Where is George W. Bush's compassionate conservatism when we need it?

Governor Rounds says increased enrollment in Medicaid may set the state back another $40 million. Candidate Scott Munsterman's solution: kick people off Medicaid.

Munsterman said the state should scale back Medicaid eligibility and provide vouchers to purchase health insurance for catastrophic events.

He also called for more personal responsibility on the part of Medicaid recipients.

“We have a higher rate of medical care within our Medicaid system than other people do who have their own insurance,” he said. “We need to look at deductibles, we need to look at co-pays. We need to have a program that they can engage in, and become responsible, too” [David Montgomery, "Munsterman Says Medicaid Eligibility Must be Scaled Back in SD," Pierre Capitol Journal, 2009.10.27].

More personal responsibility—that's conservative code for not my problem.

Sure, we can probably find folks who take advantage of Medicaid (just like we can find insurance execs who take advantage of their clients... but I don't hear Munsterman calling for dropping the hammer on that system). But the problem the state faces in funding Medicaid is not a sudden surge of goldbrickers. The problem is thousands of responsible South Dakotans who have lost their jobs or/and their health insurance and have nowhere else to turn to get their families decent medical care. They don't want charity; they don't want to face the stigma of irresponsibility that conservatives like Munsterman keep piling onto folks who need help through no fault of their own. But the recession is hammering them, the flu is coming, and they just want to be healthy and not bankrupt.

The proper response from society is to say to these neighbors, "All right, we'll get you through." Candidate Munsterman's response is plain old class warfare—if folks need help, it must be their fault, and they should pay for their irresponsibility.

Practically, his proposal makes about as much sense as cutting unemployment benefits during a recession. It continues the long, sad history of Republican "leaders" unwilling to take the lead on getting South Dakota as a community to recognize our common obligations to each other in tough times. Blame the poor, demand nothing of the well-off: typical GOP.

Update 2009.10.29 07:10 CDT: A reader forwards this breakdown of South Dakota's Medicaid enrollment and spending. The data come from 2006 through 2008, so they don't capture the recession-related surge in Medicaid enrollment. But in FY2006, here's who was on Medicaid in South Dakota:

Medicaid Enrollment	SD	US	SD	US
Total Enrollment, FY2006	118,500	58,714,800	-	-	% of total residents
Children	70,100	29,182,400	59.2	49.7	% of Medicaid enrollees
Adults	20,100	14,879,700	17.0	25.3	% of Medicaid enrollees
Elderly	12,400	6,116,200	10.5	10.4	% of Medicaid enrollees
Disabled	15,900	8,536,500	13.4	14.5	% of Medicaid enrollees

source: State Medicaid Fact Sheet, StateHealthFacts.org, Kaiser Family Foundation, downloaded 2009.10.29

83% of the people Dr. Munsterman thinks need to take more personal responsibility for their health care are children, disabled, or elderly. Evidently the Republican philosophy is to balance the state budget on the backs of those who can't fight back.

...comments and prescriptions for humane public policy welcome at the Madville Times!

Hat tip to Rebecca Blood, who points us toward a pointed essay by freelance writer Bob Simmons from Bellingham, Washington, on the public option... for electricity:
 

Electrical service had not yet penetrated the hills of rural Southern Iowa. Everyone wanted it, Hell yes. We yearned for it. The investor-owned power company wouldn't sell it to us. Analogous to millions who today can't get health care insurance (another thing we did without) we were disqualified by pre-existing conditions: We were farmers and we were poor. We might not use enough power. We might not pay our bills [Bob Simmons, "How FDR Enacted His 'Public Option'," Crosscut.com, 2009.09.08].

So in came the rural electric cooperatives, a result not of slow, deliberate Congressional bipartisanship, but of a unilateral executive order by a determined President who said of conservative animosity to the evils of government action, essentially, Bring it on!

And omigawd were they [the rural electric cooperatives] evil. Socialistic, un-American, undermining the very fabric of democracy. Legislators, businessmen, members of Congress, editorial page editors all over the country railed at the specter of Big Government shouldering into private enterprise, when everyone knew Government couldn't do it right.

Most infuriating of all, government did it right. The cooperatives became the pricing yardstick for electrical power. Investor-owned utilities had to lower their rates to compete. In four years, the cost of installing a mile of rural power line dropped from $2,000 to $600. In 2007, 72 years after FDR created the public option, customers using public power nationwide reportedly paid 17 percent less than those served by privately-owned utilities (according to the American Public Power Association, not necessarily a neutral source) [Simmons, 2009].

Anyone else see a connection between rural electrification and universal health coverage? And might President Obama take a lesson from FDR in how to get the job done?

...comments and other acknowledgments of reality always welcome at the Madville Times!

We've talked about the problem of insurance companies treating domestic abuse as a pre-existing condition and nine states, including South Dakota, not prohibiting such a nefarious practice. We've heard our state Division of Insurance assure us that no insurer is going to try excluding a domestic abuse victim from coverage, and that the state wouldn't let them if they tried.

But even if South Dakota had a specific state regulation against denying insurance due to domestic abuse, battered women would still face challenges in keeping their coverage:

Nancy Durborow, Health Projects Manager for the Pennsylvania Coalition Against Domestic Violence, says she isn't surprised that state departments of insurance haven't heard about the problem. "They don't see it because they're not looking in the right places."

Insurers never directly ask about abuse status on an application, Durborow explains. Instead, they learn about a history of domestic abuse in a myriad of other ways. They might find evidence in an applicant's medical records, such as repeated visits to an emergency room or a doctor's notation about abuse. Insurance agents may find out during an interview with the applicant. Durborow has even heard of cases where insurance agents have visited local courthouses to search for Protection from Abuse Orders, which are public information. Insurers may also see reports of domestic disturbances in a local newspaper.

In most states, insurance companies are not required by law to explain their decisions, so a domestic violence victim may never know why coverage was denied....

Lisa James, director of health for the Family Violence Prevention Fund, a non-profit group that works to prevent domestic violence, says the fear of being denied coverage is almost as menacing as the actual denials. Some women have heard about this type of insurance discrimination, she says, "especially those who have spent time in shelters with others. Women are concerned about keeping their medical information confidential."

In addition, the possibility of being denied insurance could discourage women from leaving an abusive partner. And for a woman with children, she says, the risks are multiplied. "It could be a denial not only for her, but she might also be worried that if she leaves, she won't be able to take her children to the doctor."

But the deterrent effects of these insurance practices don't stop there - they also have been known to plague the doctor-patient relationship. According to James, women may not feel comfortable discussing their difficulties with medical providers for fear that the information could be used against them down the line. She also hears from doctors and nurses who are worried that they may be compromising their patients' ability to get insurance by asking about and documenting abuse [Jenny Gold, "Domestic Abuse Victims Struggle with Another Blow: Difficulty Getting Health Insurance," Kaiser Health News, 2009.10.07].

Representative Herseth Sandlin, take note: Passing health insurance reform this year solves this problem. The bill coming to the House floor tells insurers they can no longer use pre-existing conditions as a justification for denying coverage. Pass this bill, and then when a woman has a history of going to the hospital for broken bones, it won't matter whether it's because she has a bum for a husband or just a calcium deficiency: she can keep her insurance and not go broke.

...comments welcome at the Madville Times...

A Kevin Bacon hat tip to my wife, who read this on Pandagon, who got this from the SEIU:

Loyal readers, you know I love South Dakota. That's why I live here. That's why my daughter will grow up here. But some news makes me want to take my state by the scruff of the neck and say "South Dakota! What on earth is wrong with you?!"

To wit: South Dakota is one of nine states that allows health insurance companies to reject applications from victims of domestic abuse. South Dakota women, if your husband beats you, he may render you uninsurable.

I can't sort out all the levels on which South Dakota's policy here is disgusting. Domestic abuse is all about power, usually some desperate, inadequate, pathetic man using fists and fear to force a woman into submission. Wifebeaters cut their victims off from avenues of social and financial support. Taking away a woman's ability to buy her own health insurance can cripple her financially and reinforce her dependence on her abuser. By making it possible for some brute to take away a woman's insurability with one drunken wallop, we, the state of South Dakota, become accomplices in domestic abuse.

Somewhere, some insurance company employee (any bets on whether it was a man?) had to reason out the following: "Gee, women whose husbands beat them might incur more medical costs. Women whose husbands beat them might reduce our profits. Therefore, we should not do business with women whose husbands beat them."

Our private health insurance system not only allows but embraces such appalling thinking. The state of South Dakota facilitates such evil, favoring profits over people. South Dakota considers wife-beating, like pregnancy, a pre-existing condition. I keep hearing we're a pro-life state, but our leaders keep providing evidence to the contrary.

We may not be able to legislate or educate every man into showing every woman the proper love and respect the Bible demands. But we can act to change an immoral system that perpetuates the powerlessness abusers inflict on their victims. Mitch, Gerry, Russ—fix this.

Domestic abuse is not a pre-existing condition. It is a crime for which the abuser, not the abused, should be punished. No man should be allowed to take away a woman's right, if not to receive health care, then to participate in the free market and buy with her own money the health insurance that is necessary to get care.

Read more about how the individual health insurance market fails women at the National Women's Law Center.

...submit your comments and further outrage at immoral public policy in South Dakota at the Madville Times...

I guess this is why our Congresspeople need to read the bills they are voting on....

Faithful reader Tim Higgins leaps to the defense of the grossly indecorous Rep. Joe Wilson and calls President Obama a liar:

His address also contained and he was accurately describes as such, liar.

He contradicted several things that are in the House Bill. Please Obama read the bill. Of particular interest, "We will not provide health care coverage to illegal immigrants".

After reading this statement from his teleprompter, Mr. Wilson accurately describe him as a liar. Section 152 page 50-51 HC will be provided to ALL NON-US citizens.

Wrong again, Tim. Here's the text of HR 3200, Section 152:

(a) In General- Except as otherwise explicitly permitted by this Act and by subsequent regulations consistent with this Act, all health care and related services (including insurance coverage and public health activities) covered by this Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services.

(b) Implementation- To implement the requirement set forth in subsection (a), the Secretary of Health and Human Services shall, not later than 18 months after the date of the enactment of this Act, promulgate such regulations as are necessary or appropriate to insure that all health care and related services (including insurance coverage and public health activities) covered by this Act are provided (whether directly or through contractual, licensing, or other arrangements) without regard to personal characteristics extraneous to the provision of high quality health care or related services.

Did you catch that first line: "Except as otherwise explicitly permitted by this Act..."? Read that again, then turn to Section 246:

Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.

So illegal immigrants are not covered under this legislation.

Tim and Rep. Wilson are wrong. But consider: don't illegal immigrants currently get health care in the U.S.? Do emergency room staff require ID and turn you away if your green card isn't legit? Aren't we already shouldering those bills in our insurance premiums and other payouts the hospitals use to cover the difference?

And heck, let's jump into the bizzaro alternative universe in which Joe Wilson lives. Would Joe and Tim and Rush and Glenn seriously reject a plan that could save 22,000 American citizens' lives each year just because Paco and María would keep getting free stitches after injuring themselves working double shifts at the meatpacking plant that cranks out America's cheap weiners?

President Obama is right... and the Right has nothing but fumes.

p.s.: A corollary to the health care debate: when someone cites page numbers in H.R. 3200, call their bluff. Demand a hyperlink. Make them read you the actual text, word for word. Nine times out of ten, they'll prove themselves wrong, just by reading the very bill they think they are citing.

pp.s.: The folks griping about illegal immigrants getting American health care may have an argument -- albeit thin and unChristian -- that we need to cut these lawbreakers off from health care. But the fact that illegal immigrants can get American health care is not a reason to vote against the pending health coverage reform legislation. It already happens in the status quo; it will continue to happen after passage of H.R. 3200. In policy debate, we call that a non-unique disadvantage. Even if you think we should require anyone seeking medical care to provide proof of citizenship and require doctors to refuse care to anyone who cannot produce such documents, that's a separate issue (and one I would challenge any complainer about illegal immigrants to actually float as legislation).

...comments and other voting issues welcome at the Madville Times!

President Obama delivered a speech to America's schoolchildren yesterday. Now admit it, conservatives and obstructionists: aren't you glad the President stuck with the teleprompter and didn't go off on some some Red surprise on your helpless children? He even ended with his little boost for the theocracy. What's not to cheer about that?

So as your trusty teachers return to their regularly scheduled lesson plans, teaching patriotic little books like The Grapes of Wrath (Steinbeck readers of the world, unite!), we turn our attention to a much bigger Presidential speech, Barack Obama's address tonight to a joint session of Congress on health care reform. I approach this speech with dread, as the White House has been sending all sorts of conciliatory signals that it plans to compromise with an opposition that hasn't budged and won't budge. President Obama seems likely to continue the nice-guy approach, seeking bipartisanship that will win at best three votes from a party otherwise singularly focused on destroying the President.

I won't get my wish, but I'll wish it anyway: I wish President Obama would take the podium tonight, kick over the teleprompters, and quote (with apologies to our gentle KELO readers) Rebecca Terk's fine headline:
 

Quit the Bull... Public Option Now!

Six words, Mr. President. The first three capture perfectly the nature of the obfuscations and outright lies spread by those who prefer the status quo's corporate profits and needless deaths to effective health insurance reform. The last three capture perfectly the simple and necessary element of the plan: a public insurance option that sets the standard for affordable, universal coverage that can't be taken away from any citizen.

Rebecca makes the case from her own experience of working hard to earn health benefits, only to have the insurance company do all it can to do nothing for her. Work hard, get bupkis—that's not the American way I learned in school. That's not what the President told our kids yesterday.

Darned socialist teachers like Rebecca understand that the current sytem isn't working. What a joy it would be to have the President follow Rebecca's lead on health care (and mine, David's, Adam's, and Bill's), stand up tonight, and throw the B.S. flag.

...comments welcome at the Madville Times!

Sorry, Senator Mundt: the Reds are right on this one....

My wife Erin is reading Methland, Nick Reding's account of the destruction wrought by methamphetamine in rural America. Reding connects the increase in meth use to the consolidation wrought by Big Ag (see also commentary by Patrick Deneen).

Over buffalo burgers last night (yes, we live well), Erin explained how Reding also manages to work Karl Marx's critique of Adam Smith into the argument:

Smith's capitalism depends on lots of small actors in the market, none of whom individually can wield enough influence to skew prices... or to unduly influence the government that regulates the market. The "Invisible Hand" is invisible because it is the product of umpteen Main Streets, not one Wall Street. The Invisible Hand doesn't require much regulation, since real competition is a pretty good check on individual power.

But Marx says the market's mandate to "grow or die" means all those competing actors start cannibalizing each other. Capital consolidates, and the Invisible Hand becomes visible: we can identify a few big firms that dominate the market, unduly influence prices, and (worst of all) mingle and merge with government just when we need government more to check the power of these growing gargantua.

And then I thought about health insurance. The Invisible Hand cannot work in health insurance. Thousands of tiny firms would have thousands of tiny risk pools that couldn't cover their costs, espcially not when we're talking the high costs of modern medicine. Insurance depends on spreading the risk; the bigger your pool, the better you spread the risk. Insurers have to eat each other—grow or die. That's why health insurance now lacks competition. It doesn't require an evil plot (though you can argue that); it just requires insurers to act exactly as Marx said they would. Consolidate, get big, control the government with lobbyists.

The conservatives opposing health coverage reform by chanting "Let the market solve" assume that Adam Smith's principles still apply. But the free market can't work in health insurance. There is no Invisible Hand, only big Visible Fists like Aetna and Cigna.

The only way you check the power of those big actors in the market is through stronger government intervention. Uncle Sam Insurance offered as an option alongside private insurance might help, but Marx's critique strengthens my belief that, in health insurance, the best solution is to carry the logic of consolidation to its inevitable conclusion: combine everyone into one nationwide risk pool, a single-payer system for all Americans.

...comments welcome (and cries of "Socialism!" received with mirth) at the Madville Times!

Hat tip to Adam Feser!

Indeed, when an argument invokes Hitler and the Nazis, it's hit bottom. But bless Rep. Barney Frank for living up to his name and calling the likening of health coverage reform to Nazism and protrayals of Obama as Hitler as "vile contemptible nonsense."


If more Democrats would just give simple, straightforward answers like this, simply telling people exactly what's in the bill, we'd see health coverage reform pass the very day they get back from the August recess. Too bad Barney Frank won't be at DakotaFest....

Rep. Frank also offers a wonderful rebuttal to a businessman's complaint that President Obama is taxing us into oblivion, noting that the Obama Administration hasn't raised a single tax. As a matter of fact, President Obama has actually cut taxes for 98.6% of working households to the tune fo $288 billion dollars, over a third of the stimulus package. As Adam and I and Bruce Bartlett notes a few days ago, taxes in 2009 will constitute a lower percentage of our GDP than they did in Reagan's best days. So even if President Obama does raise taxes to pay for health coverage reform, he has a lot of room to go before bringing taxes back to the levels under President Bush.

Bring on your worst, Republicans. We Dems can still win, if we just tell the truth.

...whether you love Barney Frank or not, your comments are welcome at the Madville Times!

...or "European-Style Public Health Coverage: Just Say Ja!"

My comment section brings Linda McIntyre's concern about rationing. It also brings a useful link from Tony Amert. Even though Tony wrote first, his link responds well to Linda's concern:
 

From an American perspective, Germany’s health care system represents a nettlesome challenge. Americans now spend 14 percent of their gross domestic product (GDP) on health care, while Germany spends less than 10 percent. Yet, for all that heavier spending, the U.S. health care system has never managed to provide all Americans with secure, portable health insurance. Evidently, for many low-income Americans without health insurance, the system now rations health care by income and ability to pay.

By contrast, Germans of all ages have long enjoyed fully portable health insurance that provides what is effectively first-dollar coverage for a very comprehensive package of benefits. Furthermore, unlike U.S. patients, who increasingly find their choice of doctor and hospital limited through the technique of managed competition, German patients still enjoy completely free choice of provider at the time illness strikes. In cross-national opinion surveys conducted by the Louis Harris organization in conjunction with the Harvard School of Public Health, both German patients and physicians express relatively greater satisfaction with their health care system than their American counterparts express with their system.

The relatively low level of health spending in Germany is all the more remarkable, because Germany’s population is so much older than America’s: 15.5 percent of the German population is age sixty--five or older, compared with 12.2 percent of Americans. In fact, the United States will attain Germany’s current age structure only in the year 2020 [Uwe E. Reinhardt, "Germany's Health Care System: It's Not the American Way," Health Affairs, 13(4) Fall 1994].

Catch that date: 1994. Little has changed in national differences since then. When Linda and fellow conservatives trot out the word rationing as a reason to oppose health coverage reform, they might as well be arguing that health coverage reform will make morphine addictive and cough medicine taste bad. The United States already rations care. It's been happening since well before Reinhardt's 1994 article. Americans seem to accept rationing completely... as long as it happens to lower-income people, who obviously don't deserve health care if they're poor, since lacking money evidently indicates some punishment-worthy character flaw.

By the way, Reinhardt points out in a 2003 paper that the United States' ration-by-income scheme appears to restrict care even more severely than any of the supposedly socialist dystopias across the pond. According to that paper, Europeans go to the doctor more and get more treatments than Americans do. Compared to the OECD median, the United States has fewer acute care beds available per 1000 population, fewer hospitalizations per 1000 population, shorter hospital stays, and fewer acute care days per capita. In other words, we get less health care than over half of the industrialized world. (Yet we keep spending more.)

This data shows that America already restricts care more than most industrialized countries with public health coverage do. If you're really worried about rationing, you should be clamoring for a European-style health coverage system. After all, spending less and getting more is perfectly... rational.

...rational comments always welcome at the Madville Times!

On September 11, 2001, a gang of terrorists took advantage of lucky breaks and a government asleep at the switch to kill 3000 Americans. In response to that massive loss of life, we re-organized our intelligence and law enforcement into a massive new Cabinet-level department and waged two wars off-budget at a cost of one trillion dollars and over 5000 American soldiers' lives (and counting) over eight years.

Right now, as many as 22,000 Americans die each year because they lack health insurance. (Feel free to fact-check that number by reading the study by Stan Dorn of the Urban Institute, which updated a 2002 Institute of Medicine study that put the number at 18,314 deaths per year in 2000. Politifact rates the 22K claim as True.). That's maybe 50—fifty— 9/11 death tolls since 9/11 caused by our own economy and policies. The President recognizes the urgency of the situation. He and Congress propose reforms to make health insurance more available and thus save thousands of lives each year, with a price tag of perhaps a trillion dollars over ten years.

But Republicans tell us that, 15 years after torpedoing the last serious effort at health coverage reform, we mustn't rush to action.

After al-Qaeda killed 3000 Americans, it took us two months to pass the PATRIOT Act and invade Afghanistan. If President Bush had said, "It's only 3000 deaths; let's take some time and have some more town halls," he would have been impeached (or thrown out the window by Dick Cheney).

Now, as the lack of health insurance costs us another 9/11's worth of American lives every month and a half, opponents of health coverage reform seem to think there is no urgent need for action. 22,000 deaths a year? Who cares? We've got a President to break!

Hmm... sounds to me as if the only "death panel" in the house is the Republican Party....

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p.s.: Norwegian professor Jill Walker comes to the BlogHer conference and is "horrified" by what she hears about the American health care system. Dr. Walker says, "I genuinely don’t understand how Americans can think that free or close-to-free, universal healthcare as most other Western democracies have is a bad thing." Neither do I, Dr. Walker.

pp.s.: See also the Decorum Forum's big list of real health care problems (not imagined socialist plots) that deserve immediate political action, not pompous partisan play-acting.

...comments welcome at the Madville Times...