64 posts categorized "Gray Matters"

Small Miracles (from 2010)

EDITORIAL NOTE: Time Goes By Sunday Elder Music columnist, Peter Tibbles and his Assistant Musicologist are visiting from Melbourne for a few days.

While they are here, in place of new posts are some vintage TGB stories that I kind of like and hope you will enjoy them in rerun. I won't disappear entirely. I'll be checking in now and then to see how it's going and perhaps join in the comments.

And, IMPORTANT, all Elder Storytelling Place stories linked at the bottom of these repeats are NEW.

ANOTHER EDITORIAL NOTE: For two years, a brilliant, Pulitzer Prize-winning journalist, Saul Friedman, wrote two regular columns for this blog, Reflections and Gray Matters. He was my friend, my teacher, a man I admired and respected beyond words.

He died at age 81 on 24 December 2010. It was a privilege to know this fine man and I miss him every day still. For readers who may have found TGB after Saul's death, you can learn more about him here and here.

Even better, however, is to let him speak for himself. Today's repeat column is Saul's last published just six days before he died when, I realize in retrospect, he undoubtedly knew how short his time was. It is titled Small Miracles

In this, the season of miracles, let me confess I have never believed in the big ones: the virgin birth, death and resurrection of the carpenter from Galilee or the lamp with oil for one day that somehow burned for eight days. I might as well have believed in Santa Claus.

But this did not mean I had no faith in the mysterious or the unexplainable. That would have meant having no room in one’s intellect for, say, beauty, love or music so lovely, like a Chopin etude, that it makes one cry. Here’s Artur Rubenstein playing one Chopin’s miracles.

In short, if you’ll indulge me for leaving, for a moment, my usual senior subjects, I truly believe in the smaller, more life-touching miracles. I am walking proof of such miracles.

A few years ago, when I was recovering from a stroke that partially paralyzed my right side, I worried that it might have affected my ability to hear and be moved by good music. Someone brought me a Sony Walkman (remember those?) and I cried with joy in my wheelchair when I discovered I could hear and even sing melodies.

My sound of music was not impaired. And I wheeled myself crazily down the hospital halls, singing (badly) a favorite opera aria.

Later, as I worked with a physical therapist, I watched in wonder as she coaxed from my stiff right hand some movement in my little finger. It was a small miracle, happening somewhere inside my brain, that marked my journey of recovery. And I did recover.

One dictionary says a miracle is an amazing, wonder-filled occurrence that cannot be explained by the laws of nature. Maybe, but I do not believe that the same unmoved mover that paralyzed my hand also moved my little finger. My faith in that patient and caring therapist brought us that miracle.

The esophageal cancer, discovered by accident because of the stroke, was the next big crisis - from years of smoking, competitive journalism, maddening editors and chewing Tums.

And the miracle worker was a young Chinese surgeon who specialized in dealing with older patients because, in his culture, old age is to be venerated as a kind of miracle. He once operated on and cured a 90-year-old woman of lung cancer because, he told me, reaching that age with lung cancer was, by itself, miraculous.

Most people don’t survive cancer of the esophagus because it’s discovered too late. The anti-acid remedies sold to millions of unsuspecting indigestion and acid reflux sufferers, relieve the discomfort but mask the dangers of cancer.

I was a victim and survivor of such dangers. I know of too many who have not been as lucky as I was - like the wonderful essayist and professional atheist, Christopher Hitchens, who says he’s dying.

So are we all. Both of us owe our cancers and/or the cures not to divine intervention, but to the miracles of illness and health. They are life affirming.

Life, illness, happiness, good fortune and bad, even good and bad presidents (I have covered) are all part of what the 11th Century Persian poet Omar Khayyam had in mind when he wrote, “Be happy for this moment. This moment is your life.” And,

That inverted bowl they call the sky,
Where under crawling, cooped we live and die.
Lift not your hands to it for help,
For it impotently moves as you or I.”

Too much of modern popular music and words that we don’t understand; the noise and screaming get in the way. Ella Fitzgerald, Billie Holiday and Peggy Lee were my kind of singers.

But not long ago, I listened carefully, above the hype, to a modern, miraculous piece by the late John Lennon, which voiced as well as Omar what life is and ought to be about. Pay attention to the miracle of these simple words:

The esophageal cancer was cured and I celebrated those five cancer-free years. But alas, earlier this year – again by accident – a new cancer was discovered in the lining of my stomach.

It has a fancy name – linitus plastica – and it’s unique in that there is no mass, only a few cells that don’t show up on a CT scan. And it is very slow-growing, if it grows at all, and it is without pain or symptoms.

So I live with it, as I’ve mentioned, under the care of the Hospice of the Chesapeake. And when an interviewer for a local paper asked how I live with such uncertainty, I told him, that there is no life without uncertainty.

But as Camus told us, we live and struggle and work and play and love, even in the face the inevitability of our own end. I am still lucky. I have my work, which seems to touch and help some people.

Each morning and afternoon, when the weather is moderate, I sit on my deck on the shores of Chesapeake Bay, where I sailed for many years and still have a (power) boat. And smoke one of my indulgences, a fine and expensive cigar.

The bay is ever changing and the prevailing winds from the south can be fierce, but she’s even more beautiful in a dark and clattering summer storm which I can watch as it passes over my house and heads east.

My daughters visit me often, although one is in California, and when the grandchildren are over to help me pick crabs, they understand about living with uncertainty without letting on. So we treasure those times, and we shrug off the future. And they believe me when tell them how lucky we are.

Now that the cold has closed in, my wife drives me to the nearby cigar lounge where Mike, the proprietor, picks me out a couple of good ones from his humidor. I can watch a game on the giant HDTV or simply chat with other patrons, who defer to me because of my age and experiences as a reporter.

Most of them have been in the military or they’re spooks, more conservative than I am.

One guy came in to smoke and clean his target weapons, a pistol and an elaborate 30.08 rifle with a scope. He is building a special hideaway in the woods outside Washington for the day “they” come to take away his freedoms. He was described by Mike as a RWNJ, a “right-wing nut job.”

Another smoker, between covert assignments for the Drug Enforcement Agency, is trying to develop a retirement community in Nicaragua.

The VA psychiatrist, watching a guest cigar roller at work, tells us about treating too many returnees from Iraq and Afghanistan for the shocks inevitable in war.

Mike’s wife, Connie, a nurse at Walter Reed recalls the hollow sadness in the eyes of loved ones when they come to visit their legless or armless kinfolk. Most of these testosterone-heavy cigar enthusiasts, isolationists in the best sense, don’t see why the hell we’re still in Afghanistan.

The point of all this, in a season made for reflection, is to tell the story of how it feels to become and stay old for one very lucky older American for most of us, despite and because of illness, embrace life more fully than ever.

I still order fresh cigars, as if trying to guarantee me the time to smoke them. If things go well, my wife and I will go on a cruise to the Mediterranean next month so Evelyn can see the Nile and the pyramids that I saw as a reporter. Too bad we can't visit Omar's country.

Before I leave, I came across another of these small miracles of beauty, combining great art with fine music, to rediscover words I have not understood – until now.

(View more presentations or Upload your own.)

At The Elder Storytelling Place today, Michael Gorodezky: Pinball Wizard

GRAY MATTERS: Lise's Tribute to Her Father, Saul Friedman

As you know, Gray Matters and Reflections columnist, Saul Friedman, died on 24 December 2010. He was beloved by his readers, a great man, a great journalist and teacher, someone we could all do well to emulate.

Saul's funeral was held on Tuesday, 28 December, and his family has made some some of the orations, tributes, remembrances and eulogies available to Time Goes By. Over the coming Saturdays, they will be published here in place of his column.

This is from one of his daughters, Lise Friedman Spiegel. Married for 25 years with three children, she is a licensed clinical psychologist where she lives in Encino, California

- Ronni

After Mom informed Dad’s oncologist that Dad had taken a sudden turn for the worse and had but days left, the doctor said he had never seen a case like Dad’s in all his years. No kidding.

No one has seen a case like this and I am not necessarily referring to his cancer. Personally, I keep waiting for Dad to call while he is out chasing down a story.

Many of you know the writer, the speaker, the reporter, the blogger and, of course, the sailor. But, I must express to you what this larger-than-life man, who was NEVER supposed to die, gave me.

There is not enough time for all of those things, but here are some highlights.

First of all, the love for just about anything with four legs, especially dogs. I have never known my father without a dog at his side, on the bed, at the computer, awaiting a treat under the table. Puppies born at the beach in Nags Head and naming a new mutt who we had for 16 years Ringo in 1964.

Dad knew that one of the most moving gifts he gave me a few years ago was a one-month supply of skin medicine ($200) for my debilitated rescued Akita.

It’s no accident that we have four family dogs one of which Mom and Dad had flown first class to California when they could not keep her.

Then, there are the Beatles. Dad came home one day in 1964, when I was six years old and said, “I think these kids are something special. Listen.” You know the rest.

And when Paul McCartney married Heather just a few years ago, Dad called me with condolences.

And when I was a little girl and he thought I was ready to understand it, he took me to a movie theater to see Gone With the Wind. Well, no one since has looked up a staircase like Clark Gable did and that one of my daughters is named Melanie is no accident. It is still my husband’s and my favorite film of all time.

Then there is the love of music, all kinds of music - classical, good rock, folk, bluegrass. We went to concerts and bluegrass festivals and, of course, Dad’s love for singing and playing the guitar shaped so much of my future.

He came to my concerts and recitals and paced because he wanted so much for them to go well. A friend of mine sent me an email yesterday which recalled his tears of pride as I performed solo in Carnegie Recital Hall because she watched him as he listened between bouts of pacing.

And all the while, Dad made sure [my sister] Leslie and I remained aware of the world around us, reading the newspaper, socially conscious and willing to make sacrifices to follow our beliefs.

What other father would make sure their child missed much of 6th grade to work at the Vietnam Moratorium Committee and demonstrate against the war in October and November 1969?

What other father would get a long-term press pass to make sure I could sit in the gallery every day during the Watergate hearings?

And what other father would make sure I was sitting behind Ted Kennedy at the Democratic convention in 1980 when he made one of his finest speeches?

And how many kids can say that they met presidents, went to White House Christmas parties and correspondents’ dinners? I know the answer.

A few stories:

In 1972, Dad took me out of school to hang out with him for the last two weeks of the Nixon-McGovern presidential race. I traveled all over Michigan and some of Canada, for fun, ending up in the Detroit Free Press newsroom to await election results.

It was such a sad time, but a time that I had with him as he worked and taught me how the election process worked and why the obvious man should win. And I was so proud when Nixon put Dad on the infamous White House enemies list which, appropriately, took up residence on our bathroom door.

I was celebrating my 16th birthday and Dad wanted to take me out, just the two of us, to a fine French restaurant in Gerogetown, Lion d’Or. He bought me a dress and shoes and we went.

He said I could order any drink I wanted so, like a big girl, I ordered a scotch on the rocks. At the next table was a senator who Dad went out of his way to introduce me to. I do not remember what I ate, but I so remember how that whole evening made me feel.

Then, at the beginning of 10th grade, he and Mom took me out of school to travel in England, Scotland and Wales for two months because he thought traveling was a better education than sitting in a classroom. I learned British history, a love of horse riding on the Scottish moors and that schooling shouldn’t interfere with one’s education.

Finally, as Dad coped with the effects of his stroke, his esophageal cancer and this last cancer, he showed everyone that each day can be valuable and productive if one has love, especially in the form of my mother, sister and brother-in-law, resilience and an open mind to change which, for a man in his 70s into 80s, was extraordinary.

He showed the African bush to his family for his 80th birthday and just notice the car he and Mom bought last July and drove to New York together six weeks ago.

But that is just what he was and will remain for me: simply extraordinary, full of love, life and adventure no matter what came his way.

GRAY MATTERS: Elke's Tribute to Her Husband, Saul Friedman

As you know, Gray Matters and Reflections columnist, Saul Friedman, died on 24 December 2010. He was beloved by his readers, a great man, a great journalist and teacher, someone we could all do well to emulate.

Saul's funeral was held on Tuesday, 28 December, and his family has made some some of the orations, tributes, remembrances and eulogies available to Time Goes By. Over the coming Saturdays, they will be published here in place of his column.

This is from his wife, Evelyn, known to the family as Elke which is Evelyn in Hebrew. The three boats they owned were named Elke I, Elke II and Elke III. On 20 January, Saul and Elke would have been married 59 years. - Ronni

One of the emails to [my daughter] Lise said:

“I am so deeply sorry for your loss. Your father was an amazing human being and quite an inspiration to me.”

This from a friend of our kids, some two generations removed from Saul, who now makes his living playing the guitar in his own band.

Saul played the guitar when his fingers still worked, and since we lived in Houston for several years in the 50s, we got to go to the “hootenannies” which were exhibitions of guitar playing by recognized artists.

We both learned a lot and especially about the condition of black musicians when they traveled to the South to perform.

Sometimes they had to wear turbans so locals would think they were exotic beings from other countries so that they could get a meal or a room in a hotel. If they just showed up off the road in ordinary clothes they could not get served. This was the South in the 40s and early 50s and it made a deep impression on Saul.

Later in the 50s, he decided to write a series about the condition of blacks in Houston. The Houston Chronicle, for whom he worked, said they would publish it.So he wrote a long series detailing the lives of blacks in Houston at the time.

It was factual and correct. It never saw the light of day. That’s the way it was in those days – the paper simply decided not to use it.

I was angry. He was not. He said he had expected it and so went on to the next thing. Which turned out to be the public hospital in Houston.

Jefferson Davis Hospital was the county hospital where the poor folks went and everybody else ignored. By that time, Saul had made friends with the Dutch writer, Jaan de Hartog, who had become interested in conditions at the hospital. Saul and de Hartog signed on to work at the hospital for several weeks to witness the hospital workings.

When he would come home from the hospital he would shed his clothing outside the door and come in and shower before he would sit down for a meal. Later he and de Hartog wrote a series which changed the hospital into one of the better ones in the country, mostly due to their series.

Saul covered all kinds of stories, including a murder trial in Houston which resulted in a 3AM phone call from a male who said, “Is this Mrs. Friedman?”

I answered yes.

He then said, “You tell yo husband to quit writin’ all that stuff in the papers about my friend, else he be dead.”

It infuriated me and I said, “Listen, you son-of-a-unowat, don’t you ever call me in the middle of the night and threaten me.” And I hung up. And I got nervous.

I called the Houston police, the FBI, the Texas Rangers and every other law enforcement agency I could think of. About three days later, somebody arrested a local disc jockey and that was the end of that. I moved my young children back into the house from where they had been staying for safety’s sake, and we resumed our lives.

Saul was awarded a Nieman Fellowship for the academic year 1962-63 which gave him a year at Harvard to study what he wanted to. It was a very prestigious award and so we moved to Cambridge to a large house and he went to Harvard. And so did I.

It was a year to remember. His mother flew up from Texas so he could drive her to New York to visit her sisters during the Christmas-New Year holidays. A wild snowstorm was on when they left on New Year’s Eve. I did not want to stay alone during the New Year and one of our kids was sick.

So I called all the other Niemans and told them what was happening and would they bring some food and come to help me celebrate since I couldn’t leave the child. They did. They brought much food and wine and whiskey and we were having a good party when a loud knocking came at the back door.

It was Saul, covered in snow, having driven back from New York to be with me for the occasion. I was overwhelmed.

No matter what crazy things he did, he always made sure I was all right. He called from Zaire to request some money in order to ransom his passport but first asked me if I was okay. Yeah, I was. I had to be.

He was covering a presidential campaign when he became ill in New Hampshire. Would I come up and get him? Of course I would. And did.

He went to China. Would I come and join him there? Of course, I would. And did. And then how about coming to Israel to be with him? Of course I did.

And then there was South Africa where he was invited by his best friend, Allister Sparks, to come and teach at a school Allister had founded. This was a three-month stay.

The students were mid-career and their first language was not English. The trick was to teach them how to deal with their new-found freedom as apartheid had recently ended and they now could write what they wanted to. But they didn’t know how.

It was Saul's mission to teach them how to write in the active mode instead of the passive. He made an impact and was happy teaching there. And the students appreciated his efforts.

The thread running through his work was always the same: make the world a better place as best I can. In newspaperese: “The journalist’s job is to comfort the afflicted and afflict the comfortable.”

Whether he realized it or not, Saul was always teaching. No matter what he was talking about, he was teaching. And when I was on the plane with him to Georgia or California or on the plane by myself to meet him somewhere, I never felt alone.

He was always with me, taking care of me and making me feel special. And he still does.

Saul Friedman 1929 - 2010

Yesterday, on 24 December, Saul Friedman died at home on Chesapeake Bay surrounded by his family. His 23-year-old grandson, Benjamin T. Hall, wrote this remembrance to share with Saul's many readers.

As I sit here with a hint of scotch on my breath, watching the smoke from a cigarette roll upward, turning into something beautiful, I’m wondering where to begin. Today perhaps.

It is the 23rd of December, my birthday, and the cold in the air seems appropriate. My breath as I walk down the street. More smoke. Where does it go?

Now that I sit here, in these shoes I have so desperately wanted to fill since my youth, I am at a loss of words. I have always wanted to write, just like my Grandfather, Saul. I never anticipated writing about him or to an audience so close to his heart.

As Saul has alluded, and at times forthrightly said, he has been handed many small miracles in his life. He has been given music and been afforded the opportunity to grow with the music he loved, ranging from the Beatles to Chopin, up until his very last moments.

As he lies in bed, taking in the breaths that will be his last, Frank Sinatra, John Lennon and Ludwig van Beethoven accompany him. He shared his love of music with me many years ago when he gave me Beethoven’s piano sonatas, a gift I cherish to this day.

My favorite sonata will always remind me of his beautiful, tremendous nature.

Saul was once given the idea that things were not always as they seemed.

This simple idea led him to pursue a knowledge of philosophy that forever changed his life. He said this much to me two days ago during a conversation from his hospice bed. The bed lies beside the window to give him a view of the bay he adores so much.

Over the years we too have shared this love for a deeper understanding of things, which is how I have come to truly understand our friend Nietchze when he said

“The poison which weaker natures perish strengthens the strong - nor do they call it poison.”

Witnessing the greatest man I’ve ever known wither away, his mind peeling apart like the leaves of the grandest tree, will not kill me. His wisdom has assured me it will make me stronger.

I find solace in knowing Saul has helped so many people; that Saul truly cared for people the way he implores others to do. His work in politics has always been so profound because he has been more concerned with the consequences rather than with the present actions. His entire life has been based on the sole belief that people can, and should, be better to one another.

Spend an afternoon with his family and you can meet some of the most caring, genuine people on the earth. He has shaped his two daughters into women who care and give and love, women who never take the world for granted.

I know Because my Mother is a teacher whose students share holidays with us.

I know because my Aunt is a psychologist who takes feral dogs off the streets of L.A. and turns them into house pets; house guests really.

I know because my Grandmother, Evelyn, has been able to put up with Saul for over 50 years. Another small miracle if you ask me.

Saul Friedman is still with us for the moment, but the moment can never be everlasting, no matter how wonderful it may seem. He is resting comfortably and soon will be comfortable enough with what he’s done for the world to leave.

By the time this lamenting rambling of a mourning grandchild is before your eyes, the eyes of the Friedman family may be filled with the tears of the unknown future, a future we will have to find our way through without the guidance and love that only Saul could provide.

However, our faces will hold smiles of remembrance for the times we’ve been able spend with this beautiful, tremendous, unbelievable, blue-eyed man.

Written with sadness and gratitude,
Benjamin T. Hall

GRAY MATTERS: Small Miracles

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

In this, the season of miracles, let me confess I have never believed in the big ones: the virgin birth, death and resurrection of the carpenter from Galilee or the lamp with oil for one day that somehow burned for eight days. I might as well have believed in Santa Claus.

But this did not mean I had no faith in the mysterious or the unexplainable. That would have meant having no room in one’s intellect for, say, beauty, love or music so lovely, like a Chopin etude, that it makes one cry. Here’s Artur Rubenstein playing one Chopin’s miracles.

In short, if you’ll indulge me for leaving, for a moment, my usual senior subjects, I truly believe in the smaller, more life-touching miracles. I am walking proof of such miracles.

A few years ago, when I was recovering from a stroke that partially paralyzed my right side, I worried that it might have affected my ability to hear and be moved by good music. Someone brought me a Sony Walkman (remember those?) and I cried with joy in my wheelchair when I discovered I could hear and even sing melodies.

My sound of music was not impaired. And I wheeled myself crazily down the hospital halls, singing (badly) a favorite opera aria.

Later, as I worked with a physical therapist, I watched in wonder as she coaxed from my stiff right hand some movement in my little finger. It was a small miracle, happening somewhere inside my brain, that marked my journey of recovery. And I did recover.

One dictionary says a miracle is an amazing, wonder-filled occurrence that cannot be explained by the laws of nature. Maybe, but I do not believe that the same unmoved mover that paralyzed my hand also moved my little finger. My faith in that patient and caring therapist brought us that miracle.

The esophageal cancer, discovered by accident because of the stroke, was the next big crisis - from years of smoking, competitive journalism, maddening editors and chewing Tums.

And the miracle worker was a young Chinese surgeon who specialized in dealing with older patients because, in his culture, old age is to be venerated as a kind of miracle. He once operated on and cured a 90-year-old woman of lung cancer because, he told me, reaching that age with lung cancer was, by itself, miraculous.

Most people don’t survive cancer of the esophagus because it’s discovered too late. The anti-acid remedies sold to millions of unsuspecting indigestion and acid reflux sufferers, relieve the discomfort but mask the dangers of cancer.

I was a victim and survivor of such dangers. I know of too many who have not been as lucky as I was - like the wonderful essayist and professional atheist, Christopher Hitchens, who says he’s dying.

So are we all. Both of us owe our cancers and/or the cures not to divine intervention, but to the miracles of illness and health. They are life affirming.

Life, illness, happiness, good fortune and bad, even good and bad presidents (I have covered) are all part of what the 11th Century Persian poet Omar Khayyam had in mind when he wrote, “Be happy for this moment. This moment is your life.” And,

That inverted bowl they call the sky,
Where under crawling, cooped we live and die.
Lift not your hands to it for help,
For it impotently moves as you or I.”

Too much of modern popular music and words that we don’t understand; the noise and screaming get in the way. Ella Fitzgerald, Billie Holiday and Peggy Lee were my kind of singers.

But not long ago, I listened carefully, above the hype, to a modern, miraculous piece by the late John Lennon, which voiced as well as Omar what life is and ought to be about. Pay attention to the miracle of these simple words:

The esophageal cancer was cured and I celebrated those five cancer-free years. But alas, earlier this year – again by accident – a new cancer was discovered in the lining of my stomach.

It has a fancy name – linitus plastica – and it’s unique in that there is no mass, only a few cells that don’t show up on a CT scan. And it is very slow-growing, if it grows at all, and it is without pain or symptoms.

So I live with it, as I’ve mentioned, under the care of the Hospice of the Chesapeake. And when an interviewer for a local paper asked how I live with such uncertainty, I told him, that there is no life without uncertainty.

But as Camus told us, we live and struggle and work and play and love, even in the face the inevitability of our own end. I am still lucky. I have my work, which seems to touch and help some people.

Each morning and afternoon, when the weather is moderate, I sit on my deck on the shores of Chesapeake Bay, where I sailed for many years and still have a (power) boat. And smoke one of my indulgences, a fine and expensive cigar.

The bay is ever changing and the prevailing winds from the south can be fierce, but she’s even more beautiful in a dark and clattering summer storm which I can watch as it passes over my house and heads east.

My daughters visit me often, although one is in California, and when the grandchildren are over to help me pick crabs, they understand about living with uncertainty without letting on. So we treasure those times, and we shrug off the future. And they believe me when tell them how lucky we are.

Now that the cold has closed in, my wife drives me to the nearby cigar lounge where Mike, the proprietor, picks me out a couple of good ones from his humidor. I can watch a game on the giant HDTV or simply chat with other patrons, who defer to me because of my age and experiences as a reporter.

Most of them have been in the military or they’re spooks, more conservative than I am.

One guy came in to smoke and clean his target weapons, a pistol and an elaborate 30.08 rifle with a scope. He is building a special hideaway in the woods outside Washington for the day “they” come to take away his freedoms. He was described by Mike as a RWNJ, a “right-wing nut job.”

Another smoker, between covert assignments for the Drug Enforcement Agency, is trying to develop a retirement community in Nicaragua.

The VA psychiatrist, watching a guest cigar roller at work, tells us about treating too many returnees from Iraq and Afghanistan for the shocks inevitable in war.

Mike’s wife, Connie, a nurse at Walter Reed recalls the hollow sadness in the eyes of loved ones when they come to visit their legless or armless kinfolk. Most of these testosterone-heavy cigar enthusiasts, isolationists in the best sense, don’t see why the hell we’re still in Afghanistan.

The point of all this, in a season made for reflection, is to tell the story of how it feels to become and stay old for one very lucky older American for most of us, despite and because of illness, embrace life more fully than ever.

I still order fresh cigars, as if trying to guarantee me the time to smoke them. If things go well, my wife and I will go on a cruise to the Mediterranean next month so Evelyn can see the Nile and the pyramids that I saw as a reporter. Too bad we can't visit Omar's country.

Before I leave, I came across another of these small miracles of beauty, combining great art with fine music, to rediscover words I have not understood – until now.

(View more presentations or Upload your own.)

GRAY MATTERS: Potential Medicare Dangers

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Before Gray Matters leaves the dismal subject of President Obama’s misbegotten Frankenstein monster, the deficit reduction commission, there is one tiny sliver of decent news from its lone genuine liberal, Illinois Representative Jan Schakowsky.

In one of her many television interviews, she noted that the information that the members of the commission had at last come to terms with the fact that Social Security’s pension insurance system, which is self-supporting with payroll taxes and minimal administrative costs does not, repeat, not add to the deficit.

Therefore, she said their “proposed reforms,” like slowly raising the retirement age, are meant only to stabilize its finances for the next 75 years. We now know that nothing so drastic as cutting benefits, which is what raising the retirement age will do, is simply not necessary, as Obama has said.

But alas, our unpredictable president, of questionable principles, as Time Goes By as demonstrated on the past few posts, has done his damnedest – with the suspension of the payroll taxes – to make life more difficult than it needs to be for Social Security.

But that’s not what I wanted to draw from Schakowsky’s observation. Her fear is not for the long term future of Social Security, but the more immediate dangers for the 47 million of us who depend on Medicare.

It is true that the Affordable Care Act strengthened Medicare’s Part A trust fund, and that cutting the subsidy for Medicare Advantage has helped the finances and the fortunes of Part B. But except for Schakowsky, virtually every member of the commission is about to pounce on Medicare because health care – but not necessarily Medicare - is the largest and fastest growing target for cutting the deficit.

Never mind that our for-profit health care system is filled with greed and corruption and is a drag on Medicare.

But its advocates are being heard. As I mentioned last time, a coalition of liberal economists in a Citizens Commission, including former Labor Secretary Robert Reich, economist Dean Baker and, this time, joined by separate statements from AARP, have protested strongly that the problem is not Medicare.

As the Citizens Commission wrote,

“Alarming long-term projections of growing debt almost completely come from uncontrolled growth in health care costs. We do not have an entitlement crisis; we have an unaffordable health care system.”

Nevertheless, the key members of the deficit commission, with nods of approval so far from its creator, the president, would pick on what Obama’s co-chairman, Alan Simpson, called the “lesser people” for the unkindest cuts.

Even the mildest medicine, proposed by Simpson and his buddy, former Clinton aide Erskine Bowles, would put a cap on and stunt the growth of Medicare even though other health costs are mostly responsible for that growth. In addition, as I wrote, the eligibility age for Medicare – for your children – would rise to 68.

Your expensive Medigap policy will be worth less: Bowles-Simpson would exclude the first $500 of coverage and limit coverage to 50 percent of the next $5,000.

Your annual out of pocket costs could rise to $7,500.

And, as I mentioned, the experiment for getting the feds into long term care, called CLASS, proposed by a dying Ted Kennedy, would be abandoned. From Bowles-Simpson, the gutting of original Medicare goes from bad to worse.

Former Clinton Budget Director Alice Rivlin and former Senator Pete Domenici would raise the already onerous 20 percent co-insurance for Part B to 35 percent.

And starting in 2018, their plan would substitute the present system - the government pays the bills - with a “premium support” system in which the beneficiary would get a certain amount of money to shop for his/her coverage.

Can you imagine going from the current system, which is confusing enough, to one in which beneficiaries, including the oldest men and women living in nursing homes, must shop each year for private insurance? Who would regulate the insurers?

Even worse, Rivlin and her new ally, right-wing ideologue Representative Paul Ryan [R-Wis], would completely privatize what most Americans consider the best health insurance they can get.

What makes this a dangerous possibility is the fact that Ryan will become chairman of the House Budget Committee. Under his market-oriented proposal, we would take the system that accounts for most of the present problem and make it worse.

Starting in 2021, people who turn 65 will receive vouchers to buy private insurance through a new Medicare Exchange. Vouchers would be worth $11,000 (surely that will be enough to treat a cancer), although adjustment may be made depending on the illness.

Of course, it will be up to the sick or dying beneficiary to argue his/her case with the insurer.

“I don’t think there’s any question that there’s intensifying pressure to control Medicare costs and that pressure is going to intensify more over time when you look at the deficit and you see that really Social Security is a minor contributor. It’s mainly health care,” said Jonathan Oberlander, professor of social medicine at the University of North Carolina. “Medicare has long been about budget politics.”

While Medicare makes a tempting target for cuts, John Rother, AARP’s executive vice president said,

“The burden of Medicare’s out of pocket costs is already very high, to the point where many people are literally having to choose between the necessities of life and health care. I don’t think it’s possible or advisable to further load people of modest incomes with very high health care costs.”

Rother has signaled that AARP, which successfully fought off the 1995 Bush administration effort to privatize Social Security, will be even more militant on Medicare’s behalf.

As important, the American Medical Association, has become a strong Medicare defender, especially since the Congress last week stopped for a year the pending 23 percent cut in the program’s payment for doctors. The year is expected to give lawmakers time to rewrite the formula for setting the fees.

Tricia Neuman, director of the Kaiser Family Foundation’s Medicare Policy Project, decries the premium support and voucher proposals and says the Affordable Care Act can help keep Medicare costs down.

Recently, the Department of Health and Human Services began writing regulations for an important part of the new law, called the Medical Loss Ratio, requiring insurers to spend 80 to 85 percent of health care premiums on actual health care rather than executive salaries and other administrative costs.

Getting back to Ms. Schakowksy, she had only one Medicare reform to propose that would require Medicare to scrap Part D and establish a Medicare drug plan and that Medicare be required to negotiate prices with drug companies.

Since the deficit commission seems to agree that the present system is flawed and too costly, I’d go one step further and propose what Obama used to favor, Medicare for All. But that was before he lost whatever it is that he once believed.

Contact saulfriedman@comcast.net

GRAY MATTERS: The Simpson/Bowles Deficit Commission

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Who can forget that outburst from Alan Kooi Simpson, a former senator and now co-chairman the president’s flawed deficit commission, when he told a women’s group challenging his views: Social Security is like “a milk cow with 310 million tits?”

This was nothing new for Simpson, a conservative Republican, who has rarely had a kind word for Social Security or any government social insurance program.

Yet he has been on the public tit for much of his 79 years. His position on the deficit commission (he has served on others ) is only his latest government gig. And his reputation as a quotable, if often outrageous, character has served to get him such appointments. He certainly doesn’t know much about Social Security as in this interview. Here is a sample of his words to Alex Lawson, a Social Security expert and advocate:

“We’re trying to take care of the lesser people in society and do that in a way without getting into all the flash words you love dig up, like cutting Social Security, which is bulls--t. We’re not cutting anything. We’re trying to make it solvent. It’ll go broke in the year 2037.”

The $2.6 trillion in bonds held by Social Security, he called IOUs.

A third generation corporate lawyer, Simpson’s less than sterling political career was bestowed on him by his father, Milward Lee Simpson, a former Wyoming governor and U.S. Senator who distinguished himself by voting against the 1964 Civil Rights Act.

The son served a few years in the Wyoming legislature before going to the Senate in 1979, where one of his most signal accomplishments was an attack on AARP for its lobbying on behalf Social Security and older Americans. Simpson only succeeded in making AARP, the nation’s largest and most powerful voice for seniors, even larger, stronger and richer.

AARP’s senior vice president said Simpson’s comparison of Social Security to a “milk cow”

“is offensive...for belittling a bedrock program that is the foundation of family security for all generations. The vast majority of the 310 million Americans he insulted....don’t have access to the type of traditional pension that Senator Simpson has from his decades in Congress.”

Simpson, who retired from the Senate in 1997 and has taught at the Kennedy School at Harvard, enjoys a couple of healthy government pensions, the average value of which is over $60,000 a year, and he enjoys taxpayer supported lifetime health benefits which helped him get the best of care when he had a $70,000 knee replacement. Yet his latest epithet for older Americans who are anxious to protect Medicare and Social Security from Simpson and his commission:

“We had the greatest generation. I think this is the greediest generation.”

For the record, nearly half of the 43 million disabled and older Americans on Medicare have incomes below twice the poverty level, or $20,800 for an individual and $28,000 per couple. That’s per year, senator. Nearly 70 percent of black and Hispanic beneficiaries have similar incomes. And as drug prices, premiums and deductibles have risen, median out of pocket costs are approaching 20 percent of incomes.

Yet it’s these “lesser people” that will bear the burden of benefit cuts in Medicare and Medicaid. While much attention has been focused on Simpson’s and his allies’ intention to gradually raise the Social Security retirement age to 70, which would mean an absolute cut in benefits, members of the Commission also would raise the age of Medicare eligibility to 68, which could leave millions too old to work in an uninsured limbo.

In addition, Simpson would raise the 20-plus percent that beneficiaries pay for Part B to an astounding 35 percent. Since Part B, which pays for doctor visits and labs, is the most frequently used Medicare benefit, this would all but kill the program. To add insult to the devastation, Simpson and company would cancel the portion of the Affordable Care Act that would begin a voluntary, long-term care program championed by the late Ted Kennedy.

Don McCanne, an MD, and a spokesman for Physicians for A National Health Program, noted that Simpson and his co-chairman, Erskine Bowles who, while in the Clinton administration, sought cuts in Medicare, favor raising Medicare premiums, deductibles and co-pays.

“Shifting more costs from the federal government to the patient might reduce the federal budget,” said McCanne. “But it plays havoc with personal budgets”

of beneficiaries who would be obliged to buy increasingly expensive Medigap plans. In addition, Simpson and Bowles would cut the fees to doctors, many of whom are already deserting their Medicare patients because, they say, the fees are too low. The Congress keeps threatening cuts and so far has declined to end the threat.

President Drew Altman, CEO for the Kaiser Family Foundation, noted that Medicare cuts will be especially hard on beneficiaries.

“It will be difficult, if not impossible to ask a majority...to pay more and make do with less. Warren Buffet is not the typical Medicare beneficiary.

“Instead the prototype is an older woman with multiple chronic illnesses living on an income of less than $25,000 who spends more than 15 percent on health care. It is the people on these programs and the realities of their lives that have been left out of the discussion.”

Another plan, sponsored by former budget director Alice Rivlin and Republican Representative Paul Ryan of Wisconsin, who is to be chairman of the House Budget Commiittee, would end Medicare as we know it by giving beneficiaries vouchers to buy their insurance on the market.

Whether or not Simpson and Bowles are able to get 14 of the 18 Commission members to vote for a proposal that would then go to the Congress, liberal members and allies in lobbying groups have begun their campaign for less draconian alternatives to cut the deficit.

Representative Jan Schakowsky, an Illinois Democrat, put forward a plan which would strengthen Medicare and Social Security and fund programs to create jobs, but would lower the deficit by $427 billion in four years by, among other things, cutting military spending by $110.7 billion, increasing revenues by $151.6 billion, ending tax breaks which cost $132 billion and reducing farm subsidies by $7.7 billion.

Unfortunately, most of the press, enamored with Bowles and Simpson, has ignored Schakowsky, although at least two other commissioners support her. Their view is that deficit reduction should follow job creation and be delayed until unemployment is down to six percent.

The New York Times reports that several progressive groups – Demos, the influential Economic Policy Institute and the Century Foundation as well as a coalition of economists, labor leaders – the Citizens’ Commission on Jobs, Deficits and America’s Economic Future - are weighing in on their own plans to lower the deficit without further killing the working and middle classes and the nation’s social insurance programs.

So far AARP, which is opposed to cuts in Social Security, has not weighed in with its views of the Bowles-Simpson proposals.

Let us not forget, this is Barack Obama’s commission. He made the mistake of falling for the deficit reduction frenzy which stunted his efforts to revive the economy and create jobs; he reached out to right-wing Republicans, who wished to see his presidency fail; then he reached out (too far) for the likes of Alan Simpson; and now he’s stuck with him.

Let’s see where Obama really stands on Social Security, Medicare and Medicaid – if anywhere.

Contact saulfriedman@comcast.net

GRAY MATTERS: Social Security – The Anti-Ponzi Scheme

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Even before I spent a dozen happy years living and working in Texas, one of my heroes was Sam Houston, the first president of the Texas republic, the state’s first governor and its senator. He resigned as governor because he staunchly opposed its secession from the union. Today, such principled heroics are rare in Texas.

Instead, the Texas congressional delegation is larded with an abundance of dunces and demagogues, like Representatives Joe Barton who apologized to BP for having to pay for its oil spill and Louie Gohmert who warned that illegal immigrants were coming to the U.S. to have “anchor babies” who will grow up and become terrorists. And who can forget Tom DeLay and Dick Armey?

Which brings me to the present governor, Rick Perry, who was just re-elected to a third term and will become chairman of the Republican Governors Association. Although he’s a member of Lincoln’s party, Perry is a rabid supporter of states rights and earlier this year, he said he was considering secession from the union as if that was a success the first time.

More recently he has threatened to secede from Medicaid which would leave 3.1 million poor people, including 2.3 million Texas children, without health care. And in promoting his new book, Fed Up! Our Fight to Save America from Washington, Perry suggested the state and its counties could secede from Social Security, which he said is “bankrupt.”

And he has remonstrated fellow Republicans for not calling Social Security a “Ponzi scheme.” Last week he doubled down on the charge calling one of the most treasured programs serving more than 50 million Americans. “worse than a Ponzi scheme.”

Ordinarily I would not bother with such nonsense but like the urban legend that members of Congress don’t pay into Social Security (they do), this demagoguery keeps coming back from people who should know better.

Even CNBC’s Jim Cramer, who failed to see the financial crisis coming, has likened Social Security to a Ponzi scam. Worse, too many Americans don’t know enough about Social Security to dismiss these lies.

To dispose of Perry’s initial lie about Social Security, as any fool who can read knows by now, the most recent report of the program’s trustees said that even if no action is taken to shore up the long-term finances of Social Security, it won’t go into the red until 2037.

But if it does (and it won’t), the trustees figure its payroll tax income will enable it to pay 75 percent of benefits until 2084. Moreover, as Alan Greenspan and the trustees have said, it won’t take much adjustment – perhaps a two percent increase in taxes or eliminating the $106,800 salary cap on payroll taxes - to keep it in the black until the end of the century.

One big reason: It holds in reserve more than $2.6 trillion in Treasury Notes which pay nearly $1 billion in interest to Social Security each year.

And that, of course, is the largest difference between Social Security and the schemes made famous by Charles Ponzi and, more recently, Bernard Madoff: There were no such invested funds earning money for either of them. Indeed, they made no investments.

But more important, Social Security is not and was never meant to be an “investment program.” It is, rather, a mandatory pension insurance program, financed by mandatory payroll taxes equally contributed by workers and employers. And, as the financial service Motley Fool reported last year, “that helps shore up its foundation far more firmly than a typical Ponzi scheme.”

Charles Ponzi was a Boston investment broker who became infamous in early 1920, when he sold foreign postal coupons promising, and even paying, returns of 50 percent or more. What he did, as we shall see, was to use one victim’s money to pay off another. Madoff did the same, promising 12 percent returns when the market was struggling and losing value.

Mitchell Zuckoff, the author of a book on Ponzi schemes, wrote for CNNMoney in the wake of the Madoff affair that comparisons of such cons with Social Security are hard to knock down but “since I for one consider real Ponzi schemes too important...it’s worth rebutting the myth.”

Put simply, he writes,

“[A] Ponzi scheme is a fraud in which money from one group of people is used to pay promised returns to another group of people. The money isn’t invested; it’s just transferred and at some point the scheme collapses because there’s not enough income to satisfy the withdrawals...

“In the case of Social Security, no one is being misled...Social Security is exactly what it claims to be: A mandatory transfer payment system under which current workers are taxed (6.2 percent each from employee and employer) on their income (up to $106,800) to pay benefits with no promises of huge returns.”

Indeed, the genius of the Social Security system’s design, as its web site says,

“For an average worker, Social Security replaces about 40 percent of annual pre-retirement earnings.”

That’s not much for an affluent worker, but for a low-income worker who has no other retirement plan, it’s enough to avoid the abyss of poverty. Social Security, which insures surviving spouses and children, is one of the nation’s last of the traditional defined benefit pension programs which are fast disappearing.


“Social Security is morally the polar opposite of a Ponzi scheme and fundamentally different from what Madoff did. At the height of the Great Depression, our society resolved to create a safety net in the form of a social insurance policy that would pay modest benefits to retirees (and later) the disabled and the survivors of deceased workers.

“By design, that means a certain amount of wealth transfer, with richer workers subsidizing poorer ones. That might rankle, but it’s no fraud.”

I would add, despite the bitching of conservatives and younger workers (who place too much faith in their bosses and those inadequate 401(k)s and resent the transfer of their tax dollars without a healthy return), there is something noble about a pension insurance system in which the younger generation helps support the retirement of their elders.

The young forget that, with luck and Medicare, they will grow old. And their benefits are guaranteed.

Yet today, Governor Perry and his right-wing cohorts, now in effective charge of American politics, would toss aside the morality of the Social Security system in exchange for the amorality of the stock market.

On November 8, 1954, President Eisenhower wrote his brother Edgar on “moderation in government.” He added,

“[S]hould any political party attempt to abolish Social Security, unemployment insurance, and eliminate labor laws and farm programs, you would not hear from that party again...There is a tiny splinter group that believes you can do those things...a few Texas oil millionaires...Their number is negligible and they are stupid.”

Write to saulfriedman@comcast.net

GRAY MATTERS: Raising the Retirement Age?

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

If the incoming Congress, especially the Republicans, are serious about paying attention to the American people, they could start with a couple of recent surveys, which are about life, health and even premature death.

The first, which shows how little confidence many Americans have in their newly elected lawmakers, found that

"on the heels of the 2010 midterm elections, 63 percent of retirees are not confident Medicare will be there for their children."

Indeed, according to the poll sponsored by Extend Health Inc., a private company which helps Medicare retirees choose health plans, 40 percent are unsure or not confident that Medicare will last through their lives. The rest are confident Medicare will continue to be available, but perhaps in altered form.

But on the downside, 17 percent are unsure, along with the 63 percent who are "not confident that Medicare will be available for the rest of their children's lives." That takes in a good portion of the 70-million men and women in the huge boomer generation, as well as families in their thirties who have reason to worry they will be shut out of Medicare as well as Social Security.

The reasons for the pessimism include signs among Republicans in the new Congress that they wish to cut funds for Medicare or, as the incoming Budget Committee Chairman, Representative Paul Ryan of Wisconsin, has suggested, privatizing Medicare into a system in which beneficiaries will use vouchers to buy private insurance.

In addition, the new health reforms have cut back on subsidies for Medicare Advantage plans and some of them are going out of business. Republicans favor saving Medicare Advantage in order to cut Medicare.

The other survey goes to the heartlessness of Republican efforts to raise the Social Security retirement age from 67 to 70 for if that is successful, millions of working people will be forced to delay retirement as well their enrollment in Medicare.

And the liberal Center For Economic and Policy Research (CEPR) has reported [pdf], with good documentation, that increasing the retirement age will not only be difficult for many who work in physically demanding jobs, but it would shorten the retirements and lives of many of those workers.

Using data based on the census and the Occupational Information Network, the CEPR said that "in 2009, 6.5 million workers age 58 and older had physically demanding jobs, while 5 million workers age 58 and older were employed in difficult jobs” that were physically demanding or with difficult working conditions.

In addition, many of the most physically demanding or difficult jobs were also poorly paid and most were held by Latino workers (54 percent), blacks (53 percent), Asian Americans (50 percent) and whites (43 percent).

Even higher percentages of Latinos and blacks in the most demanding jobs were much older than 58 and would be especially hurt economically by a raise in the retirement age.

The survey found that

"raising the retirement age is particularly concerning for near-retirement age workers with physically demanding jobs. Despite the fact that the retirement age increase is supposed to encourage workers to work longer, many workers would be physically unable to extend their work lives and they would most likely be left with no choice but to receive reduced benefits."

Or, after a life of hard work and paying taxes, they would go on welfare.

But that would not be the worst of it for CEPR found, in a companion survey, that many retirees from difficult jobs don't live long enough to collect benefits. Those who, like Ryan, intend to support raising the retirement age argue that life expectancy has increased and therefore the retirement age should likewise be increased.

Perhaps it doesn't occur to Ryan and his allies that Medicare and Social Security are largely responsible for increased longevity (which still lags behind other nations). Perhaps this will be the Republicans' “death panels.”

As CEPR reported,

"The average length of retirement has increased consistently since the program (Social Security) was started in 1937. However, the increase in the normal retirement age from 65 to 67 that is being phased in...largely offsets the increase in life expectancy. As a result, workers who work long enough to collect their full benefits will see little gain in the expected length of their retirement."

Graphs and charts in CEPR's paper illustrate the growing income inequality and life expectancy between minorities in difficult jobs and the rest of workers, especially those in white collar jobs that are less demanding.

"If the recent trend of growing inequality in life expectancy continues through the next three decades, these workers in the bottom half of the wage distribution can anticipate substantial reductions in the expected length of retirement, if the normal retirement age is increased...

A male worker born in 1973 retiring at age 70 can expect to live a full year less than the expected length of retirement for a worker born in 1912."

The study's conclusion:

"If the normal retirement age is increased to 70 over the next 25 years, as advocated by many policymakers, then the rise in the retirement age will continue to offset most of the increase in life expectancy....The expected years of retirement (meaning the years until death) will be less for the 1973 birth cohort than it was for the 1912 birth cohort."

We reported last August 7 on the book, The Spirit Level, which analyzed the growing income inequality in the U.S. compared to other countries, and the consequences for millions of Americans as they grow older and poorer. Trust the new Congress to do nothing to make it better for the American worker and his/her family.

The CEPR study added this note:

"From the probabilities of death, life tables were constructed based on standard methods as described by Social Security."

The bottom line: The higher the retirement age, the shorter the lives of retirees. That, of course is one way of saving money; widows and widowers don't cost taxpayers and Social Security as much as a retiree who lives a full life and draws a full benefit.

This study dealt only with the consequences of Social Security retirement longevity. But ignored during most of the debate on the subject have been the consequences for the quality of life for workers who also may be denied the protection of Medicare if its age of eligibility is also increased. Many employers have ended pension programs and most Latino, black and poor white workers in demanding blue collar jobs do not have 401(k) savings plans.

Nor do many employers provide good health coverage. And unless the recently passed health reforms continue in force, millions of America's hardest workers at the most physically demanding jobs will remain uninsured and at great risk of illness and high medical costs in their older years thanks to members of Congress who get taxpayer-funded health coverage.

Incidentally, if you wish to learn more about income inequality in the U.S., The Spirit Level is cited in a fine series in Slate called The Great Divergence, by Timothy Noah. And this U.K. site is worth examining.

Write to saulfriedman@comcast.net

GRAY MATTERS: Annual Medicare Enrollment Period Begins on Monday

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

The first shock comes when the kid in the movie booth asks if you’re a senior. Then AARP notifies you that you are eligible for membership. And three months before you turn 65, you should get some really good news - you’re about to get the nation’s best health care insurance, Medicare.

Medicare was passed in 1965 and went into effect within a year. And although it has expanded over the years and now serves more than 47 million older and disabled Americans, its basics have remained the same.

And despite what you may have been told, it is less complicated and more generous than the private insurance that you bought or had through an employer.

However, Monday, November 15 is the beginning of this year’s Open Enrollment period, which ends December 31, but you needn’t fret or rush into anything for it pertains to enrollment in private plans, not Medicare. We’ll get to that later.

When you’re about to become 65 and if you’re eligible for Social Security (even if you’re not taking the benefits yet), you will be automatically signed up for Medicare Part A, which pays most bills for hospitalization. There is no cost for this Part A, for in-hospital costs, is financed by the Hospital Insurance Trust Fund and your new Medicare card will reflect you have that coverage.

But I’m getting head of myself. If you have not been notified by Social Security or Medicare that you’re eligible for Medicare, visit medicare.gov to sign up in seconds.

If convenient, visit your Social Security office. You should also explore the Medicare site and, if you’ve got a decent printer, download the guide Medicare & You 2011. You will get a print copy in the mail after you enroll.

For those of you who are new to this or if you need a refresher, today’s Medicare has four parts:

• Part A, as I said, covers hospitalization, rehabilitation in skilled nursing centers and nursing homes, hospice and home care

• Part B covers doctors, outpatient care, lab tests and x-rays. Parts A and B together are original, traditional Medicare

• Part C, the private insurance plans added relatively recently includes HMOs (Health Maintenance Organizations) and PPOs, (Preferred Provider Organizations), now called Medicare Advantage

• Part D, passed in 2003, which covers prescription drugs, either as stand-alone, drugs-only plan or as part of a Medicare Advantage plan

When you are signed up for Part A, you will be given an opportunity to enroll as well in Part B, which is the part of Medicare most often used. Because there was no cost of living adjustment in Social Security this year, the monthly premium for most beneficiaries remains at $96.40, but it’s more on a sliding scale for individuals earning more than $85,000, or $170,000 for couples.

Check the Medicare site for the amount of the higher premiums. This means test, the first ever for Medicare, helped pay for George Bush’s flawed Part D benefit with its donut hole.

If you decline Part B and don’t have other, equivalent coverage, you could be penalized when and if you do sign up. If you have private or employer coverage for doctor and lab visits, you may decline Part B, although some employers are insisting that Medicare-age employees take the coverage to save the company money.

Be careful. If you leave the company or your coverage ends, you have eight months to enroll in Part B with no penalty.

Once enrolled in Part A and B, you have a few choices. Part A’s out-of-pocket costs, which you can learn about in the Medicare & You

That means if you don’t already have a supplemental policy from a spouse or former employer, you may buy one of several standard “Medigap” plans, which depending on cost, will cover part or all of those deductibles and co-pays. You may enroll in a Medigap plan almost anytime, and in most states, even if you have a pre-existing condition. The plan heavily marketed by AARP is as good as any, but the Medicare web site can help you shop.

If you do buy a Medigap policy, then consider a relatively inexpensive, stand-alone Part D drug plan. The advantage of this threesome – traditional Medicare (A and B) plus a Medigap policy and stand alone drug coverage – ends up being less costly, more stable and less risky than the next choice during open enrollment, a Medicare Advantage plan.

Medicare Advantage, as I’ve written, grew out of Republican efforts in 1995 to partly privatize Medicare. Thus Part C, which is heavily subsidized by the federal government, pays private insurers to cover all the basic benefits of Parts A and B but in addition, the insurers offers a drug plan (for extra money) and perhaps some added benefits such as eye examinations.

Nevertheless, MA plans are in business to make profits and they could and do go out of business and leave beneficiaries without coverage if their profits are not high enough. There will be 2,011 MA plans next year, but that’s down from more than 2,800 in 2009. In some rural areas, there are few MA plans available.

Medicare Advantage plans are convenient because they are comprehensive, all-in-one insurance policies. But there are disadvantages of MA plans, aside from taking money from and undermining traditional Medicare:

• You must use doctors and hospitals in the insurer’s network

• You must get the insurer’s approval for some procedures, many doctors have dropped some MA plans because the insurers second-guess the doctor or they are slow in paying

• The monthly premiums for MA plans and their drug plans (in addition to the Part B premium you must pay) have been relatively stable, but increases are expected

• You must pay a co-pay for each doctor or lab visit

• You will need a referral from the primary care physician for each visit to a lab or specialist. If a hospital or doctor specializes in a certain illness or kind of cancer and is not in the network, it may be difficult getting the insurer to pay or continue coverage, especially if the illness is prolonged and costly.

The new Affordable Care Act will prohibit such coverage limits starting next year, but the limits permitted are quite high. Traditional Medicare has no such limit but you can keep track of what Medicare and your supplement pays in the periodic “Medicare Summary Notices” that you will receive. (You may check them to help guard against fraud).

A further warning: The new health reforms include cuts in the federal subsidy for MA plans, which angered thousands beneficiaries, but if the law survives, the subsidy may be cut further in coming years which will put many of these plans out of business.

Meanwhile, if your MA plan or your stand-alone drug plan raised its prices, this enrollment period is the time to shop. While the Medicare web site is user friendly, some of the best information on Medicare can be found on the Kaiser Family Foundation website and for help with problems, try the Medicare Rights Center or the lawyers at the Center for Medicare Advocacy.

I can’t end without a note on one of the most important improvements in Medicare under the Affordable Care Act. Beginning January 1, there will be no charge for a variety of preventive services including a number of life-saving cancer screenings, free flu and pneumonia shots, a “Welcome to Medicare’ physical exam and annual wellness visits to keep track of your health and possible cognitive problems.

Welcome to Medicare.

Write to saulfriedman@comcast.net

GRAY MATTERS: Misunderstanding Medicare

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I read somewhere that the White House and congressional offices have been besieged by phone calls and emails from older people complaining at the news that, for the second consecutive year, there won’t be a cost of living increase in Social Security benefits.

I don’t take issue with those complaints, for most of us know that the cost of living has gone up measurably, especially for people who depend on those Social Security payments. But what caught my attention and disappointed me was the news that some seniors “erroneously believe it is the Congress and the White House that are denying them raises.”

It seems to me that people who are on Social Security ought to know enough about their most important federal program to understand that the Cost of Living Adjustment (COLA) is based on the rate of inflation measured by the Bureau of Labor Statistics in the Consumer Price Index for workers, called the CPI-W.

Some experts want to substitute the CPI-E (for experimental) which would be closer to the reality for elders, but that’s another subject.

My point is that most of us ought to know that neither the Congress nor the White House is responsible for the freeze; indeed, many congressional Democrats have been pushing for a one time payment of $250 for everyone on Social Security.

If that doesn’t happen in the lame duck Congress because of the coming changes in power, those deluded seniors who voted for Republicans because they were angry over the COLA will get what the rest of us don’t deserve – cuts in Social Security benefits or maybe an attempt at privatization.

Similarly, if the polling was accurate, millions of older voters who should have known better were suckered into falling for the ads of the phony right wing senior group, 60 Plus, the Republicans who all voted against health reform, the U.S. Chamber of Commerce and, of course, the health insurance lobby, and believing that the reforms will cut more than $500 billion from your Medicare over the next decade. They were wrong.

One of the best health care reporters, Trudy Lieberman, of the Columbia Journalism Review, put the so-called Medicare cuts in perspective on November 1:

“The health reform law cuts the growth in Medicare spending by $533 billion. Some might like to call that a saving [as President Obama has done] because Medicare might not be spending as much as it otherwise would, but the term can be confusing.

“But the law also adds $105 billion in new spending for more coverage for seniors who have very high drug expenses and the elimination of copayments for preventive services. The net reduction in Medicare spending is $428 billion over ten years...

“About 40 percent of these cuts come from cuts in payments to hospitals and other providers, except doctors. That money will be used to subsidize insurance policies for the uninsured.

“Another 25 percent comes from reductions in the overpayments to Medicare Advantage plans,” which cost nine percent more than Medicare spends per beneficiary.

“Phasing out the overpayments,” Lieberman continues, “will also hold down increases in Part B premiums...While cuts to MA plans may be unpopular with those who have them, they do strengthen Medicare for everyone.”

So, why will we haggle over the price of meat or an oil change, but we will believe the very people who voted against health reform and have promised to kill the best parts of the bill that passed? How come older Americans confused over the health care selfishly voted to put Medicare itself in danger?

Democratic pollster Celinda Lake said the right wing propaganda campaign was working in the mid-term elections.

“The biggest problem Democrats have with the health care bill,” she said,“ is the dislike of the bill by senior citizens, who have been scared to death about it.”

Judith Stein, who runs the Center for Medicare Advocacy, said of the ad campaign,

“It’s a way to get seniors to vote against those who supported health reform.”

President Obama shares some of the blame when he helped sell the reforms by emphasizing that they would “save” more than $500 billion in Medicare. The so-called savings strengthened Medicare. But because the reforms were themselves complex, what got lost in translation were at least two facts: the savings extended the life of the Medicare Hospital Insurance Trust Fund, and cut only some of the overpayments to private insurance companies that sell Medicare Advantage coverage. Those policies are not good for traditional Medicare.

Let’s recall that such policies were instituted by Republicans under Newt Gingrich in 1995 to wean seniors away from, and undermine, traditional Medicare in favor of HMOs and PPOs. Fifteen years later, only 25 percent of seniors have such insurance and under the reforms, they would not have lost their coverage.

The federal government has spent billions of Medicare dollars to subsidize that 25 percent. But these short-sighted Medicare beneficiaries were willing to privatize their Medicare. Some beneficiaries even declared during town meetings that “government should stay out of Medicare,” an obvious oxymoron since the government runs Medicare.

Now they may get their wish for they’ve opened the door to a new Republican effort to get the government out of Medicare. One coming proposal would substitute your Medicare benefits for vouchers, which beneficiaries would use to buy coverage from insurance companies.

To allay fear of change, none of the MA companies, under the law, are permitted to reduce Medicare benefits. But most were remaining in business despite the cutbacks in federal subsidies.

In any case, as Stein points out, nothing in the law could reduce Medicare’s benefits; indeed, they were expanded with the savings able to pay the full cost (no more co-pays) of yearly physical exams, preventive services such as mammograms, colonoscopies, prostate tests, flu shots and vaccinations.

Republicans, who will be in control of the House come January, have vowed to kill many of the health care reforms perhaps by starving the reforms of funds. And they want to hold hearings to grill Health and Human Services Secretary Kathleen Sibelius and the head of the Centers for Medicare and Medicaid Services, Dr. Donald Berwick.

But some of the reforms, like the free preventive services and coverage for children and adults with pre-existing conditions, may be too popular for Republicans to attack. In addition, the Democratic Senate can, in a turnabout, block the excesses of the right-wing House. And President Obama can use the power of the veto, if he hangs tough.

Sadly, though, nothing new for seniors - like long term care - will get done in this reactionary, penurious new Congress.

Lieberman concluded in the Columbia Journalism Review:

“Most people, especially those on Medicare, have never really understood how the program works. That made it easier for each side to get away with advertising flim-flam.”

I wonder if those older people have learned enough to protect not only Medicare, but the Republicans’ favorite target – Social Security.

Write to saulfriedman@comcast.net

GRAY MATTERS: A Ray of Light for Health Insurance Consumers

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

It’s nice to report, for a change, some good news for beleaguered consumers. The greedy health insurance industry, which has been lawyering up and lobbying to dodge the most important requirements of the Affordable Care Act has lost an important battle this month.

As Wendell Potter, former insurance company executive turned consumer advocate, put it at Huffington Post on October 21,

“This time our state insurance commissioners...did the right thing for consumers when they refused to cave in to intense pressure from the profit-obsessed insurance industry to gut an important provision of the health-care-reform law.”

Consumer Watchdog, covering the National Association of Insurance Commissioners (NAIC) meeting in Orlando, said it more simply: The commissioners

“sent rules to the Department of Health and Human Services that will require insurers to spend more money on health care and less on administration and profits.”

Now it will be up to HHS Secretary Kathleen Sibelius to write regulations that are designed to enforce the rules, and that will be tough. The insurance companies have not cooperated with the health reforms as President Obama naively hoped. Indeed, several companies have sharply raised premiums by double digits in advance of the rules and announced they would not offer the coverage the law promises.

As a result, Consumer Watchdog and other advocates have called on the White House to freeze premiums until the industry complies with the pricing provisions of the new law which requires them to explain further increases before they take effect.

Sadly, all Sibelius and the administration can do is appeal to the industry for there is little in the law, aside from light civil penalties, that they can do to punish the companies and there is no legislative limit on premiums.

What there is in the law, as I’ve discussed in an earlier post, is the crucial requirement called the “medical-loss-ratio”(MLR) that companies must spend 80 to 85 percent on premiums on actual health care; the former number is for smaller insurers, the latter for the big ones. The rest, 15 and 20 percent, is supposed to be spent on administration and profits. If enforced, insurers that do not meet these requirements must issue rebates to beneficiaries.

Some critics say the MLR, which grants insurers the possibility of making profits of 15 or 20 percent on the premiums is too generous. The insurance lobby has protested that the requirements will hurt beneficiaries and encourage fraud and cheating.

The law gave the task to the NAIC to look at the books of the companies and figure what costs can legitimately make up the MLR. The commissioners have been meeting for nearly six months to come up with recommendations designed to satisfy consumers and the insurers. But the companies, as you’d expect, have sought to cripple the MLR with amendments.

Aside from raising premiums to evade the effects of the MLR, the insurers have sought during the past six months to convince the commissioners to agree that every dollar they spend on sales personnel, advertising, marketing, phony promotions and other extraneous expenses should be categorized as “health care,” rather than administration.

For example, they sought to include community-based “wellness” promotion campaigns, which help publicize the insurer’s offerings and is nothing more than public relations. The companies also wanted some of their federal and state income taxes counted as health care expenditures to which the NAIC agreed.

But the commissioners turned down the insurers request to include as health care costs the taxes they pay on investment income. Similarly, the NAIC turned down the industry’s proposals to deduct broker fees, average their medical spending nationwide rather than state by state and loosen rules for smaller companies that don’t quite meet the 80 percent requirement.

As Potter pointed out, the timing of UnitedHealth’s announcement of a 23 percent increase in profits for the third quarter two days before the NAIC meeting undercut the insurers’ appeal for more loopholes to dodge the requirements. As a result, the commissioners rejected most of the insurers’ proposed amendments. Potter said the regulations approved by the commissioners represents a compromise that will make it easier for the industry to comply with the MLR.

But we can expect American Health Insurance Plans (AHIP) to take their lobbying effort to Sibelius who has already issued 30 waivers to company insurance plans that claimed they were having difficulty complying.

Consumer Watchdog said that despite the victory in Orlando, “the rules still contain significant concessions made to insurers.”

They include allowing companies to subtract the federal and state income tax they pay on premium revenues before calculating medical expenses; allowing companies to classify as “health quality improvements” the costs and salaries of clerks who reject claims; the cost of phone hotlines to handle consumer questions and complaints; and the cost of penalties the insurer are supposed to pay for not meeting the law’s requirements.

“Making these rules work,” said Carmen Balber, Washington director of Consumer Watchdog, “will require tough scrutiny of insurance companies’ spending to make sure they don’t use loopholes...to pass off overhead costs as health care.”

Sibelius said the commissioners’ recommendations “are reasonable, achievable for insurers” and she promised to “work quickly to promulgate this regulation” using the commissioners’ recommendations. But does the administration have the stomach to wage a constant fight with insurers for whom the health reforms were tailored? And will HHS have the financial expertise to examine and interpret the books of the companies? Can the insurance industry be required to cut their own profits, as the law intends?

Karen Ignani, president of the insurers’ lobby, signaled its intentions to fight and dilute the MLR on the grounds that stock prices may decline and discourage investment in insurance stocks. She commented on the NAIC meting:

“Defining health care quality initiatives in a way that is too narrow or static will turn back the clock on progress and create new barriers to investment in the many activities that health plans have implemented.”

Potter replied: “If the health plans that take our money but give us lousy coverage in return are forced out of the marketplace, I say good riddance.”

He acknowledged, however, that if smaller companies fail, concentration in the industry will increase. And so will the power of the large insurers to tailor the final regulations to their liking.

A final note: Medicare for All would generally eliminate the need for most health care insurance.

Write to saulfriedman@comcast.net

GRAY MATTERS: Possibilities for Medicare For All?

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Who would have guessed that one of the most right-wing Republicans in the Senate would predict that the American people, sooner rather than later, will see the passage of single-payer, universal health care such as Medicare for All?

I hasten to add that this prediction from Senator Tom Coburn of Oklahoma, would not be to his liking; indeed he’d probably fight to his last breath to prevent such a proposal from becoming law.

Coburn, a physician, is known as “Dr. No” because of all the nominations and legislation he has obstructed with his lone objection, the latest being the emergency aid to the earthquake victims in Haiti. He’s also the M.D. who suggested we pray that the late Senator Robert Byrd (D, WV), would be too ill to cast a crucial vote on health reform, which Coburn opposed. (Byrd voted and the health reforms passed.)

Now that the Affordable Care Act is law, Coburn predicted in a speech earlier this month to the Republican Women’s Club of Tulsa,

“There will be no insurance industry left in three years. That is by design. You’re going to make insurance unaffordable for everyone - which is what they want. Because if there’s no private insurance left, what’s left? Government-centered, government-run. Single-payer health care.”

The reforms, he said, will mean “the beginning of the end of America” unless they are killed by repeal, or the courts.

He didn’t explain who is the “they” who want insurance to be unaffordable. The Obama administration has criticized companies that have sharply raised premiums and asked them to desist. And the law’s requirement that individuals must buy insurance (the so-called individual mandate), subsidized by the government, is expected to add millions of new customers to the insurers’ rolls.

As far as I know, no one in the Obama White House is plotting to extend the health reforms into Medicare for All, which is too bad. But Coburn may be right without knowing why; the greed and stupidity of the insurance and drug industries could kill the reforms and bring on true universal health care if they continue their rapacious conduct.

That’s a strong possibility, according to a more rational and traditional conservative, Professor Paul J. Feldstein, of the University of California and an expert in Health Care Management in the school of business who has written text books on health economics. He was interviewed for the journal, Nursing Economics, by Peter I. Buerhaus, on the faculty of Vanderbilt University.

As Buerhaus wrote, he conducted the interview (may need free registration) because, while the health reforms

“did not include language to transition toward a single-payer system, this does not preclude that over time, and depending on how the legislation is implemented, a single-payer system might eventually be adopted as many people and advocacy groups desire.”

The description “single-payer” can be confusing, and Feldstein defined it:

“When a government is the only payer of health services. It does not mean that the government owns the health provider, like the U.S. owns VA hospitals. An example is Canada, where the government is the only payer for all the basic medical services provided to its citizens.”

Feldstein is not necessarily a fan of such systems; he’s a believer in the market, but he favors some regulation and restraints. When he was asked if the health reforms could lead to the adoption of a single-payer system, Feldstein said,

“I can see a scenario where there is very little cost containment and little pressure to keep insurance premiums from rising substantially. And if there is a weak mandate for individuals to purchase health insurance, then the resulting adverse selection [enrolling too many sick people] is likely to cause insurers to increase their premiums. People will become dissatisfied...and may become more supportive of a government funded public insurance option...

“Eventually, if many individuals purchase public insurance we could end up with a single-payer system or something close to one. We already pay the health care for tens of millions of people with the Medicaid and Medicare programs, and you can just pretty much put a public insurance option together with these programs into one system.”

He acknowledged that a single-payer system would cover more Americans, spend less money per patient and save on the vast administrative costs now spent on the fragmented private health insurance establishment. But Feldstein said a single-payer system would include budget restraints that could retard advances in technology and lead to rationing, inefficiencies and a reduction in preventive care because of the greater demands for acute and urgent care.

Dr. Don McCanne, of Physicians for a National Health Program (PNHP), praised Feldstein for “a more intellectual” and “sincere” discourse on the singe-payer issue. But

“it is distorted by exaggerated potential adverse consequences of single-payers,” he said, “by his failure to include certain inescapable benefits.”

Dr. Quentin Young, Barack Obama’s physician in Chicago before he became president, agrees that the new health reforms could lead to a single-payer system, if it is undermined by its critics, challenges in the courts and “destabilizing pressures” from the insurance industry. Indeed, he adds, “the law may unravel sooner than many suspect.”

Young, a founding member of PHNP, warned that if the Affordable Care Act collapses, “Single-payer Medicare for all needs to be ready to fill the gap...”

And in the meantime, he hoped Obama would reject cuts in Medicare that may be suggested by his deficit commission. “Medicare should be strengthened by improving it and extending it to everyone,” he said.

There are two bills calling for Medicare for All, one (HR 676) that has been introduced by Representative John Conyers (D. Mich), the second longest serving member of the House. Information on his bill may be found at the healthcarenow website.

The second bill, introduced by Senator Bernie Sanders, (I, Vt.), is the American Health Act, S. 703, which calls for state based single-payer systems that combine all current programs such as Medicare and Medicaid. You can study this proposal at govtrack.

When Young was Obama’s doctor, Obama favored Medicare For All, as do many Democratic lawmakers who have co-sponsored the Conyers and Sanders bills. Obama now says he would favor Medicare for All, “if we were starting from scratch.”

Well, why not start? Maybe in the second term, if there is one.

Write to saulfriedman@comcast.net

GRAY MATTERS: Medicare for All

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

When I read that so many Americans don’t understand, don’t like or worse, don’t care about the health insurance reforms that were so hard to come by, I can’t help thinking of that wonderful, climactic scene in On The Waterfront in which Marlo Brando recalls a prize-fight he deliberately lost and tells his brother Charlie that he could have won that bout. “I coulda been a contender,” he says.

I believe people could have been more enthusiastic about the reforms, such as they are, if Barack Obama had not been so quick to compromise with big drug and insurance companies. He could have fought to give us, the American people, the change he promised - a universal health care bill they could understand, like the one he was for before he became president.

Why do today’s Democratic presidents (e.g., Bill Clinton) believe they must move to the middle to govern? Franklin Roosevelt and Ronald Reagan, whom Obama praised as transitional presidents, didn’t do that.

We could have had a less complicated, more easily understood bill without all the ifs, ands, buts and loopholes that the insurance and drug industries are wiggling through as we speak. It’s downright sad that so many good Democrats in Congress are running away from the reforms in the coming election.

Or, they’re having a hard time explaining and defending their votes for the thousand page Patient Protection and Affordable Care Act (PPACA), most of which won’t take effect for three more years by which time these lawmakers and the president will have had to run again.

In September, six months after the reforms became law and despite the administration’s efforts to publicize its accomplishments, the Pew Research Center reported that only 38 percent of the public approves of the law, while 45 percent disapproves and rather than wait to see if it works, 32 percent favor repeal.

The same poll, however, found large majorities of older Americans (69 percent) adamantly opposed to a Republican proposal to replace Medicare with vouchers for beneficiaries to use to pay for their care.

The popularity of Medicare, even among younger people, should have told the Obama White House which way to go with health insurance reform. An Associated Press poll in late September reported that 61 percent of respondents believe Obama should have gone further to change the system. A Kaiser survey found only a slight increase in support for the reforms.

I can understand why so many people are lukewarm towards the health reforms. They watched as the president, in order to get some cooperation from PhaRMA, the Pharmaceutical Research and Manufacturers Association, and America’s Health Insurance Plans, AHIP, the insurers, steadily gave in on key issues and then gave away the possibility of a public option, like Medicare.

A public option, as the president himself said, would have given consumers more choices and some leverage over the big insurers to bargain on premiums and hold them to the new regulations. Obama would have earned more support from the people who voted for him.

But now we know from former Senator Tom Daschle, among others, that Obama was ready to cave in on that issue early when PhaRMA and AHIP demanded that in exchange for their support. Daschle admitted as much in his account of the health reform battle in his new book. He later partially retracted his admission in an interview, but others knew the truth.

Senator Russ Feingold (D-Wis.) has said that there was no public option in the final bill because the White House never pushed for it unambiguously. Thus, the health care we’ll get is almost completely privatized, dependent on the insurance and drug companies, all of which can look forward to record profits because the reforms mandate that millions must buy insurance with premiums subsidized by Washington.

Despite the criticism from the right, the government is not taking over health care as much as it is trying (vainly) to regulate insurance companies in return for guaranteeing them tens of millions more customers.

To be fair those regulations, if enforced, will eventually help get coverage for most of the 50.7 million Americans who are uninsured, an increase of 4.3 million over last year. For when the reforms took effect on September 23, its supporters were able to point to some positive effects of the health insurance reforms:

• Covering young adults until age 26
• Helping people with chronic conditions by ending lifetime limits on new policies
• Covering children with pre-existing health problems
• Expanding preventive care such as free flu shots, mammograms and colon exams for persons not on Medicare

But as Daschle wrote for Kaiser Health News, the top-heavy complexity of the law and the resistance to it by insurers and several states have made it necessary for Kathleen Sibelius, the Health and Human Services Secretary to issue additional regulations, guidance and clarifications to keep up with puzzled inquiries from consumer groups and lawyers for providers who read the fine print, looking for ways to dodge the letter of the law.

As a result, she has sought to set up temporary “high risk pools” run by the states and the federal government to cover adults with pre-existing conditions who have been unable to get insurance. She has appealed to insurers who have sharply raised premiums or refused to cover children; six companies, including Anthem, Aetna, Cigna and Humana say they’ll stop writing policies for children not also covered by their parents’ policies.

A reader informs me that insurers are denying coverage for neurological testing of children, thus preventing diagnoses.

And insurers have lobbied furiously with state insurance commissioners to avoid the requirement that they spent 80 to 85 percent of premiums on health care. As a result, USA Today reports, Sibelius has had to issue 30 waivers to companies and their insurers, including Cigna, who say they can’t meet those requirements. The White House said it was the best way to keep people insured until the law fully takes effect in 2014.

Medicare went into effect a year after its passage in 1965. And even now, with four parts (A, for hospitalizations; B, for outpatient services; C, for Medicare Advantage - comprehensive, partly private coverage; and D, prescription drugs), it is not as complex as the Affordable Care Act. I’m attaching here a handy list of Medicare health and drug plans [pdf] for every state.

By 2019, when the ACA is to be fully implemented - if it is not whittled away by Republican enemies who don’t believe government should play a role in health care - there will still be 23 million uninsured, and there will have been 500,000 deaths among them. So says Dr. Henry Abrons, of the Physicians for a National Health Program in California.

Those figures, derived from the Census report, he added,

“underscores the urgency of going beyond the Obama administration and swiftly implementing a more fundamental reform – a single payer national health insurance program, improved Medicare-for-All.”

Right-wing critics charge that the Affordable Care Act is a foot in the door to get Medicare For All. Let’s hope they’re right.

GRAY MATTERS: Comparing Midterms 1934 and 2010

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I was barely around in 1934 but I will lay odds that there was no argument in my parents’ household about the forthcoming midterm elections. Indeed, in virtually all of working class New York City, it would have been considered a sin not to vote straight Democrat – for the party of Franklin Roosevelt.

I have alluded to that election in other posts as a lesson for today and President Obama for Roosevelt’s New Deal, while full of promise and proposals, had not yet broken the death grip of the deep recession, which was to become known as the Great Depression.

It was to wear on until the eve of World War II. But, as I’ve said, Roosevelt’s support among voters (now called his “base”) lasted through 1945. And the New Deal’s legacy has outlived his detractors.

By 1934, Roosevelt had closed the banks, 9,000 of which had failed, to avoid further runs and losses of depositors’ money. He had shoved through a frightened Congress 100 days of action, including the Glass-Steagall Act, which barred commercial banks from speculating in investments the market with depositors’ money, and created the Federal Deposit Insurance Corporation (FDIC).

The Agriculture Adjustment Act stabilized farm prices, and the Tennessee Valley Authority held the promise of bringing electrification to the poverty-stricken deep south.

Nevertheless, in 1934, Roosevelt found himself beset by the impatience of supporters and the deep hostility of the powerful Republican money changers whose selfishness and conniving had brought on the worst domestic catastrophe of the new, 20th Century.

Roosevelt sought to save capitalism from the left- and right-wing radicals of the day, yet he was called “socialist,” “communist” and worse. Just over the horizon loomed the threats of Italian Fascism and German Nazism. And the polls of the day predicted losses in the elections for the Democrats and Roosevelt’s fledgling New Deal.


It was therefore instructive to read on the web site, New Deal 2.0, a project of the Franklin and Eleanor Roosevelt Institute, an account of the 1934 election by Roosevelt historian David Woolner, a fellow in residence at Hyde Park.

“In spite of his overwhelming success in the presidential election of 1932, there was no guarantee that FDR would lead his party to victory in 1934,” Woolner wrote. “Then as now, it was something of a truism that the party in power would lose seats in the midterm election.

“Moreover, 1934 was the year that the arch right-wing and left-wing reaction to the launch of the New Deal would begin to coalesce around a variety of newly formed ‘populist’ organizations that claimed to represent the will of the people.

“It was in August of 1934, for example, that a group of hardcore conservative Democrats and Republicans – financed by some of the most prominent names in American business – formed ‘The American Liberty League,’ an anti-government, pro-market organization that accused FDR of leading the country down the path of a socialist dictatorship.”

Among the League’s backers were the DuPont family and the leaders of General Motors, General Foods, Chase National Bank and Standard Oil.

The League will sound familiar for, as Woolner wrote,

“it attacked nearly every New Deal measure under the guise of its goals ‘to defend and uphold the [U.S.] Constitution...to teach the duty of government to protect individual and group initiative and enterprise, to foster the right to work, earn, save and acquire property...’

“In hundreds of published pamphlets, the League sent mixed or contradictory messages, variously accusing the New Deal of being inspired by fascism, socialism or communism. And the president’s leadership of being so strong that it was tantamount to the establishment of a dictatorship, or so weak that he rendered himself unable to ward off the sinister influences of his socialist advisers.

“The league saw economic planning and regulation as a threat to American values, the growth of the national debt as a sign of permanent decline.”

But Roosevelt’s fireside radio chats, his magical voice and his optimism cut through the incessant criticism from virtually every newspaper, helped in part by a rebound in economic growth and the stock market.

Besides, Roosevelt held informal press conferences in the Oval Office every Monday morning, beginning with the president asking, “What’s on your mind, boys?” He had the reporters on his side, if not their publishers. And it was his way of keeping in touch with the public.

In addition to the attacks from big business, Roosevelt had to contend with challenges from phony populists. Senator Huey Long of Louisiana established the “Share the Wealth Movement,” which called for a 100 percent tax on earnings over a million dollars and a guaranteed income of more than $2,000 for millions of American families.

The so-called “Townsend Plan,” called for the a monthly pension of $200 for everyone over 60. And the radio priest, Father Coughlin, was as popular and as vitriolic then as the Becks, Limbaughs, O’Reilly et al are today.

Woolner writes that Roosevelt took on the League, using his friends in the press to expose its ties to the business elite and the U.S. Chamber of Commerce, one of

Obama’s arch critics today. And Roosevelt, from one of America’s most aristocratic families, never hid his disdain for the corporate captains, whom he derided as “economic royalists.”

He told the Democratic convention that nominated him in 1936, what had been on his mind:

“These economic royalists complain that we seek to overthrow the institutions of America. What they really complain of is that we seek to take away their power. Our allegiance to American institutions requires the overthrow of this kind of power. In vain they seek to hide behind the flag and the Constitution.

“In their blindness they forget what the flag and the Constitution stand for. Now, as always, they stand for democracy, not tyranny; for freedom, not subjection; and against a dictatorship by mob rule and the over-privileged alike.”

The Tea Party, Woolner writes,

“shares many of the same tenets and clearly emerged from the same forces and fears that gave rise to the American Liberty League in 1934...To date President Obama has chosen not to take on the Tea Party with anything like the same rhetorical conviction, preferring to take a more reasoned as opposed to emotional approach to a remarkably similar anti-government backlash in a time of crisis.”

Americans love a good fighter. In November 1934, against the odds and history, Roosevelt’s Democrats picked up nine House and nine Senate seats. In 1936, Roosevelt embarrassed the pollsters with a then unprecedented landslide over the Republican darling of big business, Kansas Governor Alf Landon.

Write saulfriedman@comcast.net

GRAY MATTERS: New Ideas For Social Security

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Here’s a novel idea. Instead of worrying that Social Security will go bust in 30 years (it won’t) and considering absurd and unnecessary cuts in benefits for millions of Americans, why not expand this, the most popular social insurance program in the country, to provide for a universal defined benefit pension for every worker and his/her family?

It’s really not such a unique idea; most modern and civilized industrial nations have in place such pension systems, although some are not as generous as Social Security. But while Social Security was designed to replace about 40 percent of a person’s final wages, and does a good job keeping most of us out of the poor house, it has some glaring weaknesses that could be addressed by expanding the program.

Social Security (average benefit, $15,588 for men; $12,012 for women) alone is not enough to provide a stable, poverty-free retirement for many Americans – the very old, especially widows who have not worked, workers who are too young to retire but have been unable to find steady jobs with decent salaries, students whose families have lost their breadwinners, Hispanics and blacks who have made little money during their life times.

Time was that a factory or white collar worker could count on a defined benefit company pension. But they have disappeared in favor on individual retirement savings plans like 401(k)s which shifted most of the responsibility for savings and investment from the company to the worker.

And, as we shall see, those plans have proven to be a mirage; even before the market bust, their value was not nearly enough for even a couple of years of retirement.

A favorite of mine, economist Teresa Ghilarducci of the New School for Social Research, was the first to call the 401(k) a failure for retirees and she shocked lawmakers when she suggested they be ended in favor of what she calls a Guaranteed Retirement Account that would be as safe and secure as defined benefit pension plans. Today, two-thirds of the few unionized workers have such defined pensions compared to only 15 percent of non-union workers.

Even Time magazine joined her criticism of 401(k)s and their like, pointing out in October of last year “the ugly truth is that the 401(k) is a lousy idea, a financial flop, a rotten depository for our retirement reserves.”

About half of American workers have such plans and their average value is just $45,519 and, of course, dependent on the roller coaster of the market and subject to the fees charged by fund managers.

Journalist James Ridgeway summed up the retirement dilemma for millions of American families in a recent issue of Mother Jones:

“I contemplate my future at a time of deep recession with no pension and a depleted 401(k). And it occurs to me that the very notion of a comfortable, paid retirement may turn out to have been a temporary phenomenon, with a life span almost precisely as my own...

"And I have to wonder if someday the tale of a foolish generation of Americans, who imagined that a lifetime of work would be rewarded with a comfortable and secure old age, will become just another footnote in the annals of the market.”

If I may digress, there is (and was) a difference between what Ridgeway called his “foolish generation” and mine, which weathered a depression and a really big war and learned a few things. We were unionized, we fought and bargained for company pensions (and health care) and we were not so trusting of the free and unregulated market to see us through our old age.

Sure, we saved, but our savings were to be one of three tiers for retirement, along with the guaranteed company pension and Social Security. It’s also been likened to a three-legged stool.

Now, according to Richard Trumka, president of the AFL-CIO,

“[O]nly 13 percent of workers say they are very confident about having enough money for a comfortable retirement – that’s the lowest level in 16 years...With the enactment of Social Security and the growth of union-negotiated pensions, elderly Americans became [and are still] the least impoverished age group.”

But for a younger generation, Trumka said, two of the three tiers (legs) are disappearing and “Social Security is the ONLY reliable guaranteed benefit for the growing number of people without pensions.”

Just as my generation fought for Medicare and universal health care, Trumka concluded, “Universal retirement security is our next hurdle.” He could have added that it’s an idea whose time is coming.

In the meantime, the National Academy of Social Insurance has some ideas to close some holes in Social Security – increase benefits for persons 85 and over; pay a widowed spouse 75 percent of the couple’s prior benefits instead of 50 percent; provide child care as a benefit; update the special minimum benefit to 125 percent of poverty; pay benefits to students who have lost a breadwinner up to age 22 instead of 18-19; increase benefits across the board for all individuals in the next year or so, to make up for losses in savings.

Stephen Hill, reported on a study by the New America Foundation [pdf], which outlined how Social Security could double its revenue and spread its enhanced benefits further, freeing employers from providing retirement, which would eliminate the employer tax deductions, which cost the treasury billions.

Hill called it “Social Security Plus,” and suggested that greater benefits could not only help the economy but could eliminate the individual tax deductions which only benefit people who can afford 401(k)s and IRAs.

Ghilarducci makes the same point, that 401(k)s and IRAs, in which taxes on earnings are deferred, reduce tax receipts by $193 billion a year. But, she says, 80 percent of these tax breaks go to the top 20 percent of taxpayers.

Her solution: “Guaranteed Retirement Accounts” to which employers and employees would each be required to contribute 2.5 percent of salaries, with a $600 refundable tax credit for the employee’s contribution.

The accounts, which could not be touched until retirement, would be pooled and managed by professionals as private defined pensions are now managed, with a target of a three percent return above the rate of inflation.

“National savings would get a boost,” she wrote in Bloomberg Business Week last July. “All Americans, including the 64 million who have no pension plan, would get one at no extra cost.”

Hers was one of a number of proposals for guaranteed, government-sponsored annuities or pension plans offered in September at a conference on retirement security, sponsored in part by Retirement USA, a new coalition of unions, senior groups, the liberal Economic Policy Institute and the non-profit Pension Rights Center.

This month it is in the midst of a campaign called Wake Up Washington, opposing cuts in Social Security while seeking a universal retirement system for America to replace what it calls “the patchwork of private plans.”

Why do we need it? On September 16, the non-partisan Center for Retirement Research at Boston College told Retirement USA that the gap between all the assets American households have, including homes, IRAs, 401(k)s and other savings, and the amount they will need for a decent retirement is $6.6 trillion. The calculation was based on the Federal Reserve’s Survey of Consumer Finance.

I can’t begin to fathom such a number. But even this “foolish generation” must know that unless things change, their lifetime of work may not be rewarded with a comfortable and secure old age.

Write to saulfriedman@comcast.net

GRAY MATTERS: A 21st Century New Deal

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I first met Marcy Kaptur in 1982 when she was a long-shot Democrat running for a House seat in northern Ohio. As I recall, my story bet that she would win. Now Kaptur, who is from Toledo, is the longest serving woman in the House and named by her colleagues as one of the most valuable. She is also tilting at another windmill.

Because she’s a quintessential liberal Democrat with a moderate touch (she’s opposed to abortion) and 26 years of successful politics, you’d think that President Obama, who just got finished campaigning in depressed Ohio, would pay attention to her. But she’s among the progressive Democrats cursed by Rahm Emanuel as “f***ing retarded” and ignored by the rest of the White House honchos because they challenged Obama’s vain reach for the center and the mirage of Republican support.

Kaptur, who has been a Democratic activist since age 14, has deep roots in blue-collar America, which is where this administration needs help. She is the daughter of Polish-American grocers and still lives in her family home.

As a member of the Budget Committee and House Oversight and Government Reform Committee, she helped lead the grilling of the financial geniuses including Treasury Secretary Tim Geithner, who helped topple the economy then rewarded the banks for their generosity.

She is also on the Defense Appropriations subcommittee. Among her accomplishments was the success of legislation, after a 17-year battle with too many bureaucracies, for the creation of the vast World War II memorial on the Washington Mall which she helped dedicate in 2004. The idea for the memorial, which is a top tourist attraction, came from a constituent, Roger Durbin, a letter carrier who wondered why there were Korean and Vietnam memorials but none for America’s greatest conflict.

A bit of a throwback to the New Deal, she has pressed the White House and Congress to resurrect the very effective Glass-Steagall Act, which separated commercial banking from investment banking. But it was repealed in 1999 by some of the same people who are now top White House economic advisers.

And, she says, the new financial services regulations they helped craft are so full of White House compromises, few Americans understand it. Although the bankers seem to like it.

Now, once again, Kaptur finds herself backing a legislative long shot that makes sense to many economists, but not the president’s economic advisers who are stuck fast in the mud of a jobless recession and have no ideas about how to escape.

She may be whistling in the dark, but she introduced last December, HR 4318, which would

“authorize the president to reestablish the Civilian Conservation Corps as a means of providing gainful employment to the unemployed and underemployed citizens...through the performance of useful public work...”

She calls it the “21st Century” version of the CCC, one of the New Deal’s most politically popular jobs programs.

One of Kaptur’s aides called my attention to her bill which echoes the legislation proposed by Franklin D. Roosevelt in his first month as president in March 1933. As the Great Depression wore on, the CCC put three million young men to work planting trees, improving the national parks, building state parks, erecting fire towers, improving roads and dams.

The CCC’ genius is that it concentrated on jobless young men, 18 to 16, thousands of whom wandered the land as hobos. And much of their modest earnings was sent home. Kaptur’s bill, of course, would include women and there are no age limitations.

With more than 15 million Americans, including more than 10 percent of Ohioans out of work, the legislation says it is designed

“to relieve the acute condition of widespread distress and unemployment existing in the U.S. and to provide for the restoration of depleted natural resources...and the advancement of an orderly program of useful public works.”

The work to be done includes forestation of public lands, the prevention of forest fires, floods and soil erosion, pest control, construction, maintenance and repair of roads and trails, overseen by the Interior Department.

President Obama’s first stimulus proposal, which was watered down, and another just announced is running into the Republican “no.” But although they were meant to create public works jobs, the money did not go directly to hire workers, but to cities, counties and contractors and have made scarcely a dent in the jobless rate.

The CCC, like the New Deal’s Works Progress Administration, would hire and pay workers directly for their work as employees of the federal government.

Kaptur’s legislation asks for $16 billion for each of the next four years to finance the CCC. In a letter appealing to colleagues to co-sponsor her legislation (so far seven house members have signed on), Kaptur suggested that the National Guard and other federal and state agencies could help manage the corps. “We again have the opportunity to make as grand a contribution as President Roosevelt,” she said.

There is little doubt Republicans will resist the legislation but Obama could, like Roosevelt, put his power behind it, using labor unions and progressive groups to embarrass Republicans who claim they want to see progress on job creation. But I doubt the White House knows about the legislation or cares.

Obama claims he admires the New Deal, but so far he has not come close to employing its solutions despite appeals from the best economic minds in the country – including Nobelists Joseph Stiglitz and Paul Krugman.

In a New York Times Op-Ed entitled, How To End The Great Recession, former Labor Secretary Robert Reich noted that

“the Great Depression and its aftermath demonstrate that there is only one way back to full recovery – through more widely shared prosperity...New Deal measures, Social Security..unemployment insurance...the minimum wage...the GI Bill...created rapid growth and more jobs.”

Even more conservative economists have called for New Deal style job creation measures. But if Obama, mired in conventional, no-win proposals, does not respond, it would not be the first time Kaptur has been disappointed in her president. In an interview with Guernica Magazine, she blasted Obama’s economic advisers, specifically Lawrence Summers, who helped kill Glass-Steagall, and Geithner:

“Anyone who’s had their fingers on any of the financial damage that’s been done should not be allowed to serve in the federal government...That revolving door should be slammed shut How can you have the architects of the disaster in charge of the remediation?”

Asked about Obama’s record on the economy, she said,

“It’s not GDP, it’s JOB. That means we need jobs. “ She was asked, “What grade you would give him?” She replied, “The largest room is room for improvement. In my region, he wouldn’t be passing. He’s got the wrong economic advisers. But they seem to take care of Wall Street just fine.”

Perhaps that’s why he’s facing midterm losses; Roosevelt gained House and Senate seats in 1934.

Write to saulfriedman@comcast.net

GRAY MATTERS: How Socialism Really Works

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

There is at least one organization that won’t label President Obama a “marxist” or “socialist,” and it ought to know. I speak of the Democratic Socialists of America, a tiny group of less than 6,000 members that is rather benign and wholly within the American mainstream compared, say, to the extreme radicalism of the raucous anti-government Tea Parties.

The DSA was founded in 1982 by the late Michael Harrington who won fame in the Sixties for his book The Other America,” a passionate expose of rural and urban poverty that shocked the nation and brought about Lyndon Johnson’s war on poverty.

Harrington’s DSA co-founder was Barbara Ehrenreich, a prolific journalist whose books, Nickeled and Dimed and Bait And Switch, chronicled the business practices that have victimized low-paid workers and consumers. Unlike the far right Republicans and Tea Baggers, Harrington and Ehrenreich were (and are) people of talent and accomplishment and, as far as I know, they have not sought the overthrow of the government or the destruction of a president.

In fact, if you visit their web site, you will see how close to the American ideals these socialists are. They call themselves the Democratic Left and they have nothing in common with the centralized communist regimes of the former Soviet Union, Eastern Europe, North Korea and China.

It is true that Harrington embraced the theories of Karl Marx who held that unfettered capitalism would fail because the rich would get richer and the rest would be exploited by corporate excess. But those were also the views of Adam Smith and John Maynard Keynes, both of whom were in favor of government intervention to tame capitalism.

True to our Democratic values, the DSA does not call not for government ownership of private business, but for tempering the excesses of the unregulated, free-wheeling market economies with Social Democratic reforms such as health care, social insurance and public education like those in most of Europe, Japan and other enlightened countries.

As the DSA web site says,

“In the short term we can’t eliminate private corporations, but we can bring them under greater democratic control. The government could use regulations and tax incentives to encourage companies to act in the public interest and outlaw destructive activities such as exporting jobs to low-wage countries and our environment.”

These could have been the goals of Republican presidents like Teddy Roosevelt, creator of our national parks, trust buster William Howard Taft, Dwight Eisenhower, who sponsored the Interstate Highway system, or Democrats like Harry Truman who confronted Soviet communism, or John Kennedy, who championed civil rights.

Only the very far right, which is what Republicans have become, could disagree with those sentiments. But they seem so ignorant of the consequences of their hard shell, laissez faire views that they would destroy in government what is in their own best interests. Their targets include Social Security, Medicare, Medicaid, the Department of Education, public education itself (Thomas Jefferson’s idea), the civil rights laws, the Elementary and Secondary Education Act.

What’s next? The VA medical system? The Tennessee Valley Authority? Government owned military hospitals? The Post Office? Public highways? Public utilities? Surely many tea baggers use these services. Were millions of us un-American when we used the GI Bill?

My quarrel is not with these know-nothings who pop up now and again in American politics; they won’t succeed. My aim is to give lie to their fears and fear mongering of Democratic-based socialism. That happens to be as American as the pioneers who came west in communal wagon trains or the railroads, built with the help of government on public lands.

Even at its birth and in war, the government acts of 1787 and 1862, which opened the northwest territories, created land grant colleges and enabled farmers to stake their 40 acres. Jefferson’s Louisiana purchase was not specifically permitted by the Constitution, nor was the purchase of Alaska in 1867. Should we give them back?

When I wrote a few weeks ago that the VA health system, among other American enterprises, was socialist, most of my replies via the internet were positive and supportive. Many Americans, if truth be told to them, would welcome some democratic socialism - in health care and other public services like good roads and strong bridges and street lights, which are disappearing.

One of my readers, unsigned, wrote,

“The only thing better than Medicare or the VA is having both...I was on my way to the Minneapolis VA hospital for a 2PM MRI on a Sunday...when I had chest pains and shortness of breath. So I went to the VA emergency room...I had three doctors, three nurses and three technicians treat me before sending me on to my MRI (where the technician waited for me until 4PM.) Anyone who claims the government can’t do health care should walk a mile in my orthopaedic shoes.”

On the other hand, Marcelo M. writes,

“If anything, the VA system is the poster child as to why we shouldn’t have socialized Medicine...Mandates that require you buy health care violates the Constitution...”

(That is questionable, but the issue is before the courts.)

And Jerry L. says “medical care can’t be a free lunch,” and he suggests competition could hold down costs if patients and insurance companies can choose among doctors and hospitals.

But “kerewin21" asks,

“How does the VA system violate the Constitution? And he adds, “It’s really hard to make medicine into a truly competitive marketplace...Do you choose the doctor who costs half as much for your knee surgery? Do you call around to emergency rooms to find out who charges the least for a CT-scan?”

Americans who have not traveled abroad tend to belittle the experiences of Europeans like David Jordan, who is a British PhD, in geophysics and leader of a university research team. He was in business for many years and now lives in Germany’s social democracy.

“Politically,” he writes, “I’m a caring capitalist but my only affiliation is to Whatever Works. Ideologies give me the creeps.”

He’s a fan of Britain’s National Health Service even though the waiting room at a doctor’s office may include unwashed working stiffs. But he praised his emergency room treatment of a bad chest infection, and the NHS was there to help his wife give birth at home (his choice) to two children. “For free,” Jordan said. “It was wonderful. Can’t do that in the U.S....Isn’t socialism a bitch?”

The Nation’s Katha Pollitt, back in New York after a year in Germany, observed in a September 2 essay entitled, It’s Better Over There, that

“not once in my time in Berlin, which is a relatively poor city,” did she see “the kind of destitution we take for granted in the United States...The strong German safety net keeps people from plunging into the abyss.”

She cited a new book by Chicago labor lawyer and writer, Tom Geoghegan, Were You Born on the Wrong Continent?.

As Pollitt writes, Geoghegan contrasts the Western European social democracies with laissez faire America which victimizes not only the poor, but the middle class, which has meager economic protection compared to their counterparts in Europe. He argues,

“contrary to U.S. popular opinion, life is better for almost everyone in a social democratic system like those in Western Europe, especially Germany. ”Even with high taxes that support the system and its benefits for workers, the unemployed, students and new mothers, Germany’s economy is in better shape than ours.”

Also missing in Europe’s social democracies is the kind of irrational hostility towards government that has led Republicans to advocate deep cuts in taxes and government services. There are consequences: In wealthy San Diego, a two-year-old boy, Bentley Do, choked to death on a gum ball last July when help was delayed for a precious nine minutes because budget cuts had closed the nearest firehouse.

The next day, Bentley’s Vietnamese mother, six months pregnant, was sworn in as a U.S. citizen and collapsed from exhaustion and grief. I saw mention of the tragedy only in the New York Times, which reported that San Diego is still reluctant to consider a tax increase to restore public services.

Write to saulfriedman@comcast.net

GRAY MATTERS: Wiggling Out of Health Care Reform

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Surprise! Surprise! The nation’s health insurance companies, while paying their executives handsomely, are trying every trick in their lobbyists’ books to wiggle out of some of the most important cost-savings and patient care provisions of the health care reforms.

One obvious reason can be found in the compensation paid in the last year to the CEOs of some of the top insurance companies as reported by Modern Health Care:

• Stephen Hemsley, UnitedHealth Group, $106.6 million

• H. Edward Hanway, Cigna, a retirement package worth $110.9 million

• His successor, David Cordani, $26 million for his first year

• Michael McCallister, Humana, $14 million

• Ronald Williams, Aetna, $13.6 million

• Allen Wise, Coventry, $10.2 million

• Angela Braly, Wellpoint, $10.1 million

All have sought steep increases in their premiums while enjoying healthier profits thanks to the health reforms which, among other things, requires that people obtain health insurance much of which will be subsidized by government.

Aside from satisfying our prurient interest about these outrageous salaries, there is a reason these compensation amounts are important; they may be counted as contributing to the quality of care, which helps the companies make a mockery of the new health reforms and the amount and quality of patient care they are supposed to deliver.

Their multi-million dollar salaries, bonuses, retirement packages and stock option dollars, in other words, come out of the premium money a large portion of which they are supposed to devote to patient care.

But here’s the ultimate in chutzpah: A spokesman for Wellpoint told the Los Angeles Times that the compensation reflects their effort to improve care and hit corporate goals, including profits. Yet the record of the insurance companies reflects their chiseling on patient care, not only through premium increases, but by arbitrarily droppng or refusing coverage for potentially expensive patients - a practice that eventually is supposed to be banned.

At issue are the requirements of Section 2718 of the Patient Protection and Affordable Care Act - that is, smaller insurance companies must spend 80 percent of the premiums on patient care; the larger companies, like those cited above, must spend 85 percent.

This is known as the Medical Loss Ratio (MLR). Some advocates say that a 15 to 20 percent margin is too generous, especially given the salaries of company executives. Yet the companies are trying to chip away at the MLR requirement, deducting more and more from the 80-85 percent, by labeling even more than the salaries as “medical expenses.”

The battle by the insurance companies over Section 2718 and the MLR took place recently at a meeting of the National Association of Insurance Commissioners, which has been charged by the law with reviewing and developing regulations that will be proposed by Kathleen Sibelius, the Secretary of Health and Human Services, who is supposed to oversee the implementation of the law.

Senator Jay Rockefeller, D-WV, who helped write the MLR into the law, said,

“I hope as the NAIC continues to meet...they will remember that the purpose of this law was to make sure Americans’ health insurance premiums are spent on actual care – not obscene CEO salaries and industry profits.”

Some of the best work monitoring the NAIC proceedings in Seattle was done by Ellen R. Shaffer, co-director of the California based EQUAL Health Network. In August she told Sibelius, in a detailed letter, that

“we are concerned that the standards” under consideration by the NAIC “include an edit that would allow the insurance industry to count marketing campaigns...in conjunction with state and local public health departments [including sales and brokers’ commission] as medical expenses.”

Thus, a company’s self-serving publicity advertising for “health awareness” campaigns would count as “activities that improve health care quality,” she wrote, “rather than the administrative expenses they are.

“The insurance industry has stated its intention to game the system by raising premiums to make up for any constraints imposed by the new law,” she added. And she noted that Rockefeller’ Senate Commerce Committee had “documented that Wellpoint has already ‘reclassified’ more than $500 million dollars of administrative expenses as medical expenses.”

The health reforms give the insurance companies exemptions for certain insurance company taxes in calculating the MLR, which lowers their income. But Shaffer asked the NAIC and Sibelius to “discourage efforts by insurance companies to create and benefit from insubstantial programs that masquerade as clinical treatments.”

Judy Dugan, of Consumer Watchdog, reported from the NAIC meeting that despite the intent of Congress to limit the taxes the insurance companies may claim as part of patient care, lobbyists and lawyers argued to allow industry to deduct “every tax on every part of their business when they’re calculating how much they spend on actual health care.”

The companies even argued to deduct taxes on investments from their premium revenues.

The NAIC came to a unanimous agreement, which some advocates hailed as a victory for consumers. But Don McCanne, of Physicians for a National health Program said,

“We are still stuck with a middleman industry that has been granted the right to keep 15 to 20 percent of our premium dollars to use for their own purpose.”

Now, we await Sibelius and the regulations and more lobbying from the insurance companies, which, according to Bloomberg News, are shifting their financial support to help Republicans who voted against the reforms.

In the meantime, there’s some good news from the health care reforms – “Promoting Prevention Through the Affordable Care Act” – which is the subject of a paper written for a recent issue of The New England Journal of Medicine by Sibelius and public health physician Dr. Howard K. Koh, assistant secretary for health. I know, everyone talks about prevention, but few have taken it seriously, until now.

As the paper says,

“The Act provides individuals with improved access to prevention services...For example new private health plans and insurance policies beginning on or after September 23, are required to cover a range of recommended prevention services at no cost.”

These may include vaccinations, screening for colon, breast and cervical cancer and for men, prostate cancer. These are the same prevention services available to Medicare beneficiaries, except as of January 1, there will be no cost for Medicare patients and for the privately insured.

As you may have read, the new health care reforms include, as of September 23, coverage with no cost sharing of tobacco-use counseling and evidence-based tobacco-cessation interventions as well as risk, alcohol-misuse counseling, depression screening and immunizations, along with obesity screening for adults and children.

In 2014, states will be forbidden from excusing from Medicaid coverage, drugs to help people quit smoking.

Alas, 45 million Americans still smoke, including 5.5 million on Medicare. They are high risk for the lung cancer that is killing a good friend. She quit, but too late.

For more information on preventive health and the Affordable Care Act, see the Health and Policy Reform section of The New England Journal of Medicine.

Write to saulfriedman@comcast.net

GRAY MATTERS: Of Death Panels and Palliative Care

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I assume you recall the summer of the “death panels.” That was last year when a few right-wing demagogues led by Sara Palin (who else?) warned that the health care reforms under debate would lead to deaths of patients whom doctors considered too old or ill to treat. Now we know they probably helped hasten the deaths of the desperately ill.

Here’s the background. In August, 2009, with the help of unthinking journalism and, naturally, the Fox loudmouths, Glenn Beck and Rush Limbaugh, the phrase “death panels” set off a fury of raucous town meetings with organized right-wing plants stirring up the mob, bringing confused innocents along with them on a tide of anger.

Few would listen to or even allow speakers, members of Congress, to explain the issue and call the lies for what they were. Even veteran Senator Charles Grassley, R-Iowa, who helped write the reform bill (he voted against), told a crowd that there was a genuine fear that “Granny” would die at the hands of a death panel. He regretted that stupidity, but the damage was done.

The section of the reform legislation that caused the furor, which was introduced by a Republican, was optional and totally benign. It merely authorized Medicare (and insurance companies) to pay physicians for their services if, during a period of five years, they are asked to and provide counsel to patients on alternatives to treatment, including hospice or palliative care.

Republicans and assorted right-wingers who did not support any health care reform cried “euthanasia.”

Cowed and frightened by the furor, President Obama and Democratic sponsors of the health reforms deleted the section. There have been sad consequences. Those fear mongers who raised the false alarm of “death panels” may have been responsible for the early deaths of terminally ill patients, who could have lived longer and more comfortably, free of pain, with hospice or palliative care.

That is one of the conclusions of a study in the August 18 New England Journal of Medicine on the value of palliative care for terminally ill patients. As The New York Times reported,

“[D]octors have found that patients with terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier and in less pain as the end neared – but they lived nearly three months longer...The findings...confirmed what palliative care specialists had long suspected. The study also, experts said, cast doubt on the decision to strike end-of-life provisions from the health care overhaul passed last year.”

Palliative care, which is optional for the patient, means forgoing curative treatment such as surgery, radiation or chemotherapy any of which may be more painful or debilitating than the disease.

A physician, whose office visits, exams and treatments are partly covered by Medicare, may also advise a patient (for no extra fee) on the possibility of palliative care. If the doctor states that the patient has less than six months to live, the palliative care (which may include pain-killing drugs, physical examinations, and even chemotherapy that is not meant to cure) is usually provided by a hospice organization whose services are fully covered by Medicare.

And, as I’ve written, hospice care won’t end if the patient lives beyond those six months. It’s called “open access.”

Indeed (a personal acknowledgment), I have been on ‘open access” palliative care, with the help of the Hospice of the Chesapeake, for more than six months because the cancer I’m fighting seems not to be growing. I live with uncertainty, but I have the comfort of knowing the hospice professionals are there to help if things change.

Dr. Diane E. Meier, director of Mount Sinai School of Medicine’s Center to Advance Palliative Care told the Times, the study

“...shows that palliative care is the opposite of all that rhetoric about ‘death panels.’ It’s not about killing Granny; it’s about keeping Granny alive as long as possible – with the best quality of life.”

Dr. Atul Gawande, a Harvard Medical School surgeon who has written long articles on medical care for the New Yorker, called the results of the study “amazing.” His latest article, Letting Go – What Should Medicine Do When it Can’t Save Your Life, recounts the long suffering of patients who chose to fight cancer with radiation, surgery or poisonous chemotherapy before their deaths.

As the Times reported, while the study could not determine why the patients lived longer, experts pointed out that depression and constant pain deprived patients of sleep, and chemotherapy means th loss of appetite, nausea, hair loss and other debilitating side effects.

Dr. Sean Morrison, president of the American Academy of Hospice and Palliative Medicine, told the Times that the study was the

“...first concrete evidence of what a lot of us have seen in our practices – when you control pain and other symptoms, people not only feel better, they live longer.”

Of course, depending on the diagnosis and prognosis, some people opt for any treatment no matter how painful to fight their disease. But there is no way of knowing how many people have been denied access to hospice and the comforts of palliative care for their terminal or extended illness, which may not be cancer. And there is no way of knowing how many people were denied a longer, better quality of life.

But my hospice social worker pointed out that many doctors are more inclined to treat illnesses and try for a cure than suggesting palliative care. That’s part of their training. End-of-life counseling and palliative care are fairly new developments in dealing with illness.

If my case is an indication of the process, my oncologist did not know how my cancer was progressing, but he told me that some chemotherapy could not cure it or get rid of it, but may curb its growth. That meant palliative, non-curative care. I could have opted for more aggressive treatment. But I was admitted to hospice, which has cared for me ever since, sparing me from having to go to emergency rooms for small problems. As luck would have it, something, perhaps the chemo, stopped the progress of the cancer – for now.

I’m not accusing doctors of being greedy but under our system, the vast medical industrial establishment of physicians, specialists, hospitals and labs get paid more by Medicare and insurance companies for the expensive efforts to cure, which may include CT scans, MRIs, blood tests, radiation, chemotherapy and surgery. And they have great investments in buildings and technology to pay for.

In addition, there is a natural conflict between palliative care specialists and oncologists and surgeons who are battling cancer and see palliative care as “giving up.”

Because of the “death panels” furor, doctors won’t get paid (the fees would have been relatively small) to counsel on end-of-life decisions for Medicare patients. But with that section no longer part of the health reforms, privately insured patients in their fifties who have spreading cancers or other terminal illnesses will have difficulty getting covered for getting access to information about palliative care and hospice unless the physician volunteers it.

A note to Sarah Palin, et al: your death panels rants have probably denied at least some Grannies of a longer, more comfortable life.

Write saulfriedman@comcast.net

GRAY MATTERS: The Downside of Medicare

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Those of us of a certain age sing the praises of Medicare which, thanks to the recently passed health reforms, according to the latest report of the trustees, has a new lease on life. It will serve the needs of upwards of 45 million disabled and people over 65 for longer than some banks and businesses will be around.

That is to say, the life of the Hospital Insurance Trust Fund has been extended 12 years to 2029. That fund, if you don’t know, pays for Medicare Part A, which includes hospitalization, and rehabilitation or skilled nursing care after, say, an accident or surgery, and for some home care.

In addition, the Obama administration’s bean counters estimate that the new health care overhaul, Medicare Part B – which pays part of the cost of labs and physician visits – will save $8 billion by the end of next year and a whopping $575 billion over the next ten years.

That’s something people over 65 and those approaching retirement to celebrate. Medicare will be there when employment benefits run out.

But Medicare, which was passed 45 years ago, is far from the universal health care that we one day hope to have. Unless a beneficiary has supplementary coverage from a former employer, Medicare’s deductibles and premiums or the Medigap policies to cover those costs have gotten expensive.

If you don’t yet qualify for Social Security (or haven’t had 40 or more quarters of Medicare-covered employment), Part A’s premium (normally free) can cost from $254 to $461 a month. A hospital stay will cost $1,100 for up to 60 days, $275 a day for days 61-90 and $550 a day after that.

Part B, as you know, costs most beneficiaries $96.40 a month, but much more if you are a bit affluent because Medicare under George W. Bush instituted means testing for the first time. It also carries a yearly deductible of $155, which goes up every year.

Part B covers 80 percent of the bills, with those out-of-pocket costs going up. And Part D is an added expense if you need prescription drugs and fall victim to the doughnut hole. Medicare is saving that $8 billion a year mentioned above by cutting Medicare Advantage for 10 million beneficiaries. That’s the right move, in my view, but it’s an indication that Medicare penalizes some people who were hoping to get more coverage.

We could have done better than Medicare or the cumbersome health reforms, most of which won’t take effect until 2014, if the nation wasn’t so stuck in an ideological rut.

One great alternative is called socialized medicine and it’s practiced right here in the U.S. - the Veterans Administration hospitals and health services. And its beneficiaries, non-socialists all, have included the four star generals now running our wars as well as Senator John McCain and many members of Congress.

Although they are not run by the VA, among the socialized institutions that have tended to the needs of presidents as well as lawmakers, are Walter Reed Hospital, in Washington, D.C., run by the Army, and the Bethesda Naval Hospital in the Maryland suburbs.

A few years ago, millions of Americans and I were beneficiaries of the VA health system when it developed, along with Merck and California researchers, an effective vaccine for the dreaded shingles. That was just one of the innovations credited to the VA in a new edition of a book, The Best Care Anywhere, with the subtitle, “Why VA Healthcare Is Better than Yours.”

Written by Phillip Longman, a professional demographer, and a fellow at the New America Foundation and the Washington Monthly, the book tells the story of the quality revolution launched by Dr. Ken Kizer when he took over the VA health system in 1994.

According to the Century Foundation’s Health Beat blog, Longman’s book includes “eye-popping evidence” based on peer-reviewed research

“...that when it comes to everything from outcomes to patient satisfaction and patient safety, the VA out performs. Most people don’t associate the VA with innovation. But a majority of its doctors have faculty appointments at academic institutions, one reason that the VA is on the cutting edge of evidence-based, patient centered medicine.”

Over the years, Longman reports, “the VA has been responsible for developing the CT-scanner, the first artificial kidney, the cardiac pacemaker, the first successful liver transplant, the nicotine patch,” and the shingles vaccine.”

The VA installed the VistA software program, the centerpiece of the VA’s electronic medical record system, which is now used elsewhere. With the use of the software, Longman writes that the VA system, in which everyone - doctors, researchers, nurses and technicians who work for the VA -

“...is the only health care provider in the U.S. whose cost per patient has been holding steady in recent years.”

Dr. Donald Berwick, the new head of the Centers for Medicare and Medicaid Services wrote on the back cover of Longman’s book,

“The improvement of the VA health care system in the past decade is one of the most impressive stories of large-scale change.”

Who says government can’t do anything right?

In this case (as in many civilized nations), socialized medicine works, but it’s doubtful that the VA system will serve as a model for health reform in the U.S. We blindly reject “socialism”without knowing what it is. But we veterans know how it can be helpful in obtaining good treatment and cheap prescription drugs. Unfortunately, budget cuts over the last eight years have forced the VA to sharply limit eligibility for its health system.

While searching for alternatives to Medicare and the inadequate health reforms, I came across a paper published earlier this month on “the impact of universal national health insurance on population health” in Taiwan, of all places, a successful bastion of free enterprise on the doorstep of communist China.

Taiwan established its National Health Insurance in 1995, which covers more than 98 percent of Taiwanese, at the cost of small co-payments. In the years after the system became effective, the paper reported, deaths from

“...causes amenable to health care” declined by nearly six percent a year. The decline was highest among the young and the old and was “associated with substantial reductions in deaths from circulatory disorders for men, whilst an earlier upward trend in female cancer deaths was reversed.”

The U.S. might have had something similar to Taiwan’s NHI, Medicare For All, except for the timidity of Barack Obama, who did not have the courage of his own convictions, and the ignorance of conservative Republicans and Democrats who worried more about their political futures than the health care of their constituents.

Republicans would have had trouble attacking “Medicare For All.” It’s easier to call for the repeal of the confusing “Obama care.”

We pay for this ideological narrowness with lives; in contrast to the good news of Taiwan’s NHI, the U.S. has the worst rate of amenable mortality among 19 industrialized nations, with more than 100,000 deaths per year from disorders amenable to health care.

Write to saulfriedman@comcast.net

GRAY MATTERS: Social Security's Diamond Jubilee

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.


”We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life," said FDR that day. "But we have tried to frame a law which will give some measure of protection to the average citizen and to his family against…poverty-ridden old age.”

I have not yet celebrated the Diamond Jubilee – the 75th anniversary last week of the adoption of Social Security. That’s because I suspect President Obama may consider agreeing to a cut in benefits for future retirees by raising the retirement age, which would be disastrous for them and for his presidency.

So far, he has not said whether he’s for or against the idea, advanced by Republicans and his fiscal commission. Once he was against it but now, as you’ll see, we cannot be sure.

In the days leading up to the August 14 anniversary, Obama said most of the right things. In his White House proclamation, Obama recalled that in the midst of the Great Depression,

“...the Social Security Act brought hope to some of our most vulnerable citizens, giving elderly Americans income security and bringing us closer to President Roosevelt’s vision of a nation free from want or fear.”

He added,

“My administration is committed to strengthening...and protecting Social Security as a reliable income source for seniors, workers who develop disabilities and dependents....Let us ensure we continue to preserve this program’s original purpose in the 21st century.”

He didn’t say how, but presidential proclamations are usually empty of substance. Obama followed with his weekly Saturday radio address in which he repeated his administration’s

“...obligation to keep that promise (of Social Security) for our seniors, people with disabilities and all Americans – today, tomorrow and forever.”

Then he vigorously promised to protect Social Security from

“...some Republican leaders in Congress who are pushing to make privatizing Social Security a key part of their legislative agenda if they win a majority in Congress this fall.”

Privatization, allowing workers to create personal retirement accounts, like 401(k)s, he said, is

“...an ill-conceived idea that would add trillions of dollars to our budget deficit while tying your benefits to the whims of Wall Street traders and the ups and downs of the stock market.”

That’s true enough, but to mix a metaphor, Obama was beating a dead straw man.

George W. Bush’s failed attempt to sell privatization in 2005, crippled his presidency. And as the Associated Press pointed out in reporting on the president’s speech,

“...most Republicans, in fact, are wary of touching that idea because Social Security is virtually sacrosanct to voters, particularly seniors.”

Indeed, the most prominent Republican favoring privatization of Social Security and Medicare, Representative Paul Ryan of Wisconsin, has gotten little support from his Republican colleagues.

What was missing from Obama’s address was a single proposal to solve Social Security’s long-term shortfall which the program’s trustees estimate will come in 2037. That is when the program’s $2.6 trillion trust fund, which is held in treasury bonds, may run out. According to the trustees, a one percent raise each in the payroll taxes split between employee and employer enacted now would end the problem. Even now, the trust fund is continuing to grow with interest payments of more than $100 billion a year.

During his presidential campaign, Obama criticized Republican John McCain for favoring cuts in benefits. And Obama, who repeatedly has said that Social Security was not facing a “crisis,” offered a sensible, relatively painless proposal, which is now favored by most Social Security advocates.

Obama proposed raising the amount of one’s income that is subject to the payroll tax from the present $106,800 to $250,000. And in a gesture to the middle class, he proposed exempting from the tax the first $20,000 of a worker’s salary. (Some advocates would abolish the ceiling, which would go a long way towards putting Social Security in the black for the rest of this century.)

But Obama has not repeated that proposal nor has he said what he would oppose. Instead, he has created a commission to cut the deficit, a commission which is populated with right-wingers who are hostile to Social Security and believe, wrongly, that Social Security adds to the deficit.

Even before the commission went to work, members made cutting Social Security benefits one of their targets. One proposal that is most prominently supported by deficit hawks and Republican congressional leaders is raising the retirement age from 66 to 70.

As I’ve said, Obama has taken no position on this but he said in his radio speech that he’s

“...committed to working with anyone, Democrat or Republican, who wants to strengthen Social Security.”

It would be easy for a Republican or the commission to claim that Social Security would be “strengthened’ by raising the retirement age and saving the benefits that now go to those under 70. Besides, when have Republicans worked with Obama, except to cut spending? Today’s extremist Republicans have never supported Social Security – probably because it’s a government program that works.

That’s why my alarm bells rang when a search in Google brought me a story in Slate by Peter Bray about the Obama campaign and Social Security, way back there on September 19, 2008. It said,

“This week the Obama campaign modified his position on a sensitive issue, Social Security. Compare the current ‘Seniors & Social Security’ page with the previous version.

“Now, tell me, why, oh why, would the Obama campaign delete the following sentence: ‘[Obama] does not believe it is fair to hardworking seniors to raise the retirement age...The new page includes some reassuring language about ‘work[ing] with members of Congress from both parties to strengthen Social Security and prevent privatization while protecting middle class families from tax increases and benefit cuts.’

“Still, for those who pay attention to such things, what the new page leaves out is as important as what it puts in.”

As I said, I believe Obama has not taken a position on raising the retirement age; and I don’t know if he’s been asked. But such a proposal is anathema to most of Obama’s supporters. Ruben Burks [pdf], an official of the labor-backed Alliance of Retired Americans said,

“Can you imagine working until 70? In physically demanding jobs like construction, manufacturing and the service sector, I just don’t see how you can. And in a tough job market who would hire someone in their late 60s? Raising the retirement age is a benefit cut – plain and simple. We cannot allow it to be done.”

Social Security is keeping 20 million older and disabled Americans and over a million children out of poverty. Polls report that 77 percent of Americans an 68 percent of Republicans believe that Washington should find other ways, rather than Social Security, to reduce the deficit. And AARP’s survey shows strong majorities would prefer that their payroll taxes are raised rather than see benefits cuts.

Because Obama has yet to make his views known on raising the retirement age, AARP – the nation’s largest and most powerful organization of older Americans - has yet to take an official position on the issue which is an ominous sign. But a high-ranking source told me,

“In fact, we opposed raising the age to 70. The idea is tremendously unpopular and amounts to a serious, across-the-board benefit cut and is based on the fantasy that employers would hire people that age.

“Most have forgotten that normal retirement age goes to 67 under current law. Half of all people turning 62 claim Social Security today. Accepting a 25 percent benefit cut is mostly shortsighted in view of needs later on.”

The National Academy of Social Insurance says raising the retirement age would save about a third of the projected shortfall, but it suggests caution because low income and older workers in physically demanding jobs have shorter life spans than, say, white collar workers.

I will repeat what I asked in my column some weeks ago, how many men and women in their sixties will die while waiting for their first Social Security check.

Richard Eskow of ourfuture.org reported that while voters, Democrats and Republicans, oppose Social Security benefit cuts

"...not enough Democrats have promised they won't. Some, including the president, are avoiding the issue...The president spoke about Social Security again [on Wednesday] in Columbus, Ohio. While reassuring voters the program is 'not in crisis,' he repeated his statement that 'fairly modest changes' will stabilize it...voters will get the benefits they deserve' rather than the benefits as designed."

Might those changes mean raising the retirement age?

Liberal economist Dean Baker says that those who would slice benefits are saying, in effect,

“In the future, Social Security might have to cut benefits. To prevent these possible future benefits cuts, we must cut future benefits.”

Economist and New York Times columnist Paul Krugman charges that Republicans and the deficit commission say,

“...in order to avoid the possibility of future benefit cuts we must cut future benefits.”

Tell us this isn’t so, Mr. President.

Write to saulfriedman@comcast.net

GRAY MATTERS: Medicare Anniversary

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

It’s not too late to observe and celebrate the 45th anniversary of Medicare, for it’s a good occasion to wonder, in this time of economic distress, what life would have been like without it for the 45 million of us who are eligible because we are disabled or over 65.

One reason I ask is I suspect those deficit crazies have not thought about the consequences for Medicare if, as Republicans suggest, the Social Security retirement age is raised from 66 to 70 on the grounds that we’re all living longer.

It does not occur to these loonies that Social Security and Medicare are among the reasons for the increase in longevity. But then members of Congress will always have all the coverage they need for themselves and their families, subsidized by your taxes and mine.

Nevertheless, by putting aside the human issues for a phony bottom line and a deficit that matters little to most of us, it would not be long before these lawmakers on Barack Obama’s deficit commission would raise the Medicare age eligibility. That, of course, would sharply increase, by at least a few million, the nearly 50 million Americans under 65, including 10 million children and babies, who are without adequate health coverage and are dependent on emergency rooms or free clinics.

If I may get personal, let me tell you what Medicare has meant for me, for my experience has not been unusual, although I’m lucky to have supplementary coverage through my wife’s former employer, which used to be free but now costs a bundle. Most other Medicare beneficiaries have similar secondary coverage through former employers or one of several Medigap policies sold by several insurers to cover some or all of the costs not covered by Medicare.

I don’t mean to get too basic, but Medicare Part A, which pays for hospitalization, has rather high deductibles; Medicare Part B covers 80 percent of the cost of physician and lab services. Secondary insurance covers those Medicare gaps, and some may provide drug coverage.

Anyway, in 2003, I had a serious stroke, which partly paralyzed my right side and necessitated hundreds of hours of inpatient and outpatient rehabilitation at several of the nation’s finest facilities. The stroke was caused by a heart malfunction which was cured with minor surgery.

In 2005, after too many years as a smoker (I had quit in 1976), I was diagnosed with cancer of the esophagus, which is usually fatal. But chemotherapy, radiation and radical surgery at Johns Hopkins in Baltimore saved my life.

For all this, plus frequent checkups, CT scans, routine doctor visits and a recent prostate procedure, I have paid nothing aside from the reasonable Medicare Part B premiums and the cost of secondary coverage. In short, I can say what millions of Medicare beneficiaries say: without Medicare, I’d be broke, bankrupt or dead.

But that, alas, has been the experience of the millions who, because they are too young, have been denied Medicare. Nor do they yet have decent, dependable and affordable health care because a compromising president and a spineless Congress, mostly Republicans and conservative Democrats, have declined to give the rest of the nation what they and the rest of the world have, universal health coverage like Medicare.

The anniversary of Medicare’s adoption, by a liberal Democratic Congress and president (Lyndon B. Johnson), has give advocates an opportunity to list its lesser known accomplishments. While most of the new health reforms won’t become effective until 2014 (the Part D doughnut hole won’t close until six years later), Medicare was serving 19 million Americans a year after passage.

LBJ Signs Medicare Bill

In a paper written by June Eichner and Medicare’s first director, Bruce Vladek, they point out that beginning in 1966, as the nation’s largest purchaser of health care, Medicare desegregated most hospitals as a condition for receiving Medicare reimbursement. Since then, they wrote, Medicare has contributed not only to the improvements to the lives and health of the disabled and older populations, but has gone far in erasing disparities between blacks and whites. More than 25 percent of Medicare beneficiaries were living in poverty in 1965.

The passage of Medicare came just after the Civil Rights Act of 1964. Which is why southern Democrats joined Republicans in resisting Medicare. But because of those two landmark pieces of legislation, the National Bureau of Economic Research found that

“the gains in black access to hospitals (in Mississippi) coincide with a striking reduction in black post-neonatal deaths for causes considered preventable.”

The cost for these improvement were borne by Medicaid, passed along with Medicare to provide care for the very poor.

Another study noted that Medicare played a significant role in the education of today’s physicians. According to an April Wall Street Journal story, there are about 110,000 resident positions in teaching hospitals that rely heavily on Medicare funding.

Medicare pays $9.1 billion a year to teaching hospitals which pays residents’ salaries as well as the higher operating costs associated with teaching hospitals which tend to see the sickest, most costly and uninsured patients. Unfortunately conservative diehards kept out of the health reforms any increase in the number of funded residencies.

There are, too, a few glitches that have shown up lately in Medicare that need fixing. Under current law, persons over 65 who end their employment and employer health coverage must apply for Medicare during a “special enrollment period” up to eight month after that coverage ceases.

But if the workers chooses to get COBRA coverage, which usually lasts 18 months, they may not realize that they will be disqualified from the special enrollment period and will have to wait until the regular open enrollment period, from January through March 31. In that case, their Medicare coverage won’t begin until July 1. This rule is 24 years old but because it’s happening frequently, legislation is pending to permit signing up for Medicare when COBRA runs out.

Here’s another glitch, discovered by Bloomberg News. Under current law, a person (who suffered a stroke or was injured) is entitled to skilled nursing care and rehabilitation after three days in a hospital. But lately some hospitals, to save money, are keeping patients “under observation” and not admitting them, thus depriving them of the rehabilitation they need. Medicare auditors are challenging this practice, which should be reported as fraud to Medicare.

Finally, the biggest necessary fix is the one Obama said he was for before he became president; Medicare For All. It is the subject of a new appeal to the Congress by Representatives Dennis Kucinich (D, Ohio), John Conyers (D, Mich.), and Independent Senator Bernie Sanders of Vermont.

If Congress won’t pass it, they asked that states be permitted to adopt it. It would be better, of course, if Medicare for All was federal law. If Obama led the way, he could be in the same leagues as LBJ. But our president for change, who has yet to speak forcefully against cutting or tampering with Social Security benefits, is too busy to listen. Maybe it’s possible in a second term, if he gets one.

Write to saulfriedman@comcast.net

GRAY MATTERS: The Consequences of Unequal Wealth Distribution

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Shirley Sherrod had it about right when she said,

“Y’all, it’s about poor versus those who have. It’s really about those who have versus those who don’t. And they could be black, they could be white, they could be Hispanic...”

That wasn’t exactly the whole truth, for she and her husband. Charles, were ardent, longtime civil rights activists who understood that years of racism, played a large role in perpetuating the ignorance and poverty in the south among blacks as well as whites.

(Racism is here defined as the belief among many whites, supported by the law, that Negroes were inferior. Only in America did the Supreme Court, in Dred Scott, hold that black slaves were chattel, less than human.)

Overcoming that sad heritage, Ms. Sherrod, who has spent a lifetime helping in the struggles of the poor of all shades put her finger on a fundamental human problem in much of the world, especially the United States - the unequal distribution of wealth among too many of us.

That is the subject of a new book that has become the rage among social scientists and activists in Europe, especially Britain. It’s called The Spirit Level: Why Greater Equality Makes Societies Stronger, written by British public health researchers Richard Wilkinson and Kate Pickett who have produced an unprecedented rediscovery of the causes of so much of today’s anger towards the institutions of government and finance.

The book was called to my attention by a Canadian reader, Dr. Rob Dumont, a PhD, from a prominent and wealthy family. In a reply to one of my pieces on poverty, he quoted from the book to tell me that according to its central thesis, the growing gap in many countries between the haves and the have-nots is responsible for more than the misery of poverty.

According to the book, such health and social problems as “Obesity, Mental illness, drug and alcohol abuse, homicides, imprisonment rates, lowered life expectancy, overconsumption of resources, teen pregnancy and the lack of social mobility,” all have in common strong links to inequality of wealth.

Interestingly, the authors, who have exhaustively documented their work, do not denounce the wealthy. Rather they point out that the most affluent citizens as well as the most wealthy countries also suffer from these ills. Their analysis mocks the American Declaration of Independence which proclaimed, “all men are created equal.” The original sin of slavery gave lie to that promise and the lack of equality has taken a toll in this nation even today.

As one knowledgeable Amazon reviewer, Dr. Nicholas P. G. Davies, a Briton, wrote,

“Inequality issues are often presented as being about the poor, but this book shows we are all poorer for living in more unequal societies. Inequality is as bad for the rich as it is for the poor. Society is poorer as inequality becomes greater.”

As Wilkinson and Pickett make clear with dozens of graphs, which rate the nations based on the problems that come with inequality,

“The impacts of inequality show up in poorer health, lower educational attainment, higher crime rates, lower spending of social capital, lower cooperation with and trust of government.”

One graph that shows the “health and social problems are worse in more unequal countries,” makes these points:

“The U.S, Portugal and the United Kingdom rate high in the amount of income inequality. For the U.S., low taxes (by international standards), a weak trade union movement, low minimum wage and a tradition of individualism have resulted in a high level of income inequality.”

Indeed, the U.S., with its obsession with the market economy, has modest social programs, Social Security and Medicare, while most of the other 20 nations listed are social democracies with a broad array of social insurance benefits, including universal health care. Canada is roughly in the middle of the pack, along with France, Spain and Switzerland. Japan and the Scandinavian nations have the lowest income inequality, offering cradle-to-grave social programs.

Some critics suggest that the book cherry picks its statistics and the alleged problems to prove their point. But who could argue with the graph that puts the U.S., the richest country, almost off the charts showing the relationship between a huge income gap – perhaps the highest among civilized countries – and such health and social problems as infant mortality, higher than most European nations, homicide and imprisonment rates (the highest in the world), obesity, child well-being (poverty among children has reached new heights) and drug and alcohol addiction?

Any thinking American can verify the sad truth in another graph that shows these health and social problems are worse in more income-unequal states. With the rise of unfettered rapacious, anti-labor capitalism, which touted sweatshops and child labor, income inequality rose to criminal levels.

And today, as you might expect, the southern states, namely Mississippi, Louisiana, Alabama, Texas, Tennessee, Kentucky, West Virginia and Florida “have high levels of income inequality and much poorer outcomes in the health and social areas.”

These states also have the highest levels of poverty and the lowest levels of education attainment, and in the last couple of years, income inequality has become worse throughout the United States, especially in the industrial north, as a result of the 2008-9 recession which has increased home foreclosures, personal bankruptcies and the numbers of Americans – nearly 50 million – struggling against poverty or near poverty.

Yet at the same time, the rich are becoming obscenely richer. Michelle Singletary, reported in the Washington Post last month that while the average income for the top one percent of earners rose 281 percent, or $973,000 per household, in the last decade, the bottom fifth saw their incomes increase 16 percent, or $2,400 per household.

Former Labor Secretary Robert Reich, who wrote the forward for the American edition of the book, noted that today’s CEOs are paid more than 350 times that of the average worker. Surely we’ll see the results of such inequality in health and social problems in the next few years.

In his inaugural speech, President Obama said, “The nation cannot prosper long when it favors only the prosperous.” But that’s exactly what has happened as bankers have made huge profits and gotten scandalous bonuses while real unemployment reaches towards 15 percent.

Franklin Roosevelt fought the economic royalists of his day to help Shirley Sherrod’s Georgia get electricity and survive the Great Depression with the Tennessee Valley Authority and the Works Progress Administration. What has Obama done?

One can blame the Republicans or the U.S. Senate, but where is the leadership of the President? It won’t do to give Ms. Sherrod a job. Platitudes like, “I feel your pain,” are not true. It might help to use the powers of his federal government to put Americans to work. But as she said,

“Folks with money want to stay in power and they’ll do what they need to do to stay in power...It’s always about money, y’all.”

Find out more about Spirit Level, at the excellent British web site, The Equality Trust, which supports the messages in the book.

Write to saulfriedman@comcast.net

GRAY MATTERS: Obama and Elders

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

It may be said that Barack Obama, among his other firsts, has become the first president of the Internet age. The Internet, specifically the World Wide Web, did as much as anything in his campaign to help him win the presidency. And with some unprecedented techniques, he has governed through the internet - explaining his positions, publicizing his major proposals, making promises on issues such as Medicare and Social Security, and assuring prospective voters that his is one of the most open and tech-savvy administrations.

From the beginning of his campaign through his first year in office, he has had great help from a booming, left-leaning blogosphere including Move-On, the Center for American Progress, Buzzflash, Common Dreams, The Daily Kos, Crooks and Liars, Firedoglake and the very profitable Huffington Post.

George Bush could have used the net but as in most things worldly, he seemed ignorant about the internet and oblivious about its uses; and there seemed to no one able to teach him, if he was teachable.

Towards the end of his presidency some corporations helped found a couple of phony grass roots groups and sites such as Freedomworks.org, which was run by lobbyist and former House Majority Leader (under Newt Gingrich) Richard Armey, who helped create the Tea Party movement and now seeks the privatization of Social Security and Medicare, among other right-wing causes.

During Bush's tenure, Armey got money from corporations, to bring in audiences to the White House to support some of Bush’s initiatives; I doubt that Bush knew. But Bush and Vice-President Dick Cheney did not use or need the internet as long as they had the cheerleaders of Fox (faux) News.

Now with no Bush to love, Fox has continued to have more influence that the pro-Obama blogs in its scurrilous campaigns, with Glenn Beck, Rush Limbaugh and Bill O’Reilly to cripple the Obama presidency. Think of what Fox did to Georgia Agriculture Department official Shirley Sherrod; it was a television lynching and Fox has still not owned up to its crime.

Obama has had relatively friendly relations with networks like MSNBC, and its commentators, Rachel Maddow, Chris Matthews and Keith Olbermann. But they have not been Obama toadies, for they have been critical of the president and his policies, especially his compromises, when warranted. But they have not resorted to the kind of loony, hateful vindictiveness seen on Fox.

In an effort to bypass the mostly wrongheaded and irrelevant mainstream media, Obama has depended on several well done, professional web sites to get his messages of accomplishments across. The site www.change.org, ended with the beginning of Obama’s presidency.

It became the president’s perennial campaign site, Organizing for America, where people can link with the Democratic Party, sign up for the latest news from the administration, volunteer to help Democratic campaigns, read the White House analyses of new legislation such as the Wall Street reforms and the latest battles in the Congress. If you sign up, you’ll get periodic updates and you may be asked to contribute to Democratic organizations.

When last I looked at the site, it was linked to just about every social networking service, under the heading, Obama Everywhere. And I watched a fair but simplistic YouTube presentation on what the Wall Street reforms mean to homeowners. It does not include the giveaways to banks as a result of Republican opposition and Obama’s compromises.

If you want to know more than that, try financialstability.com which is a private search engine for financial planning and advisors. I don’t know if they have financial ties to Democrats.

As the administration perfects its internet strategy, it has created sites specific to the messages it wishes to deliver. The newest and most useful is HealthCare.gov which was launched earlier this month by the Department of Health and Human Services.

The site was designed for relatively simple searching to learn what the new health care reforms are offering and how to find private insurance. You may choose your state and find coverage options for yourself and your family and you can familiarize yourself with the new regulations that prohibit cancellation of your insurance if you get sick or refusal of coverage for a pre-existing condition.

Also, there is some handy information on what is now the law: Adult children can stay on their parents’ insurance until age 26. If you enroll in Medicare on a private plan, after September 23, most preventive tests, mammograms, prostate tests, colonoscopies and immunizations, will be free – no deductibles, or co-insurance.

And I guess you know by now that if your Part D drug coverage finds you in the dreaded doughnut hole, let HHS know and the government will ease your pain with a $250 check. Beginning next year the law calls for the gradual closing of the hole. The site has a link to one of the better nonprofit advocacy sites, The Center for Medicare Advocacy.

All this internet stuff is good, but the White House internet machine and its blogger allies are missing an important audience that Obama has overlooked to his political peril. Older people, who should be his natural constituency are not as enamored with Obama as many younger voters. One reason they are ignored; most of elders don’t use the internet. And the Obomans have, from the start, gone after the votes and enthusiasm of younger people.

But older people are the most consistent voters and their number is growing. The latest Pew Research poll reports that older voters are inclined this year to vote Republican by a 52-41 margin, Even voters over the age of 49 say they’ll vote Republican by a 45-43 margin.

Only young voters say, by a 57-32 margin, they’ll vote Democratic. Pew says Obama’s approval rating has dropped this summer by nine points among white independents and 12 points among women over 50.

Those figures for older voters, which reflect how they voted in 2008, suggest they will be voting against their interests for the Republicans promise to privatize Medicare and dismantle Social Security. But the older generation, may not believe those threats and may be more concerned about and afraid of the huge federal debt. They are, after all, still recalling the Great Depression.

Beyond that, Barack Obama’s youth and his cool and cerebral style, according to many commentators, are not connecting with the older generations. Their members of Congress hold meetings about the health care reforms, but they reach only a few people.. And the Medicare manuals they will get can be confusing.

Older people don’t care much about the reforms in private insurance, which they don’t use.

While more and more older Americans are taking to the internet, large numbers depend on the mails, television, their neighbors and doctors to figure out how the health reforms will or won’t affect them.

I’m not aware that HHS is reaching out to older people with mailings. And all they know is that they don’t want the government messing wit their Medicare.

Write to saulfriedman@comcast.net

GRAY MATTERS: Dr. Robert Butler

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

My friend and mentor, Bob Butler, liked to tell the story about the old man who went to his doctor complaining of pain in one of his knees. When the doctor told him that it was a sign of old age, the patient told the doctor, “My other knee is just as old. Why doesn’t it hurt?”

The lesson, of course, is one of the simple truths about aging which marked Dr. Robert N. Butler’s long career: Old age, he taught us, is not an affliction but a blessing and a vital part of a life to be lived.

People don’t die of old age, he said, nor do they inevitably decline into senility. They die of diseases, some of which can be prevented and cured. And it so it was with Butler, who died earlier this month at 83 of acute leukemia. But he worked until three days before the end. And what work he did.

He came to fame winning an unlikely Pulitzer Prize for a book on, of all subjects, aging. But the book, Why Survive? Being Old in America, gave new hope and publicity to the fastest growing group in the nation’s population, Americans over 60. The book described the plight of older people, nearly 20 percent of whom were struggling in poverty which was much higher than the 9.7 percent rate today. It was just ten years after Medicare and Medicaid, and the practice of geriatrics was relatively primitive.

Butler had been a research psychiatrist, but became a geriatrician promoting the specialty in medical schools throughout the country. According to The New York Times, the Mount Sinai School of Medicine in New York asked Butler’s advice on whom to hire for a new geriatrics chair. He proposed successfully that the school create a department devoted to gerontology; it was the nation’s first.

Geriatric medicine has not been a popular specialty, partly because most patients end up sick and/or dying and the practice is not as rewarding as, say, orthopedics or pediatrics. But as Butler wrote in his book, he learned about the strength of the elderly from his grandmother:

“What I remember even more than the hardships of those years was my grandmother’s triumphant spirit and determination. Experiencing first hand an older person’s struggle to survive, I was myself helped to survive.”

But he has taught the current generation and millions of older Americans, who have never heard of Butler, that mere survival is no longer the goal of old age. It’s a new time to live as well as you can.

Butler’s book and his rather revolutionary approach to aging made him the natural to become, in 1975, the first head of his creation, the National Institute on Aging which is part of the National Institute of Medicine.

He held that post for six years, during which he wrote and spoke against what he called “ageism,” the mostly legal discrimination against people because of age. At the Institute, he established research on aging as a legitimate field. He helped found the National Council on Aging, and numerous federal and state laws have erased much of that discrimination and have given older people special help, like handicapped parking.

As a result of the Butler revolution, organizations promoting healthy aging and the political, cultural and social aspects of aging have become important parts of American life. AARP is the largest and most influential membership organization of its kind in the nation fighting for Medicare and Social Security as well as how to live the good life after 50.

And there are at least a dozen other groups lobbying and advocating for older Americans. If aging has been transformed so that 60 is the new 40, Bob Butler is at least partly responsible.

After his first book, he wrote Sex After Sixty, in 1976, with his second wife, Dr. Myrna Lewis, who died in 2005. And he’s written dozens of articles, papers and books since.

But his most definitive work, two years ago, was The Longevity Revolution, The Benefits and Challenges of Living A Long Life. As Butler was fond of noting, life expectancy in the United States and most nations of the has gained an average of more than 30 years in the last century, more than had been attained in the preceding 5000 years of human history. And it’s still growing rapidly, as a result of medicine, genomics, revolutionary drugs and preventive health techniques like tests for cancer.

Butler has called these great advances in longevity the Age Boom. And his final life work has been the creation of the International Longevity Center in Manhattan, a superior think tank on aging.

He established an annual Age Boom academy for journalists and researchers and in 2001, I was privileged to attend the first of these intensive, week-long seminars on the latest research into aging, where I learned of new drugs, new discoveries on brain function.

It was there that I learned that, contrary to a long-held belief, that the older person’s brain does not necessarily deteriorate, but continues to grow neurons and synapses almost until death. Dementia is not the inevitable result of aging.

Butler and another writer, Theodore Roszak in America the Wise, called on all of us to celebrate, rather than fear, the growing population that is living longer, healthier, more productive and rewarding lives. Yet, as Butler wrote,

“Despite this great human achievement, one of the most striking demographic events of all times, some politicians, pundits and economists respond to this revolution in this longevity with gloom and doom.”

Butler was an ardent advocate for Social Security, Medicare, Medicaid and, eventually, universal health care. But he and Roszak condemn those forces, mostly Republicans, headed by former hedge fund billionaire and Nixon Commerce Secretary, Pete Peterson, who believe the nation’s social insurance cannot afford longevity. So now they seek to privatize Medicare and cut Social Security benefits.

Although Social Security is sound for another 30 years but could be extended even further with minor adjustments (a one percent raise in payroll taxes or removal of the $106,000 cap on the income subject to taxes), Peterson, most Republicans and some conservative Democrats are talking about raising the Social Security retirement age to 70.

They do not take into account the workers in heavy industry or the coal mines who cannot wait until then to quit working. Raising the retirement age is an automatic cut for millions of workers in their fifties or sixties. And who can estimate how many workers will die after they are 65, waiting for their Social Security checks.

Peterson, who once suggested that the United States was becoming a “nation of Floridas” with unproductive older people laying about, has been in the forefront of those who wished to privatize Social Security. Now, he’s using longevity and the debt and economic crisis that he and his Wall Street buddies helped create to get their hands on the $2.5 trillion in Social Security trust funds.

Would that Butler were still alive to continue his fight to preserve the social insurance legacy that helped give this century the longevity revolution he celebrated.

Write to saulfriedman@comcast.net

GRAY MATTERS: Growing Poverty

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Long before there was a war on terrorism and the war on drugs, the nation declared war on poverty. Specifically, Lyndon Johnson in his first State of the Union, in 1964, declared amid great cheers from the Congress, an “unconditional war on poverty in America” and he pledged not to rest “until that war is won.”

In his last State of the Union in 1988, Ronald Reagan, who had been no fan of Johnson’s agenda, declared to snickering lawmakers, that in the War on Poverty, “poverty won.”

He was right, of course, but at least part of the reason was the hostility of the Republicans and segregationist Southern Democrats to the array of Johnson’s civil rights and anti-poverty campaign.

Richard Nixon adopted the War on Poverty and gave us the Social Security cost-of-living protection, but he abolished the Office of Economic Opportunity and other key segments of the law. Jimmy Carter eroded part of Social Security, and Bill Clinton boasted that he “ended welfare as we know it” by destroying the Depression-era Aid to Families With Dependent Children.

This bipartisan gnawing away at anti-poverty programs has had consequences for millions of poor American families.

In 1964, 19 percent of Americans lived below the poverty line; the numbers of poor Americans was estimated at a shameful 50 million. That declined to 12.8 percent in 1968, and 11.1 percent as late as 1973.

But after that brief decline in the poverty rates, since Reagan’s speech in 1988 and his emphasis on the “truly needy,” poverty in the United States has made a slow climb upwards to the 2008 rate of 13.2 percent, nearly one percent higher than in 2007, the most significant increase since 1994. And that doesn’t count the near-poor who live desperately just above the poverty line.

But the overall figures don’t tell half of the ugly story of poverty in the richest nation on earth. The 2008 Census Bureau figures – bad as they were – do not take into account the effects of the Great Recession. It will doubtless show an alarming slide into poverty for millions of American families, especially children and young workers and minorities who for the first time in their lives, need food stamps, Medicaid, extended unemployment insurance and the poverty programs that have been decimated.

In these cynical times, with deep divisions between left and right, it’s hard to believe there was a time when a book and a couple of articles struck a chord in the American conscience that made the plight of the poor a major issue.

University of Virginia historian Kent Germany recalled the works that caught the attention of President John Kennedy and his brother Robert. The New York Times’ Homer Bigart wrote a series on poverty in Appalachia which is at Washington’s door step. And the New Yorker’s Dwight MacDonald wrote a glowing review of Michael Harrington’s The Other America, a searing portrait of the 50 million poor.

John Kennedy had campaigned in the desolate areas of West Virginia. Later, Robert Kennedy made a tour of the most poverty-stricken areas and his report to his brother set in motion what became Johnson’s War on Poverty. Part of the groundswell for action came from the moral imperatives of the civil rights movement which opened many wounds including the plight of the poor – rural whites as well as blacks who lived without basic amenities.

Thus the Johnson administration, in the wake of Kennedy’s murder and his 1964 election sweep, pushed through the Congress the elements of his war on poverty, some parts of which still stand: the Office of Economic Opportunity (OEO), Volunteers In Service to America (VISTA), Upward Bound, Head Start, the Neighborhood Youth Corps, the Community Action Program, programs for rural areas, the urban poor, migrant workers, small businesses and local health care centers.

And because the reasons for poverty had their roots in racism and segregation, the Great Society programs included an $11 billion tax cut, the Civil Rights acts, the Food Stamp Act, the Elementary and Secondary Education Act (which encouraged school desegregation), the Higher Education Act, the Voting Rights Act, and, of course, the monuments of Medicare and Medicaid.

Those two years, 1964-5, were the greatest periods of the federal government’s social activism since the Great Depression’s New Deal. But Johnson’s agenda and the latter years of his presidency were crippled by the Vietnam War and a Republican come-back in 1966.

Since then the turn away from government has been dramatic, epitomized by Democrat Clinton’s declaration that the “era of big government is over.” But what have we wrought in this time of the near-depression and the need for government? The poor and the newly poor have only a tattered safety net and official indifference.

According to the Census Bureau there were nearly 40 million American men, women and children struggling in poverty in 2008, before the full effects of the downturn were felt. Now the numbers surely reach past 50 million. The Pew Research Center estimates that 55 percent of adults in the workforce have become unemployed, taken a pay cut or had their hours reduced. The official unemployment figure is 9.5 percent, but many estimates say the real unemployment/underemployment rate is closer to 20 percent.

The long-term unemployment rate has not been seen since the Great Depression, with a quarter of the jobless without work for more than a year. Yet Republicans refuse to help with extended unemployment benefits; they cry crocodile tears over the deficit caused by the recession they helped create, but they seem not to care about the human costs.

Economist Dean Baker says, with some knowledge, that the Republicans want to keep unemployment high to discredit Barack Obama’s economic policies the better to win the off-year elections in November.

High, long term unemployment has put a strain on pantries and other facilities providing food for the poor. And most shameful are the unemployment rates (more than 25 percent) among young workers and their families.

And no one is suffering more than children. Before the recession, the official poverty rate among persons under 18 was close to 20 percent. Poverty rates among children over the last 40 years ranged from 15 to 23 percent. So we are at a new high. According to the Urban Institute, before the downturn, 37 percent of children lived in poverty for their first year, and ten percent spent half their childhoods (nine years) in poverty.

Kids know what poverty is like. I remember the humiliation when my mother applied for what was called “relief” and inspectors came to the house to determine if we were really poor.

During the Depression, writers like James Agee, Sinclair Lewis, T.S. Eliot and photographers like Dorothea Lange, Walker Evans and Robert Capa helped Franklin Roosevelt’s New Deal stir the American conscience to action as Homer Bigart, Michael Harrington and the Kennedys did a generation later. Where are such voices now?

Write to saulfriedman@comcast.net

GRAY MATTERS: New Medicare Services (CMS) Administrator

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

While we await the hoped for improvements in the health care reforms, the latest news about the irrational, fragmented and profit-driven American health care system is not good.

In a report released last month by the respected Commonwealth Fund, the United States, which spends twice as much money on health care than other advanced nations, ranks lower than all of them on the quality, efficiency and the cost of care for their citizens.

Most important, the care given and available in these countries is more equitable than in the U.S. The disparity in the care available here for more affluent whites, compared to the poor, blacks and Hispanics is too obvious. There are no uninsured in the countries cited.

The report ranked the United States last when compared to six other nations – Britain, Canada, Germany, Netherlands, Australia and New Zealand - all of which have some form of universal, nationalized or socialized health care.

The report uses data from patient and physician surveys in the seven nations in 2007, 2008 and 2009. In 2007, the U.S. spent $7,290 per person on health care. The per person spending in the six other countries ranged from $2,454 for New Zealand to $2,992 in Britain to $3,895 in Canada. Overall, the survey found that Britain’s National Health Service ranked first in patient and physician satisfaction.

“The findings demonstrate the need to quickly implement provisions in the new health reform law,” said the report. “The new legislation should begin to improve the affordability of health insurance and access to care when fully implemented in 2014.”

The other piece of sorry news is that despite meetings with the president to implement the reforms and warnings from the White House and Health and Human Services Secretary Kathleen Sebelius, insurance companies have raised the premiums on 14 million private policies and Medicare Advantage by an average of 20 percent.

That survey by the Kaiser Family Foundation [pdf] which found that double digit premium increases were not unusual, was released on June 21. The president ignored that when he met on June 22 with insurance company CEOs and spoke glowingly about the reforms and the hope that the insurance industry would cooperate.

He had warned earlier that “health insurance companies should not use the new health care reform laws as an opportunity to enact unjustifiable rate increases.” But they did and chances are that conduct will continue.

One reason is the trend reported by Wall Street analysts and Bloomberg that U.S. health insurers are “moving towards an oligopoly” in which only a few companies will dominate so much of the market that they will have the power to thwart the already weak regulations. Don McCanne, of Physicians for a National Health Plan, said,

“The insurers will keep 15 to 20 percent of the (increasing) premiums to sell us plans that cover only 60 to 70 percent of our care and they won’t really have to compete with each other.”

Many policyholders have fled to cheaper insurance but their deductibles, now averaging more than $5,000, will go even higher while their coverage will decline. One in five policyholders complain that they or a family member did not get the care they paid for. And four in ten policy holders (38 percent) reported having a problem getting their insurer to pay a bill.

Under the reforms, the insurers must spend 85 percent of their premiums on patient care. But who is to closely enforce that? The answer may be found in why the insurance industry, conservatives who oppose regulations of all kinds and most public health programs and Republicans in the Congress who seek to privatize Medicare have joined in opposition to the President’s choice to run the Centers for Medicare and Medicaid Services (CMS).

For the last eight years the leadership of CMS has been benign at best, going along with every Republican effort to weaken Medicare. Medicare was shut out of the Part D prescription drug program which is wholly private and increasingly expensive. The Republican administration increased by billions of dollars the slush fund that finances privatized Medicare Advantage to the financial disadvantage of original Medicare.

Expectations that the weakening of Medicare will cease rest with the president’s CMS nominee, Dr. Donald Berwick, a pediatrician, Harvard Medical School professor and head of the Institute for Health Care Improvement in Boston. And judging from his background, there is little doubt he’d be a strong advocate for Medicare which often influences the conduct and standards for private insurance.

I expect Berwick to be a the strongest defender of Medicare since Bruce Vladeck, who ran what was then the Health Care Financing Administration under President Clinton. That was killed by the Republican Congress and then-Speaker Newt Gingrich.

Vladeck’s successor, Nancy De Parle, now chief adviser on health reform in the White House, agreed to allow HMOs to sell Medicare policies which began the slow privatization of Medicare. (De Parle became an executive for health care firms, earning $3.5 million in 2006-2007).

Berwick would be an advocate for a stronger Medicare, which would weaken the power of the health insurance lobby. That, I believe, is a major reason Senate Republicans have vowed to kill his nomination which had languished since April in Senator Max Baucus’ Senate Finance Committee. He has yet to schedule hearings or give a reason for the delay.

Tired of Republican stalling, the president gave Dr. Berwick a recess appointment this past week to run CMS. He will still have to be confirmed when the Congress returns, but that should be easier. And in the meantime, CMS will have the strong leadership It's been lacking for too long.

Praise for Berwick has been universal among the academic health community including Harvard, Yale, Princeton and Dartmouth. He has won praise from AARP executive vice president John Rother who said Berwick’s Institute has “saved lives and money” and that his “appointment is welcome news to Medicare beneficiaries.” The American Hospital Association praised Berwick for leading a movement to make hospitals safer. And Kaiser Health News called Berwick an “inspirational leader.”

So why are Republicans calling him a “radical?” One of his sins was to give limited praise for the British National Health Service although, as Linda Bergthold pointed out in Huffington Post on June 1, Berwick has criticized its faults and is not seeking a government takeover of U.S. health care.

Republicans and Fox News commentators have also jumped on part of a 2008 speech, in which he said,

“Any health care funding plan that is just equitable, civilized and humane must – must – redistribute wealth from the richer among us to the poorer and less fortunate. Excellent health care is by definition, redistributional.”

Berwick was charged with wanting to “spread the wealth around” as if that’s a bad idea.

Berwick was also accused of supporting health care rationing because he spoke truth when he said,

“the decision is not whether or not we will ration care – the decision is whether we will ration with our eyes open. And right now we are doing it blindly...”

That is, allowing insurance companies to decide who and what they will cover.

One cannot write about Berwick without recalling his personal encounter with the dangers in American health care, when his wife almost died from a medical error when she was receiving powerful chemotherapy. He was at her bedside to save her from what might have been a fatal overdose of the medicine. Reducing medical errors in hospitals, said Bergthold, has become Berwick's life’s work.

Write to saulfriedman@comcast.net

GRAY MATTERS: Celebration of Our Union

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

On the occasion of the holiday we celebrate tomorrow, here is a story I wrote in 2008 for another publication. But because there has been such a resurgence of all the forces that sought to weaken or destroy the American union more than 145 years ago under the phony mantra of “states rights,” I thought it worthwhile to repeat the column, with a few changes.

Despite the naysayers and thinly disguised racists who would divide us today, we have a new reason to celebrate this Independence Day. For if you take the long view of history, as I do, you could say that the events on another Fourth of July, in 1863, saved the America that was envisioned by the founders and made possible in our time the presidency Barack Obama.

When that day arrived, decisive Union victories over the Confederacy at Gettysburg, Pennsylvania and Vicksburg, Mississippi effectively ended the threat that the United States would be permanently broken in two. And when he spoke at Gettysburg that November, Abraham Lincoln declared that the nation that had been "conceived in liberty and dedicated to the proposition that all men are created equal...shall have a new birth of freedom."

The union had been preserved. But with these words at Gettysburg, scholars say that Lincoln, who had been seen as ambiguous on the issue of slavery, became more fully committed to the abolition of slavery, and the unconditional surrender of the Confederacy.

Thus, in 1865, soon after the end of the Civil War, the nation adopted the 13th Amendment to the Constitution, ending and forbidding slavery through the country and its territories. That was followed by the 14th and 15th amendments guaranteeing equal protection of the laws and the rights of citizens, including former slaves, to vote.

These amendments, resisted then and now by segregationists and states' righters, became the basis for the 1954 Brown v. Board of Education decision and the civil rights movement which also were part of the history of my generation and the greatest generation.

We forget these generations' part in this great social movement. For blacks, many of whom moved out of the South along with whites, came through the Great Depression and two world wars to become the leaders of that movement on the streets, in the courts and in Congress.

I covered the civil rights movement as a Southern reporter in Houston and followed Dr. Martin Luther King Jr. as he campaigned through the South from Montgomery and Birmingham to Selma, and in Chicago and Washington. In 1960, when presidential candidate John F. Kennedy offered to intercede for King, who was in jail for participating in a lunch-counter sit-in, many black voters deserted the little that remained of Lincoln's Republican Party.

After Kennedy's election, members of the greatest generation in the Congress, led by Kennedy and later Lyndon Johnson and a fine group of postwar legislators, mostly Democrats and a few Republicans, broke through die-hard Southern filibusters to pass civil rights laws that have enforced the 13th, 14th and 15th amendments.

Johnson predicted that supporting King and the passage of the civil rights bills would hasten the defection of many Southern whites to the Republicans and that the once-solid South would be lost to Democrats for years. He was right; racism is still alive like the sections of a snake that won’t die.

In 1968, amid the tumult following the murder of King in April and Robert Kennedy in June, the riotous Democratic convention and the demonstrations against the Vietnam War, Richard Nixon won the presidency with the help of a "Southern strategy" based on states' rights and law and order.

Thus, while the Democrats, under Franklin D. Roosevelt, Truman, Kennedy and Johnson, had evolved into the party of blacks as well as white workers favoring social insurance and civil rights, the Republicans of Lincoln, who had waged a war for a strong federal government, had become, under Nixon and his successors, the party of whites and states' rights.

Ronald Reagan underscored his hostility to Washington and his states' rights sentiment when he began his 1980 campaign in Philadelphia, Mississippi, the town where three civil rights workers had been murdered years before when they sought to register blacks to vote.

Despite the Southern Strategy and Republican dominance in much of the Old Confederacy, the civil rights bills and the legacies of Martin Luther King had their effect. Slowly the black vote has grown and together with newer, more enlightened generations of whites, black men and women have won key congressional, city and state elections in the North and South. King's home, Atlanta, has had black mayors.

But every black member of Congress is a Democrat. So are the vast majority of blacks who hold elective office throughout the country. President George W. Bush's failure to provide timely aid to the mostly black victims of Hurricane Katrina seemed to personify, for many critics, another racist facet of the Southern strategy.

Bush was the first president to refuse to meet with the NAACP. His 2004 campaign manager and then Republican chairman Ken Mehlman told the group in 2005 that the "Southern Strategy" was "wrong," because it "benefited from racial polarization."

While all the Republican presidential candidates this year were white, male, conservative and Christian, the Democrats included a Hispanic as well as a woman, Senator Hillary Rodham Clinton. The winner, Barack Hussein Obama, is heir to all that has come before and he has acknowledged that heritage.

He made his acceptance speech at the Democratic convention, on August 28, 45 years to the day after Martin Luther King told the vast throng at the Lincoln Memorial: "I have a dream that one day this nation will rise up and live out the true meaning of its creed: 'We hold these truths to be self-evident, that all men are created equal.'"

Despite repeated Republican vows that they would reach out to black voters, the opposite has happened. And their Libertarian and Tea Party followers have outdone their confederate forebears in their efforts to undermine the federal union. Indeed, Republicans have probably ended any hope of getting any black votes for a generation with their shameless opposition to virtually every Obama proposal.

From the beginning, the Republicans have sought to destroy an historic presidency. How else to explain their voting record or their loyalty to vicious, lying radio demagogues? Will no Republican have the courage to disagree with them in public?

Consider the blasphemy of radio racist Glenn Beck who intends to hold a rally for white people at the Lincoln Memorial on the anniversary of King’s historic speech. Beck should be excoriated by all decent people, especially Republicans. Their party’s first president would be ashamed of his heirs.

Write to saulfriedman@comcast.net

GRAY MATTERS: Health Care Reform Benefits for Elders

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

The final health reform law is much too long, more than 2,000 pages, mostly because of dozens of compromises to get Democrats (liberals and conservatives) on board, and in a vain effort to get support from Republicans who marched in lockstep to vote no like, say, the goosestepping North Korean army.

Nevertheless, a 2,000 page bill is not unusual for even routine legislation like the budget but the length reflects these contentious days in the Congress, especially for such a massive and comprehensive legislative enterprise as the historic Patient Protection and Affordable Care Act.

Most of us know, or will soon see, the main benefits, requiring insurance and drug companies to provide – with the government’s help – affordable health care and prescription drug coverage for 40 million uninsured Americans, including children, no matter their current health problems.

But in reviewing the bill and the analyses of various organizations, the PPACA, as it has become known, includes some valuable unpublicized benefit nuggets. For example, the June AARP Bulletin tells me than the law has set aside $2 billion over five years to encourage states to use Medicaid dollars to help older people “transition” out of nursing homes to more independent living arrangements – their homes or assisted living.

These patients ought to know about this and take advantage of it; best to stay home or in your community.

Preventive medicine also will be a high priority in the law, from which you’ll benefit in coming years. Just last week, Health and Human Services Secretary Kathleen Sibelius announced the law will allocate $250 million for public health initiatives on preventing and dealing with chronic diseases including curbing tobacco and alcohol abuse (something the British health system is tackling).

She wants to spend the money training hundreds of needed primary care doctors, but lawmakers want more spent on preventive medicine. This is part of the $500 million Prevention and Public Health Fund, the first of its kind under Medicare, created by the act. Money will be available through grants to community clinics, hospitals and researchers.

If you didn’t already know, beginning next year, all preventive screening and tests for Medicare patients – mammograms, colonoscopies and annual comprehensive physical exams will be free. Private insurers are expect to follow suit; at present, beneficiaries have had to pay 20 percent of the cost and use their yearly deductible.

One of my favorite obscure provisions is in section 4207, which requires employers to “provide a reasonable break time for an employees to express breast milk for her nursing child for one year after the child’s birth” and to provide a place, not a bathroom, for mother to nurse the child.. Other benefits are enhanced for infant care.

The respected Center for Medicare Advocacy has compiled a number of important, but obscure provisions of the reforms. Beginning next year, Medicare Advantage Prescription Drug plans may not manipulate premiums for low-income beneficiaries in order to force them into other plans.

But the HHS Secretary is authorized to auto-enroll low-income beneficiaries who have lost their plans into more advantageous plans. Effective January 1, 2011, an individual whose spouse dies in the middle of a low-income eligibility period is granted continued eligibility for a full year beyond the date when his/her eligibility would end.

Of course he/she could reapply for the low income benefits. You should check with the center to see if you qualify as low-income.

“Dual eligibles,” low-income individuals who are eligible for both Medicaid (health care for the poor) and Medicare, have always presented the Centers for Medicare and Medicaid Services (CMS) with bureaucratic problems. The Republican Part D law, took away availability for cheap medicines from Medicaid beneficiaries and forced them to use more expensive and limited Medicare Part D, with its co-pays, limitations and the notorious doughnut hole.

Low income people can get “extra help” in paying for drugs. And the doughnut hole is to be phased out slowly. If you fell into the hole, you should have gotten a $250 rebate by now. That’s a pittance, but the next big change comes next year when the cost of brand named drugs, while you’re in the hole, will be cut by 50 percent.

A reader asks why the Republican congress in 2003 created the doughnut hole during which the beneficiary must pay the full, retail cost of his drug. This year the beneficiary who has purchased $2, 830 in drugs, at the cost of small co-pays, must pay, while in the hole, the full price until he/she reaches $4,300 in out of pocket costs.

The congress created the hole, which has grown larger each year based on the economic theory called ‘”moral hazard,” which means beneficiaries will buy more drugs that they may not need if there were no such curbs as the doughnut hole.

Put another way, persons with good auto insurance are more likely to drive recklessly and have accidents. For the Republican sponsors it was their way of saving money by forcing beneficiaries to pay more out of pocket.

Anyway, the problems of dual eligibles will be assigned to a new Federal Coordinated Care Office to integrate benefits under Medicaid and Medicare and, under the law, to provide dual eligibles “full access to all benefits of both programs.”

Too often the elderly poor who are on Medicare do not get the full benefits of Medicaid if they are under home care or in a nursing facility.

More specifically for dual eligibles, effective January 1, 2012, the reforms call for the elimination of cost-sharing (co-pays) for Part D drugs for all full benefit, dual-eligible beneficiaries who are receiving Medicaid and Medicare at home or on a nursing institution. The center says, “This provision creates equity in Part D cost sharing between those in institutions and those getting substantially the same services” at home or in assisted living.

Long term care remains, as AARP said, the greatest unmet health care need in the country. Perhaps two-thirds of people who are 65 today will need long term care, at home or in an institutional setting. The U.S. spends $207 billion on long term care, much of it on Medicaid funds which are used by many middle and working class families who game the system by transferring their assets to loved one, impoverishing themselves in order to become eligible.

They should not be condemned, for they have little choice; long term care insurance is expensive and few will spend years paying the premiums for insurance they probably won’t need. Only seven million Americans have long term care insurance. It’s not feasible for a person who is, say 60, to pay for 20 years on the chance he/she will need it.

If it is not needed, the money is lost. And often the insurance companies, several of which have been absorbed by conglomerates, will raise premiums when the elderly beneficiary can least afford it.

According to the center, the reforms call for better regulation of the thousands of nursing facilities, some of which have been literally getting away with murder, neglecting residents mostly because of poorly paid, insufficient staffs. There are perhaps a dozen provisions policing nursing homes to hold them accountable for maltreatment of patients.

Medicare, of course, covers medical needs of nursing home patients, but after 20 to 100 (expensive) days in rehabilitation after a hospitalization, say for a hip replacement, it does not cover long term nursing home care. Medicaid does, but the Congress has been cracking down on those who get rid of their money to get the Medicaid benefits.

The reforms, thanks to the late Senator Edward M. Kennedy, include the modest Community Assistance Services and Supports Act (CLASS) under which employees may voluntarily sign up to contribute $50 a month into a fund which eventually will pay a tiny fraction of the current $150 per day rate for a good nursing home. It’s an obscure provision of the massive health reforms. And it means less than minimal progress in dealing with long term care.

Maybe it deserves obscurity, for while some say it’s a start; I say it’s a shame. The Congress and President Obama, who speaks of his late grandmother in long term care, could have done more. Where is the real concern for older Americans, the fastest growing part of the population?

Finally, for the best and latest information on the 2,000 pages of the PPACA, try The Alliance For Health Reform website.

Write to saulfriedman@comcast.net

GRAY MATTERS: Assisted Death

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

The poet Dylan Thomas said it best for those of us of advanced age: “Do not go gentle into that good night; rage, rage against the dying of the light.” But what if there is no good alternative to quietly turning out your light?

In Connecticut, the home state of insurance giants, a legal and moral battle rages that may have national implications as two physicians have sued the state for an action that could eventually allow patients to choose a peaceful, drug-induced death to avoid the pain and terrors of a terminal illness.

As CNN's Randy Kaye reported,

“While courts have addressed constitutional questions connected with aid in dying, no court has directly considered whether a mentally competent, terminally ill patient’s desire to bring about a peaceful death should be considered a ‘suicide.’”

That’s vital, for a suicide is generally against the law and the family of the person who dies may suffer spiritually and legally, including the loss of insurance and other claims.

Thus, Connecticut physicians Dr. Gary Blick and Ron Levine are suing the state, asking that the state’s laws restricting assisted suicides should not include cases in which mentally competent, terminally ill patients take their own lives to avoid pain and suffering.

The suit, which a superior court judge has dismissed on technical grounds, was prompted in part by several cases in which people have been punished for helping friends or relatives to die. Right to die advocacy groups are expected to appeal.

In the most publicized case, in 2004, John Welles, who was dying of cancer and suffering, pleaded with a friend, Hunt Williams, to give him a pistol. Williams did as his friend asked. As Welles walked away in the woods, Williams shouted “God bless” and heard the gunshot. Welles died and Williams was convicted of “assisting a suicide,” a felony in the state.

Blick’s suit was aimed, in part, to clear and free Williams and win permission to end a dying patient’s suffering. Said Blick,

“We’re not talking about hooking up a potassium chloride drip and have our patient’s heart stopped. We’re talking about terminally ill patients who I’ve counseled over the years and that I would like to give them prescriptions and help them die with dignity.”

Blick, the Medical and Research Director of CIRCLE Medical, is a specialist in infectious diseases and HIV-AIDS, which raised for me a question. Not a few years ago, AIDS was considered always fatal. Now it’s not. How many AIDS patients took their lives, rather than wait for the life-saving treatments now available?

Nevertheless, if Blick and Levine are successful in their campaign, Connecticut could join a growing number of states that recognize the right of a terminally ill patient to end his/her life with the help of a physician.

The recent HBO film, You Don’t Know Jack, was a sympathetic portrait of Jack Kevorkian who was jailed for helping a number of people die, most them not his patients. But he brought the issue to a life that is growing. Recent polls indicate that 60 percent of whites (38 percent of blacks) favor allowing physicians to assist the terminally ill to die.

By all accounts, Oregon’s pioneering “Death With Dignity” law has been doing what was intended. The 1998 law (which has been copied in Washington state) has survived legal challenges including protests by members of Congress because of its safeguards. A physician must determine that the patient has less than six months. and a second opinion is required. The patient must make repeated requests, waiting at least 15 days between requests.

If these procedures are followed, an Oregon physician can prescribe the life-ending drugs, which may be taken with or without a doctor present. In this way about 30 persons a year have gone through the process and died, usually with close family members present. Most of the patients were suffering from advanced cancer or ALS (Lou Gehrig’s Disease).

Leading medical institutions, Harvard Medical School and organizations such as the American Medical Women’s Association, the American Medical Student Association and the American Public Health Association support legislation permitting physicians to assist terminally ill patients to take their lives with drugs.

The American Medical Association stands opposed. And the American Academy of Hospice and Palliative Medicine is neutral, possibly because proper hospice care (in which I am now a participant) can avoid the need to take one’s life and even put off death.

But in the end, hospice provides for pain free and comfortable last days with the help of a hospice nurse to tend to the patient and a hospice social worker to work with the family.

Much of the opposition to assisted death also comes from the severely disabled and persons with serious chronic diseases. They fear, with some justice, that they and people like them will be vulnerable if, for example, their insurance companies balk at the cost of their care. Remember former Colorado governor Richard Lamm telling such people to “get out of the way” because they were costing Medicare too much money?

Other opposition comes from religious institutions and right-to-life organizations who also oppose elective abortions. I disagree, of course, but I believe that just as the state should stay out of a woman’s right to choose, so the state should not need to come between a dying patient and his/her right to choose the manner and time of his/her death.

Oregon’s statute, I admit, is a model of regulation for the safety of the patient’s rights and to guard against abuse - say by relatives who can no longer care for the patient. But the choice of hospice seems to be minimized. That’s why I’m uncomfortable with such organizations like Compassion and Choices, which seems to advocate an end-to-life as if it were a walk in the park.

They may encourage people to seek the alleged comfort of death for no good reason. A woman I know whose medical problems are serious but not life threatening seems to have given up on life because she’s despondent over the death of her husband.

End-of-life advocates seem to provide little encouragement to fight a disease, as I am, and the reasons for their despondency, the better to hang onto life and “rage against the dying of the light.”

As another, more gentle poet, Robert Frost. has written, “The woods are lovely, dark and deep. But I have promises to keep and miles to go before I sleep. Miles to go before I sleep.”

Write saulfriedman@comcast.net

GRAY MATTERS: Republicans and the Health Care Reform Law

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Nobody likes a sore loser. But congressional Republicans, who have not yet come to terms with the election of Barack Obama, cannot get over the passage, with not a single one of their votes, of the health insurance reforms called the Patient Protection and Affordable Care Act.

Thus the Republicans plan to campaign this summer to repeal the law, which they call unpopular. They have not read the latest polls which say otherwise.

The Wall Street Journal poll found that 55 percent want the reforms to have a chance to work. A Vanity Fair poll found that 42 percent would keep all the provisions. That may be why the Republicans won’t say, specifically, which provision should be repealed.

If they did, they would have to support denying insurance coverage to children with pre-existing conditions like asthma or diabetes which is outlawed by the reforms. Or perhaps the Republicans would force middle-class parents to buy separate policies for their adult children; the reforms would cover them until age 26.

How about getting rid of the provisions lowering the Part D cost of drugs, gradually closing the infamous doughnut hole or paying for cancer-preventive screenings?

Or maybe the Republicans simply don’t want coverage that will be available at low cost for the 40 million men, women and children who have no insurance.

More than a dozen state Republican attorneys general have taken a different tack – a fool’s errand, paid for by taxpayers, which pleads that the courts to stop the reforms and declare unconstitutional the provision mandating that all of us purchase insurance (with and without help from the government), the better to create a healthy risk pool.

I don’t have a clue how Republican-dominated courts may rule, but chances are the mandate will stand for each state similarly requires drivers to buy insurance. State laws regulating real estate also require the purchase of homeowners insurance. Becoming eligible for Social Security generally means automatically becoming a beneficiary for Medicare Part A, and Medicare sets a stiff penalty if beneficiaries do not sign up for Part B or Part D when they are first eligible and have no equivalent coverage.

The latest whine of the sore loser is the Republican criticism of the perfectly straight-forward brochure from Health and Human Services (HHS) Secretary Kathleen Sibelius, explaining the admittedly complicated, many-faceted law, which will take years to have full effect. Republicans call it “propaganda” as if their flacks never heard of such a thing.

Her biggest boo-boo, according to the Republicans, was her defense of the law’s reduction of the slush fund for Medicare Advantage plans which George W. Bush gave us as part of the GOP effort to privatize Medicare. Said Sebelius:

“Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than Original Medicare...The new law levels the plying field by gradually eliminating Medicare overpayments to insurance companies.”

More important, she added, “If you are in a Medicare Advantage plan you will still receive guaranteed Medicare benefits.”

That has not been the case with MA insurers for in April, the Government Accountability Office reported that in 43 percent of MA plans, more than half the beneficiaries were in the “average or poor health group,” meaning they did not receive the best of care.

The reforms will hold all private insurers to a higher stand, mandating that 85 percent of premium income be spent on care. Perhaps the Republicans would repeal that provision.

Here is an example of how ridiculous the sore loser can get. In Britain, the heavy use of alcohol poses a serious health problem for the nation and its National Health Service. As a result, Britain’s National Institute for Health and Clinical Excellence (NICE), which produces guidance on public health, suggested the nation’s doctors question and screen patients on their use of alcohol, the better to understand and treat their health problems and their addiction.

It sounds reasonable. But according to Don McCanne of Physicians for a National Health Plan, America’s Health Insurance Plans (AHIP), a leader in the resistance to the American health reforms, picked on Britain’s socialized health program and blasted NICE for requiring doctors “to invade the privacy of every one of their patients by submitting them to a questionnaire on alcohol use.”

There is no such requirement, but McCanne says AHIP is simply doing its conservative Republican thing, defending the “waste of the superfluous insurance industry” in order to discredit any health reform as “socialist.” I guess we should call this the “booze panel” scare.

Putting aside such silliness, it would be worth understanding how HHS intends to enforce the laws, something advocates have worried about because insurance companies have signaled their intent to poke holes in the reforms. Thus, according to Kaiser Health News, the administration has appointed four watchdogs, with plenty of experience dealing critically with insurance companies.

The new director of the Office of Consumer Information and Insurance Oversight is Jay Angoff, a former Missouri commissioner. They’ll be watching for unseemly premium increases, denials and cancellations of coverage and fraudulent sales pitches.

Finally, there is good news for Medicare Advantage, as well as original Medicare beneficiaries who can get eaten alive by deductibles, co-payments and other out-of-pocket costs. The reforms included changes for the better, including lower costs, in the 10 standard Medigap plans that are now offered in most, but not all states.

The plans with increasing benefits range from A, the most basic; B,C,D, and F, the most popular; G, which is similar to F; and K, L, M and N. You can check them out at the Medicare website.

Depending on the level of coverage one needs and can afford, these plans are designed to fill the gaps in Medicare by paying co-insurance, co-payments, some deductibles and even needed blood transfusions and ambulance service.

Medigap plans cover you throughout the nation and some plans include travel and overseas coverage. With such a policy, many beneficiaries pay virtually nothing towards the cost of their care. And Medicare plus Medigap can end up costing less than Medicare Advantage, which does not have a great record when you’re really sick.

Write to saulfriedman@comcast.net


SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Ordinarily, this column, devoted to issues confronting older Americans, doesn’t get into more cosmic subjects of war and peace. But I can’t let tomorrow’s date go by without notice for it marked the most significant event in the war of my youth, my generation.

We gathered in the athletic stadium of my high school that morning to hear the news. It was D-day and American and allied forces had landed on the beaches of Normandy. We heard the voice of General Dwight Eisenhower telling us and the soldiers, sailors and airmen under his command: “You are about to embark on the Great Crusade.”

There was never a doubt in our minds that this was the beginning of the end of this noble and terrible war and the threat of fascism that had occupied most of our young lives.

Now, we are engaged in an endless, pointless 10-year-old war – the longest in our history – against corrupt and backward Third World nations that were and are no threat to us. They are certainly not in the same league as the Nazis, the Japanese and the old Soviet Union. But these wars are robbing us of the national pride and the sense of purpose that we felt in 1944, and have passed on to our children and grandchildren.

For my generation and its boomer children, the financing of Medicare, Medicaid and the dozens of domestic programs have been compromised by the costs of these wars. Deficits are wrongly blamed on Social Security and social insurance programs for the poor and elderly, but not the wars.

Ironically, the wars are being paid for, in part, with money borrowed from the Social Security trust fund.

More tragically, these wars in Iraq, Afghanistan, Pakistan and elsewhere have now cost our treasury, which means you and me and our kids, one trillion dollars and thousands of lives – more than 4,000 American dead in Iraq; more than 1,000 dead in Afghanistan - and more thousands of the dead and terribly maimed here and in the countries we say we seek to save.

Imagine what even part of that trillion dollars could have done in this country for health care, long term care, education and the renewal of roads, collapsing bridges and decrepit schools. Indeed, it’s fair to ask – in the midst of this longest war, which seems to have no end – has it been worth it? Is it still worth it? Nearly ten years and still counting.

As of May 30, at 10:06 A.M., the National Priorities Project, which maintains a computerized counter on the costs of these wars, announced that the U..S. had spent $1 trillion. That’s $1,000,000,000,000.

So far, $747.3 billion and $299 billion have been appropriated., respectively, for the costs of the wars in Iraq and Afghanistan. New pending spending measures working through the mostly compliant Congress will add nearly $137 billion. (See the National Priorities Project) And that doesn’t include the costs of burying the dead and healing the wounded and giving comfort to families here and in the countries we occupy.

In practical terms, according to the Project, that trillion could have paid for Pell Grants for 19 million of our kids for nine years, health care for nearly 300 million people for a year, nearly 8 million low cost housing units, the cost of 16 million elementary school teachers for a year.

If you think you’re not paying for these wars, the Project estimates that taxpayers in Brooklyn (Kings County), New York will pay $9 billion of their taxes for the wars in Afghanistan and Iraq.

This past Memorial Day, television and most of the press gave us unctuous, flag waving interviews with veterans and high ranking officers who recommended honoring the Americans who died. Edmund Wilson called it “patriotic gore.” None was asked if any of these wars were truly just. None was probed on the human and financial costs of these wars.

Only one of our best social commentators, comedian Bill Maher, observed that the U.S. has gotten into more wars than most other nations. Only a few members of Congress, all Democrats, took action to demand that the country get out of the wars in Iraq and tribal Afghanistan, which only wishes to return to the 13th century and grow opium.

Unfortunately, President Obama seems unable to complete what he has promised, like getting out of Iraq. Other great presidents labored, often in vain, to keep the nation out of war; Obama chose to go to war.

Representative John Conyers [D, Mich.], the second longest serving member of the House (44 years), recounted the losses to the American taxpayers as a result of the wars., and what that $1 trillion might have paid for:

“We might be enjoying the fruits of a green economy... investments in wind and solar...a single-payer health care system...we’ll never know because our political leadership never explored alternative means of achieving peace...instead of overextending our military forces abroad.”

He called for the administration to honor its commitment, which seems to be slipping, to leave Iraq by December 31, next year. And he asked colleagues to join the “Out of Afghanistan Caucus” and vote against new funding for the war “because $1 trillion is more than enough.”

Unfortunately, but predictably, the mainstream American press has all but ignored the significant and growing movements against the wars. Last month, 18 members of the Senate voted for Wisconsin Senator Russ Feingold’s amendment to the administration’s war spending bill calling for a timetable to redeploy American forces out of Afghanistan. Some of the supporters are among the most senior members of the Senate, including Richard Durbin of Illinois, the second highest ranking Democrat.

On the House side, 92 members have co-sponsored companion legislation to Feingold’s. Introduced by Representative Jim McGovern of Massachusetts, it would require a timetable for getting out of Afghanistan. In all, more than 100 members have voted for a scheduled withdrawal from a war that has no light at the end of the tunnel.

Representative Alan Grayson calls his legislation for withdrawal, the “War is Making Us Poor Act,” not only because it’s costing lives among innocent civilians in Afghanistan as well as allied troops. More important, these wars are making us poor in spirit. Grayson pointed out that George Orwell in 1984 noted that it seemed as if America had always been at war in Eastasia.

So far, no Republican has joined any of the efforts to end American involvement in Afghanistan. The Republicans are saying in effect, “Let you and the other guy fight” while they wait to see how to make political capital, however it turns out.

That’s a departure from a president of my generation, Ronald Reagan, who “redeployed” American forces out of Lebanon in 1983 after 241 Marines were killed by a terrorist bomb (for which Reagan took responsibility) and he saw no reason to risk more lives. I think it can be said that fewer Americans died in combat on Reagan’s watch, than under George W. Bush or Barack Obama.

Why is it that we don’t learn, even from the recent past?

Write to saulfriedman@comcast.net

GRAY MATTERS: Preserving Social Security

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

It’s past time that Social Security’s advocates, friends and beneficiaries quit playing defense for the single most popular American program and take the offensive against those who attack and lie about Social Security with intent to kill it.

First, find out if you have an IRA or other retirement saving accounts with a bank or brokerage or investment house that has been calling for the privatization of Social Security. If so, transfer the account (without penalty) and tell the broker why.

My broker/financial adviser with Merrill Lynch, is a champion of Social Security as a necessary and dependable leg of one’s retirement income. Ask your broker/financial adviser where he/she stands on Social Security privatization, i.e., changing it from pension and disability insurance into millions of 401(k)s subject to the rock and roll of the stock market.

If you’re affluent enough to have invested with the Blackstone group, transfer your money elsewhere. The hedge fund, whose trade in funny money helped bring on this recession, was founded by billionaire Peter Peterson, who retains an interest in the firm and spends millions through his various foundations to undermine Social Security with the claim that the program and the benefits for the undeserving elderly population’s are bankrupting the nation.

Second, Social Security advocate organizations and politically active beneficiaries and older members can join in the new effort by the National Academy of Social Insurance to expand Social Security to resume the coverage of 22-year-old students, especially the disadvantaged, which was ended in 1981, when Social Security was in imminent financial danger.

Such an expansion could dovetail with the new health insurance reforms which mandate coverage on their parents’ policy for children up to age 25. And it would not only help these families and kids pay for college, but it would strengthen the Social Security system with support from the young which has been eroding as too many the mainstream media buy into the Peterson nonsense that Social Security is in financial trouble. It isn’t.

Indeed, the 75-year-old program, which is in the black for another 30 years even if nothing is done, will outlast Blackstone as it has outlasted Lehman Brothers, Bear Stearns. Enron, Eastern Airlines and the Pennsylvania Railroad, a few recessions and lots of wars.

During those years, Social Security has never defaulted on a payment. Indeed, it expanded to cover the disabled and the spouses and children survivors of beneficiaries who died before age 66, like those killed on 9/11.

And since the fixes of 1983-4 by the Reagan administration and Alan Greenspan’s commission, Social Security has run a surplus every year, enough to guarantee benefits for the huge boomer generation. Even this year and next, when high unemployment forces the program to pay out more than it takes in in payroll taxes, Social Security will still run surpluses of more than $100 million.

That should lead defenders to their main point, which they should repeat like a mantra: Aside from its administrative costs, Social Security’s benefits for 50 million Americans does not contribute even one dollar to the federal deficit. Let me repeat for reporters who are too lazy to understand Social Security: Aside from its relatively small administrative costs (which are in the Social Security Administration’s budget), Social Security adds nothing to the deficit.

In fact, Social Security earns around $700 million a year, financing the federal debt by selling the Treasury its low-interest special issue bonds. Social Security could solve its long term fiscal problem if it could sell the government higher-interest bonds. But, of course, that would raise the deficit.

Ignoramuses suggest that these bonds in Social Security’s West Virginia vaults are nothing more than “worthless IOUs.” As the Chinese, Japanese and other investors know, U.S. IOUs are as good as cash. Indeed, if you examine your paper money or your employer’s check, they are IOUs until you spend or cash them out.

If the IOUs were “worthless,” why would Peterson and his greedy Wall Street and hedge fund investment banking allies be so eager to get their hands on the $2.5 trillion in Social Security bonds? What a tasty dish to set before the kings in their counting houses!

A friend at AARP says it will do no good to bash billionaires. I disagree because their message, backed by their money and the megaphone of the media, conservative Democrats in the Congress and the hysteria over the deficit has undermined support for Social Security and Medicare. And AARP has not been aggressive in helping to challenge Peterson and his deficit hawk allies who have been given aid and comfort by the administration which was bullied into creating the anti-Social Security commission on the deficit.

Fortunately, the latest defense and offense on behalf of Social Security has come from a definitive report on the future of the program prepared with the help of the Congressional Budget Office and published by the Senate Special Committee on Aging.

The seemingly alarming news is that Social Security faces a $5.3 trillion shortfall over the next 75 years. But the committee chairman, Senator Herbert Kohl (D., Wis.) echoes the current conclusion of Alan Greenspan, the Academy of Social Insurance and nearly every other expert, that the shortfall could be fixed with what Kohl called “tweaks.”

For Kohl and most advocates, cutting benefits is not an option, nor is reducing the criteria for the mandated cost of living (COLA) raises. And Kohl rejects the report’s suggestion that the future fiscal problems could be solved by raising the retirement age from 66 to 70. That would solve only 30 percent of the shortfall, and would delay and thus rob millions of workers of the benefits they now expect and count on.

Besides, many blue collar workers in tough, physically demanding jobs should not be required to work until 70; a coal miner may not be able to keep working after 66.

There are more likely alternatives which are obvious and simple: As the Social Security Trustees’ conservative outlook for the future reported last year, a 1.1 percent raise in the workers' and employers' payroll tax (now at 6.2 percent each) would wipe out the shortfall for 75 years. The trustees, incidentally, base their estimates on 1.5 percent annual growth in the GDP, which is far less than the past years.

More popular with the Obama administration, if Congress abolished the $106,800 cap on the wages subject to payroll taxes, the entire $5.3 trillion shortfall would disappear. Obama has suggested raising the cap to $250,00. Interestingly, several of the nation’s more honorable billionaires, like Warren Buffet and Bill Gates - junior and senior - have called for an end to the cap, noting that they are paying no more in Social Security taxes than a well-paid secretary.

As far as I know, they do not hold that Social Security’s assets should be put up for grabs on Wall Street. But then Buffet and the Gates's helped create wealth and something tangible, instead of a house of paper that collapsed.

You can see the Aging Committee’s information as well the views of advocates at the Committee's website, and you may read or download the full report here (pdf).

Write to saulfriedman@comcast.net


SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

My cancer doctor told me in writing, that I had six months to live. But he acknowledged he could not be sure and that the six months could be extended indefinitely.

That made me eligible to take advantage of a little understood, free Medicare program that has been enhanced by the new health insurance reforms, and could be available to anyone with a prolonged, chronic, life-threatening illness. I’m talking about the Medicare/Medicaid hospice program.

Until recently, entering a hospice program was frightening because it meant you understood you were dying and you voluntarily agreed to forgo chemotherapy or any other curative treatment, and were given only palliatives, painkillers and bedside help from professional whose job it was to make you comfortable.

All that has changed. As Dylan Thomas told us, we should “not go gentle into that good night.” So hospice should no longer be feared and avoided like the “dying of the light.” Rather, it should be embraced as a fine, comprehensive, home health care program.

A little background: In 1995, Medicare was under assault from the Republican Congress led by Newt Gingrich. Specifically, Medicare’s funds were cut to pay for private Medicare HMOs. And Medicare was criticized for the amount of money it was spending on the care of beneficiaries in the last year of their lives. Indeed, it accounted for a third of Medicare spending.

Medicare responded with its pioneer hospice program to care for the dying. Hundreds of hospices were founded around the country, most of them funded by Medicare which included nurses, social workers and devoted volunteers who became the providers of palliative care for the dying.

Private insurers followed with coverage of hospice services, but private insurance carried heavy premiums; Medicare covered 100 percent of hospice costs.

I watched how it worked for a close relative who was dying of lung cancer and his family. Hospice supplied the hospital bed set up in the home. Hospice supplied the drugs he needed for pain as well as the care to keep him clean and comfortable. And hospice helped with bereavement counseling for his wife and son.

Then, as now, he was admitted to hospice because his doctor attested that he had less than six months to live. He died three months after his diagnosis. But remember the columnist Art Buchwald who cheated death and remained in hospice care for much longer than six months?

Because such predictions are more and more uncertain as treatment options have become available, the courts forced a change in Medicare regulations. A person could not be discharged from hospice because he lived longer than six months; the six months could be renewed indefinitely.

Since 2007, Congress and Medicare have realized that with medical advances such as the CT-Scan, PET-Scan, open heart and by-pass surgery, radiation and chemotherapy, Medicare could not insist that hospice patients cannot take advantage of these possibilities while fighting his or her disease. Medicare and private insurers adopted an “open access” policy, admitting into hospice – for curative and/or palliative treatment, as long as a doctor said they had no more than six months to live.

Thus hospice has become a comprehensive health care program for the seriously ill, who may or may not be close to death. Indeed, as I have learned, it is not at all rare that a beneficiary can get well enough to graduate from hospice. My hospice expects me to be one of those beneficiaries.

In the meantime, hospice assigns to a beneficiary a nurse who comes by your home regularly to check your vital signs, see how you’re doing and help with chronic or even acute medical problems. Even more important, the assigned nurse or another nurse is on call 24/7. That means that if there is an emergency, such as a urinary problems, or the side effects of the chemotherapy, you need not go to the emergency room.

I’ve learned that the hospice nurse on call is equipped and trained to deal with such problems. No longer do I need to call 911 on a weekend and go to an emergency room. Besides being traumatic and tiring, it would cost Medicare hundreds, even thousands of dollars.

Similarly, while a hospice beneficiary may keep routine appointments with doctors, hospice nurses are equipped to deal with colds, the flu and other ailments that would ordinarily send you to a physician at Medicare’ expense. And hospice will help a patient’s oncologist by drawing blood often to keep track of possible problems such as a drop in the red or white cell counts or potassium and iron levels.

Thus hospice becomes your caregiver in fighting the disease as well as preparing for the worst. Medicare hospice, for example, supplies beneficiaries with kits that include morphine and other powerful painkillers; I’ve put my kit away and have almost forgotten about it. The best option is to avoid hospitalization for your illness for Medicare requires that hospital patients forgo curative treatment.

In addition, Medicare hospice assigns to beneficiaries a licensed, professional social worker to help family caregivers with advice, counseling and resources to help patients and families cope with the stresses of life-threatening and debilitating illness. Hospice may supply a hospital-style bed with linens or oxygen, or an IV to prevent dehydration.

The recently passed health reforms expanded curative and palliative hospice care for children in Medicaid or the Children’s Health Insurance Program (CHIP). It allows children enrolled in either program to receive hospice services without forgoing curative treatment. The Centers for Medicare and Medicaid Services (CMS) are expected to require states to comply with the changes, which are to take effect in 2013.

Finally, as of next January 1, the reforms will require that a nurse practitioner or doctor must have a face-to-face encounter with the patient at the end of the six month period to recertify his/her eligibility.

You can read or download and print [pdf] Medicare’s 16-page booklet on its hospice services, including where to find a hospice near you.

Write to saulfriedman@comcast.net

GRAY MATTERS: Government-Run Health Care

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I would not live anywhere but the United States (except maybe in an Italian villa). But we could take some lessons from what we patronizingly call the “old world.” Old, after all, usually means they know how to survive and learn. And we’ve yet to learn how an adult nation should act.

For example, we don’t need the barbarous death penalty, especially if we stop the insane easy access to guns. We stop mothers from boarding airplanes with too much baby shampoo, but our Congress refuses to bar people on the no-fly watch list from buying assault rifles.

And if the right-wingers truly believe in limited government, should not our government stay out of a woman’s right to choose abortion and my right to die?

Along those lines, virtually every nation in the old world provides for its citizens access to free or inexpensive health care. But only one reporter covering the hotly fought British parliamentary elections for CNN-World (which is seen by too few Americans) told us, in a fine story, that all three major party leader candidates – with ideologies ranging from left to right - agreed on one thing: The British National Health Service is so popular that in the campaign, it was an untouchable. Indeed it got high praise and support from all the prime minister candidates. Paul Armstrong reported,

“To many Republican politicians [and some Democrats] in the United States, a publicly funded national health system like the NHS is the embodiment of austere, Soviet-era medical care but in the UK, it is viewed as sacrosanct.

“Launched in 1948 by a left-wing Labor government [which replaced the conservative Tories under Winston Churchill], the NHS was created out of a long held ideal that everyone should have access to good health care regardless of wealth.

“More than a half-century on, millions of Britons still enjoy free medical care, from routine consultations on coughs and colds to open heart surgery. Over the years it can boast pioneering breakthroughs from Britain’s first heart transplant in 1968...to the 1988 breast screening program, providing free mammograms to reduce breast cancer in women over 50.”

There are four parts of the National Health Service, for England, Northern Ireland, Scotland and Wales. The scale of the NHS is vast, with thousands of doctors, technicians, nurses and administrative personnel working for the service.

There has been criticism of waiting lists for treatment or elective surgery. But those critics ignore the chaos and the waiting in America’s packed emergency rooms on a weekend or Monday morning. In Britain, as I discovered years ago when I was struck with flu symptoms while covering a story, I could choose from dozens of neighborhood doctors who worked for the NHS. I was treated at no charge. (It was the same for me in Israel and South Africa).

Despite the criticism, the NHS spends $2,300 per capita on health care costs in the U.K., which is far less than the $6,700 in the U.S. And U.S. spending is way more than any of the comprehensive and universal health care systems in the old world. Still, there are 40 million people in the U.S. without health insurance, which is unheard of and would be scandalous in the old world.

Armstrong writes, the Conservative Party leader, David Cameron, now prime minister, was effusive in his praise of the NHS, noting on his web site, ”Millions of people are grateful for the care they have received from the NHS – including my own family.” (British conservatives have no ideological relation to American right-wingers. We should remember that the conservative icon Margaret Thatcher, who would not be considered conservative enough in the U.S. today, declined to mess with the NHS).

Perhaps if President Obama had used and learned from his own family’s access to government-run, socialized medicine, we might not have given our health care reforms over to the drug and insurance companies. But it turns out that Obama, unfortunately, is neither a liberal or a socialist and was not as willing as his British counterparts to even consider single-payer health care reforms. A little socialism is okay for the banks, GM and the president’s family but not for us.

In Britain, the Labor Party and the middle-of-the-road Liberal Democrats, who will be part of Cameron’s government, joined in defending and praising the NHS. In the U.S., said Ruth Thornby, a British researcher who studied the American health care system, Republicans are

“worried about rationing by government or an official bureaucrat making decisions about who gets what. (But) bureaucrats within private health insurance companies are making those decisions all the time...”

Indeed, in the U.S., only original Medicare, untainted by private schemes like Medicare Advantage, provides beneficiaries with free choices of doctors, labs and hospital, anywhere in the country. For those of you who consider any socialist system as austere, I’d urge you to browse the colorful and informative website of the NHS.

While the old world has placed its trust and health care systems in the hands of their governments, the reforms just passed by the Congress have been entrusted to private insurance and drug companies, with the hope they will voluntarily comply with the reforms. This despite the fact that the companies are bound by their fiduciary responsibility to their stockholders to return as much as possible on their investments.

On May 9, Senator Jay Rockefeller (D, W.V.), scolded the nation’s leading health insurance companies for “gaming” the new law to dodge and weaken it in subtle but important ways. In a letter to Health and Human Services Secretary, Katherine Sebelius, Rockefeller noted that the law provides that insurance companies are supposed to spend 85 percent of premiums on health care. Rockefeller charged the companies are redefining administrative costs as medical costs and thus not spending more on patient care, as the law intended.

On May 6, CNN reported that large companies, such as Verizon, AT&T, Caterpillar and Deere, were secretly considering dropping health care coverage their employees have had for years. This would mean undermining a crucial Obama promise of the health reform, that beneficiaries could keep the coverage they’ve had. In addition, the companies are balking, as too expensive, that part of the law which provides insurance for employees’ children up to age 26.

If employer-sponsored plans were dropped, it would help the bottom lines of the companies but raise considerably the projected costs of the health care reforms. Representative Henry Waxman (D, CA), chairman of the House Energy and Commerce Committee, reacted angrily and demanded internal documents of the companies on their intentions. So far, possible change is on hold.

Similarly, Sebelius’ public pressure forced Anthem Blue Cross and Wellpoint in California to back away from an announced 39 percent increase in premiums. And she criticized Wellpoint for cancelling coverage on women diagnosed with breast cancer, to be prohibited under the new law. Wellpoint denies this.

Surely the companies will keep trying to nibble away at the reforms. If they do, government has little recourse except moral suasion. But the only punishment, tucked into the deep innards of the law, is a paltry $100 fine for each day of a violation. A multi-billion dollar insurance giant will find it more profitable to pay the fine than abide by the law.

Thus, this question for Americans: Who would you trust more with your health care? Government (as in Medicare or the NHS) or your insurance carrier?

Write to saulfriedman@comcast.net

GRAY MATTERS: Hunger and Shame

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

My mother, may she rest in peace, would have called this a shanda, the Yiddish word for a shame, something you’re not proud of and that you’d rather your neighbor doesn’t find out.

So shame is what I thought about and felt when I read the latest survey by academic researchers for the Meals on Wheels Association of America. It found that in 2008, at the beginning of this Great Recession, nearly six percent of Americans over the age of 60 - more than 2.7 million - suffered from hunger. Not just the lack of enough food, but hunger. In the United States of America in the 21st Century.

But the deeper shame was in the 2009 survey which found that the trend upward was especially discernible between 2001 and 2007 - the years of tax cuts for the wealthy and a couple of pointless wars - when the number of older people (especially women) experiencing hunger rose by 700,000 to upwards of 3 million.

Now, as a result of the recession, when many programs for the aged and poor were reduced, partly to pay for those tax cuts, that figure has reached to over 3 million and with unemployment more than 10 percent, the figure is still climbing.

The highest concentration of hunger risk among older people are in those states with low or no income taxes and fewer social insurance programs: Mississippi, South Carolina, Arkansas, Texas, New Mexico, Georgia, Alabama, Louisiana, North Carolina and Oklahoma. These states, most of them conservative, also have higher concentration people with only a high school education, plus a higher number of blacks and Hispanics and older people living in poverty. The south remains the most ignorant and badly-led part of the country.

More definitive studies of hunger in the U.S. are published yearly by the Economic Research Service of the Department of Agriculture. But these studies refer to the problem as “food insecurity,” a phrase begun during the Reagan administration which named “ketchup” as a food and denied there was hunger in the U.S.

Nevertheless food insecurity means not knowing where or when you’re getting your next meal.

In its latest study, noted on an inside page of The New York Times last November, the number of Americans who lived in households that lacked access to adequate food rose to nearly 50 million, the highest level since the government began tracking food insecurity 14 years ago.

Thus at some time during the year, 50 million Americans, including 17 million infants and children and more than 5 million older people went hungry.

According to the Times, about a third of 506,000 households in which children and older adults faced hunger, they skipped meals, cut portions or tried to make do with food stamps. Now 36 million people have applied for food stamps, a 40 percent increase over two years ago. But the benefit is only $133 a month, not very generous for the richest debtor nation on earth.

More than 6.7 million Americans who are described as having “low food security” regularly lack sufficient food to eat. Nearly all reported that the food did not last a month.

These dismal facts have not made much of a dent in the news, for hunger in the U.S. - a huge story 50 years ago when the nation began a war on poverty – has now become a silent epidemic. But the foreign press, representing nations where hunger is unknown, has made much of America’s troubles.

The British Guardian’s headline on November 17 was, “Record Numbers Go Hungry in The U.S.” Another Agriculture Department global study of food security found that percentage of households in Canada classified as “food insecure” was 7 percent compared to 12.6 percent in the U.S., and that was before the recession.

As you might expect, Robert Rector of the conservative Heritage Foundation told the Times:

“Very few of these people are hungry. When they lose jobs, they constrain the kind of food they buy. This is regrettable, but it’s a far cry from a hunger crisis.”

James Weill, whose department did the study, replied,

“Many people are outright hungry, skipping meals. Others say they have enough to eat but only because they’re going to food pantries or using food stamps. We describe it as ‘households struggling with hunger.’”

Perhaps we should take comfort in the Agriculture Department’s overview of food security assessment which found that while there is no such hunger problem in most other industrialized nations with strong social welfare programs, the problem of food insecurity is far worse in the developing world than in America.

Sliding onto a related subject, the recession and the holes it has torn in retirement savings mean the percentage of people who expect that Social Security will be their major source of income has risen from 27 percent to 34 percent. That’s the highest percentage since 2001, according to a Gallup survey. That translates to 54 percent of retirees who said in 2008 that they expected Social Security to be their major source of income.

This comes at a time when older Americans were frightened by what seemed scary news – that for the first time, this year and next and maybe a couple more years, Social Security will be paying out more money that it will take in in payroll taxes. The reason is obvious: high unemployment means millions of jobless workers are not paying payroll taxes. But despite that frightening news, as economist Dean Baker points out, what SS will pay out will be a minuscule portion of the $2.5 trillion it holds in government bonds.

Some skeptical readers insist these bonds (in a vault in West Virginia ) are just so many IOUs. Well, so are your personal checks and the treasury bonds you hold. But the SS bonds, which produce about $700 million a year in interest for the Social Security trust fund, are backed by the full faith and credit of the U.S. It would help SS if the law permitted the agency to get a higher rate of interest, or if Social Security could remove the current cap ($106,000) on taxable earnings.

But Social Security, with its huge trust fund, is a tempting target for people like billionaire Pete Peterson and other deficit hawks who would love to privatize the system and make all that money available to Wall Street. And the shortfalls for the next years has given them an excuse to focus on Social Security, which is self-sustaining and contributes nothing to the deficit.

For example, the Wall Street Journal reported that the Social Security trust fund would show a deficit in 2010. “This is not true,” said Baker, director of the Center for Economic and Policy Research:

“The Social Security trust fund is projected to show a surplus of close to $100 billion in 2010...The Journal likely forgot to include interest on the bonds held by the trust fund.”

I doubt that the Journal forgot. The Journal did not see the Wall Street crash coming but would now take advantage of this temporary problem to turn the social insurance on which millions depend over to those who caused the problem. Shame.

Write to saulfriedman@comcast.net

GRAY MATTERS: Safest Reverse Mortgage

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Welcome to Older Americans Month, the theme of which, according to President Obama, is “Age Strong, Live Long.” I’ll buy that. And he pledged again that his administration is committed to strengthening Medicare, Medicaid and Social Security.

So why is he scaring the hell out of older Americans by appointing a commission filled with deficit hawks who threaten to cut benefits from these programs, including Social Security which adds nothing to the deficit but helps finance it?

But I digress from my purpose this time, which is to tell you that there’s a way, not used often enough, to protect yourself against too many medical bills, high property taxes and the downers in your retirement savings plans. I am referring to the federal government’s reverse mortgages which too many beleaguered older Americans have ignored. Some don’t want to mortgage a home that’s free and clear; some are discouraged from tapping the equity in their homes by children who are waiting for their inheritance.

So here’s some welcome news for older Americans who own their homes and can use some extra income and cash. The up-front costs for many FHA-guaranteed reverse mortgages have gone down, which means the possible proceeds will go up by as much as $10,000.

I’m referring to the most popular and safest reverse mortgage, the Home Equity Conversion Mortgage, fondly known as the HECM. It is the safest for the lender as well as the homeowner-borrower because it is backed, insured by the Federal Housing Administration which has never defaulted on a mortgage that it has guaranteed.

Indeed, of all the mortgages that have fallen on hard times, or have been the subject of scandalous behavior by bankers and investors, the HECM has been largely untouched by these troubles. Last year, the Department of Housing and Urban Development raised to $625,000 the value of a home that could qualify for a HECM.

But because of falling home values, the recession and its budget problems, HUD cut by ten percent the amount one could borrow on a reverse mortgage. As a result, HECMs have experienced a slump.

As The New York Times pointed out last month, “Consumers were becoming increasingly reluctant to sign up for reverse mortgages – homeowners could not pull out as much equity as they once could because of the drop in home values.”

As a consequence, the largest HECM lenders – Bank of America, Wells Fargo, Metlife Bank and my lender, Financial Freedom, have waived their origination and servicing fees on certain HECMs. The origination fee is usually two percent of the first $200,000 of the home value plus one percent of the value over that, with a maximum of $6,000. Normally those fees are deducted from the proceeds and tacked onto the end of the loan.

But as a result of the waiver, Metlife said, “homeowners could receive additional loan proceeds ranging from $3,500 to $10,000 or more.” The single condition is that borrowers must take the proceeds in a lumps sum rather than in periodic payments or a line of credit, which costs the lender more to service. If they choose payments or a line of credit, the fees are not waived.

Craig Corn, Metlife’s vice-president in charge of its reverse mortgager business, explained that the option to take a lump sum in exchange for a waiver of the fees can give home owners “additional proceeds to help them pay off existing debts, meet basic needs, cover unexpected expenses...or whatever else they feel is appropriate.”

Let me add that the proceeds of a reverse mortgage are tax free and you may wish to invest the cash or turn it into an annuity. As of last year, you may use the proceeds to buy a second, vacation home, as long as you sell the first home and pay off the loan.

I should add that if and when the mortgage is paid off by the borrower or his/her heirs, the fees and interest are tax deductible. In the meantime, of course, the home is yours to live in as long as you wish. Only if he home is vacated, does the loan come due.

Even with the downturn in home values and the proceeds for reverse mortgages, HECMs have become safer for lenders as well as home owners because FHA limits the proceeds of most HECMs to about 50 percent of the appraised home value, which means that there is a huge cushion to prevent default in case of declining home values. That also means that despite the accrued interest and fees on the tail end of the mortgager, chances are there will be sufficient equity remaining at the end of the loan, if heirs wish to take over the debt and sell the property.

There are a couple of dark clouds that could further depress the demand for HECMs. David Stevens, the FHA commissioner is seeking $250 million from HUD to offset defaults and costs to the program because of declining home values. This would be the first time in the 25 year history of the program that it needed possible help from the treasury. In addition, Stevens is seeking an increase in insurance premiums, which are built into the costs of a HECM. And Stevens asked for cuts in proceeds for younger borrowers.

Borrowers must be at least 62, but the older the borrower the higher the proceeds he/she would receive. Unless such changes are made to offset possible added costs of the HECM program, Stevens warned that HUD may have to cut proceeds by 21 percent next year. With such a reduction in proceeds – $23,000 to $27,000 — the program could become moribund.

Critics of the HECM program, most prominently, Senator Claire McCaskill (D - Mo.), has charged that lenders fail to tell borrowers of the downside of reverse mortgages, but most of those she cited were private loans. HECMs have been free of such problems and the National Association of Reverse Mortgage lenders have taken steps to keep HECMs clean of scams.

In addition she has worried that reverse mortgages could fall prey to “securitization,” investors who slice and dice mortgages as they have done with conventional mortgages. But reverse mortgages are safer – for investors as well as borrowers because they are insured by FHA.

All in all, then, HECMs are a good deal if you intend to remain in your home for at least five years; otherwise you’ll be saddled with the closing costs that will eat up the proceeds you get.

To sum up HUD’s guide to HECMs:
  • You must occupy your home (condo, or co-op) as your principal residence
  • There are no income, credit or health requirements
  • Social Security and Medicare benefits are not affected
  • You keep title and may sell it at any time
  • You may use HECM proceeds to buy a second, vacation home as long as the loan on the first home is paid
  • And of course, no repayments as long as you occupy the home.

Still it would be wise to shop for a provider who may be able to arrange the loan and lead you through the process. HUD requires that each borrower undergo counseling by an approved agency (cost is $125). The counseling of the National Council on Aging, is even better and free. Call 800-510-0301.

And you can calculate the proceeds you may expect at the HUD website or call 1-800-530-6434.

Write to saufriedman@comcast.net


SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Justice Oliver Wendell Holmes said it elegantly: “Taxes are the price we pay for civilized society.” I’d put it less nobly: “You get what you pay for.”

Picking up from last week, despite the bitching and moaning from all of us from time to time, Americans pay fewer taxes than the citizens of most advanced and civilized countries, which may explain why we get bubkas – next to nothing - in social, human benefits. Rather, we get bailouts for the biggest thieves, assaults on what social insurance we have and endless, pointless wars.

The trouble with the duped crazies of the so-called tea party, they don’t recognize their real enemy. I wish one of them would tell me which rights and freedoms have been taken away. They like Medicare, Social Security and their public services. Even Ronald Reagan came to understand when he saved Social Security, raised taxes and made peace with the Soviet Union that the problem is not government, but the lack of it.

As I mentioned last time, in most of the civilized world, the 30 advanced nations of the Organization for Co-operation and Economic Development (OECD), people enjoy the benefits of universal (and mostly free) health care, inexpensive public transportation, cheap and sufficient inter-city rail travel, public education, paid vacations and leave for new mothers and fathers, strong unions, unemployment insurance, pensions and long term care for the elderly.

The most important reason? They pay for it. Despite the recession and financial troubles in most of these countries, their governments can afford these benefits and it will be more affordable as the recession fades because their taxes collected from individuals and corporations are relatively high.

The United States has the fourth lowest tax collection rate after Japan (which has not yet emerged from its depression), Korea, Turkey and Mexico.

The OECD has a uniform measure for each nation’s taxes: “total tax revenues as a share of the economy,” the Gross Domestic Product. The United States, the richest of all the nations, is 26th out of 30 with the lowest share of its GDP, except for Japan (which is still struggling with recession, in part because of its low spending), Korea, Turkey and Mexico.

The average of total tax revenues among all the nations is 36.6 percent of GDP. For the U.S. it’s at 28.3 percent. And that low figure reflects the deep tax cuts in 2001 for the wealthiest Americans and corporations.

During most of the years from 1996 through 2007, the U.S. cut the rate of spending on social benefits while reducing taxes and fighting two wars. You might say an exception was the Medicare Part D drug benefit, but it privatized a public program and was not paid for.

While the U.S. was seeking ways to cut public programs and taxes, the richest and most beneficent of the OECD reported their tax revenues were more than 40 percent of their GDPs: Denmark (48.7), Sweden (48.3), Belgium (43.9), Norway (43.6) and, France (43.5) and thus were able to offer their people generous public benefits – which we don’t get, or pay for out of pocket one way or the other.

Now, as a result of the Obama administration’s cuts in the taxes of 95 percent of mostly working and middle class Americans, William Gale, co-director of the Brookings Institution Tax Policy Center, says that federal taxes are at the lowest level in 60 years. A middle income family will pay only 4.6 percent of its income in federal taxes. (They pay more than that in payroll taxes for Social Security and Medicare, both of which are in danger from the deficit hawks.)

Perhaps a few of you will remember when the marginal tax rate for top incomes, now at about 30 percent was 90 percent during the years of the New Deal and World War II. Indeed, according to Moshe Adler writing for Truthdig, between 1913, when the income tax was instituted with the passage of the 16th Amendment, and 1981, the highest marginal tax rate averaged 68 percent. Yet it was during those years, when the wealthy paid their way in a progressive tax system, that the U.S. experienced its greatest prosperity and growth in social benefits and public works while fighting four wars.

Despite the average tax cut this year of $1,158 for nearly all American families and individuals, many are not aware of money they don’t have to pay partly because they’ve been dribbled out in reduced withholding from wages. Yet, we Americans are so attuned to those who cry “tax cut” that a CBS News/New York Times poll earlier this month found that 53 percent said Obama had kept taxes the same, 24 percent believed he had raised taxes and only 12 percent believed he had cut taxes.

Some polls have found that Americans may be willing to pay higher taxes for more and better public services and benefits, but the poll didn’t ask about raising taxes as if it were a sin to even think of that.

So consider the American dilemma: We are in love with low taxes but we fight two wars, spend more than any nation on the military and now with a Democratic administration that has increased social insurance benefits, we have record-high and unsustainable deficits.

And still the tea party goers, big business, Republicans and assorted deficit hawks would further slash benefits and taxes. No one dares to seek the tax increases we need for civilized society.

Combine this uninform no-new taxes attitude with an ignorant, unthinking antipathy towards the federal government that does not exist in most of the OECD counties and no wonder that our screwy priorities give us a deeper poverty and homeless rates than exist elsewhere in the civilized world. No wonder the U.S. has more people without health insurance and more children living in poverty than virtually any OECD country.

Social Security provides $13,300 a year for a single elderly woman in New York City. Medicare provides some basic health care. But out-of-pocket medical costs, housing and other expenses for basic daily living have put thousands of older persons in the country’s richest city living on the edge.

Cities throughout the nation are cutting Medicaid, firing thousands of teachers, closing schools and slashing the services of government. That prompted Matt Ryan, the mayor of Binghamton to advertise with an electronic sign at city hall demonstrating the costs of wars to cities like his:

“I wonder if we’re ever going to get our priorities straight...I can see so clearly what increased federal spending could do for the people of my city.”

We’re about to hit the $300 billion mark in the cost of Afghanistan according to the National Priorities Project. That would pay for health care for 131,780,734 children for a year. The total cost of two wars since 2001 is $980,000,000,000 – or $7,334 for each American taxpayer. You can see what your low taxes are not getting at the National Priorities Project.

It’s not something for a great nation to be proud of.

Write saulfriedman@comcast.net

GRAY MATTERS: Socialized Medicine?

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I am not now, nor have I ever been a Marxist. But I studied Marxism in a philosophy class in college. I have visited communist countries (China and the old Soviet Union) and lived in semi-socialist counties (much of Europe) and have taken advantage of their socialized, government health plans when I got sick.

Obviously, I survived. But it has occurred to me that these experiences qualify me to recognize Marxism or socialism when I see it in the health insurance reforms that are about to become law.

Socialism means every provider in the health care system works for the government agency that runs the system. So let’s examine the reforms and see which ones, if any, are Marxist, socialist or in danger of destroying America.

ITEM: Within six months this year, young adults – like your kids in school – may stay on their parents’ health insurance until they are 26. The provision applies to all health plans and includes children under 26 who are married. Socialist? No, but it’s obviously paternalistic; critics could argue that children that age should be able to work and buy their own insurance.

ITEM: Also within six months this year, insurers will be barred from excluding coverage for children with pre-existing conditions. I don’t see anything socialist in this provision, but the administration did extend government power to insist that the insurance companies sell such policies at fair prices.

Later this prohibition will include adults but at least one Republican, Missouri Representative Roy Blount, opposes this on the grounds that adults should take better care of themselves. That may be government interference with the free market. But it’s not socialism.

ITEM: Another regulation that goes into effect in six months would prohibit group health plans and insurers of individual policies from rescinding or canceling a policy except in cases of fraud. It means once you sign up in good faith and pay the premiums, the insurer cannot cancel your policy even if you get very sick. Not socialistic, but another case of government telling a company it must assume the risk that some policy holders will get real sick, which may cost the insurer and stock holders a bundle.

ITEM: Under present law, the government just ordered Aetna, one of the largest insurers, to stop selling Part D drug and Medicare Advantage policies because it suddenly changed the drugs offered current beneficiaries. That’s a no-no. Aetna’s stock prices declined after the order.

ITEM: Similarly, the government is telling companies this year that it cannot set lifetime limits on benefits and in 2014, they will be prohibited from setting yearly limits on benefits. You might argue that that’s getting close to the government dictating and hurting business. Why should a company go on paying and paying even if the patient has some kind of incurable disease. What good would the medical help do? That’s not good for businesses, but it stops short of socialism.

ITEM: In what critics might call another government effort to bribe small businesses, many will be eligible this year for new tax credits to help them pay for their employees’ health insurance which they’ll be required to offer. The full credit will cover 35 percent of the cost of premiums this year and 50 percent in 2014.

This isn’t socialistic or a government takeover of the business but it is interference with an employer’s right not to offer health insurance. A tax break on 50 percent of the cost means the employer must pay the other 50 percent, which he may not be able to afford and besides, what if business is bad?

ITEM: Some critics believe workers should be able to take some responsibility and buy their own insurance or take their kids to an emergency room when they run a high fever. Again, not socialistic, and it’s far from Marxist for here the capitalists and workers help each other with the help of government.

ITEM: Another provision that supporters say is especially good for seniors would gradually close the so-called “doughnut hole.” There was a reason for the coverage gap which was deliberately created by the Republicans in their great Part D drug law in 2003 to help drug companies’ profits. When in that gap, beneficiaries must pay the full cost of the drugs, which will be going up if the companies are practicing the American way of business.

Did you know that the reason the gap was created is called “moral hazard?” Republicans wanted to be sure seniors didn’t overuse their benefit and buy drugs they didn’t need. So because some critics argue that closing the doughnut hole may encourage drug use, it’s probably good for the drug business that the hole won’t close until 2020.

ITEM: I see no ideological objection to another benefit this year touted by Obama - the elimination of cost-sharing (deductibles and co-insurance) for preventive medical screening exams such as colonoscopies, mammograms and prostate examinations and annual checkups. Maybe some people will take advantage of this too often and it can end up frightening people. But I do not think this benefit will bring America down.

ITEM: The primary health reforms come in 2014 with the establishment of state health insurance “exchanges” monitored by the federal government. Contrary to the belief that the government is taking over our health care system, these exchanges are supposed to offer a variety of competing private health plans with various benefits at various prices.

But there are to be standard benefits. And low income people will receive subsidies much the way Medicare helps people pay their premiums. All the companies will be private and so will most of the providers, hospitals, labs and doctors, so no socialism here.

In fact, the VA health care system will not participate in the exchanges because it is thoroughly socialist in that all providers work for the VA and it seems to work well, especially for lawmakers like Senator John McCain.

Sarcasm aside, why do people who do not know anything about Marxism or socialism toss those epithets at reforms that can only help them and millions of others? Perhaps the reforms may help the U.S. catch up to the 30 countries in the Organization for Economic Cooperation and Development, which includes most of capitalist Europe where they have been able to live comfortably with government-run health care. They are social democracies, with social (public) ownership of health care and other vital public services.

Bill Quigley, a Loyola University law professor and a director of the Center for Constitutional Rights has compiled some of the differences between the U.S. and counties that have adopted a modicum of socialism.

Their citizens pay higher taxes, but they get their money’s worth in health care and other benefits including education, transportation and paid leave for new mothers. Infant mortality in the U.S. is fourth worse among the OECD counties, better only than Mexico, Turkey and the Slovak Republic. Child poverty in the U.S. affects one out of five kids; that’s double the average in the 30 OECD countries. See for yourself at oecd.org.

“The facts say the U.S. is not on the path towards socialism,” says Quigley. And surely we are not close to Marxism which holds, among other things, that the rich get richer and the great corporations prevent the rest of the population from enjoying the fruits of their labor. (See, for example, the recent Massey mine disaster).

Write to saulfriedman@comcast.net

GRAY MATTERS: Nursing Homes and Drugs

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

If you have a friend or a loved one in a nursing home, you should be aware of one of the more insidious practices facing many residents. They can save the nursing home money but they rob patients of what remains of their spirit, dignity and independence.

It’s not easy for residents, especially newcomers, to come to terms with being in a nursing home, especially if they are relatively healthy, ambulatory and generally of sound mind. But if they’re restless, troubled and a bit depressed (and who wouldn’t be), too many nursing homes will take measures that can be debilitating.

Instead of helping unsteady residents go to the restroom when they need to, attendants often will fit them with diapers as a matter of routine because there’s not enough staff to tend to every resident’s needs when they need to go to the toilet quickly. And staff members don’t want to be blamed for a fall.

Worse, if an elderly patient who is rebelling against being in the home and its restrictions or rules, or is unruly, the staff may get a doctor to prescribe a sedative. Only the worst of homes will use physical restraints which are forbidden by law, but more often – too often – nursing homes are resorting to anti-psychotic drugs for residents who are not psychotic but suffering from dementia, anxiety or a show of anger and impatience with being confined.

In January 2007, according to the Center for Medicare Advocacy, a nursing home ombudsman reported to the California Health Department that a resident at a skilled nursing facility had been held down and forcibly injected with an anti-psychotic drug. The patient was not psychotic, but suffering from dementia and Alzheimer’s disease. An investigation, said the Center,

“determined that 22 patients, including some who were suffering from Alzheimer’s...were being given high doses of psychotropic medication not for therapeutic reasons but to simply control them for the convenience of the staff.”

This investigation, which may include criminal prosecutions, is still underway, but the problem persists elsewhere.

The Boston Globe reported on March 8 that 2,500 nursing home residents in Massachusetts were given “powerful anti-psychotic drugs last year that were not intended or recommended for their medical condition.” The drugs were intended and licensed by the Food and Drug Administration for people with severe and diagnosed mental illnesses such as schizophrenia or bipolar disorder.

But the FDA has sought to discourage the use of these drugs for dementia, a gradual loss of memory or anxiety, by issuing what is known as “black box” warnings on the inappropriate uses for the drugs. But warnings are often ignored by doctors who serve nursing homes and are not usually available, or by short-handed nurses and poorly paid or trained attendants who tend to too many demanding patients.

Toby Edelman, a senior attorney for the Center told me, “Anti-psychotic drugs are used because there’s not enough staff and facilities. They know they shouldn’t use physical restraints. Using drugs inappropriately as chemical restraints is less visible, but has the same effect.”

“The misuse of anti-psychotic medications in the treatment or control of nursing home residents is pervasive,” said the Center. “In the fourth quarter of 2009, the federal government reports that 26 percent of the nation’s 1.4 million nursing home residents –354,900 people – received anti-psychotic drugs...frequently for reasons not approved by the FDA.“

In February, 2007, Dr. David Graham, an FDA official, told a congressional committee that as many as “15,000 elderly people in nursing homes (are) dying each year from the off-label (not FDA approved) use of anti-psychotic medications for an indication that FDA knows the drug doesn’t work.”

The drugs include Seroquel, Risperdal and Zyprexa, which replaced an older drug, Haldol. The use of these chemical restraints is not all the fault of besieged nurses and aides. Last November, Omnicare, the nation;’s largest nursing home pharmacy agreed to pay $98 million and its supplier-drug manufacture paid $14 million because of a kickback scheme involving Johnson & Johnson’s drug Risperdal. The scheme allowed Johnson & Johnson to push the sale and use of the drug.

On March 10, Bloomberg News reported that despite the FDA warnings on the possible misuse of Risperdal, the largest selling drug of its kind, Johnson & Johnson made plans to reach $302 million in geriatric sales of the drug for this year claiming it was safe and effective. According to Bloomberg, unsealed documents in a lawsuit by Louisiana against the company disclosed “a J&J business plan...called for increasing the drug’s market share for elderly dementia sales, an unapproved use.”

In January 2009, Eli Lilly agreed to pay fines of $1.4 billion for illegally pushing the sales and off-brand use of its anti-psychotic drug, Zyprexa. According to the U.S. Justice Department, the company promoted the use of Zyprexa by claiming it would help facilities sedate resident who would otherwise require more care.

Nursing homes are handsomely paid by Medicaid, long term care insurance or by the resident. Numerous studies have found that residents get better care in not-for profit homes.

With these drugs at hand, physicians are often unaware of the possible side effects on people who are not psychotic. But then, the Center notes, physicians who are supposed to supervise patients often prescribe without seeing them.

Psychiatrists are rarely available except for the most troubled residents. Edelman said that nursing home and the long term care pharmacies rely on “chart orders” left by doctors when they are unavailable.

“Physicians are present in nursing homes only intermittently,” Edelman said, They do not have offices, they work out of their cars.”

The Center and other patient advocates seek federal legislation to enforce existing law requiring that a physician be on call and available when a patient requires prescription drugs.

Nursing homes and pharmacies argue that if federal law is not amended to allow “chart orders,” residents will not get pain medications they need. But anti-psychotic drugs are not mere pain killers. They can turn an anxious or slightly depressed or forgetful patient into a zombie.

And the easy access to painkillers can tempt staff members into overusing or even stealing them for their own use. That’s why the Drug Enforcement Agency has been involved in the effort to reduce the availability and use of these drugs on unsuspecting patients.

Said Edelman, the Center’s concern “speaks to the dangers of indiscriminate use of pain medications and the lack of physicians to detect and respond to life-threatening problems involving their use.”

Got a friend or loved one in a nursing home? If he or she is asleep most of the time or non-responsive, demand to know the drug that’s been used and question why. If there is no satisfactory answer, complain to the home’s ombudsman or contact the Center for Medicare Advocacy.

Or write to saulfriedman@comcast.net


SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Judging from the negative reaction to my attempt last week to provide a fair and balanced assessment of the health insurance reforms, which I support with reservations, I’ve been persuaded to amend my views. The primary reason is the new President Barack Obama, who at last has given us the presidency we hoped for.

Edward Luce of my favorite journal, The Financial Times, said it best. The shock of the election of Republican usurper Scott Brown to Ted Kennedy’s senate seat,

“turned him (Obama) from America’s lecturer-in-chief, who had even his most ardent supporters nodding off in mid-paragraph, into the robust campaigner who could electrify his troops...Mr. Obama finally took day-to-day control...By showing spine, Mr. Obama made it easier for Democrats in marginal seats to show spine as well.”

By finally abandoning his futile and damaging search for bipartisanship, to be liked by everyone, Obama was able to provide strong, more convincing leadership for tepid Democrats without losing committed liberals. In a sense, the blind and dumb Republicans, by hollering “hell, no,” helped remind Obama and the Democrats that they were Democrats – and in the majority, and in 2006 and 2008, were chosen to govern.

Thus, I was impressed by a speech he made in Iowa after his health insurance reforms became law, in which Obama clearly explained why, as he had intended and planned, “this is a middle-of the road bill.”

Perhaps because the burden of the battle had been lifted, Obama seemed to find a different voice, laying out as never before the thinking that went into his version of the health reforms. As he put it, without sounding defensive,

“This isn’t single payer, which some people wanted. It’s also not what the Republicans were looking for, which was basically to deregulate the insurance industry...This is a commonsense bill...It moves us in the direction of universal coverage.”

He dared Republicans to try to repeal its most popular provisions, knowing they would have difficulty seeking the repeal of the measure which would provide insurance, for children under parents' policies, until they reach 26, or covering children in with pre-existing conditions, or giving seniors $250 if they fall into the Part D drug doughnut hole.

But Obama also explained frankly that the bill, more than anything was not about health care, but about regulating and restricting the conduct of insurers so that care becomes accessible when you need it.

“What this reform does is build on the system of private health insurance that we already have,” he said. “But it finally tells the insurance companies that in exchange for all the new customers they’re about to get, they’ve got to start playing by a new set of rules that treats everybody honestly and treats everybody fairly. The days of the insurance industry running roughshod over the American people are over.”

Never before have the nation’s health insurers, which have been subjected to state regulations, faced rather stringent national regulation. Obama acknowledged that “it’s going to taker four years to implement this entire plan–because we’ve got to do it responsibly and we need to do it right.”

The president was challenged by an audience member who asked why a public option was not in the bill as part of the insurance choices. “Because we couldn’t get it through Congress,” Obama replied. That was true, in part, but Obama didn’t really push the issue and use his clout to organize support.

Nevertheless, he told his questioner,

“Thirty two million people are going to have health insurance because of this legislation...what this is is a historic step to enshrine the principle that everybody gets health coverage in this country. Every single person.”

Despite the complicated nature of the reconciliation process, the bill was passed in pieces by the newly disciplined Democrats who ignored the rather childish Republican tantrums. And like a magic potion, its passage has given new life to the Obama presidency, said The Financial Times. First, said the article, he “seems to be getting better at governing.”

That bodes well for him in the next fight for Obama intends to take on, with or without Republican help, the re-regulation of Wall Street and the nation’s rogue banks. That will be more difficult for Republicans to oppose; a few may even say “yes.”

It’s possible, as I have speculated, that with the health care issue behind him, Obama feels free to tend to other issues. Thus within a week of the passage of the bill, Obama fired a warning shot at Israel that said Obama will not be trifled with; sent a similar message to Republicans by making 15 recession appointment that they’ve been obstructing; he announced he had concluded a new arms reduction treaty with Russia, before he flew off to his war in Afghanistan to lecture its leader, Hamid Karzai, on the need to shape up and to tell the American troops why they are there.

Success at home helps build credibility and power and a president’s confidence for success abroad.

Still, the scars and wounds of the health insurance bill remain. And Obama will struggle to prove that he has no illusions about the for-profit insurance industry, which is beholden to stockholders and the bottom line. Already, the administration came down hard to thwart an effort by some insurance companies to avoid providing insurance to children with pre-existing conditions.

The companies promised to behave, but you know they won’t. Even as we speak, they’re plotting ways around the law. With his legislative success, Obama has gained power to be used to compel, as well as persuade the insurance companies to abide by the new rules.

But there will be plenty of opportunity, as the government writes the rules and regulations, for the insurance and drug companies to make mischief. New Yorker medical writer Atul Gawande notes in the April 5 issue that in the year after the passage of Medicare, Lyndon Johnson was forced to fight a series of nearly crippling rear guard attacks on the program, which was damned as “socialized medicine” by the American Medical Association and thousands of physicians who threatened to boycott Medicare. Today the AMA is an ally, but will the insurers and drug manufacturers behave?

While the Obama health reforms “could prove as momentous as Medicare,” Gawande wrote, “because most of the provisions phase in more slowly than Medicare did, they are even more vulnerable to attack. “ This time, he said, the threat comes from party politics, specifically the obstructionist Republicans.

If Obama and the Democrats follow up their legislative victory with an improvement in their prospects for 2010, the Republicans won’t continue a fruitless cause without their natural allies and source of funds, meaning the insurance and drug companies. They could use loopholes to deny or delay coverage and thus weaken the complicated the law and keep costs too high.

States could help implement and strengthen the law, yet 14 state attorneys general seek to overturn as unconstitutional its provision that everyone must buy health insurance eventually or face penalties. That is similar to state laws mandating the purchase of auto insurance or Medicare’s Part B penalties for persons who don’t sign up.

Nevertheless it’s a sign that resistance among conservative states and communities could endanger even this middle of the road health reform without the continued tough leadership of the new Obama.

Write to saulfriedman@concast.net

GRAY MATTERS: Health Care Reform

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Amid all the well-deserved celebrations and self-congratulations on the passage of the health insurance reform bill, I thought I heard a dog bark. I was wrong. From the very beginnings of the late great debate, this dog didn’t bark.

I speak of the one most popular alternatives to provide guaranteed comprehensive and universal health care coverage – not just private insurance - for all of us; Medicare for All was not even considered.

As a state legislator, senator and candidate, that was Barack Obama’s choice. But despite what he now says, he does not tell the truth when he says every idea was truly considered. In fact, he refused to allow others to consider any proposal for single-payer health coverage.

As a result, Obama, Nancy Pelosi, Harry Reid and most health research groups, and the mainstream press boycotted and wouldn’t permit discussions of the simplest, most straight forward possibility for health care reform, Medicare for All. It was shut out of White House meetings. Not even Kaiser or the Commonwealth Fund or AARP responded to my repeated appeals to at least give an airing to the single-payer alternative. Eventually, the process passed it by.

So it was ironic that John Dingell, a Michigan Democrat and the longest-serving member of the House was given the honor of calling for the decisive vote on the reform bill. But the universal health care legislation he and his late New Dealer father championed for years was ignored. Nevertheless, Dingell gallantly praised the passage of the Obama bill and was at the signing.

But the second longest-serving member of Congress, John Conyers, Jr., also from Michigan, was nowhere to be seen in the celebrations. His bill, HR 676, the U.S. National Health Care Act, Expanded and Improved Medicare for All, just 30 pages long, had nearly 100 congressional sponsors, including several blue-dog Democrats who voted against the Obama bill, plus more unions, doctors, nurses, advocacy groups and consumers than the White House was able to enlist for its proposal.

But Conyers was gracious, praising passage of “the first comprehensive set of reforms to our ailing health care system.” He noted that he “would have preferred a different approach,” but he didn’t repeat an earlier observation, that after a year of debate and compromises and deals with insurance companies and drug makers, the Obama bill passed the House by only three votes more than needed.

Conyers reiterated his support for a public health option which Obama gave away, “because I fundamentally believe in the value of public health insurance and remain an ardent supporter of universal single-payer health care,” like Medicare. And he called for a new campaign to achieve it.

Obama has said he would have favored Medicare For All “if we were starting from scratch.” So let’s review what might have been and may yet be.

The Conyers legislation would have established a “publicly financed, privately delivered health care system that uses the already existing Medicare program...”

It would cover, at no charge, all medically necessary services, dentistry, long term care with patients having the right to choose their providers. And because the free care would be paid for by taxes and premiums, private health insurers would be unnecessary and would be prohibited from selling coverage that duplicates the benefits.

And unlike the plan that has passed, HR 676 would eliminate the need for dozens of fragmented, wasteful programs by including the Children’s Health Insurance Program, Medicaid, and other government funded programs with the exception of the VA health program, which may eventually become part of the system. And it sets a goal of converting to a non-profit system in 15 years. Read for yourself here.

One problem with the bill that has passed is that it leaves in place all the federal, state and private insurance bureaucracies for the dozens of competing and duplicative agencies with their complex rules that differ from state to state. Premiums for Medicare Advantage and the Part D drug benefit, for example, may differ from one county to another. While subsidies for Medicare Advantage insurers are to be eliminated over time, the current system is to remain in place, although these plans will be required to spend at least 85 percent of their revenues on the care of patients.

Indeed, to give the Obama bill its due, while it is not a health care plan, it is a health insurance reform which can be strong measure to regulate and restrict the behavior of health insurance providers.

Insurance companies will be barred from dropping people from coverage when they get sick. They will be barred from excluding children for pre-existing conditions; later that will apply to adults as well. They must provide immediate access to insurance for Americans who are uninsured because of a pre-existing condition. Children will be able to remain on their parents’ health plan until age 26.

In addition, insurers cannot impose lifetime or yearly caps on benefits, and new plans are required to cover preventive services such as mammograms, colonoscopies and immunizations without cost-sharing. That’s to become a standard Medicare benefit for all beneficiaries, who have been required to pay for co-insurance.

As expected, the 40,000-member Physicians for a National Health Program, which supports HR 676, worried that the bill that has passed will take too long to implement, that it will further enrich the for-profit insurance industry by $447 billion, that costs will go higher and that the new regulations are riddled with loopholes.

All we can do is see how it works. Here is the best and clearest graphic to explain the bill. (pdf)

If things don’t really change for the better and Democrats remain in the majority in Congress, maybe we can come closer to the Conyers bill, and hear the dog bark.

Questions? Write saulfriedman@comcast.net

GRAY MATTERS: Estate Planning

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

[NOTE: This cancer they say I have is isolated in my stomach, has not spread and is slow growing. I begin taking pills (xoloda) for chemotherapy in a week or so. Otherwise I feel OK.]

The dozens of books on aging that come to me from publishers and authors are mostly useless. One reason: There is no such thing as an instruction book on aging, although Aging for Dummies, would be appropriate since most of us take it and learn one day at a time.

My complaint is that most of the advice is rather obvious, as in The Complete Idiot’s Guide to Secrets of Longevity. “How do you live, sleep, eat and play to live a long, healthy life? Adopting a longevity lifestyle. Quitting smoking is the single most important lifestyle measure you can do to increase your overall longevity.” Really?

I don’t mean to poke fun, but for those of us who have achieved a certain age, we don’t need to be told what we already know. Aging is not necessarily “golden,” as one book has it. (My late sister-in-law had a throw-pillow which said, “Screw the Golden Years.”)

This column was designed as a survival guide, for as most of us have learned, our older years, rather than becoming simpler, have become more complicated – from learning to negotiate the thickets of Medicare to conserving and protecting your home and savings, your estate.

Thus I am partial to books like Estate Planning Smarts ($19.95) by Deborah Jacobs, a lawyer and financial journalist, because it takes on a subject that we need to know about, and that provides solid, useful information. As I told her, this book is a keeper for those of us who need help riding the unpredictable currents of the economy and surviving with our estates intact.

The notion of an “estate” may seem overblown for many of us. But if you have some savings, a house, a pension, some bonds, insurance policies, a car and maybe an IRA, you have an estate to protect and care for. Estates are not just for the rich. As Jacobs writes,

“Estate planning is, above all, a way to take care of yourself and the people you love. It can minimize the hardships of your old age and ensure that less of what you leave behind goes to taxes...”

And keeping up with contemporary issues can help you make intelligent and money-saving decisions.

For example, financial advisers these days, leaping on the latest commission-making fad, are trying to sell clients on converting their traditional IRAs to the more recently created Roth IRAs. For the first time this year, there are no restrictions on one’s income in order to be eligible for a Roth.

The big advantage over a traditional IRA: There are no requirements that the owner must take required minimum distributions after age 70-1/2, which means the assets can grow tax free as long as the markets are kind. And after five years you may withdraw some of the converted funds, tax free. Non-converted funds are taxable.

It sounds great, but Jacobs, who has devoted a chapter to the Roth says, “they are a wonderful tool for some people but not right for everyone.”

The biggest problem, which your financial adviser may minimize, is the cost of conversion, for if you’re rolling over $100,000 from a traditional IRA to a Roth, that $100,000 is deemed income on which you must pay income tax.

If you convert, this year only, says Jacobs, you can delay the tax payment until next year and take two years to pay. But raising your income by, say, $100,000 may have complicating consequences for means-tested Medicare premiums and other benefits pegged to income.

In a neatly summed up table on page 106, Jacobs’ bottom line: If you can’t afford to pay taxes on the amount converted and you won’t recoup that money anytime soon, don’t do a Roth. If you don’t or won’t need the money in the IRA for household expenses (or emergencies) and you want to leave as much as possible to heirs, a Roth can build your estate, tax free, which is as close you can legally get to money growing on trees.

On a more mundane level, many readers have puzzled over whether a simple will is enough to leave behind. That depends on the will, the size and value of the estate and the probate laws and issues in your state.

Wills are subject to probate, a court-ordered process, which seeks to determine whether the estate has left debts to be settled and whether there are contesting heirs. Probate can take time and it could be expensive, so except for the most modest estates, probate should be avoided.

Enter the living trust.

Simply stated in an AARP paper, “...just like a will, a revocable living trust is a written document that lets you direct how your property will pass after your death.” But “unlike a will, it also directs how you want your property managed during disability.” When creating a living trust, the creator may name himself or herself as trustee, with a loved one as co-trustee. That means you maintain control over the property during your lifetime.

The trust does not take effect until the creator transfers ownership of the property, such as the home, to the trust. That’s called “funding the trust.” For example, you transfer ownership of the home to the trust and you become the owner-trustee. IRAs need not be transferred because the beneficiaries are designated.

A living trust may not be necessary if the estate is small and probate is not problem, but it’s a handy device for avoiding probate in many states and allowing the co-trustee to manage the estate and divide the assets among heirs.

As Jacobs points out, while a will is a public document, a trust is private. One caveat: A living trust won’t help you escape estate taxes. But it can help save on those taxes on properties that appreciate in value after they’ve been put into the trust. And because you, the living person, has control of the trust, a spendthrift nephew can be prevented from stealing from it.

Trusts may also be used to transfer funds from older persons as part of what has become known as “Medicaid planning,” divesting one’s self of assets to qualify for Medicaid, which will pay for long term nursing care for persons with few assets. But be careful, Congress during the last eight years has imposed restrictions on such transfers and Medicaid funds are being slashed in every state.

Here, in sum, is Jacobs list of documents you ought to have:

  • Will

  • Living revocable trust

  • Durable power of attorney given to a trusted family member, friend or adviser

  • Health care proxy (some states won’t recognize the right of a spouse or child to make decisions)

  • Explicitly written living will or advance directive

For more information, visit Deborah Jacobs' Estate Planning Smarts website.

Questions? Write saulfriedman@comcast.net

GRAY MATTERS: Update on Saul

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

[NOTE FROM RONNI] While reporting on Medicare and home health care in this column last month, Saul wrote about one of the most common accidents that afflict elders, falling, and his own recent fall. Now he has been diagnosed with stomach cancer. But I will let him explain, as he did in an email he sent earlier this week:

“I'm anxious to get back to writing, but better to hold off until we see what's in store.

“This week I will be getting my new denture, then later in the week a conference with the oncologist to see what my options are. Near as I can tell, the cancer in the stomach is slow-growing and in its earliest stage.

“Only two options, radiation and/or chemo, here in Annapolis or Johns Hopkins in Baltimore, which would be a shlep. Radiation is usually a daily thing; chemo is weekly. But they are both weakening. I am truly optimistic, but the question is how much strength will I have. I'll be better able to tell in a few days.

“I have signed up again for home health care, which will keep track of my general health (blood levels) during the next few weeks. And I'll be doing physical/occupational therapy to regain my muscle strength.”

As Nance wrote in a comment on last Saturday's post: We wish you wellness and well-being, Saul.


SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

[NOTE FROM RONNI] Saul is under the weather – hence, no Gray Matters column today. He is taking some time to recuperate and refresh, and will return to these pages as soon as possible.

Meanwhile, you can read his always excellent and thoughtful past Gray Matters columns here or his other Time Goes By column, Reflections. Also, you may want to know that Saul celebrated his birthday on Thursday 4 March. We wish him a speedy recovery and many more birthdays. We need his important voice.

GRAY MATTERS: Obama's Deficit Reduction Commission

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

This time President Obama, in his obsessive reaching across the political aisle, may have gone a stretch too far. For the Republican he picked to co-chair the so-called deficit reduction commission, former Senator Alan Simpson, has been a harsh critic of Social Security and Medicare. And he sought to destroy their most powerful defenders, especially AARP.

That was 15 years ago, but as recently as 2005, Simpson, a conservative from Wyoming who left the Senate in 1997, supported attempts by President George Bush to privatize Social Security by turning part of the pension and insurance program into millions of individual investment accounts, which by now would have lost 20 percent of their value.

Bush’s plan failed, largely because of the opposition of AARP and other advocates that Simpson sought to discredit.

Even now, Simpson, who should know better, conflates or deliberately confuses Social Security’s long term fiscal problems, which are minor, with its supposed contribution to the federal deficit, which is almost nil.

In an interview with the NewsHour after his appointment, Simpson said of Social Security,

“You have two choices...you either raise the payroll tax or decrease the benefits or start affluence testing. The rest of it is B.S. And if the people are really ingesting B.S. all day long, their grandchildren will be picking grit with the chickens. This country is gonna go to the bow-wows unless we deal with entitlements, Social Security and Medicare.”

His colorful language aside, what does one problem have to do with another? The Social Security trustees and the Congressional Budget Office have said the nearly $3 trillion trust fund will last for at least another 30 years. Former Federal Reserve Chairman Alan Greenspan said the projected shortfall after that is easily fixed for decades with a small raise (two percent split between employer and employee) in payroll taxes.

Obama also minimizes Social Security’s fiscal problem and suggests simply raising or removing the current $106,000 ceiling on salaries subject to the tax. Will his pledge to maintain Social Security as a pension program clash with Simpson?

But here’s my point: Social Security's long term fiscal problem has nothing, absolutely nothing, to do with Social Security’s role in the deficit. For, as I have emphasized in my column for years, Social Security costs the budget not one cent – aside from the one percent it spends on its thousands of employees and field offices.

Indeed, Social Security helps finance the deficit by loaning the treasury money, for which it earns interest (about $700 million a year.) If what’s owed to Social Security must be cut as part of deficit reduction, will that help Social Security?

Nevertheless, Simpson’s statements help perpetuate the myth among right-wingers that Social Security contributes to the deficit. Here is former Texas Representative Dick Armey, chief organizer of the Tea Baggers and a longtime enemy of Medicare and Social Security:

“If you’re not courageous enough to look at mandatory spending the two biggest components being Medicare and Social Security, then don’t tell me you’re serious about fighting the deficit.”

Simpson’s record in the Senate raises questions about his appointment: Did the president have any notion of his background of hostility towards the twin pillars of American social insurance? Has Simpson left his right-wing politics far enough behind? Can he be an honest broker when, say, advocates for Social Security and Medicare come before his panel? Here’s why I ask.

In December 1994, when the Republicans were on the verge of taking over the House, the right-wing Capital Research Center, one of several relatively new think-tanks funded by prominent and wealthy conservatives, launched assaults on the Clinton administration and two major organizations that supported Clinton’s failed efforts to pass health care reform and resisted Republican efforts to cut Medicare funds.

The organizations were AARP and the labor-backed National Council of Senior Citizens (NCSC), which had played a major role in the 1965 passage of Medicare – over Republican objections. They were vulnerable because they held small federal contracts to train workers and also lobbied, which they were permitted to do.

According to consumer and medical affairs writer Trudy Lieberman, in her book, Slanting the Story, the conservative campaign took off when it was joined by Simpson, a rich rancher who was chairman of the Senate Finance subcommittee on Social Security and Family Policy.

A rather goofy dilettante, he was about to announce his retirement and had nothing to lose so he took on his antagonists, especially AARP, which had criticized him and lobbied against Republican efforts to slash Medicare funds and privatize Social Security. According to Lieberman,

“Simpson liked to tell stories about how he had to pay out of his pocket for his own parents’ care and believed everyone should do the same.”

Simpson’s father, Milward Simpson, had been Wyoming’s governor and a U.S. Senator.

Using what Capital Research had found, Simpson wrote an op-ed column in the conservative Washington Times in February 1995, attacking AARP’s director, Horace Deets for criticizing the Republicans and charged that AARP was illegally using member funds and the federal grants for lobbying.

Simpson also resented AARP’s opposition to the pending Balanced Budget Agreement. AARP had run afoul of the IRS for mixing its royalty revenues with its nonprofit business and was forced to pay a fine and separate its profit and nonprofit ventures.

But with the help of the press and the network of conservative groups, Simpson’s assaults –and his hearings – put AARP and the NCSC on the defensive. The latter folded and reorganized as today’s Alliance of Retired Americans. AARP’s Deets retired and was replaced by a Republican, public relations executive, William Novelli, who had become friendly with House Speaker Newt Gingrich.

Novelli, in 2003, stunned congressional Democrats when he threw AARP’s support behind George Bush’s private Part D drug program, which also provided huge subsidies for private Medicare Advantage plans.

Those plans, then called Medicare Plus Choice, became the first wedge in the privatization of Medicare in 1997. Under pressure from Republicans to slash Medicare funds, AARP was toothless, and Clinton agreed to allow private companies to sell insurance under Medicare.

That was part of the 1997 Balanced Budget Agreement, which slashed more deeply than ever into Medicare and Medicaid funds and severely restricted the use of Medicaid for long term care.

The Balanced Budget Agreement, which did produce a one-year balanced budget, was shepherded through the Congress by Clinton’s chief of staff, Erskine Bowles, now president of the University of North Carolina and the other co-chair of Obama's new Deficit Reduction Commission.

Write saulfriedman@comcast.net

GRAY MATTERS: Republican Agenda

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Thanks to the Republicans’ lurch to the far-out right, they can at last be honest in their intentions if they get another chance at governing in 2010 or 2012. They no longer need hide in sheep’s clothing; they can now be more comfortable as what they are: wolves in wolves’ clothing. And that means they will do what they say if they get the chance.

That is to say, the present Republican leadership and its young new ideologues, have put pretense aside and now openly intend to destroy, during their next watch, the twin pillars of the nation’s public social insurance system – 75-year-old Social Security and 50-year-old Medicare.

If you think I exaggerate, check out their legislation, for H.R. 4529, introduced by the top Republican on the Budget Committee, Representative Paul Ryan of Wisconsin and S. 1240, introduced by the most right wing member of the Senate, Jim DeMint of South Carolina.

Some excerpts in a moment, but underlying the proposals, “Roadmap for America’s Future,” is the belief of the now-dominant right-wing of the Republican Party that Americans should be weaned from Medicare and Social Security to reduce the national debt, permit deep reductions in taxes for the wealthy, encourage self-reliance, personal responsibility and less dependence on government and while putting the billions in Social Security taxes to work in American enterprises, the stock markets, to build individual investment accounts instead of a pension.

Republicans, of course, have long advocated self-reliance and individual responsibility - when they opposed child labor laws and opposed Social Security during the Great Depression and Medicare and Medicaid in 1965. But they’ve been disguising their opposition partly because these programs have been so successful and popular with the hundreds of millions of Americans who have been made whole with medical care and pensions. And the Republican Party was closer to the main stream.

Thus, when Ronald Reagan won the presidency in 1980, he calmed the fears of older Americans when he promised to cut only “waste, fraud and abuse” in government. As a commentator, he had spoken in vigorous, ideological opposition to Social Security and Medicare – as the harbingers of socialism. But as president, Reagan left Medicare alone and in 1983, he appointed a commission that strengthened Social Security to build today’s $3 trillion trust fund for the boomers’ retirement. The Trustees say the trust fund will last until 2037, unless the recession drains it more rapidly.

More background: In 1994-5, when Southern Republicans under House Speaker Newt Gingrich of Georgia, his sidekicks Richard Armey and Tom Delay of Texas took over the Congress, their “Contract with America” noted that Reagan had been unable to end many federal programs and the contract proposed a “Personal Responsibility Act,” to end welfare for poor women. But the Contract refrained from frightening the nation for it mentioned not a word about Social Security - which Gingrich called “the third rail” in American politics - nor Medicare.

But Armey let it be known at a press breakfast that the Republicans intended “wean our old people away from dependence on Medicare.” An aide quickly denied Armey meant to kill Medicare. Gingrich told health insurers that the Medicare agency would “wither on the vine.” Eventually it became clear what they meant.

Under the Republican threats to slash Medicare, Bill Clinton agreed to allow private companies to sell Medicare policies, now called Medicare Advantage, which are heavily subsidized and serve a fifth of Medicare beneficiaries.

In 2003, George Bush took Medicare privatization further with the Medicare Part D drug benefit which is wholly private. That bill also put limits on Medicare’s budget growth and instituted a means test for the first time.

Some of that has been reversed in the Democratic Congress, but Medicare is more private than it has ever been, although the proposed health reforms would end most of the $250 billion subsidy for Medicare Advantage.

In 2005, Bush sought to build on his Medicare privatization with an attempt to turn Social Security and its trillions into millions of individual investment accounts. While no one, except Bush, was burned by the third rail, his effort failed partly because even Republicans were afraid of ending Social Security’s $650 billion a year in insurance and pension benefits.

But the opposition, which continues to denigrate and undermine Social Security, has grown bolder and more radical and has not given up.

Sensing new opportunities because of the deficits they helped create and the strain the recession has put on Social Security and Medicare, the Republicans and Democratic deficit hawks have set their sights on both programs as if all “entitlements” contribute to the deficit. Social Security, for example, is self-sustaining and only its administrative costs (one percent) contributes to the deficit.

Nevertheless, the “Roadmap for America’s Future” (a more appealing name than the legalistic “Contract With America,“) would end future Social Security protection for all persons under 55 and substitute a “Personal Social Security Savings Program” - that is, investment accounts like that provided by the government (federal employees now also get Social Security).

Incidentally, the trust fund would no longer be available to loan money to the treasury and thus earn money. Instead the trillions in the trust fund, which belong to you and me, would be “liquidated” and available for Wall Street.

Instead of the guarantees of Medicare, persons who will become eligible in, say ten years, would get an average of $11,000, in vouchers to purchase health insurance on the open market. That would be available through a newly merged Federal Hospital Insurance Trust fund and Federal Supplementary Medical Insurance Fund. You tell me if that would be enough insurance to last the rest of your life even if, G-D forbid you have a catastrophic illness. Funds would be slashed for the Part D drug program, which would be means tested and voluntary.

There is no mention of restraining the costs of premiums or regulating insurance companies’ practices; that would be a restraint on free enterprise. The clever part of the proposal would pit the old against the young who will be on their own and would no longer have to pay for their elders.

But imagine grandma or grandpa, when Medicare is no longer available, having to shop for coverage if they are already ill or disabled or suffering from dementia. Ask your parents what it was like before Medicare. Consider what would be lost if there was no longer any intergenerational responsibility.

But the juiciest part of the Roadmap, the one that will bring joy to the rich and appeal to fiscally conscious Republicans are the numerous tax breaks it proposes. It would end taxes on capital gains, dividends and interest, estate and gift taxes and the corporate income tax. (Unfortunately, President Obama has caved in to the deficit fears with his creation of a deficit commission and he even praised Ryan as a person with “ideas.”)

Finally, a page from Dickens and the 19th century workhouses: The bill would end, next January 1, the Children’s Health Insurance Program (CHIP), which the Congress passed over George Bush’s veto. You don’t believe Americans would do this to children? Look for the bills at GovTrack or OpenCongress.

Write to saulfriedman@comcast.net

GRAY MATTERS: Depression

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

For those of us along the East Coast, flooded by weeks of rain and buried by five feet of snow since December, this surely is our winter of discontent, or worse. Add to that the state of the economy and the stock market, and as I warned during the approaching winter after 9/11 2001, older people need to be very aware of the danger of depression.

That desire to crawl under the covers and hibernate can be more than the winter blues. I know; I had a brush with depression only because of a fall and a bump on the noggin, which laid me low for a few days and nagged at my thoughts: “Why wasn’t I bouncing back faster? Will I regain my strength?

When last I wrote about depression, an unprecedented surgeon general’s report on mental health in 2000 pointed out that depression, in one form or another “is strikingly prevalent among older people,” too often accompanied by alcohol or drug dependence. But many older people tried to ignore their symptoms as simply a sign of age.

Coincidentally, just after my fall, Ilaina Edison, a vice-president and researcher for the superb Visiting Nurse Service of New York, the nation’s leading home health care provider, told me that ten to 20 percent of older people seen by primary care physicians “have critically significant depression.”

Moreover, many of these physicians, not specializing in geriatrics, don’t diagnose or they under-treat depression. Edison wants home health care nurses, who know their patients best, to be able to diagnose a case of depression before it takes root.

In one of her papers, Edison says that depression “places a significant burden on the health system” and impedes a patient’s ability to comply with medical treatment. The classic symptoms – sad, empty, hopeless feelings, trouble concentrating, a lack of energy, trouble sleeping, a loss of interest in what you like to do, and even vague or passing thoughts of suicide – can complicate getting better from even a routine illness.

The surgeon general’s report noted that there is no need for older people to put up with depression and risk their health further because there are modern and relatively safe drugs, among other treatments. And since the report, Medicare has led the way in recognizing and paying closer to parity for the treatment of mental as well as physical illness.

However, Medicare has been slower in understanding how its regulations can become a barrier to home health care for depression which, in a sense, is the front lines for the discovery and treatment of depression. Says Edison, ”Mental health status is not being addressed by hospitals when discharging a patient, even if he or she is taking an antidepressant.”

When I was discharged from a fine hospital after my fall, a doctor prescribed home health care for my physical problems, including physical therapy. But no one asked after my emotional well-being.

“Another barrier,” said Edison, “is the way Medicare reimburses for depression and mental health services in home health care.” Medicare has been demanding a positive diagnosis before it will pay. But if a home health care nurse discovers a patient’s depression, mild or severe, during a visit for other purposes, reimbursement may be complicated.

Thus she believes Medicare should allow and train the visiting nurse practitioners to diagnose depression and help guide a patient’s treatment with guidance from a psychiatrist.

Medicare Part A helps pay for inpatient mental health care; Part B covers outpatient visits to mental professionals, subject to the yearly deductible ($155). For a visit with a doctor to diagnose your problem, Medicare pays 80 percent of the cost. But to get treatments, such as psychotherapy, the patient now pays 45 percent and that will decline to the parity of 20 percent in 2014.

But to return to the surgeon general’s report, it recommended getting help from modern drugs that can treat and even prevent anxiety and depression. And if you feel you need something, a pre-emptive strike to get you through the winter, consult with your physician but be very careful about what you choose.

The surgeon general reported that certain widely used anti-anxiety drugs, called benzodiazepines – Ativan, Lorazepam, Librium, Valium, Xanax – are immediately effective but have been misused by many older people because they are chemically addictive over time, which means the more you take, the more you need. Some Medicare Part D drug plans are not required to provide these drugs.

These drugs are often over-prescribed and withdrawal from these drugs is likely to be difficult and could be dangerous. Similarly, sedatives and sleeping pills such as barbiturates, including Butisol, Nembutal and Seconal are highly addictive.

Less dangerous or addictive, although they take longer to work, are the anti-depressants including the granddaddy, Prozac, along with Zoloft and Paxil and other newer compounds such as Celexa, which are purged more quickly from the body and present fewer problems for older adults. These are a class of anti-depressants known as selective serotonin reuptake inhibitors (SSRIs), which can prevent mild depression from getting worse.

Other new anti-depressants (SNRIs), including Cymbalta, are being advertised for more serious problems.

However, all these drugs may produce unpleasant side effects and dependency. Your physician can fit the drug to your needs – if you need drugs at all. A pet that you can care for where you live, or perhaps a trip this winter to somewhere sunny could give you the lift you need.

What we’ve been calling the winter blahs has been given an appropriate name, SAD, for Seasonally Affective Disorder. And if you use a computer (which can be a great help in keeping you mentally fit (I play freecell or spider solitaire to check on my mind.), you can find sources for special lamps and lighting which, according to many legitimate-sounding claims, helps brighten those dark days.

You may want to visit the Medicare website and search for “mental health care and Medicare.” To learn more about the services of the Visiting Nurse Service of New York, visit their website.

Write to saulfriedman@comcast.net.

GRAY MATTERS: Medicare Home Health Care

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I learned the hard way: The greatest and the most predictable danger for older people is falling. Too often, a broken hip can lead to a deep and irreversible decline in one’s health or well-being if you don’t get the best of help quickly. For me, I was laid temporarily low by a mild concussion.

Fortunately, for those of us who are eligible, Medicare and Medicaid have made some advances in fashioning benefits that will keep patients at home to mend instead of keeping them in a hospital which can be dirty, dangerous and expensive, or sending them to a nursing home, where the pampering, diapering and surroundings can be even more debilitating.

I hope this is not too basic, but in case you’re a caregiver or a potential patient and you don’t know, or haven’t read the 2010 “Medicare and You” manual, under the Medicare law, after a hospitalization of at least three days – say, for an accident, a stroke or for a broken or surgically mended hip – a patient is entitled to up to 20 days of rehabilitation and therapy in a skilled nursing facility at no cost. (After 20 days the cost is more than $133 a day). The skilled nursing facility, I should add, is not a nursing home. But nurses and therapists are available to help you bathe and dress until you’re able to do so for yourself.

A very important (and inexpensive) alternative, when leaving the hospital or the nursing facility or if you simply need medical help getting over a wound or illness is home health care, which Medicare covers and will cost you nothing. This is one of the best Medicare benefits, although too few beneficiaries or caregivers know about it.

I learned something about Medicare Home Health Care just a few days ago after I took a serious fall from the steep brick steps leading into my home, which left me with bruises, a minor concussion and further impairment of my right arm and leg, which had been weakened by a stroke six years ago. For those of you who are wondering, even six years into a stroke, therapy can help.

That meant I needed trained professionals to look after my recovery from the concussion and to provide physical therapy to get me back on my feet. All it took to get part-time home health care was a prescription from a savvy emergency room physician who wrote in his Rx that the care was “medically necessary.”

As the manual says, “a doctor must order it and a Medicare-certified home health agency must provide it.” That’s especially important for in past years, Medicare cracked down on fly-by-night agencies who charged but didn’t deliver adequate care.

The hospital may recommend an agency, but you should use one that is recognized. In my area, the best is the Johns Hopkins Home Health group.

The home health services may include medical social services, making sure you have help in the home, and part-time or intermittent home health aide services such as checking on a bandage or an IV, administering drugs or simply keeping track of your vital signs and the healing of a wound or a surgical site. The manual says that “you must be homebound” to receive such services, but that means you can leave home to visit a doctor, go to religious services or even go to adult day care.

In my case, the nurse, Anne Bilderback, came to the house twice a week to check my progress in getting over that concussion which left me weakened and occasionally dizzy. Another fall in the house could have been disastrous. She checked to make sure there were no side effects and lectured me on the need to drink fluids and keep my feet up to minimize swelling. And twice a week a physical therapist came to the house and spent an hour with me helping me to walk, exercise my leg and even get up and down the steps from which I fell.

Medicare will not provide 24-hour nursing care nor will it provide meals or help with bathing and dressing unless these services are necessary for your plan of care. In short, if bathing, dressing and meal taking are the only problems you have, they won’t be covered by Medicare. And if oxygen or a wheelchair or other durable medical equipment is required, Medicare will pay 80 percent of the cost.

One more important thing about home health care. Medicare generally pays for up to nine weeks of visits and as much as 35 hours of care per week, although that may vary depending on the reasons for the care. My problem required much less than nine weeks. But Anne told me that a private, for profit company, for which she worked would urge her to discharge patients too soon in order to save money.

If you have a Medicare Advantage HMO or PPO, it is supposed to offer you the same benefits that original Medicare offers. But some private insurance companies use only those health care agencies with which they have special business relationships - such as getting kickbacks. This, plus the fact that some agencies billed Medicare for patients they did not see, were among of the reasons Medicare cut its support for home health care a few years back.

So be careful about which company you choose; check with a doctor or someone you know. And if you think you’ve been discharged too soon, you have the right to make a quick appeal.

See the Medicare website where you or a care giver may find and compare Medicare certified private (proprietary) and public non-profit home health care agencies. Or if you enter home health care in the search box, you may download or read all 35 pages of the manual on the subject, which may be more than you want or need to know.

After discharge from home health care, you may continue physical or occupational, or speech therapy with a doctor’s prescription. If you go to a private therapist, you may run into a cap on the number of visits which was imposed by Congress a few years ago, although there are exceptions for some conditions.

But there are no caps if the therapy takes place in a hospital. In any case, Medicare pays 80 percent of the cost of therapy; you or your supplemental policy pays the rest.

Finally, most of the benefits I’ve described are provided by Part B of Medicare which, as most of you know, pays most of the cost of outpatient services – doctor visits, labs, x-rays. If you don’t have Part B, it’s open for general enrollment until March 31.

This is one of two pieces on Home Health Care. Next time: Medicare and the blight of Depression.

Questions: Write to saulfriedman@comcast.net.