Thursday, August 16, 2007

LA on my mind

Louisiana has been through a lot in the last couple of years. There have been scandals of government abuse regarding FEMA money and shoddy disaster relief efforts across the board. The New Orleans Saints had a heroic season where they all but pulled out a miracle that the city so desperately needed.

Alarming still is the rate at which Cajun/Creole culture is disappearing in the lower part of the state. I mean to say that the state is actually disappearing. Over the years, the Mississippi River that has showered the delta with new sediment has been so diverted as to prevent the natural replenishment of this coastal environment. More wetlands are being lost every year than most people would even fathom. The numbers are staggering indeed, but it's not numbers that matter. It's people and living things.

Destroying an ecosystem is tantamount to murder. Sure development must occur and the re-routing of the Mississippi River has had advantages, but the failure to manage environmental concerns while watching development take place is shameful. We ought to think about the unintended consequences of our attempts to change the natural course of things.

As the bayous are vanishing, so too are the shrimpers, artisans, oil workers, and others who make up the distinct cultural phenomenon of bayou existence. We're not only losing land, but we're also losing people as land washes away into the ocean and young generations move north.

Louisiana brings together an interesting array of questions that touch upon development needs, ecosystem management, tourism policy, and cultural appreciation. The issues at play are too complex to discuss in any one place and have been the subject of many books and articles. I hope that Louisiana and its bayous are on the minds of all United States citizens as we think about our policy priorities.

Are we even talking about the same Massachussetts?

Michael Tanner of CATO is waxing smug because the Massachusetts plan for universal health care is facing some trouble as deadlines approach. The uninsured in Massachusetts have four months to buy insurance, or they'll face a tax penalty. But as things stand now, "of 170,000 people who are uninsured but have incomes too high for subsidies, only 17,500 have complied with the mandate so far." Tanner claims that CATO called this one in the air - the mandate was unenforceable and they knew it. To bolster the tanks "I-told-you-so" cred, he directs us to his earlier writing on the subject, noting,

"Someone should have pointed out that the Massachusetts mandate is probably unenforceable and almost certainly not going to achieve universal coverage. Oh, that’s right, we did."

Funny thing is, his earlier piece says absolutely nothing about enforceability. In fact, the extensive hand-wringing over allegedly severe restrictions on consumer and employer choice seem to belabor the worry that the Bay State Politburo might enforce it's social experiment all too well (ominous music, lightning).

Interestingly enough, the criticisms that CATO did make turn out to be pretty far off the mark when we consider what's actually going on in Massachusetts.

Criticism 1: " The individual mandate opens the door to widespread regulation of the health care industry and political interference in personal health care decisions."

Now I could always be wrong, but I am almost positive that was the point of passing a regulation on the health care industry. Y'know? So, conceded, I guess.

Criticism 2: " The act's subsidies are poorly targeted and overly generous."

Actually, no. The MSNBC article that Tanner links to (see "trouble", above) reports:

About 160,000 uninsured people in the state have incomes that are too high to qualify for subsidized health insurance — but too low to afford the lowest-cost unsubsidized plans.

The Massachusetts plan is fading in the stretch because the subsidies aren't extended generously enough. For too many people, the mandate has become a choice between paying insurance premiums or paying for their housing or groceries. It takes a willful ignorance of reality to make Tanner's claim. I don't know how to make this any clearer: people are not refusing to enroll because the market is over-regulated. They are refusing to enroll because the current market is cost prohibitive for the working poor of Massachusetts.

Criticism 3: "The Massachusetts Health Care Connector, which restructures the individual and small business insurance markets, is a form of managed competition that has the potential to severely limit consumer choice."

Again, point ceded. Consumer choice does get sidelined by a mandate to purchase insurance. But does this have anything to do with the failure of each Massachusetts citizen to enroll? The market restructuring should be a boon to providers - faced with the threat of fines (a clumsy method of implementation in my opinion), employers and individual buyers have an extra incentive to spend money on premiums that they might have chosen to hold onto before.

Criticism 4: "The act imposes new burdens on business and creates a host of new government bureaucracies to manage the health care system."

I did read a piece talking about some delays in processing caused by a deluge of applicants as the deadline nears... somehow I doubt that's what Tanner was getting at. If you read the MSNBC article, some small business owners are miffed at having to take on the costs of insurance. One restaurateur is perfectly livid. But no examples are given of any businesses actually tipping into bankruptcy from the requirement, while we know that hundreds of thousands of Americans declare bankruptcy annually from insurmountable medical fees. That observed, I'll ad that I'm currently working for a restaurateur who gets ticked when I remind him that he has to pay me the minimum wage. So my sympathies for small businesses are diluted. Small -time capitalists do have a lot of troubles to face, but the idea that they are totally incapable of cutting profits to care for their employees is a myth.

In any event, taking all four criticisms into account reveals that contrary to the CATO blog's current swagger, Tanner's actual predictions are either ideologically driven truisms that are immaterial to the current dilemma faced by Massachusetts - or - in one case, an ideologically driven policy criticism that succeeds in nailing the exact opposite of what is actually going on.

I'll note in closing that I am not a devotee of Plan Massachusetts. I do not think it goes far enough. And I think it leaves an awful lot of power and economic privilege to insurance companies, most egregious being the lack of a cap on annual medical expenses as a proportion of income. Not to mention, every one of the issues at hand - from burdening businesses to non-compliance due to a cost-prohibitive market - are issues that would not exist in a nationalized system funded by a progressive tax scheme. In theory, I'm open to alternatives to a system like Canada's, but I'm seeing few practical reasons to maintain that position as of late. But I'll stick to my guns: I just want to see every person have access to affordable health care. So ideological implications aside, I do hope the Massachusetts plan succeeds. Let the CATO crowd preemptively notch their belts based on who-knows-which facts - the reality based community will keep watching and hope for the best.

Tuesday, August 14, 2007

No, but seriously, what is your proposal for health insurance?

It's way past official Giuliani simply does not care about health reform. Because anyone who understood the magnitude of the health care disparities in this country would not seriously believe that a plan like this could make a significant impact on the number of uninsured Americans. Then again, it is not designed to - the plan "does not even cite universal coverage as a goal." Giuiliani's plan strikes out right there and not just in the opinion of raving Leftist ol' me, but in the opinion of all 69% of Americans who agreed in November of 2006 that the government has a responsibility to guarantee coverage for everyone. Yet another example of how far out of the mainstream so-called-moderate Republicans truly are when it comes to social policy. And tactically speaking, If Giuliani manages to wrest the Republican nomination away from Romney, any Democrat who runs against him should be making health care the strongest part of their campaign.

That crucial flaw bracketed momentarily, Giuliani's plan does not aspire to alter the current market-based system much at all. It comes down to a Health Insurance Credit and a tax deduction for low income families. Both of those proposals, fortunately, would alleviate some of the tremendous burden that poor Americans face when purchasing health care - although we have to hope that Giuliani is more generous with the eligibility on those than he was with, say, welfare, food stamps, subsidized housing and essentially every major social service offered in NYC under his mayorship.

All the same, what Giuliani is offering fails on two critical counts - highlighted by Matt Miller's recent piece in Time. First, for whatever aid it provides them with, Giuliani's plan still holds out that " individuals' buying their own solo health insurance can be the answer to the problem of the uninsured." Without any new mandates, health insurance companies are still free to reject clients with a history of illness (and these are the men and women who need insurance most) or to cheat their poorest customers out of any real coverage by offering plans with low premiums but through-the-roof deductibles that render the plan useless. Secondly, Giuiliani does not "support limiting a family's annual exposure to medical costs to some reasonable percentage of its income." In fact,

Giuliani actually boasts of an approach certain to hurt people. His health-care tax deduction, he gushed in Iowa recently, "allows you to go out and buy cheaper and cheaper policies [because] you can have higher and higher deductibles." When Americans earning $25,000 a year get sick and end up paying $10,000 or more in hospital charges, their "affordable" insurance courtesy of Giuliani will become a ticket to bankruptcy.

Avoiding political hyperbole is nice, but any critical analysis of what America's Mayor has put on the table for health care reform makes it clear: Giuliani does not care about poor and sick Americans.

Monday, August 13, 2007

Death in Detention

Via Kaiser Network:

A 23-year-old HIV-positive person, Victor Arrelano, recently died while in custody at an immigration detention center in San Pedro, Calif., the Los Angeles Times reports. Arrelano's family plans to file a wrongful death suit against the U.S. government that claims Arrelano was denied vital medical treatment while in custody. According to the Times, the case highlights an "inadequate, even dangerous, medical system for the nearly 30,000 undocumented immigrants in custody nationwide."

Attorneys for Arrelano's family say that while in custody, Arrelano's condition deteriorated to the point that fellow detainees urged staff to provide medical care. Roman Silberfeld, the family's attorney, said that 70 detainees signed a petition urging that Arrelano receive medical attention. When Arrelano's condition became critical, he was transferred to a San Pedro hospital and died several days later, according to the Times. Lorri Jean -- chief executive of the Los Angeles Gay and Lesbian Center, which provided treatment to Arrelano two years ago -- said she has "no doubt" Arrelano died because he was "denied the medications that [he] needed to stay alive." Jean said that she and her staff on Monday will discuss Arrelano's death and their concerns about treatment at the detention center with Rep. Henry Waxman (D-Calif.), the Times reports.

Immigration and health services officials on Friday defended the quality of medical care provided at dozens of facilities nationwide. They would not discuss individual cases because of privacy concerns, the Times reports.

This should come as shocking news to anyone who reads it. There is no standard by which human rights are judged in which it is acceptable to deny a detainee - someone who is quite obviously incapable of accessing their own medical care - needed assistance. Of course, I doubt an unadulterated sentiment of outrage or even sympathy for the victim will be demonstrated by Americans, since the victim, being an HIV positive man and an illegal immigrant, happens to be in not one but two categories of people who are vilified, feared and marginalized by conservative Americans.

Whether or not this country is ready to take up responsibilities to its immigrant populations, there should be absolutely no question that when we detain someone we become accountable for their health care. Only the most extreme of nativists would propose the death penalty for violating immigration laws. And yet that is essentially what Arrelano received.

Sunday, August 12, 2007

Apparently the safety net is only catching men

A recently released report by Academy of American Actuaries finds that more elderly women (40%) than men (28%) depend on Social Security to survive their retired years. They are also receiving smaller payments than men due to a variety of gender differences in American work culture. The end result is dismal though - the Social Security disparity is just one more factor contributing to high rates of poverty amongst senior women.

The causes are legion and not all of them reflect poorly on America's gender divide. For example the fact that women tend to live longer after their retirement should come as a welcome sign of progress in women's health care. Yet this seemingly benign fact means women get hit twice in the income department: they have to depend on payments longer, and they are more likely than men to spend some of their retired years single.

Some of the factors are more troubling - women still aren't reporting as much earned income as men. That should be a surprise to no one. That women are still taking a great deal of temporary leave from the workplace is not inherently unsettling, but it should raise questions about why men are still not doing their share of child-rearing, and why there is not some formula to reward mothers for their work when it comes to claiming social security.

And really, that point - revising the formula - is the most salient priority to be gleaned from the report, which in itself simply reflects a great deal of what we already know about gender and work in America. I think advocates for work parity will be unsurprised by just about every factor highlighted in this article, and they will appropriately continue to fight for reform. What the report should tell the people working to dispense Social Security payments is that a gender-blind formula like the one we have know is simply inadequate. If women are inordinately performing the uncompensated labor of child-care and are still facing discrimination in salaries, then a formula for Social Security payouts ought to be cognizant of that fact. The American workplace is still not a place where women are equal to men. Until it is, our social services will only consign more elderly American women to poverty if they insist on conflating gender equity with gender neutrality.