Author Archives: Julian O. Long

caveat emptor all over again

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It’s getting harder and harder to defend the Affordable Care Act.

That difficulty underscores the fact that health care in our society is not a right but a commodity. Recent observers have noted that President Obama has backed away from moral arguments for health care reform in favor of transactional ones. That seems to me to spell defeat for the very idea of the ACA as reform in the humanitarian sense we still hoped for six years ago.

I recently wrote that I think the intention and potential of the ACA were and would be to improve our present system of private insurance, to increase coverage and ensure greater fairness. But yesterday’s Washington Post reported that

Thousands of primary-care doctors and specialists across the country have been terminated from privately run Medicare Advantage plans, sparking a battle between doctors who say patient care is being threatened and insurers that insist they have to reduce costs and streamline their operations.

After the Supreme Court decision that allowed states to opt out of Medicaid expansion, many states, though not a majority, did so—and led by the American Legislative Exchange Council have now enacted and/or proposed a host of repressive state laws designed to deny health care to as many citizens as possible. Then with the rollout of the new health care exchanges, insurance carriers began to cancel plans that didn’t meet new federal guidelines for minimum coverage and blamed their bad faith on the government, spawning a spate of horror stories that made perfect raw material for the Republican hate-Obama industry. Then some large low-wage employers ceased to provide health insurance for their workers, dumping them into the new health care exchanges and plans that require government subsidies to be “affordable.” Not to mention those large employers who for one reason or other have sought “religious” exemptions from the parts of the ACA affecting women’s health. And now this: thousands of doctors terminated from perfectly good Medicare Advantage plans providing medical care for the frail and the elderly, cutting them off from access to their doctors, interrupting years old doctor-patient relationships.

It’s unconscionable, but to Jack Larson, United Healthcare chief executive for Medicare and retirement, the Medicare Advantage provider making the largest cuts in its physician network, these changes are business as usual.

I’m not diminishing at all the short-term disruption when someone loses access to their physician. That’s a hard thing. . . . But we do believe that to have a quality health-care system we need to seek those physicians who have exceptional quality related to cost.

For years Medicare Advantage programs were a cash cow for insurance providers bacause the government paid these plans more per patient than it spent on regular medicare patients. But the ACA cuts payments to Medicare Advantage by $156 billion over the next decade and uses the savings to pay for other parts of the new system. Physicians are protesting individually and through the AMA and other medical organizations. Patients’ groups will likely organize as well. I’m joining the first one that comes to my door.

Thus far I’ve received no notice of any changes in my Medicare Advantage plan. However, I have received several letters from my provider offering me the opportunity to participate in an “entirely voluntary” program of home visits by doctors working for a subcontractor. I’ve not responded and don’t intend to respond. I’ve done some research on the subcontractor and it appears that it is a company that employs problematic physicians (hacks at worst) and that the intent is to get my insurance provider in between me and my own physician. I’m already bombarded by questionnaires after every doctor’s visit, checking up on my experience. I always respond to these because I don’t want any failure of mine to compromise my doctor. I think all this is worse than insidious, but it is likely the best face of present-day managed care. For various reasons my Advantage plan is a very good one.

Returning to the health-care arguments that animated the Clinton/Obama debates prior to the election of 2008 is a bit like returning (assuming that one could do such a thing) to Prague Spring after its brutal suppression. And the ACA? What began as a noble effort to provide access to health care for all Americans became in the working out of it a Rube Goldberg contraption full of unexamined assumptions and naïve expectations about how the strengths of the American capitalist establishment could be marshaled in a good cause requiring action through the state. There may have been a time when such a thing could have worked in America to promote the general welfare, but not now. What has been created in fact is a new complex of opportunities for gaming the system in the interest of predatory capital; with of course the usual losers, in this case physicians as well as patients.

The reasons why the ACA didn’t include a public option get clearer and clearer. They are the same as the reasons why a single-payer system is impossible in this country and why Medicare was designed and is administered for inadequacy—and of course that inadequacy has created the presently large market for supplements and PPOs. In a recent press conference the President was heard to say that we adopted the ACA as the least disruptive of alternatives for health care reform. So far “least disruptive” looks pretty disruptive, and it’s clear that the intent was not to disrupt the patrons of the system: clients (physicians and patients) pretty much be damned.

So how do we measure the success of this program? Sure, you can’t now be turned down for coverage for preexisting conditions, and parents can keep their children on parental policies for a longer time. But the cancellations of recent weeks and months are just as arbitrary as rescissions (now supposedly illegal) were in the former dispensation, and it’s now reasonable to ask, I think, whether in the final analysis the ACA will have been worth its human cost when it will end up leaving 31m people still uninsured.

I think the ACA will survive, and in some as yet to be foreseen future perhaps it can be made better. A popular left wing source seems to indicate that public approval is growing. On balance these are probably good things; but given the ACA’s flaws, with ALEC and the Republican party attempting to sabotage it on every hand and large insurers gaming it in order to continue their present obscene profit growth, it’s hard to imagine that it has the slightest chance to become the universal health care system we once imagined.

Twelfth Night

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Love and joy come to you,
And to you your wassail too;
And God bless you and send you
A Happy New Year . . .

Today is the twelfth day of Christmas; the festival ends some hours from now, on Twelfth Night. In times past the celebrations would have included mumming and wassailing that would have been going on for days, as barriers of class and rank relaxed temporarily and the Lord of Misrule commanded festivities in the courts and great houses of Europe. The popular carol we know as “The Twelve days of Christmas” is a remnant of this past.

According to legend, it was the beauiful Princess Rowen, daughter of the legendary Saxon mercenary, Hengist, employed by equally legendary British King Vortigern, who introduced the custom of Wassail to Britain. Approaching King Vortigern with a golden bowl filled with wine, she offered to toast his health, saying “Lauerd King, wassheil” to which the king was instructed to reply with the word, “drincheil” before imbibing. Vortigern was so beguiled that he sought the lady in marriage and immediately began to give away pieces of his kingdom to her relatives. I first encountered this story in Geoffrey of Monmouth’s Historia Regum Britanniae, but Geoffrey had translated it almost verbatim from another pretty much legendary poet we know as Layamon.

Christmas revels have been variously intertwined with pagan celebrations of the new year pretty much from the beginning. In the English speaking world, January 1 was first appointed as the beginning of the new year by William the Conqueror in honor of his own coronation, and secondarily as the traditional date of Christ’s circumcision. The practice, which came to be known as circumcision style dating soon gave way, however, to the older practice it had replaced, which began the new year with the Annunciation, and appointed March 25 as the day of celebration.

The confusion of dates and dating is partly a result of confusing solar and lunar calendars; our present New Year’s day more or less inaugurates the solar year. In 1582 Pope Gregory XIII appointed January 1 as the beginning of the new year, and that date was adopted widely on the European continent. In Britain and the British colonies, however, March 25 continued to be celebrated as the beginning of the new year until 1752, in the American colonies as elsewhere. Present-day arguments about Christmas in the United States have mostly to do with developing pressures to celebrate or to deplore multiculturalism, but the winter festival has always been a time of cultural dissonance.

We recall, too, how the winter festival comes bearing the faces of Janus, the Roman god who looks forward and back, for whom the month of January is named. Light in darkness, ease after war, joy after pain, love and hate, springtime and harvest, youth and age, the coming and going of things. And there is that other as well. “Pity would be no more/if we did not make somebody Poor”—Blake calls it the human abstract, the source of discontent and its like, indifference. The watchmen on the heights at Advent looked backwards towards the death of time and called us to a new wakefulness, a new sensitivity (not different from the old) to the issues of life and death that are woven into the fabric of our being whether we like it or no.

Shall we survive the winter? It is always a question of how much warmth we can husband about us, but if it is we who are to survive it is always a question, too, of how much warmth we can share. Such warmth (which is also warmth of heart) is not a commodity but the pearl of great price. We are given it for a time only that we may give it away.

Next Winter comes slowly, Pale, Meager, and Old,
First trembling with Age, and then quiv’ring with Cold;
Benumb’d with hard Frosts, and with Snow cover’d o’er,
Prays the Sun to Restore him, and Sings as before.

Are change and decay, like growth and presence, built into the nature of things? And do we do them honor in this time when the world turns upside down—is that what it means to celebrate the death of time? “I should be glad of another death,” says Eliot’s Magus. This, in solsitio brumali, the very dead of winter.

Cultural dissonance ought not to blind us to the hospitality and generosity we honor and hopefully extend to others at this season. These have been part of the winter festival as we know it, both Christian and Pagan, for many centuries. The mumming and wassail are reminders that generosity and hospitality are owed among humans. To deny them is not only to deny compassion to others, but also to deny what is best in oneself, to make oneself a worse person. That’s the lesson Ebenezer Scrooge learns, what legendary Wenceslas (about whom I wrote last year) already knew, the lesson Dives in Jesus’ parable fails to comprehend. At bottom, it isn’t a rational lesson; indeed some forms of theology may be its enemy. There are problems with the idea of setting aside a season for honoring generosity and hospitality, but perhaps we need to be reminded that these virtues and their grounding in love of one’s companions are basic to civilized life.

As I say, it’s the twelfth day of Christmas, but Twelfth Night can be understood to conclude a festival time that begins with All Hallows Eve and is perhaps associated in the remote past with the ancient Celtic Samhain and the Roman Saturnalia. Death and rebirth, “Sorrow to sorrow as the sparks fly upward“: all of which might serve to remind us of Shakespeare’s play, which features reversals and misrule of many kinds, though it ends happily as we like to think the twelve days of Christmas do. After all it’s the Bard’s best fool but one who reminds us at the close that the world began a great while ago.

Here’s our holiday letter. Just click on the image to open it. Love and joy to all.

last Advent

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So, what horizon do I look towards as Advent closes?

Perhaps not a new miraculous birth, but a couple of posts ago I wrote about some signs of the times that give me pause. Here’s one that gives me hope. Just hours ago my long-time Internet friend, Hadar Aviram, swam the length of the Sea of Galilee. I can’t even imagine swimming nine and a half hours, and Hadar is quick to point out that she did not do it all by herself, having been assisted by members of her family and friends. You can read various narratives and see some photos here.

Hadar’s swim raised funds for Beit Dror, an Israeli shelter for homeless LGBT teens. According to the shelter’s website, it is “the first and only center designed to meet the needs of out-of-home GLBT youth in Israel, and one of the few similar institutions in the world operated by governmental organizations.” Opened in 2002, Beit Dror has a modest program at present, but its goals call for expanding programs and services. Hadar’s fundraising goal was a modest $2000, which she has substantially exceeded. I want to tell another story now, but I’ll come back to this.

My calendar shows that December 29, 1957 was a Sunday. I’m thinking it must have been that evening I found myself driving back to Dallas from Waxahachie, where I had a church job. I’m sure it was late, after an evening service. I was driving my four-year-old Oldsmobile 88, a lemon for sure; I had to shift the Hydramatic manually. I had traded a beautiful De Soto coupe for it, but it had a twelve-volt electrical system, whereas the De Soto had an old-fashioned six volts, which made for dim lights at night and bad radio reception.

The Oldsmobile had bright lights and a great radio. That evening, December 29, 1957 (if that’s when it was), I was listening to Monitor, the NBC weekend radio service, as host Dave Garroway mused ironically about quirky things in between news episodes with Chet Huntley, and skits by Bob and Ray and Mike Nichols and Elaine May and other Monitor regulars. At one point, Garroway chuckled about how Americans had been down recently because the Soviets had launched Sputniks one and two and made us feel inferior, or at least a little insecure. Indeed the Soviets’ capture of the lead in the space race, a race we Americans didn’t even know we were running until we found ourselves losing it, had become a major political issue at the end of 1957. Sputnik two had carried a dog and weighed a thousand pounds. We Americans didn’t even have a Rocket capable of launching such a behemoth.

But we had launched a Santa Claus, as Garroway pointed out with a gentleness that gave the cliché some cover, who had been sighted many times orbiting the earth (or at least our part of it) just days before, as he had since time immemorial. I was twenty that year, old enough to have been stung in a bad car deal, and it still embarrasses me a little to acknowledge that for a moment I took some consolation and perhaps a bit of hope from Garroway’s sentimental ramble. We had launched Santa Claus, that particularly American myth figure, whom my Grandmother had taught me to think was the spirit of Christmas: brash, jolly, generous, full of good will, and fearless—all that and a lover of children, somehow the guarantor of the good middle-class world many of our parents in my generation had died, we thought, to preserve in the preceding decade.

The Soviets might have the better of us for a little with their beeps in the night and thousand-pound flying dog houses; they may have stolen Eastern Europe and China from the good world. But Americans knew we were not totalitarians in the depths of our hearts. We were still a long way from achieving racial and economic justice, but we had repudiated McCarthyism. Our understanding of life and the world and the social contract we had based upon it offered more of the goods of life, more liberty and prosperity than any other. It disturbed us a little that some outside our country thought of us as ugly Americans, but we wished them well as we did our best to spread the same liberty and prosperity we enjoyed around the planet. Or so we thought, some of us at least.

Why think of this now? Perhaps because I hope my fellow citizens have not lost the naïve impulse towards human good will I took from Dave Garroway on my evening road home that fifth day of Christmas so many years ago. It’s problematic, to be sure. We err in its service, as I have often erred. But it’s the best thing about us as a people. Still, if the last century taught us anything it taught us the limits of our mythology. If we are to remain major stakeholders in the evolving world we shall need a better vision of ourselves than that offered by present versions of American ambition. We ultimately won the space race, only to abandon it. Neil Armstrong’s first step on the moon proved to be somewhat less than a giant leap for all humans.

So who or what else might escape the surly bonds of earth and point the way for us towards a usable future? What present brightest and best might dawn on our darkness and lend us aid? I take present hope from young people like Hadar Aviram. You can read about her at the websites I’ve linked. I don’t know why Hadar chose the day of the winter solstice for her swim, but it seems fitting. It draws together both the adventurous and philanthropic aspects of the winter festival as it is celebrated in many traditions; for it isn’t just Christmas, or even the ancient Yule—it’s ecumenical whether we like it or not and always has been. It crosses seas and deserts. I will never ponder another Advent without thinking of this one and of Hadar’s Swim. Then too, there are profound ethical and human issues involved in the very existence of Beit Dror. You can read about some of those at the shelter’s website as well.

Finally, I’m thinking of the orchestra that Daniel Barenboim and Edward Said founded. To proclaim such things, to support such enterprises as Beit Dror and the Divan Orchestra, is to preach the gospel of peace, however one does it; though how fine a gesture to swim the Sea of Galilee! And I’m thinking of the words of Isaiah as James Jenyns fit them up for Handel’s music: How Beautiful are the feet of them . . . who cross such seas. Deer walk upon our mountains now, as the poet says. Great white bears still swim amongst the polar ice floes. And the universe rolls on into what heavens, what still unspeaking and unspoken Word to one who has seventy six winters and fewer tomorrows than he used to have? There is more in heaven and earth than is dreamt of in anyone’s philosophy.