65 posts categorized "Gray Matters"

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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?

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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.

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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.

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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.

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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.”

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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.

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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?

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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 [email protected]


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 [email protected]

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 [email protected]

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 [email protected]

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 [email protected]


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.

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