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.

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.

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.

Sick and tired of racism?

Two studies, both concerning Asian Americans, found evidence of a causal connection between discrimination and depreciated health. The first study examined experiences with discrimination amongst Korean immigrants to the United States and measured those findings against the mental health quality of the subjects. "Researchers found that both overt and subtle discrimination seemed to influence participants' mental health. Overt discrimination was associated with the erosion of positive mood, while subtle racism was associated with symptoms of depression, possibly because more subtle forms of discrimination create 'ambiguities in terms of social identity.'" A second study looked at the impact of discrimination on chronic illness. They observed associations between discrimination and various respiratory, cardiovascular and pain-causing conditions, concluding:"that the everyday perceived discrimination minorities experience could cause stress that can lead to chronic illnesses."

Studies like these have a lot of interesting implications. They illustrate the extent to which cumulative disadvantages still track to characteristics like race not simply because of class conditions, as some materially inclined post-racists may conjuncture. but as a tangible result of discrimination that is currently happening. They also raise a tough moral dilemma for proponents of a health system like the one in the status quo (though I will admit now they do not go far enough to establish the moral necessity of a completely socialized health system).

If we take up the meritocratic position held by many (though certainly not all) opponents of socialized medicine which states that people's capacity to afford health care should, and more or less does, track to decisions about work, education and life-path that people have freely made themselves the status quo would be easier to accept. As one anonymous interlocutor put it in an online forum, claims that the 40 million or so uninsured Americans represent a failure of distributive justice suffer from "a lack of true knowledge as to why those "40 million" are uninsured (here's a hint - a significant number choose to be that way for a variety of reasons beyond "I can't afford insurance") and we start getting down to the real issues at hand." Following this argument to it's conclusion, the quality and cost of a person's health care, and indeed whether a person has any at all, is just if it indexes to that persons choice. So if I choose to remain unemployed or to become obese then I deserve whatever hardships come my way in the market-based health system. Bracketing the (numerous) complications that employment, obesity and the like raise in terms of cumulative disadvantage, we will take that idealized, rationalist approach and put to it the question of race.

A Korean American who either (1) suffered from a mental health disorder as a result of discrimination or (2) suffered from a chronic illness as a result of stress caused by discrimination would face considerable difficulty in paying for health care. At best, our hypothetical Korean would pay much higher premiums and/or deductible and face still higher expenses in treatment. At worst, she or he might be totally unable to find a provider, as many people with chronic and mental illnesses are.

Now, in this person's case there is absolutely no sense in which she or he could be said to have "earned" discrimination, even indirectly by putting oneself in a risky position. Yet she or he may well be priced out of insurance simply as a result of a prejudiced society. Why should our Korean have to face inordinately high costs of health care - or worse, go without any - simply because living as a Korean in a racist white society is difficult?

The moral dilemma illustrated by these studies, put simply, is that there are systematic inequalities in the allocation of health burdens in our society, which impose costs on the people burdened with them that are, as Rawls would have said, arbitrary from a moral point of view. Yet we ask that those people face the costs with whatever resources they can cobble together (forgetting for now that their capacity to do so will be inhibited by their health conditions ). Why shouldn't all members of a society marked by inequality that is arbitrary (morally) and systematic (distributively) have some obligation to contribute to offset those disadvantages?

The Visible Vote

I'm going to live-blog the Visible Vote forum that LOGO and HRC are hosting. All of the Democratic candidates - excepting Biden and Dodd - will be appearing to discuss issues of concern to lesbian, gay, bisexual and transgender people and their allies. I've also submitted some questions, mainly at the intersection of health policy and LGBT rights. But my guess is they're a bit on the wonkish side for a general debate.

The hosts: Journalist Jonathan Capehart, singer Melissa Etheridge, and HRC President Joe Solmonese. You can stream the debate live here.

Obama is up first.

9:06 PM - Obama draws an analogy between the outsider status he has often confronted due to his racial and ethnic heritage and the marginality faced by LGBT people. He argues strongly from anti-discrimination/civil rights framework for civil unions that are legally equivalent to marriage. He wants to leave marriage up to individual religious denominations. One of the panelists presses this - what about civil marriage?

9:08 PM - Obama just concern trolled the gays. He said they should choose their battles, and maybe the lack of access to civil marriage isn't the one they should focus on. He also said that whether or not civil marriage was available to same-sex couples was mostly a semantic issue. That does not sit well here. He actually comes of as dismissive and patronizing.

9:15 PM- One of the hosts, Mr. Capehart, raises the issue of homophobia in the black community. Barack responds that he has previously addressed to black audiences the impediment that homophobia has raised in adequately responding to the crisis of AIDS amongst black Americans. He also laments the use of homophobia to fragment progressive alliances between blacks and LGBT people. He is very good on this issue. His answer is very thoughtful and considered. I believe him when he says he will advocate for LGBT people not solely when he's on the burner before America's wealthiest gay rights group.

9:22 PM - Edwards steps up to the plate. I've previously blogged (quite unfavorably) on his discursive representation of LGBT people in public debates. Let's see how he does tonight.

9:24 PM - Melissa Etheridge has a great moment where she touches on the solidarity she feels with Elizabeth Edwards in their mutual struggle with cancer. She pivots from there to the incredible privilege she and Edwards share in being able to afford their expensive treatments. She asks if Edwards understands that the health care crisis hits LGBT people especially hard given that they cannot depend on employers and spouses to provide health care for them like most Americans.

Edwards answer is okay, but not impressive. He plugs his universal health care plan. Then he discusses his empathy for the large portion of LGBT people who are homeless as a result of discrimination. He does touch on an actual answer - between his stances on civil unions and his universal health care plan he'd see the problem addressed. He doesn't seem to have much to say about LGBT health at all, and is instead trying to soundbite on as many issues as possible.

9:29 PM - Edwards states, albeit equivocally, that he would support education about sexuality in public schools that emphasizes the naturalness of homosexuality and the need for tolerance. He comes across as empathetic, but admits he hasn't thought through the specific policy issues involved. It shows.

9:31 PM - Why, oh why, has Edwards spent the past three minutes talking about Anne Coulter?

9:33 PM - Edwards takes the first transgender specific question of the night - how would he react to the knowledge that one of his staffer was trans-identified and planning to transition? Edwards replies that he would be tolerant and as supportive as he could be (fair enough), and expresses his support for a transgender inclusive federal ENDA. This is his strongest answer yet.

9:35 PM - Edwards is finally taking on the marraige question. He says that he cannot impose religious views, that he believes in equality to his core and that he can understand why anything short of full equality before the law will be seen as a sleight to the LGBT community. But he doesn't give a direct justification for his policy. So he is asked for one, in a question that strongly indicts his "I'm on a journey" crap. His answer... is that Don't Ask Don't Tell ought to be repealed. Very disappointing.

9:41 PM - Kucinich takes the stage to the warmest welcome of the night. Right away Capehart points out that Kucinich seems to stand with the LGBT community on every issue. He then asks Kucinich why he stands in such a minority amongst candidates in his support for same-sex marriage. His response, simply, is that he stands for true equality. Capehart takes this and runs - is Kucinich saying that Obama and Edwards, who speak for equality as well, have jettisonned the LGBT community for political reasons. Kucinich takes the high-road and doesn't endorse Capehart's theory, but he gives a great answer on the role the federal government can play as an agent for social change.

9:47 PM - Kucinich is still getting a lot of flattery. The moderator calls him "evolved." Kucinich accepts the compliment. He says his role is to help all Americans "evolve" with him. He also emphasizes that his path is easy - he just has to listen to LGBT people and then act. They are the ones who have to struggle courageously with discrimination. How can he not help them? Kucinich understands solidarity, I'll say that.

9:49 PM - Are you serious? I guess this can't be a cakewalk the whole time, so Etheridge (after endorsing Kucinich's candidacy to his face) throws him a question on medicinal marijuana, citing the pain caused by AIDS and cancer in the gay and lesbian communities. Kucinich says - yes. He does not waffle. Just, yes - as a matter of compassion our approach to marijuana should be informed primarily by health policy not criminal justice. He also plugs his health care plan: the only universal single payer health care plan proposed by a candidate, the only one that is not-for -profit. Nice, but he sure swallowed a heck of a soundbite on the pot question.

9:52 PM - The panelists seem to concede that Kucinich can't win this as much as they'd like him to. They ask if he is electable. Kucinich is giving a terrific answer. He replies that middle America does believe in tolerance and equality. He'd like to lead that America, but at the same time his candidacy is not just about representation - it's also about transformation. He is trying to transform and persuade even as he positions himself for the White House.

9:54 PM - Now Kucinich gets the wonkiest question of the night: will he make HIV/AIDS prevention funding part of Ryan White? For those not in the know, Ryan White Care Act is the source of most federal funding to care for people living with HIV/AIDS but does not cover preventative care. Kucinich says he would advocate for that. Succinct, but he doesn't seem prepared to talk in detail about Ryan White, so he just talks about health care generally for awhile. Not a stellar answer.

9:59 PM - Kucinich's closing remarks are very eloquent. He talks about love and his wife, transformation and equality. I'd like to point out that Kucinich is the candidate who has talked least about "tolerance." He never uses the word. He talks about equality a lot, love almost as much and occasionally uses the word justice. But he is not talking about tolerance. It does not seem rehearsed, he just seems to be past that point. I'm consistently impressed by this man, and tonight is no exception.

10:05 PM - Now Gravel is on. He gets a question about how, as a member of his generation, he talks about his support for LGBT rights generally and same-sex marriage specifically. He answers that most of his generation is wrong, and in time the issue will not be one.
Gravel blames demagogues for dividing America on marriage equality. He thinks most Americans, if they followed their sense of fairness, would support marriage.

10:08 PM - Interesting and ballsy: Gravel calls out LGBT voters for supporting people like Clinton and Obama when candidates like himself and Kucinich are doing the hard work on LGBT issues. Point taken, sir.

10:10 PM - Capehart turns the blade at Gravel: Why aren't you as popular as Clinton and Obama with LGBT voters? Gravel seems to backtrack and acknowledge that there is a political liability that he does take on by supporting LGBT equality. And he says he does not want the support of Democrats who are not willing to take on that liability as a show of solidarity.

10:13 PM - Gravel has talked a lot about politics and public opinion. This is working against him because he isn't getting to talk much about the range of issues that Edwards and Obama did. He comes off as committed, but not particularly informed.

10:14 PM - Gravel is talking about nuclear testing in the Pacific? He's also kind of being a dick to Joe Solmonese, but that's probably okay since no LGBT activist worth their rainbow stripes actually likes the HRC.

10:17 PM - So now Gravel is giving a great schpeel on the prison system, the war on drugs and de-criminalization. It's decent enough... but unfortunately the question was about HIV/AIDS in the inner cities. Not particularly convincing.

10:19 PM - Now it's Richardson's turn.

10:22 PM - Richardson's "concern troll" is a lot more convincing than Obama's. He talks about using winnable battles against hate crimes, against No Child Left Behind (which he points out hurts good sexuality education and anti-bullying work). But he emphasizes using these battles to build the community of allies concerned with LGBT support and to transform public consciousness. He sounds like a realist, where Obama and Edwards just sounded evasive.

10:25 PM - Richardson apologizes the "miracon" gaffe, and minimizes. He wants to talk about his record, which is impressive (pioneering support for transgender rights, working against hate crimes, and moving aggressively for domestic partnerships and against DOMA). He is tremendously focused on talking about (1) what political goals are achievable for LGBT issues, (2) what his political record is and (3) how the community can move forward.

10:28 PM - Now Richardson takes a hypothetical: if you could sign a marriage act into law, would you? This is a great question because it challenges Richardson's position, which is the "achievable" bit keeping his own stances out of the picture. He dodges a lot, before finally saying that he isn't "there yet." Saw that coming. I think Richardson still comes off great. He admits that he isn't there, but neither are most Americans. And he seems to have really thought about how he will transform American politics for LGBT people. He has a plan.

10:31 PM - Interesting. Richardson says at first that homosexuality is a choice. Then he waffles. But his answer, that he continues forward with, is that categories don't matter. LGBT people are people, and whether they have chosen, been acculturated, or been born a certain way then they should not give up their rights. I agree. But I also agree with Etheridge's answer that it is alienating for LGBT people to be told that they have chosen their identity when their personal narrative reads otherwise. When pressed, Richardson makes it clear that he is about politics, not identity. He can't say what homosexuality is like, or what being transgender is like - but he can offer political protection. This is actually where I stand as well. There is no need to define identity to make a political coalition. I respect a man who demures from doing so, especially when he has the humility not to define the identities of others.

10:36 PM - And here comes Clinton, closing out the show.

10:38 PM - Mr. Solmonese asks why Clinton has never introduced legislation against Don't Ask Don't Tell, being a vocal advocate against it for so long and given her place on the Senate committee working on military issues. She basically answers that the political climate is wrong and we need an executive branch that will accommodate the change (or at least not veto the bill).

10:42 PM - Clinton isn't against same-sex marriage, she's just really for civil unions. Ick. She says equality matters, and civil unions can provide full equality. She wants states to make decisions. But she is personally against same-sex marriage. Her position is much like Edwards and Obama's: she doesn't have a plan to provide justice for LGBT people, but she sees the country moving in that direction and will not obstruct that movement. But she is herself unwilling to take the position (and political risk herself).

10:45 PM - Clinton says the states are better battlegrounds for LGBT people than the federal governments. I'd agree if so many states hadn't explicitly repudiated that hypothesis with bblatantly discriminatory statutes last November.

10:47 PM - Next to Kucinich, Hilary is doing the best job of answering the questions she is asked. But her discussions is kind of wonky, she talks a lot about the powers that be - not the powers the she will use and the moves she'd like to make for LGBT people. She also isn't talking much about her record, other than emphasizing her record with HRC (oh boy). She is coming off as a political advisor and something of a political historian even. In apologizing for the conditions facing LGBT people now she gives phenomenally informed answers on why their legal position is the way it is. But she seems lacking on vision, on a gameplan, and on a record. She understands the political waters, but doesn't know where she wants to swim.

10:50 PM - Clinton says she wants to reverse the "mean-spirited assault" political assault on LGBT people. Other than that, she doesn't seem to have much to offer.

Commentary: I loved the format. Very intimate, like a conversation. Questioners could follow-up easily, and answers were lengthier. The answers were even more substantive, where the candidates wanted them to be. I applaud the planners for that. I really feel like I know where each candidate stands.

Kucinich was clearly the star of the evening. Richardson would be my second - he isn't on my page on all the issues, but I know exactly what he'd do for me as a gay citizen were he to sit in the White House. Obama performed well when talking about race, AIDS and progressive coalitions. But his answers on marriage were nearly offensive. Gravel was alternatively solid and way off topic. Clinton just didn't seem to have much to say other than that she wanted to support LGBT people but needed to change the political climate to do that effectively. Edwards was awful.

There's an exit poll on the LOGO site seeing how people felt. I'd expect to see it swing a bit now that the debate has ended. But here's the breakdown:

Question: Who's your candidate?

1. Barack Obama (37%) - My 2nd choice candidate, 3rd best performance tonight
2. Dennis Kucinich (24%) - My 1st choice candidate, 1st best performance tonight
3. Hilary Clinton (19%) - My 4th choice candidate, 5th best performance tonight
4. John Edwards (9%) - My 5th choice candidate, worst performance tonight
5. Bill Richardson (5%) - My 3rd choice candidate, 2nd best performance tonight
6. Mike Gravel (4%) - My 6th choice candidate, 4th best performance tonight

Question: What's your issue:

1. LGBT Rights (40%) - my 2nd choice out of the poll
2. Health Care (31%) - my 1st choice out of the poll (and 1st overall in this election)
3. Gay Marriage (29%) - my 3rd choice out of the poll (and important overall, though I'd be hard pressed to rank it precisely)

Invisible and barely getting by

The rhetorical weight swung hardest in debates over socialized medicine is the ghastly number of Americans - over 40 million - who live without health insurance. Overlooked too frequently are the stories of Americans who can afford health insurance, but not comprehensive health insurance, who spend their entire lives fighting with their providers over plans, omissions, coverage gaps and reimbursements. They often find that themselves uncovered and unable to pay for crucial medical treatment and preventative care. What I found most powerful about Moore's SiCKO was not it's celebration of nationalized systems in Canada and Europe, but the haunting portraits of insured Americans for whom the system does not work.

Take for example, childhood immunizations. New reports indicate that children who are underinsured (as opposed to fully insured or uninsured) are the least likely to get vaccinations on time and at affordable rates. Working class families are left to choose: pay thousands for the injections, or let their kids go without critical preventative medicine. For families with good plans, the costs are covered - but many providers simply don't cover the vaccinations. And for those without any insurance, there's Medicaid and the FQHC system. As with so many other places in the American class system, its those who barely get by who feel the squeeze.

All the same, libertarians like John Stossel lambaste the type of government guidelines for providers that would close these coverage gaps:

Does it never occur to the progressives that the legislature's intrusion into private contracts is one reason health care and health insurance are expensive now? The average annual health-insurance premium for a family in Wisconsin is $4,462 partly because Wisconsin imposes 29 mandates on health insurers: Every policy must cover chiropractors, dentists, genetic testing, etc.

Absent those "intrusions", however, the full cost of health care is passed on to the people who are not able to pay, but who all the same are not the listless hordes of welfare-state-dependents that libertarians like to deride (a blogger at KXMC seems convinced that anyone who can't afford to pay for every health expenditure is a "lay-about").

Free marketeers and fiscal conservatives don't like to discuss the working poor because they defy easy stereotyping: they don't have much money but are demonstrably hard working; they pay taxes but still need state assistance. They make visible the long spectrum between dependency and autonomy that rabid individualists can't seem to grasp as the fundamental quality of social life.

Costs of living

Much political rhetoric on poverty invokes the "vulnerability" of the poor. It's an appropriate term, I think. It does not hold that the poor are helpless or that they are necessarily victims. Neither does it deem poverty a source of shame. What it does emphasize is the capacity of the poor to become victims. The support structures that middle-class Americans enjoy and take for granted cannot be depended upon by those who live on so little. Simple things like health care or a well-funded school that can be so crucial in preventing something like childhood asthma or being held back a year in school from developing into a life-long impediment to success. And I think that, as those examples illustrate, no one is truly more vulnerable than children living in poverty.

The Annie E. Casey Foundation - which takes it's mission to be "helping vulnerable kids & families to succeed" has released it's KIDS COUNT report on children living in poverty. The extensive research reveals a lot of heartbreaking information about the inequalities that are weighing down so many lives.

Local newspapers from Indiana to Michigan are already running stories on the plight of poor children in their states. Perhaps this information will act as a corrective to the apathy with which poverty is treated in so many states. My home state of Texas ranks worst in the nation for children living without health insurance - 1 in 5 children under the age of 18 are not covered for health insurance at any point during the year. What makes that figure all the more troubling is that I know how stricken by inequality Texas is. We have wealthy metropolitan suburbs, communities soaked in oil money. And we have cities, especially along the border where stable jobs and decent pay are too hard to come by. Where people still can't expect to take home more than six dollars for an hour's labor. We have rural areas, where agriculture has been sidetracked to agribusiness and tiny underfunded schools have to service two or three counties worth of impoverished kids. These are the places I lived in and traveled through before leaving to college. And I know that in these places it would be met as a welcome improvement if 1 in 5 kids could be insured.

Growing up my sister had a lot of trouble with allergies. She was sick a lot. In the worst patch, which lasted about two years, she missed so many days that we had to petition the school to let her pass. But she got a lot better after that because we did have a good insurance plan from my Dad's government job, and we could take her to a specialist. She also had a speech impediment but there was a teacher at the magnet school who counseled here through that. She's fine now. You would never know she had those problems. For a family without the support that we had, her health problem could have become more serious. She could have been held back and given up on by the education system. She could have had to deal with the consequences of her speech problem for her whole life - stigmatized in classrooms and in interviews for jobs, But we had the material support we needed and now she is going to graduate in the top of her class and go to college next year.

I haven't been back to Texas in awhile. I now reside in Minnesota most of the year. Coincidentally, Minnesota consistently ranks lowest on all the indicators of child poverty. By and large our children are insured, our families make enough money to get by. I've come to like a lot about Minnesota. I even think about living there after I finish school. The people are more tolerant than in Texas, and yes, more liberal. Minneapolis-St. Paul have everything I would want from a city. And even the winters aren't so bad when you've got the right people to share them with.

But as I start to seriously think about what I am going to do with my life, part of me feels that I need to return to Texas. To organize those communities that are so neglected, and so vulnerable, and fight for justice. For a more egalitarian Texas. It wouldn't be easy - not in terms of politics, and not in terms of lifestyle. But how can I turn my back on my home? What am I doing organizing for homeless people and immigrants in Northfield when there are even more poor immigrants and people without homes back in my hometown who don't have a couple thousand idealistic college students willing to go to bat for them? The Texas Republicans won't help them. The Texas Democrats won't fight for them. And our President thinks programs like S-CHIP are irresponsible - as though there could be anything more irresponsible than allowing children to grow up without food and medicine and a decent place to learn. It might take a whole life to just lay the groundwork for a progressive movement in Texas. But if no one is willing to do that work, then there really is no hope. I got out of Texas because I was one of the lucky ones who was never made vulnerable by inequality. That's why, when I'm done with school, I'm going to be able to live wherever I want. Do something I love. That's why I'm even in school right now. And so maybe the only right thing to do is to go back.

Are Republicans MORE likely to support a single-payer healthcare system? No, but maybe they should be.

Much of the controversy surrounding filmmaker Michael Moore’s lambasting of the American healthcare system in his recent documentary SiCKO has revolved around his analysis of healthcare costs in America as compared to costs in other Western countries. Moore and CNN medical correspondent Dr. Sanjay Gupta recently debated some numbers on Larry King Live after Gupta suggested that some of the information presented in the film was misleading and even flat-out inaccurate. Regardless of whether or not Moore fudged some data in the film, his fundamental critique of our healthcare system cannot be disputed. Americans pay much more for healthcare than citizens of other nations while receiving lower quality care. The single-payer, government financed healthcare in these nations provides a high-level of care without wasting money on administrative overhead and without generating nauseatingly enormous profits in the private sector. Gupta and Moore’s data on healthcare costs may have been conflicting, but both sets of data reveal this truth.

Moore goes on to suggest that the major barrier to implementing a single-payer system is the size of the healthcare lobby in Washington. Politicians, including presidential hopeful Senator Hillary Clinton, the leader of the failed 1993 effort to implement sweeping healthcare reform, depend on the support and financial backing of the healthcare industry. It’s not surprising that she and the other “first-tier” presidential candidates are not advocating a single-payer system. Insurance companies would have no role in a single-payer system and, to protect their livelihoods, are throwing money—the real thing that wins elections in the U.S.—at all the major candidates. Even if they were not so dependent on the industry for campaign dollars, the candidates would likely still balk at promoting a single-payer system for fear of the ruinous “socialist” label that would come along with it.

For obvious reasons, Republicans, typically the pro-business party in our two-party system, are overwhelmingly opposed to a single-payer system. But if they were to take a step back for a moment and consider the impact of lower-quality care on the American workforce, they might become the stronger advocate for single-payer. One of the most cited reasons for their support (albeit, sometimes lackluster and/or misguided support) of public education is that it pays of financially in the long-term. Educated people accomplish more and are more productive than uneducated people. Famed economist Adam Smith, hero of the Reagan administration when it sought smaller government, even posited the benefit public education provides to the economy. Taking this sentiment to the next step, wouldn’t better healthcare lead to higher worker productivity? In the long run, wouldn’t a healthier, more productive workforce lead to a healthier and more stable economy? Moreover, if a single-payer system lead to lower healthcare costs overall, wouldn’t new investments stemming from those healthcare savings grow the economy?

I think the answer to these questions is yes. Perhaps a single-payer system would be pro-business in the long-term. Unfortunately for us, politics in this country is rarely concerned with the long-term. As Niccolo Machiavelli realized a half-millennium ago, the most important goal of those in power is to do whatever it takes to stay in power. No serious presidential candidate will support a single-payer system until that breaking point when support from the for-profit healthcare industry does not translate into enough campaign cash to buyout the votes of an American electorate too fed-up with our increasingly dreary system of healthcare. I’m not going to get my hopes up, but maybe SiCKO will get a rise out of us.

Good (but not great) news for trans people

Jamie Tyroler has a great column up at CAMP situating the AMA's newly minted non-discrimination policy within debates over transgender equality and universal healthcare. Medical discrimination is an issue that transgender people have struggled with for too long, and in a way that no other group in the United States has. Tyroler's article relates a disturbing and personal example:

A few years ago, a transgender friend of mine tried committing suicide by swallowing a large amount of over-the-counter medication. She walked to a local emergency room where the doctor on duty ordered her to leave and not to return. The doctor told her that this hospital would never treat someone like her. Fortunately, she survived her suicide attempt. Unfortunately though, walking home in a very fragile state, she was raped.

A post at MySoCalledGayLife reminds us of another tragedy:

In 1999, Robert Eads, a female-to-male transsexual, died of ovarian cancer after multiple doctors refused to treat him. His case was documented in the 2001 documentary, Southern Comfort.

All around the country, people have been dying simply because the ethical commitment that doctors have made to respond to those in need seems to be outweighed by their irrepressible disgust for those who do not, and indeed, can not, live within the confines of the binary equation of sex and gender. This is not an issue that requires a PhD in Gender Studies to grasp. There is little that deconstruction can offer in comprehending the great pain and misery that medical discrimination deals. It is an issue as simple as whether or not we will heal the sick and tend to the suffering, regardless of how they relate to the loaded vocabularies of "man" and "woman".

Thankfully, the AMA gets it right. In fact, they nail it. From employment, to insurance, to treatment, the AMA will now forbid discrimination based on gender identity. Many trans people who have labored to find help from our nation's doctors will rest easier with the burden of medical discrimination lifted from them.

But there is still much to be done on the front of transgender health. Transgender cultural competency needs to be a priority in medical training. No one should have to feel like alien or unsafe when they go to visit the doctor. Insurance providers should research the actual (not hypothetical, stereotypical, or downright mythological) costs and benefits of sexual reassignment so that their trans clients can receive fair quotes - rather than being unfairly gouged, or as is usually the case, completely denied coverage. Surveys and studies need to identify trans subjects so that a profile of the health needs of the trans community can emerge. If we do not effectively and preemptively concern ourselves with the health needs of American minority populations and prioritize a strong response to disparities in health care and research, then we will continue to watch each underserved population die in unnecessarily high numbers. It doesn't seem like a hard choice.

But the Christian right is ful of surprises. Led by Tom Coburn and the AFA, they're already lining up against such efforts. They would rather see tax cuts than an increase of spending for the CDC. And they are especially incensed that the CDC has made strides to include trans people, MSM, WSW, sex workers and drug users into the fold of people whose health will be addressed. Forget that we know little about most of these groups except for the simple fact that they appear to be at elevated risks for a variety of illnesses. Apparently, the price of deviance is not only shame, but marginalization, destitution, sickness and death. The AFA even offers a direct action meme, which lures in fundies with the "outrageous" claim that the CDC has used their money for an event focusing on trans people! The horrors!

And so now, the bizarre alliance between "family values" voters and free market capitalists has one of the largest Christian organizations lobbying the President to spend less on health care. The followers of a Christ who not only healed lepers and the blind, but counseled and comforted prostitutes, criminals and adulterers, cannot bear the idea of spending their money to assist the ill and at-risk who must exist on the fringes of the social mainstream because of absurd norms of propriety and sexual conservativism. Irony does not do the situation justice. It is merely a disgrace.

No Asylum

Though the sentiment most associated with Guantanamo is certainly outrage, readers of Kafka can only greet the reports from the world-infamous prison with grim familiarity. The intractable tangle of bureaucratic language and legal jargon that has confounded what progress the executive is willing to attempt – trials canceled because what we once thought were “illegal enemy combatants”, already a dubious conceptual category, have not proven to be discernibly “illegal” but merely “enemy combatants” of a more vanilla variety – recall the unnavigable bureaucracy of the The Castle, while Josef K could only take Jose Padilla as kin.

But long before Guantanamo became the symbol par excellence of America's institutional nightmares and grotesque easiness with egregious human rights abuses, Kafkaesque tales of absurdity and horror could be heard. Or at least they should have been.

Imagine a prisoner. He is in solitary confinement, spending twenty-three hours a day in utter isolation. Typically unsupervised, he babbles to himself, pound the walls with his fists and head. He may come to occupy an entirely hallucinated world. Or he may attempt suicide. He may succeed. If he even consciously committed a crime, his memory of the event may have deteriorated alongside his other capacities. You wouldn't find this man in Cuba. You would find him in New York City. And not just in the past six years, when Guantanamo's dark odyssey unfolded, but at virtually any point in the past three decades.

Solitary Housing Units (SHUs) are the places that too many prisoners call home. They are not easy for anyone to withstand. But for the mentally ill, they are sites of unparalleled suffering. The Department of Justice concedes that 16% of America's inmate population suffers from a diagnosable mental illness. The American Psychological Association and Human Rights Watch estimate that the number is closer to 1 in 5. Depression, schizophrenia, bipolar disorder, and many other acute mental illnesses impact over some 300,000 inmates. For some, mental illness motivated their crime. For others mental illness emerged after imprisonment. But either way, the likelihood that mentally ill prisoners will end up in SHUs is extreme. As Jamie Fellner of Human Rights Watch explains:

They end up in segregation because their illness makes them less able than other prisoners to cope with prison life. They are more likely to be victimized and more likely to be injured in a fight. They are more likely to break the rules. They are more likely to behave in ways that annoy, disgust and even enrage security staff who have scant training in how to recognize, much less cope with, symptoms of mental illness.

Not only are they more likely to end up in SHUs, but solitary confinement is uniquely hellish for inmates suffering from mental illnesses because it virtually guarantees that their condition will deteriorate as their needs go unaddressed. Fellner continues:

The very architecture of SHU facilities, as well as SHU rules, keep them from receiving group therapy, up therapy, individual therapy, daily living skill training, educational and vocational programs, structured and unstructured group recreation and other activities that can play a crucial role in restoring or improving mental health—or at the very least in preventing further deterioration in the patient’s psychiatric condition.

Fortunately, the State of New York has taken action to close this disturbing chapter in the history of America's prison system. S333, once signed by Governor Spitzer, will amend New York's correction and mental hygiene laws so that inmates suffering from mental illnesses will not be eligible for placement in SHUs. All inmates being considered for SHU placement must first be screened by a board of professionals prior to transference. Those found to be suffering from mental illnesses will be placed into special treatment programs where supervision and close treatment are mandated by law. A simple attentiveness has saved hundreds of women and men from a hellish existence, and it is possible that more states will take thus cue from New York. It is certainly welcome news. But it is also a relatively minor step in correcting the sprawling system of bureaucratic shortcomings, institutional failures, and social aporiae that have brought about the system in which the inhumanities described above can occur.

America's health and human services system, sprawling beast that it is, has utterly failed the mentally ill of this country. The web of failed and flagging programs that has produced the deplorable status quo is so complex and mutually reinforcing that it is difficult to even begin the discussion. But one thing is certain: responding to the crisis of mental health care in this country will be impossible within an individualist paradigm. Reinvigorated communities and an ethic of care must have a part in the process – easy enough to theorize, but wickedly difficult to implement since the communities and caregivers in most need of solutions already have their resources stretched thin.

Americans, committed to an ideology where “equal opportunity” is seen as the upper limit on egalitarian obligations tend to downplay inequalities in outcome. And the mantra of “individual responsibility”has dealt plenty of harm to the robust redistributive and welfare-provision policies that would actually be needed to redress the dire inequalities of wealth and assets that cut across America's socio-political landscape.

The dire implications for the mentally ill are made clear in this eye-opening report on mental health care in low income communities. Medicaid and Medicare programs that can't reimburse hospitals enough to even keep sufficient numbers of psychiatrists on the payroll make affordable mental health service hard to find. For uninsured Americans, or for Americans whose providers don't practice parity for mental health, mental health problems may go untreated until a serious lapse lands the sufferer in jail or in an emergency department (ED). Of course, EDs themselves, especially those serving low-income communities where huge numbers of people are on Medicaid or totally uninsured (and on avearage 20% of all mentally ill people are uninsured), have to cut back on which services they can provide and frequently send mental health patients away without treatment, as their emergencies are often easier to ignore than those suffering a physical emergency. Inadequate Social Security payouts are a problem, too. Currently, SSI payments average $632 a month. But a modest, single-bedroom apartment in the United States averages $715 a month. People dependent on SSI for income simply can't compete in the current housing climate. And, of course, many of America's mentally ill, unable to find consistent work, are in precisely that position. So they end up untreated on the streets, often facing prison as the ultimate destination. With all of these support networks – Medicare, Medicaid, Social Security, public hospitals – failing, is it any wonder the prison system has emerged as the de facto “solution” to the problem of mental illness – a solution that looks increasingly like reinstitutionalization?

Some necessary solutions are clear: Medicaid and Medicare must receive more funding, SSI payouts must increase, housing prices may need to be capped or controlled, and government-paid health care (that includes parity for mental health care), needs to become a reality. The government should provide people who cannot afford a place to live and the mental health care they need with the income and assets necessary for survival.

But a more fundamental shift is also necessary. It is interesting to observe the drastic differences in treatment between the developmentally disabled and mentally retarded on one hand, and those suffering from psychological illness on the other. Americans, defying the typical individualist ethos of self-reliance, have by and large stepped up to the plate to provide for the former group (Vladeck, 2005). Many of the coverage caps in Medicare/Medicaid programs have been addressed, and political advocacy has been more effective on their behalf. It seems that Americans can comprehend permanent disability, but the idea that a person may experience episodic mental illness that requires extending the offer of assistance throughout a lifetime, to be taken as needed, strikes many as a blank check for welfare. People must either announce “dependency” (perhaps the most loaded word in the wide lexicon of social policy) or strike out on their own. Gray areas need not apply.

Feminist critics like Iris Marion Young have long pointed out the obvious problem with this ideological construct: most everyone falls somewhere in the middle of the autonomous/dependent spectrum. Those of us who can find all of the care we need within the private sphere – through family or friends – are fortunate, but atypically privileged. Again, it is the most vulnerable, those for whom everyday support structures are inadequate or absent, whose cases force us to reexamine our public policy. But in any event, we should not make the error of believing that it is only those people who are dependent while the rest of us live autonomous lives. The binary cannot stand, and social services ought to be implemented with the diversity of cases in mind. The goal of social policy should be the creation of communities of mutual aid which respond to the emergent needs and crises of members, but perhaps more importantly, support and care for members in affirmative ways that make crisis intervention less and less necessary.

At the level of policy, this might look something like a flexible fund, perhaps created at federal or state-wide levels so that patterns of inequality would not leave the most vulnerable communities with the least funding, that could be applied to support EDs, aid needy people in finding housing, or pay for routine psychological wellness exams for all who consented to them. These types of solutions would encourage communities to come together and analyze their needs, rather than suffering under larger bureaucracies whose shortcomings only become clear in the wake of failure. A community-oriented approach would also empower the mentally ill to participate in and with community aid projects, rather than facing strictly medical/institutional solutions that dehumanize on the basis of condition.

In short, a socialism that is truly “social” will emphasize community and communication as means of empowering and nurturing the most vulnerable segments of society, rather than expecting the kind of harrowing systems that have been producing incomprehensible no-exit nightmares since Kafka's day to do the work of justice. Nowhere is the need for such a revolution in thinking more apparent than in the crisis facing the mentally ill today. With their fate so firmly in the hands of ailing bureaucracies, the mentally ill in America are often the hapless playthings of a system that is dully malevolent in its neglect. Where the status quo produces Kafkaesque vertigo, it is incumbent on all who see the social bond as a site of obligation to respond with care.