, but not powerful minority.

It's a real indication of the failure of Republicans in the northeast that "Country Club" Republican types - especially women - were never particularly interested in having government intrusion back into women's lives by excessively restricting or limiting abortions. Or, more pointedly, starting with abortions... and moving on to banning access to birth control. And the minute the Southern, religious conservatives made anti-abortion and other social issues central to whether or not you were a real Republican or a RINO... the exodus of northeastern Republicans began.

A big part of the Republican crack-up - the part that's keeping them from really figuring out how to reassert themselves into the majority - is just what the abortion tensions signify, a whittling down of the right to a smaller, more conservative core group much more homogenous in belief and approach to issues. "Prolife" is one of the easiest unifying points of the current Republican/conservative narrowing, pretty much a given among one and all, and virtually no candidate - even perceived "moderates" - can really voice any kind of support for women's reproductive freedom. That's one reason Stupak was so obviously going to pass - Republicans had no way to oppose it. And you can have unity around an unpopular doctrine... but you can't do it and be in the majority.

All of this means that, with Democrats in the majority, the question of who's got deep internal tensions on abortion suddenly switched, and in ways I think many people were unprepared to face. Yet the indications were always there - in the conservative and "Blue Dog" candidates being chosen, in the soft pedaling of "abortion rights" to rehtoric about "pro-choice" and "safe, legal and rare."  Liberals have operated under an illusion that we all supported women's reproductive rights... but never really determined just what everyone thought those rights should be.

One of the most problematic aspects of the "abortion debate" - a debate, as with other controversial topics, we talk more about having than ever actually have - is that much of the terms of debate are mush.  Neither "prochoice" nor "prolife" ever really meant anything, and both, really, served as fig leaf descriptions meant to protect people from the extremes of either side. You may not like abortions... but you'll support "choice."  You may not like clinic protesters... but surely, you support "life."

For years, feminists who believe in abortion - me included - have accepted that "choice" rhetoric was a necessary, if occasionally unhappy, compromise; you learned to live with the "I don't like the idea of abortions, myself, but I think a woman should be able to choose..." type logic even though, deep down, it meant that, at times, you couldn't count on that kind of support to keep abortion available. It's why we have the Hyde Amendment - you can be in favor of choice and believe, wholeheartedly, that it's just not "federal funding" of abortion... as opposed to keeping abortion services essentially unavailable to poor women on Medicaid.

I've argued - and still argue - privately that the real failure of progressive feminists is to stick to our terms: abortion is a medical procedure, and what we don't want, really, is government making decisions about which medical procedures we like and don't.  I want for women what I want for anyone - the right to determine, with a medical professional, the right care for a given situation. Sometimes, that choice is an abortion. And it's not about deciding what's a good abortion or a bad one, who's a woman who's suffering and who's a tramp. It's a medical procedure. And too often, the "choice" argument comes down to feelings over basic, medical facts.

We on the left have no one to blame but ourselves for where things stand, in the Democratic Party, with the Stupak Amendment still (still!) potentially standing as a possible element of healthcare reform. We have for years, blithely ignored that abortion is, for the left, hardly a settled issue, that women's reproductive rights are by no means solidly settled among liberals, and that the reason Stupak passed isn't about the hardline right, but about an inability on the left to use precise terms and come to internal agreement on a position. It may make us a (slightly) smaller party... but like many, I am convinced that most Americans believe in reproductive freedom, and believe, even in limited ways, that access to abortion is a reasonable part of that freedom.

As angry as many people are, as much as people are convinced that healthcare reform can happen without Stupak (I'd say 50-50, at best), the bigger fissure that's been blown open can't be dismissed or ignored. Until we do with abortion what needs to happen on so many issues right now - have a healthy, internal debate that is not about "right and left" but about finding common ground within our own party - we will have more Stupak moments. And we will not know how to solve them. And that, too, is a choice. A bad one.

No Thanks (To You, Or To Me)

This Thanksgiving seems to have unleashed a particularly strong strain of sincere, slightly maudlin sentiments along the lines of "what I'm thankful for" meant, I think, to be a reminder that we have, you know, so much to hang onto in these tough times. You know... let's be thankful for family, our health, our great golden retriever, Barky... and on and on.

All due respect to Mom and Apple Pie, but I think no one should be allowed to get off so easy.

As nice as it is to step back and take a moment to be grateful for, you know, all we have, it's also, you know, not really what Thanksgiving is, as a national holiday. Thanksgiving is, really, a story of survival, about being thankful not for our individual good fortune, but for the power of a community to hang together through incredible adversity and manage something quite so basic as to live and see another year.

It's the kind of desperation that makes stuff like being thankful for that new Kindle we just got (Karen Tumulty, via twitter) seem a bit, well, shallow.

I don't want to seem sour or (too) churlish, but I feel like as a nation we really need to be shaken out of especially self interested, self satisfied complacencies just now. More than ever, it seems, we need a reminder that this isn't about just us, or our immediate circles of friends and family. And part of that, I think, is someone saying, enough with the "thanks for all I still have." Try and think about the people who don't.

This year, more people are unemployed than in the past 25 years (among black men, unemployment is the worst since the Great Depression). People are still losing their homes, their jobs, wondering how they will put food on the table and care for their kids. We are losing more people in Afghanistan than ever, with the likelihood of sending yet more troops there. This isn't about you, or me, or all that we have.

It's insidious, the way we have moved from seeing something as simple as a day to be reminded of the struggle that came with settling in a new land has become an easy, self-satisfied moment of personal gratification. So much of what we have lost - our sense of community, our sense of valuing not what we have, but what we give away to others - hasn't been taken from us... it's been set aside, made easy by celebrating ourselves first, and worrying about others less. And less. And less.

Today, my boss will spend her day working in a soup kitchen giving food to others, as she has for many years. I am humbled by the simplicity of the act, by the fact that she does it, by herself, just because she feels she should. It is the highlight of her day. Her act reminds me that I don't do nearly enough, and makes me wonder why I don't do more.

And yes, today I will be grateful to spend time with my nephews, to be with my family, to share in a wonderful meal. I'm thankful that we have survived another year, and have the chance to go on, and do more. But this isn't a day for cheap, easy sentiment; or to just eat without abandon. We've survived... but we won't survive a whole lot longer if we don't figure out how to think less about ourselves, think more about others, and do something for people who need help. Those are the values, and the America, I'd like to be thankful for. And proud of. And we're so not there... no thanks to me. Or to us.

We Have Nothing To Lose But Our... Er, Um... Those Things In Our Boobs!

Vive la revolucion, and all that... but I'm hard pressed to buy that massive protests and highly focused opposition to what is being called the "bo-Tax" on elective cosmetic medical procedures that's being used to fund parts of the Senate healthcare bill will amount to very much.

Conservatives have never met a tax they didn't like, so naturally they're prepared to stand up and fight for breast implants, collagen injections and liposuction... though, of course, they've often been the same people decrying Hollywood and the kind of fake, bought beauty represented by plastic surgery. Now it's all for one, all for implants.

Veronique de Rugy (I've always wanted to quote her name alone) makes the case today:

The Senate version of the health-care bill has a cosmetic tax. The idea is to make the rich (who are assumed to be the ones consuming plastic surgery) pay for the cost of the health-care reform. Wrong. First, according to Laurie Essig:

Cosmetic surgery is now primarily consumed not by the rich, but by the working and lower-middle classes, sometimes even by the poor. According to the American Society for Aesthetic Plastic Surgery (ASAPS), about 1/3 of cosmetic surgery is consumed by people who make less than $30,000 a year.  About 70% of it is consumed by people who make less than $60,000 a year. It is mostly women (90%) and mostly white, middle-aged women (80% and between 35-55 years old).

Plus, why tax a good that increases people's happiness permanently? According to Will Wilkinsonvery serious academic research), plastic surgery (breast implants in particular), unlike expensive cars, increases people's happiness in the long run. (and based on

Like a number of reports, de Rugy cites a new statistic from the ASAPS - an organization, one might point out, devoted to selling more people on more plastic surgery - that suggests that "ordinary, working class folks" will be hurt by a tax on cosmetic procedures. That's all well and good... but one can bet that they're lumping about as many things as possible (Botox injections and other in house treatments costs hundreds of dollars, while a major procedure like implants or lipo starts around $5,000) into a stat of dubious usefulness. People with $30,000 may be getting something - they may even, with loans and long term payment plans, be having major surgery - but the industry is driven, most clearly, chasing after high levels of disposable income. Or disposable life savings.

Conservatives ought to be careful about who and what they're planning to celebrate here; this new celebration of "The Wonderful World of Boob Jobs" relies heavily on self-interested propaganda and marketing materials that generally try to disguise notions of pain, discomfort, never mind massive expense in support of notions about "perfection" and certainly some level of unhealthy body image and societal expectation that ought to be rejected more than embraced. It's lovely to think of plastic surgeons are doing sainted work bringing happiness to ordinary ladies as simple as an extra cup size... but that's not the reality, and I suspect many conservative agitators know it quite well.

And no, I'm not some angry anti-surgery advocate either; the women I've known with implants do indeed seem quite happy and healthy, comfortable with the choices they've made, and pleased with the results. So too the people I've known who've had lipo, breast reductions, lifts... you name it. Cosmetic surgery - even the occasional Botox injection - is not what I'm opposed to. But I think we should always be clear about what we're talking about: dangerous, possibly life threatening procedures involving risky chemicals and substances that shoud, preferably, be avoided. We should always ask, when repeating promotional statements handed out by plastic surgeons, what kind of self-interest motivates the information, and maintain a healthy skepticism. And we can and should do more to question why personal happiness depends, so much, on such expensive, potentially dangerous, possibly mutilating, work.

If there's a reason to question the "Bo-Tax" it's probably more on common sense fiscal grounds: given that, as New Jersey has demonstrated (with the only cosmetic surgery tax in the nation), that the tax will probably bring in less revenue than forecast and succeed, as taxes do, in reducing a particular activity or behavior, does it make sense to count too heavily on the tax as a moneymaker? Will the tax drive wealthy patients overseas or over borders to have work done... and will we, in turn, be creating a new "surgery scandal" over the Mexican border? It's not that an elective medical practice tax will "hurt the middle class" - many people, clearly, will simply have to factor in the added cost - but it's that a tax aimed at a luxury behavior of the wealthy often fails because the rich have so many discretionary spending options: travel elsewhere, trumping up "medical necessity" (it's the return of "deviated septum" nose jobs!) and the like... will probably take much of the punch out of any anticipated revenue stream.

And, yes, hurt plastic surgeons. Given the recession, we were always bound to see - and have seen - a crisis in an overabundance of cosmetic specialization; that pain, surely, drives a lot of the fear among the plastic surgeons about how much more harm a tax will inflict. But like so much of our health care crisis, the real problem here stems from the needless surgeries, the high rates of specialiazation, and the attraction of a quick, easy buck over the health care people actually need. That conservatives would be more concerned about cleavage, well... that's just par for the course these days... isn't it?

Sarah Superstar

In all the breathless coverage of Sarah Palin's memoirs, I've been debating what to say. Like many I share a concern about her prospects, even the vague fascination with Palin's popularity on the right... but mostly, I find her a somewhat interesting, but irrelevant diversion. And little of the coverage of her seems to get at this.

It wasn't until I saw a clip of her with Sean Hannity that something crystallized for me: Palin is not seen, I don't think, for what she is. In reality, Palin is riding the wave of celebrity culture to her 15 minutes of major fame, and she's doing it by turning politics - perhaps the last bastion of "seriousness" - into the same kind of celebrity name driven gossip currently given to Hollywood and the music industry.

Seeing Palin as a serious politician, it seems to me, is the mistake. What she is, really, is famous for being famous. And by not seeing her book tour for what it is - a chance to consolidate her attention getting - conservatives are deluding themselves into making her vague political ambitions into a huge mess up, while liberals may wind up doing damage control from the needless energy of trying to stop her.

The Fox Armistice

When The War on Fox News broke out, I was quick to point out my skepticism that it would amount to anything; the refusal to do interviews with Fox folks, the criticisms from Robert Gibbs and Anita Dunn, White House Communications Director, seemed restatements of the obvious, and not designed to change anything. As I said then:

I find myself less than thrilled with the Obama folks, not because I think they're tilting at a losing windmill... but because they don't, really, have any interest in trying to change the status quo. Making Fox News the enemy suits their political agenda; "exposing" Fox as conservative (really? can you expose something so nakedly obvious?) is easy headlines... but no real payoff. Fox gets to be just what it is, the Obama folks get an easy scapegoat... and we get less and less served by good news outlets.

... And, well, the war is over. Anita Dunn "resigned" her post as Communications Director, and the next day, President Obama was announced to be having a sit down interview with Major Garrett. The War is Over. Let 1000 flowers bloom.

Or something. Garrett's not going to be the issue - he's another example of what passes for reporting at Fox (and a good illustration, really, that most TV news reporters are neither that memorable nor exceptionally great at reporting), and he's really only a symptom of the larger problem where hard news takes a backseat to what is mostly the televised version of talk radio; he'll get the tape that's eventually played over and over on O'Reilly and Hannity while they cherry pick some non-issue to make hay over... and the cycle continues.

Like I said, you'd need a clearer definition of what you're fighting for, and what you's like to see change, in order to make a "War on Fox" amount to something; and that was never there. And the snort of derision I have over throwing Dunn out to win favor with Murdoch and Co isnot one of surprise or anger. It's just the familiar, cynical feeling that this was what we were bound to get all along. And the thing I want - better, more informative news - is just a pipe dream, never to be seen again.