Boreal B[l]og

Jonah Goldberg, conservative columnist, wrote yesterday how government intervention into American medicine would be no panacea.  He cited that while Australia had 3 years’ longevity on average more than Americans, Denmark had only a year and a half.  Then he took issue with the average.  At my age, an extra three years looks good.

Goldberg compared Summit County, CO with Pine Ridge, SD, showing about a 20 year difference in life expectancy, commenting that lifestyles have a lot more to do with the discrepancy than having insurance.  Of course, lifestyles affect longevity.  Native Americans have a high rate of unemployment, diabetes, and alcohol/other drug abuse, but their medical care is not as good as mainstream America.  Yes, they have the Indian Health Service, which I have been a part of, not Mr. Goldberg, and I can attest on reservations the IHS is not staffed nearly as well as it is in, say, Anchorage or Phoenix.  The anecdote fit Mr. Goldberg’s case, however, so it stayed.

He then went on to say a study by a member of the Hoover Institution (on War, Revolution, and Peace, the full name of which he did not mention, and I think is relevant) said while America was ranked 19th of 29 in life expectancy, if we “removed fatal car crashes and murders” we would rank first.

Wow.  If we didn’t count cancer, we’d blow away the field.  This reminded me of a cardiac surgeon I once spoke to, back when my hospital had one of the highest cardiac surgery death rates in the country, ostensibly because we did sicker patients.  Why we operated on them when others didn’t was never explained.  Anyway, one day a surgeon told me most of his fatal outcomes were “non coronary.”  I was speechless, because to me, as a neurologist, the patient had an operation and the patient died.  Period. Very end. Don’t dress up a pig.  Given that the Republican leadership has steadfastly refused to fund studies by the CDC to help us learn from and deal with firearm violence, I hardly think murders should be removed from the count, especially since we rank 99th in the world by rate per million, a third more than Uzbekistan, and four times that of Australia, which did do something about firearms, and eleven times that of Japan.  Imagine, Uzbekistan has a lower murder rate than the US.

Then Mr. Goldberg trod where he had no business treading.  He quoted the Medicaid study in Oregon, where several years ago, extra money allowed more people access to Medicaid via a lottery, which made an ideal study group (comparison of like groups with only presence or absence of insurance as a variable).  Mr. Goldberg stated that with the exception of depression, having health insurance produced no significant improvement in health.  Many of the outcome variables tracked, such as treatment of hypertension, diabetes, PAP smears, colonoscopies, and smoking cessation treatment will require years to determine whether access to affordable medical care will in fact make a difference in longevity.  Mr. Goldberg would do well to show some patience; health care doesn’t file quarterly earnings statements. People who haven’t been able to afford a doctor aren’t going to suddenly feel great when they finally can.  Still, increased health related quality of life and happiness was measurable, and that increased significantly along with a decrease in depression scores.  People sleep better at night when they know they can see a doctor without becoming bankrupt should they fall ill.

Depression is not a minor disease.  A major depressive disorder afflicts up to 25% of all women during their lifetime and 10-15% of men.  I treated thousands of people with depression during my medical career.  The disorder has protean manifestations; it is not a matter of someone’s  being down in the dumps.  Depression is a cause of appetite disorders and subsequent obesity or severe weight loss.  It affects energy level and productivity.  It may present as chronic pain.  Sleep disturbances are present in most depressed people; lack of good sleep is a major health problem today. The immune system is affected. Depression is a major cause of significant memory disorder, often masquerading as dementia; indeed, my father’s depression looked like dementia, and my mother’s dementia presented as depression. Moods are affected, and depression is a significant cause of sexual dysfunction.  These six: S-A-E-Me-Mo-Sex were written on my medical records in the upper right hand corner as soon as I saw a person with many somatic complaints that didn’t fit neatly into a neurological container.  In the ‘80s, I risked patient anger when I diagnosed depression.  People assumed I thought they were crazy, rather than having a chemical disturbance in their brain that was potentially treatable.  Today, we know better, but suicide by firearm is more common than murder by firearm, and depression remains a major cause of the former.

Goldberg concluded by stating that while the Affordable Care Act was correlated with the decline in America’s life expectancy in 2016, he said that some people were helped, quickly adding that there was no evidence that government run medical care did any good.  Mind you, Goldberg wasn’t blaming the ACA, although he didn’t refer to it by that term, which I find annoying.

Mr. Goldberg didn’t mention that the number of bankruptcies fell in half from 1.5 million to under 780,000 from 2010 to 2016, long after the bankruptcy law was tightened.  Some wrote: “bankruptcies disappeared ‘overnight’ with the advent of the ACA.”

I think it is entirely fair to have a reasonable debate on the role of government in medical care.  Let us, however, have a debate based on all the facts, not cherry picked ones. I resent Goldberg’s using his anecdotes then claiming the ACA was anecdotally helpful.  That is galling.  The ACA probably prevented 4 million bankruptcies so far, bringing peace of mind to millions.  Market based care, “choice,” the word used when it doesn’t involve a woman, and lifestyle changes are not the answer.  People need to be able to access basic medical care without financial hardship.  We need to catch illnesses early, and we need to screen for medical conditions, like cancer and yes, depression.

It’s time for the Congressional Budget Office to put a price tag on peace of mind, not declaring bankruptcy, and the long range value of early screening for disease.  Until then, I state that a good night’s sleep without worry about medical care is worth $100/night.  I’m open to negotiation, but it must have a dollar value.  We’re in America.

Now, I am beginning to understand, thanks to budget director Mick Mulvaney.  When asked by Sen. Debbie Stabenow of Michigan why money for water protection in the Great Lakes was zeroed out in the budget, he said we had to look at this through the eyes of a taxpayer in Arkansas: “Should I really take some of his tax dollars to do something in Michigan?”

Stabenow commented, “that’s called having a country, with all due respect.”  She went on to say that 20% of the world’s fresh water bordered 8 states. I wonder how many Americans can name all the Great Lakes.  I wonder if Mulvaney could even name the states; he’s from the South.

I would have gone right back at Mulvaney asking why I, here in Oregon, should give a damn about a trailer park in Arkansas that gets leveled by a tornado, something that happens virtually every year.  Or some chicken farmer, when I’m vegetarian.  Why should I care if some cattle rancher’s herd dies in a winter blizzard?  That doesn’t affect me.  Why should I pay to truck sand into some North Carolina beach, so it will get eroded away the next storm?  Or to fight grass fires in Texas, build levees in Louisiana, where the ground is sinking and the Atchafalaya River needs to flow naturally again, which means taking over from the Mississippi.  Why should I care about floods in South Carolina?  That’s Mulvaney’s home.  Let him pay for it.  I’m not going there again.  If there is an EF-5 in Oklahoma, why should I care?  It’s a red state, most of the people there wish somebody like me would drop dead, and they certainly wouldn’t want my money.  Why then?

Because we are the UNITED States, not the UNTIED States.  We fix things in the country that matter.  We help people who need help.  We protect the environment for the next generation, and if I, a guy who neither desired nor wanted nor had children, thinks that helping those who lives have yet to begin is important, why can’t the president’s budget address this fact?

How local to we go, Mr. Mulvaney?  Do we go so local that we only pay for medical bills that affect us?  That our taxes shouldn’t go to medical research because I may see no benefit, to building trauma centers I may never use, to research that tries to cure other childhood cancers, like we cured acute lymphoblastic leukemia (it wasn’t prayer that did that, you know) even though I will never in my life have a child who could have it?  Mr. Mulvaney, it should be noted, failed to pay payroll taxes incurred by a nanny for his triplets from 2000-2004, arguing she was a babysitter.

Why should I pay for somebody who has head trauma and wasn’t wearing a helmet?  Or somebody with a gunshot wound when I think the NRA ought to pay for it? They use firearms, I don’t.

Are we becoming a nation of crowd source funders, passing the digital hat, without a clue what a country is about?  Is this the rugged individualism approach that sounds good when you hear Sheriff Richard Mack, of the Constitutional Sheriffs and Peace Officers Association, the same Mr. Mack who hated Mr. Obama and his ACA?  Sheriff Mack, to remind some and to educate others, had a heart attack and his wife became ill as well.  They went to GoFundMe to try to get their medical bills paid for, since they didn’t have insurance. Crowd sourcing isn’t the answer, because medical bills are far more than most realize, and Sheriff Mack, your bill and many others with similar conditions can’t be anticipated, so that’s why we have a thing called insurance.  Now insurance isn’t all that great when it restricts what you can use it for, so it was changed.  Personally, I would have the government cover all medical care to a certain extent, but I am open to honest, fair debate as to what that extent should be.

For example, I think medical care for heart conditions, cancer, aneurysms, blown out knees, fractured clavicles, broken necks, concussions, childbirth, strep throats, ought to be available so that people—even right wing, red state folks who hate me and everything I stand for—get it when they fall ill, rather than dying and as Charles Dickens would have said, “decreased the surplus population.”  I think a 30 year-old, uninsured, in a coma, should be given medical treatment to try to save his life, not “let him die,” which is what the audience yelled at a Ron Paul rally in 2011. Paul himself said, “let people assume responsibility for themselves.”  Really?  People in a coma can assume responsibility?  Old people can shop for the best value medical care?  Should those who were too stupid not to wear a helmet be left at the side of the road to die?  Granted, I didn’t like coming in at 2 a.m. to care for them, but these people needed medical care, unless or until there was a time when in the my judgment where care would no longer help. I wasn’t, of course, trained as an OBG like Paul, just a neurologist, and I was a few years behind him in medical school, so I didn’t hear the part about having the churches take care of these people.  That’s been tried in this country, and it doesn’t work, although if some of the megachurches put their dollars towards actual hands on care, we could probably make a moderate dent in the scope of the problem.

By the way, Paul’s 2008 campaign manager died at 49 from pneumonia, leaving behind a $400,000 medical bill, because while he could raise money for Paul, he couldn’t afford a few hundred a month for COBRA coverage.  Paul managed to extol the man’s skills and tried to raise money for his medical bills.  Is this the America he envisioned?

Are we united or untied?  Will my America be money for defense, tax cuts for the rich, where the money will not trickle down, but we will continue to hear that it is true? Will my America be where the president’s family uses the office to generate money and virtually nobody will try to stop it?  Where Mr. Putin’s approaches to journalism and money are copied here?  Is it here where we make a budget based on unrealistic growth expectations?  What happens when a Cat 5 hurricane levels Miami, storm surge again wipes out New Orleans, or a cluster of EF-4 tornadoes takes out Birmingham?  Are those people expected to take care of themselves?  What happens if the San Andreas or Cascadia Fault slips, and Los Angeles, San Francisco, Eugene, Salem, Portland or Seattle is leveled?  Or we have an oil spill from a pipeline that a lot of us didn’t want, and the Ogallala Aquifer or Lake Superior are polluted beyond repair?  You’ve heard, I assume, Mr. Mulvaney, of the Enbridge 5 pipeline under the Straits of Mackinac.  What happens if this 65 year-old pipeline, whose supports have failed, leaks? Who fixes Lake Superior?

This is what I finally understand.  I know now where we are going: we are to become a nation of take care of yourself, because nobody else will.  That’s the case in many places in the world today.  I’ve seen those places and those people, in Manila, La Paz, Caracas, Lima, Djakarta, New Delhi, Johannesburg, Cape Town, Lusaka, Nairobi, Cairo, and Tripoli.  Of course, we have them here, too. And we will have a lot more.  You see, the AHCA will remove insurance from 64,000 in Oregon Congressman Greg Walden’s district, and he helped craft the bill.

You know what?  He will be re-elected in 2018.

Social and other media have been abuzz the past few weeks about impeachment of the president, a display of both magical thinking and forgetfulness of with whom we are dealing.  In the same vein, the “resistance” is taking credit for things that perhaps are not worth crediting.  In short, while I support all steps that fight the current administration and run down the clock, I want to inject a harsh dose of reality into our lives, too.

I wouldn’t bet against the current president.  He survived insulting of McCain, the Pope and Ted Cruz’s wife, dissing a Gold Star family, giving away Graham’s phone number, and took apart not only the entire Republican field, but the Democrats as well.  He was shrewd enough to bring several of his rivals into his cabinet. He has gotten away with all of it, and other than a few brave judges slowing down some executive orders, is quietly moving to dismantle health care, give a big tax break to the wealthy, remove food stamps, Medicaid, Social Security, and Medicare, and all environmental restrictions.  Maybe this can be stopped, but I am not betting on it right now.

The rules have changed.  While the media is finally stepping forward with investigations into his ties and his campaign’s ties to Russia, already there are those who may find a way to weaken the investigation.  I’ve heard countless times of the dysfunction in the White House and how this can’t continue.  And yet it continues.  He can fire the current special counsel should he choose, like Nixon, more than 40 years ago, and there would be a huge outcry…but nothing to show for it, were I betting.

Despite all the transgressions the current president has made, his approval rating stubbornly remains in the mid to high 30s, back to 40% when we had our $90 million raid on Syria.  Oh, I read that the firing of Comey had a 29% approval rating, but the disapproval rating is today barely over 50%.  The president would get at least 40% of the vote were the election held today, and until or unless I see polling numbers in the 20s, I will not be impressed much has significantly changed.  It doesn’t matter that Mr. Obama ran a scandal-free administration, stymied every step of the way, had unproven conspiracy theories abound, and would have been impeached in a New York minute had he secret conversations with the Russians.  This president has the backing of the Republican Party, who sees more what they can get from him than what is right or wrong in the country. I heard before the election all the Republicans who weren’t going to vote for him. And they all did anyway.  I’m not sure what—if anything—will take this man down.  I suspect if something does, it may be a minor sleeper that takes everybody by surprise.

Currently, I am trying to unsubscribe from the voluminous number of emails I get from so many different groups.  Today was the Democratic Governor’s Association.  I fought the battle 10 years ago, back when Napolitano and Sebelius were still red state governors, until Mr. Obama’s ill-timed use of them in his cabinet.   If the Democrats were too stupid to realize what they needed to do, it isn’t up to me to be their money tree.  I’m retired.  It’s time for somebody else to step forward. I’m tired of losing, of candidates not wanting the national organization to come to their district, because national is out of touch, running candidates with high disapproval ratings who worry more about raising money than going to the heartland in all 50 states and just discussing matters like health care, defense, taxes, and trade.  I’ve had it with voters who demand perfection in race, gender, sexual orientation, medical plans, fighting terrorism, or they will stay home.  These same voters are getting creamed by this administration, and frankly a tax cut would be economically beneficial to me.  If they are too stupid to realize that only the Democrat can beat the president, not a Libertarian or a Green, and that down ballot measures like Congress and School Boards matter, then they deserve what they get.

Resist, yes.  But don’t think for a moment that the resistance killed the AHCA.  It didn’t kill it the first time, the Freedom Caucus did.  And whether the town halls will make a difference at the voting booth, I’m not optimistic right now.  People have short memories.  People are stupid, when they think “Obamacare” was different from the ACA.  I’d predict that if the AHCA became law today, the House wouldn’t change much in 2018. Nobody is protesting the lack of enforcement of the ACA, which is causing more insurers to pull out, the Blues now from the KC area.  Enforcement of the law is a presidential duty.  At least it was for a Democratic president.

Worse, it may be too late.  An estimated 300,000 in Wisconsin alone were disenfranchised because of harsh rules to vote.  It is more difficult to vote now, the districts were gerrymandered, the voting rights act was gutted, and now we are going to have a commission to look into voter fraud, most of the single digit cases of fraud being by Republicans.  In 2020, the census will be politicized, and minorities will be undercounted, underrepresented, and districts drawn by Republicans, because most of the states are run by Republicans now.  The Democrats in power were too busy doing—well, I don’t know what—while the Republicans took 1000 offices nationwide.

It’s not up to me.  If it were, I’d have mandatory national service, military out of South Asia, single payer health care, and a tax plan I’ve discussed here many times.

People would do well to cool it a little bit.  Nobody is going to impeach the president in a Republican run Congress.  Even if that happened, conviction would require two-thirds of the Senate, and other than an occasional feel good bill, there aren’t two thirds the votes for even free enemas in this country.  Maybe the guy will resign.  Or just quit.  Or die or get Alzheimer’s, assuming he doesn’t have that right now.  Then we get Pence, whom I would bet money that very few people in this country realized what those implications might be, because the media was so focused back then on the presidency.  Pence may be investigated too, but to count on that is counting a second generation chicken.

The media is helping uncover a lot of bad stuff now, true.  I’m glad that they are doing their job.  I can be forgiven for not being a fan of theirs when they gave untold amounts of free advertising to this president, who is a candidate still, with packed rallies and a lot of strong support, people who will vote.

I am remaining hopeful that something will end the darkness that has ensnared this country, but I do not underestimate the resiliency of this president, the desire of his party to keep him in office, and the damage he can do.  If one wants to have a feel good moment, that’s fine.  From time to time, we need one.  But it is important to be realistic, look at appropriate sources of news, fact check information, and stay realistic, focused on results, and keep reminding people why elections matter.