Avuncular American

Ageless, Boundless Energy

Vicarious thrills, courtesy of friend Liam, pictured here with a dozen friends atop Machu Picchu (who got there hiking the 4 day Inca Trail, not your touristy train/bus ride).  It was, by the way, Liam's 67th birthday.

Yet another piece of evidence, if we needed any, of the increasingly elastic definition of - how can I put it? - "old."  Liam would probably shoot me if I used his name and that adjective in the same sentence.

I'm in Washington this week, attending the first board meeting of the foundation that just hired me - a spring chicken in my late fifties! - to head an institute in Morocco.  I'm thrilled.

In the 8 years since I retired from the US Foreign Service, all of my employment experiences have been with US-based organizations.  I mention this because the matter of retirement age, employment for seniors (or people older than the 35 that is sometimes listed as the outer age limit for EU jobs), and lifetime employment is seen differently in Europe.  85 year old baggers in supermarkets have not yet appeared in Europe.

Nor would I wish that on societies that generally appear to bequeath a right to a decent life to their elderly.

But Europe simply must find ways to emulate what appears to be a matter of course in the US: considering the resource that the recently-retired represent.  If you can schlep up Macchu Pichu, you can probably manage a program for an NGO.

Repeal This?

You're turning me down?  Hey, I got news for you, you little two-bit prick, son of a bitch, rat-bastard you did nothing for me! You did f*****g NOTHING for me!

Boss Paul Vitti (Robert De Niro), Analyze This (1999)

As Mike Madden writes ("Why healthcare reform could work for Democrats now") in today's Salon.com

Some of the most popular provisions in the legislation will be active... just in time for the elections. Which is why some Democrats are practically begging Republicans to make repealing the healthcare law the centerpiece of the fall campaign, the way top GOP leaders have promised to do.

Imagine millions of De Niro-like reactions this November should Republicans try to repeal this:

• HELP FOR EARLY RETIREES—Creates a temporary re‐insurance program (until the Exchanges are available) to help offset the costs of expensive premiums for employers and retirees for health benefits for retirees age 55‐64.  Effective 90 days after enactment.
• ENDS RESCISSIONS—Bans insurance companies from dropping people from coverage when they get sick.  Effective 6 months after enactment.
• NO DISCRIMINATION AGAINST CHILDREN WITH PRE‐EXISTING CONDITIONS—Prohibits new health plans in all markets plus grandfathered group health plans from denying coverage to children with pre‐existing conditions.  Effective 6 months after enactment.  (Beginning in 2014, this prohibition would apply to all persons.)
• BANS LIFETIME LIMITS ON COVERAGE—Prohibits health insurance companies from placing lifetime caps on coverage.  Effective 6 months after enactment.
• BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE—Tightly restricts the use of annual limits to ensure access to needed care in all new plans and grandfathered group health plans.  These tight restrictions will be defined by HHS.  Effective 6 months after enactment.  (Beginning in 2014, the use of any annual limits would be prohibited for all new plans and grandfathered group health plans.)
• FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles.  Effective 6 months after enactment.
• NEW, INDEPENDENT APPEALS PROCESS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan.  Effective 6 months after enactment.
• IMMEDIATE HELP FOR THE UNINSURED UNTIL EXCHANGE IS AVAILABLE (INTERIM HIGH‐RISK POOL)—Provides immediate access to affordable insurance for Americans who are uninsured because of a pre‐existing condition ‐ through a temporary subsidized high‐risk pool.  Effective 90 days after enactment.
• EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE – Requires new health plans and certain grandfathered plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice.  Effective 6 months after enactment.
• COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years.  Effective beginning in fiscal year 2010
• INCREASING NUMBER OF PRIMARY CARE DOCTORS—Provides new investment in training programs to increase the number of primary care doctors, nurses, and public health professionals.  Effective beginning in fiscal year 2010.
• PROHIBITING DISCRIMINATION BASED ON SALARY—Prohibits group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees.  Effective 6 months after enactment.
• HEALTH INSURANCE CONSUMER INFORMATION—Provides aid to states in establishing offices of health insurance consumer assistance in order to help individuals with the filing of complaints and appeals.  Effective beginning in FY 2010.

The full list of the reforms is available from Democrats Abroad.  For those who are hazy on dates, "90 days after enactment" is June, "6 months after enactment" is September, and "effective beginning in FY 2010" is, well, now.

So, if I understand it correctly, the Republican Repealers want to take all this away from Americans?  The Party of No wants to relegate kids with pre-existing conditions back to the ranks of the uninsured?

Citizens might exhibit a Boss Vitti reflex in the voting booth - "You did f*****g NOTHING for me!"

Repeal this?  Go ahead, make my day.

Healthy Boost For Obama's International Standing

"It's Safe To Come To America"

Such a headline might be premature - the US House of Representatives' passage of the Senate Health Care Reform bill is only hours old, and even after the President's signature, will require time for implementation.  In the meantime, foreigners traveling to the US will still need to check the fine print of their insurance policies, many of which exclude the US, given its costly and byzantine health care system.

Byzantium just got updated, though it's not over 'til it's over.  Meaning that even though this reform represents historic progress, much more needs to be done to make affordable health care available to all.  The training of new doctors and nurses.  The reform of tort laws and accompanying stratospheric malpractice insurance.  Instituting a culture of preventive medicine and prophylactic public health.

Fixated as Americans were on the outcome of yesterday's vote, they may have missed the fact that foreigners were too, especially foreign leaders.  It went beyond European incomprehension at American reluctance to join the club of civilized health care providing nations.  Had the President not succeeded with his own party, on the key domestic proposal of his first term, what would happen to US leadership abroad?  That breeze you feel coming off the Atlantic is a huge sigh of relief.

We were on the road all day Sunday, driving through France back to Belgium, and the BBC provided regular real time updates on the state of the vote. French commentators noted that Benyamin Netanyahu, who treated Vice President Biden with barely concealed contempt as little as a week ago, will be meeting a President Obama newly invigorated by his domestic victory.

The Obama Way should be especially instructive for the Israeli Prime Minister.  The President focused on a major problem, persevered when pundits said the patient was dead, and pulled off a reform that is being compared with the major progressive initiatives (Social Security, Medicare) of the last century.  Now that he'll be more free to zero in on the Middle East, the moribund peace process between Israelis and Palestinians will likely be tops among his major international priorities.

Important as the health care vote is, it is a reminder that nothing comes easily, and that the Democrats can count on no Republican support.  The sole priority for Republicans appears to block what they can, and that includes necessary reforms of America's casino financial system.

At least now those ads promoting travel to the US (which did get bipartisan support) can include some very good news on the health front.

Clowns To the Left, Jokers To the Right: Stuck in the Middle?

The old song was swimming around in my head, and I knew I'd have to turn it into a post: Stuck in the Middle With You, a 1972 hit by the Scottish group Stealers Wheel (lyrics available here).   Some may remember the refrain.

President Obama was only about 9 years old when the record came out, so it may not have been on his mind when presiding over the Bipartisan Health Care Meeting this past week.  But the man deserves sainthood for his calm.

Actually, the line about "clowns to the left" is not fair, and may not be accurate, if The Nation's John Nichols is to be believed: he calls them and other advocates of Medicare-for-all or single-payer the "Missing Voices at the Healthcare Summit."  I agree that single-payer should have been seriously considered all along, but it never had a chance after "death panel" voodoo had taken hold last summer.

But "jokers to the right" there were aplenty, and like Dana Milbank, I wish that the moderate Presidential moderator had smacked some of them down when they got ornery.

Here's one of the things that bother me about the post-summit spin coming from the Democrats: the notion that

At the meeting, both sides found common ground on critical issues including

o   Eliminating waste and fraud in Medicare and Medicaid

o   Reforming medical malpractice laws

o   Providing more choices in coverage for individuals and the option to pool coverage for small businesses

o   Reforming the insurance market

"Common ground?"  Why should the Republicans be given any credit for seeming reasonable, when all indications are that they will continue to oppose any changes to the broken system?  If reform passes, it will be thanks to Democratic votes, and Democratic votes alone.

When the Republicans say "start over" on health care reform, that is not "common ground." It's code for grind to a halt.  Pass the bill, then go on to these nice "common ground" points in Step 2, from a position of strength.

Store Your Containers in Haiti

Matthew Price, BBC Port-au-Prince, 12 February 2010:

In just a few weeks, by the end of March, or in April, the rainy season will begin. Some 700,000 people are living out in the open, in makeshift shelters. The luckier have found old and rusty corrugated iron roofs. Others huddle under bed-sheets strung between wooden poles. Shelter is, according to aid agencies, a monumental challenge.

As Haiti marks the one-month anniversary of its devastating earthquake, attention turns to shelter before the rainy season.  Matthew Price goes on to report the additional misery that a pre-season deluge caused in the shanty town.  However, as the Clemson University SEED Project (image) has shown, the solution is at hand:

Shipping containers are designed to carry massive amounts of cargo and withstand extreme weather conditions making them a logical housing component.  Completely constructed of steel... [they] resist overturn when exposed to winds up to 140 mph.  Without modification a 40 foot shipping container has 304 square feet of floor space and eliminates problems associated with insects, fire, and hurricanes.  With modification a 40 foot shipping container can be a safe, comfortable, and environmentally friendly home for numerous local inhabitants who would otherwise have less.

Okay, combine Clemson's research (begun, according to Science Daily, in response to hurricane damage) with this fact: even though the worldwide recession has hit the container shipping business badly, and traffic is down a massive 10 percent last year, container ships continue to be built.  See "New Ships Idle, Waiting for Cargo to Fill Them," Matthew Saltmarsh, New York Times, 15 January 2010:

... shipbuilders are expected to deliver 371 container ships this year and 127 in 2012, according to Alphaliner. The container fleet will grow 14 percent in 2010 and almost 10 percent next, meaning that even more ships will be competing for cargo.

Okay: shipping industry, meet container warehouses, meet aid agencies.  It's a perfect storm.  Meanwhile, the weather report for Haiti predicts heavy rain.

Medevac Diplomacy Requires Public Diplomacy

"Not our finest moment"

One of the main developing stories on BBC and other international media over the weekend is the mystery surrounding the apparent freeze - since Wednesday, 5 long days ago - of US military medevac flights from Haiti to the US, meaning Florida.  It's time to get a grip before this becomes a major calamity, human and diplomatic.

[UPDATE I, 1 February: the White House has announced that flights will resume Monday.  UPDATE II, 2 February: according to the New York Times, the Federal government will now reimburse hospitals for Haitians treated under the emergency.  The doctor whose outcry galvanized concerted action said the system was back "in sync."]

The White House has told the BBC that the suspension is due to "logistical issues," but the Miami Herald indicates that state-federal wrangling over reimbursement of medical costs has played a part in the confusion. A Florida doctor on the ground in Haiti said that "it is not our finest moment right now."

One Florida official referred to confusion over having to deal with multiple federal agencies.  Oops, there we go again, despite years of work and millions spent on "interagency" coordination.  Granted, well-intentioned people of numerous nationalities and organizational affiliations are pitching in during this dire emergency, under daunting conditions.  But that is exactly what interagency planning is for - coordination.

The decision to have the US military go in with overwhelming numbers, take charge of the Port-au-Prince airport, and regulate the flow of relief supplies and medevacs means that that the US is solely responsible for making this work.  When it doesn't, it shouldn't be up to Florida officials and US Transportation Command (TRANSCOM) spokesmen to trade charges over who is responsible for the holdup.  In addition to unblocking the jam, let's exert a little message control here.

Despite the destruction and the initial rush to help, things started out promisingly - hell, even Cuba granted special flight clearance for US military planes to fly through its airspace.  If Florida is having trouble admitting a few hundred additional Haitians, why not expand on this diplomatic breakthrough and work with Cuba's ongoing Haitian medical program to land patients there?

Image from the Commission for Aviation Regulation.

Health: It's Broke, And This Alone Won't Fix It

Within a 24 hour period, I've spent quality time with wonky Democrats and Republicans in Brussels.  The Dems were my fellow Democrats Abroad Belgium (DAB) people, and the lone Republican was a former boss, whose friendship predates any party political differences.  Health care reform and the state of the nation were the common themes, appropriate on this day of the SOTU (State of the Union speech by President Obama, his first since taking office).

Health care reform can and should raise the level of emotion in any debate, and the passion was clear when each of us recalled personal horror stories: family members denied care and expat (or binational) Americans who feared returning to their country because they feared prohibitive health care costs.  Among the overseas Dems, all of us know that there's another way to approach health care, and that is the social democratic way, i.e., as a basic human right, the way most of the European countries - whether governed by free marketers or socialists - have come to view health care.

But what struck me most was how little passion there was in favor of the options that present themselves to the Democrats in Congress.   Yes, Pass the Damn Bill was the reluctant consensus, but only because Democrats need to show something for their year in control of White House, Senate, and House of Representatives.  No one expected it to solve all ills, or, beyond a few health care jobs, to create any of the employment that the country needs to earn its way out of the recession.

My Republican friend, meanwhile, saw "health care reform" as a mislabeled good, when what we appear to be discussing is just "health insurance reform," and not a complete fix of even that.  How about tort reform, a genteel way of saying that trial lawyers should not be able to game the system to extort hideous "damages" for medical errors.  My sister the nurse, going back thirty years, used to wow us with stories of frivolous lawsuits after medical procedures deprived patients of their "psychic powers" - okay, said the juries, here's a few million in compensation.  Yes, tort reform is a necessary - and apparently missing  - part of comprehensive health care reform.

None of the conversations I've had over the last 24 hours have shaken my belief that we need to fix the broken health care situation in the US.  It's a "situation," not a "system," and it's by all accounts "broke" - i.e. broken, and bereft of resources.  But the bill(s) - Senate and House - that are now under consideration are not the final answer.  They are only the preamble.

Pass what's passable, yes.  But don't stop there.  If Step One was Medicare in the Johnson Administration, and Step Two the current "health insurance reform" bill, to be passed willy-nilly by the Democrats, Step Three will need to be a truly comprehensive health care reform, one that the Republicans have to be co-partners in adopting.

But Step Three can't happen without Step Two, and Step Two would never have happened without Step One.  Health care, like good governance and civilization itself, is a work in progress.

Image from Car Basics.

Health Care: Too Big To Fail

Go ahead and swallow the pill

Now that Democrats have had a few hours to weep and gnash teeth over the defeat of their candidate in the Massachusetts election, let's remember this: they still have large majorities in both Senate and House, and both chambers have passed health care reform bills.

The progressive blogosphere is starting to resound with calls of "Pass The Damn Bill" (Steve Benen's Political Animal).   He gives several devastating arguments as to why they should do so, mostly having to do with what might be called sunk costs - having spent so much time and political capital, to abandon health care reform now would be craven cowardice in the face of resurgent Republicans, who after all are the minority party.

Jonathan Chait ("Mass Hysteria") in The New Republic predicts that Democratic lawmakers will come to their senses and pass the bill - or else:

[B]oth chambers have already voted for a bill and set themselves up to be attacked for tax hikes, Medicare cuts and all the rest. The only chance the Democrats have to change that perception is to pass the bill, so that it can be explained in the context of success rather than as a tar baby subjected to endless criticism. If they let it die, they not only keep all the baggage of their votes, but they add a general stench of failure and profound demoralization of the base to their burdens. That would be a recipe not just to lose the House but to lose 50, 60, 80 seats.

I agree with Benen and Chait (Kevin Drum and Josh Marshall say similar things); how can the other important business of the nation be tackled if we don't finally pass the landmark bill of Obama's first year?

But what if this doesn't happen, and the House insists on changes to the Senate Bill?  What if the Republicans, instead of just threatening to filibuster, are made to actually put up or shut up?  The last actual filibuster, apparently (I'm relying on Fox News, not my usual source for facts), was in 1992, during Father Bush's presidency.  Since then, "filibuster" has really meant "threat of filibuster."

So what would happen if the minority of 41 Senators stood in the way of the majority, over an issue of such importance to Americans?  Those 1 million sick person marches that I've been wondering about might have a better chance of getting under way.  People who've lost their insurance because they got sick, and others who've lost coverage because they got fired, maybe they can start showing up in their hundreds of thousands on Republican Filibuster Day.

Enforcing democracy (as opposed to honoring outmoded Senate rules like the filibuster) can be difficult.  More than a century ago, the Speaker of the House, Thomas B. Reed, had to endure cries of "despot, tyrant, dictator, Czar" when he single-handedly ended the practice of the "silent quorum," whereby a party could hold up legislative business simply by its Representatives remaining silent during roll call.  Then, the reformer was a Republican, and the diehards were Democrats.  We need similar intestinal fortitude a century later to kill filibustering.

Today, in his first post-election news conference, Senator-elect Scott Brown sounded conciliatory on health care, which may not come as a surprise, since he voted for Massachusetts' plan as a state senator.  So if Senator 41 is called to filibuster, maybe he can read the Massachusetts health care bill out loud, as a model for Federal legislation.  But wait a minute, it already is.  So what's the problem?

Two choices, Dems: either "pass the damn bill" now, or make the Republicans suffer so much for their filibuster that they filibuster all the way to November.  How will that look to voters?

For It Before They Were Against It: GOP & Health

The President of the United States said:

Our... goal is high quality, affordable health care for all Americans. The American system of medicine is a model of skill and innovation, with a pace of discovery that is adding good years to our lives. Yet for many people, medical care costs too much — and many have no coverage at all. ...We must work toward a system in which all Americans have a good insurance policy, choose their own doctors, and seniors and low-income Americans receive the help they need.

The President was George W. Bush, and he said the above in his State of the Union speech of January 28, 2003.

Of course he also said, in the same speech: "These problems will not be solved with a nationalized health care system that dictates coverage and rations care."  So even though the 2009 Christmas bill falls far short of "nationalization" and is a far cry from dictating or rationing anything, I guess the Republicans can say that they would be for "affordable care for all Americans," as long as we're only talking theoretically.

Not to be confused with a chance to help pass actual health care legislation, which 100% of Republican Senators have refused to do.

President Obama has said "words mean something."  Which means you don't include, like Bush did in January 2003, words in your SOTU that promise "affordable health care for all Americans" and then proceed to do nothing towards that goal in your remaining 6 years in office.  Or as a party, oppose even the proposed moderate reform of a broken system by calling it a "Trojan Horse" for "nationalization."

I suggest you take a little tour of the Republican National Committee (RNC) website, especially its "What We Believe" page.  Health care - affordable or otherwise - appears nowhere on their list of beliefs.  It's also instructive to look at the "GOP Heroes" link, replete with sepia-toned 19th century portraits of black Americans who battled against slavery and for equal rights.

The problem is that the current GOP in the Senate and the House is a far cry from those days, and is likely to be on the wrong side of issues that concern contemporary black people.  An ostensibly bipartisan organization, the Congressional Black Caucus (CBC website) currently has no Republican members, and some white GOP legislators are suspected of "racial Tourette's Syndrome," where appeals to racism have entered the health care debate.

I hope the Senate and House bills pass in the new year with enhanced protections against subsequent attacks by dead-ender die hards who currently enjoy  one of the best health insurance plans - the Federal Employees Health Benefits Program (FEHB).

If the GOP is ideologically opposed to "nationalized" health insurance, how many Republican elected officials have given up their taxpayer-subsidized coverage?  You can count them on the head of a pin. 

Fear of Filibusters: Model For Democratic Governance?

[W]e need to take on the way the Senate works. The filibuster, and the need for 60 votes to end debate, aren’t in the Constitution. They’re a Senate tradition, and that same tradition said that the threat of filibusters should be used sparingly. Well, Republicans have already trashed the second part of the tradition: look at a list of cloture motions over time, and you’ll see that since the G.O.P. lost control of Congress it has pursued obstructionism on a literally unprecedented scale. So it’s time to revise the rules.

Paul Krugman, "Pass The Bill" - New York Times, December 17, 2009

The bill Krugman wants to see passed, however imperfect, is the health care reform bill that Howard Dean calls "hocus pocus."  I'll return to that question in future posts, I'm sure, but today I want to vent on why 60 is such a magic number, and why Senators from states with populations smaller than most large American cities get to wield veto power over the will of the great majority of Americans.

It's called The Filibuster.

Wikipedia nicely traces the piratical origins of the word, from the French and Dutch words flibustier and vrijbuiter... freebooter.  "Pirating or hijacking debate" is the usage we are looking at, and though the current culprits are the Republicans and their Democratic (or "Independent") enablers, it wasn't always the GOP that had a corner on this market.

Barbara Tuchman, in her portrait of the world before the First World War, "The Proud Tower" (1962), dedicates the better part of a chapter on the United States to a long-forgotten parliamentary firestorm over the "silent - or disappearing - quorum."  She explains:

It was a practice whereby the minority party could prevent any legislation obnoxious to it by refusing a quorum, that is, by demanding a roll call and then remaining silent when their names were called.  Since the rules prescribed that a member's presence was established only by a viva voce reply to the roll...

In other words - and Tuchman provides jolly examples - Congressman Cretin (generic moniker) could be sitting in full view of the Speaker, but if he chose to deny his presence, he and his minority cronies would simply remain silent and could not be considered present.  Hence, no quorum.

Until the day the rules changed.  The day when the Speaker of the US House of Representatives, Thomas B. Reed, Republican of Maine, stood his ground against a fuming and foaming pack of Democratic filibusterers.  These were the days when "the party of Lincoln" was on the side of the angels, and the Democrats included numerous unreconstructed racists bent on enforcing poll taxes and opposing the seating of elected black politicians. 

I recommend reading Tuchman's account for the full drama of the confrontation, where if Reed saw Congressman Cretin, he checked him as present, whether or not Cretin wanted to be recognized.  But the point is this: a ludicrous rule whereby physical presence meant nothing unless you said "here" or "present" out loud was shown for what it was: ridiculous, and unworthy of a democratic forum of a great power.

Fast forward to 2009 and the debate over health care in the United States.  The institution that haughtily calls itself "the world's greatest deliberative body" lives in fear of the one Senator who threatens to read ad infinitum from the Washington D.C. telephone book ("Abigail Abbey, Abner Abbey, Archibald B. Abby...") as he prevents debate on the provision of health care to American citizens?  Please.  Fear of filibuster has replaced the Hollywood image of righteous filibustering.  You just have to utter the F(ilibuster) word and the party with healthy majorities in House and Senate suddenly goes weak at the knees and caters to the lowest denominator, meaning 1/60 (or actually 1/100 of the full Senate complement).  Strange math.

As Paul Krugman reminds us, the US Constitution doesn't mention filibuster, and there's no right to hijacking debate in the Bill of Rights.  The US Declaration of Independence was a stirring call against the tyranny of a king.  What about the very real tyranny wielded by a minority of one, Senator Sixty, whoever he is today?  Yesterday it was Joe Lieberman, today it's Ben Nelson; who will be the courted sixtieth filibuster-avoiding freebooter tomorrow?

Next time you hear about the United States lecturing Foreign Country X about "good governance," read how Byzantium lives in the Senate Rules Committee and consider how much the US has to learn about transparent democratic governance.

(UPDATE December 20: Today Krugman suggest ways to reform or eradicate filibuster)