Pandering To Xenophobes

On 60 Minutes last night, the President vowed to take ownership of the health care legislation and its consequences. But he will then need to own the crippling of access to reproductive services for women. And you see a similar dynamic with the arguments over the immigration provisions in the bill. The President was not wrong when he said any bill would not insure undocumented immigrants - he's just wrong to carry out such a spiteful, shortsighted threat.

Consider a few statistics. According to a July article in the American Journal of Public Health, immigrants typically arrive in America during their prime working years and tend to be younger and healthier than the rest of the U.S. population. As a result, health-care expenditures for the average immigrant are 55 percent lower than for a native-born American citizen with similar characteristics. With the ratio of seniors to workers projected to increase by 67 percent between 2010 and 2030, it stands to reason that including the relatively healthy, relatively employable and largely uninsured illegal population in some sort of universal health-care system would be a boon rather than a burden. "Insurance in principle has to cover the average medical cost of all the people it's serving," explains Leighton Ku, a professor of health policy at George Washington University. "So if you add cheaper people to the pool, like immigrants, you reduce the average cost." More undocumented workers, in other words, means lower premiums for everyone.

The actuarial advantages don't end there. As it is now, undocumented workers (and others) who can't pay their way receive free emergency and charitable care—a service that costs those of us with health insurance an additional $1,000 per year, as Obama noted. But if illegals were covered, this hidden tax would decrease, further lowering our premiums and "relieving some of the financial burden on state and local governments," says Harold Pollack, a University of Chicago professor who specializes in poverty and public health. What's more, employers currently have a clear economic incentive to hire undocumented immigrants: they don't require coverage. A plan that mandates insurance for native workers but not their illegal counterparts actually makes life harder on the blue-collar Americans competing for jobs (and railing against immigrants) because it means that hiring them will cost more than hiring a recent transplant from Mexico City. As The Washington Post's Ezra Klein recently explained, "If you're really worried about the native-born workforce, what you want to do is minimize the differences in labor costs between different types of workers. A health care policy that enlarges those differences—that makes documented workers more expensive compared to undocumented workers—is actually worse for the documented workers."

I'd add to this that blunt enforcement mechanisms like what is used in Medicaid cost millions of dollars for almost no material benefit, which even George Stephanopoulos was inclined to point out this weekend. Such systems also tend to weed out legal US citizens without proper documentation. And not letting immigrants participate in the exchanges with their own money, as was floated by the White House over the weekend, completely cuts them off from the individual market and further strains emergency rooms, who will be the doctors of last resort, making this whole spite-based policy grossly more expensive.

(By the way, when some legal resident gets denied coverage because of immigration enforcement provisions, I fully expect Republicans to be the first in line to usher him to a press conference as proof of how government doesn't work.)

Meanwhile, Amanda Marcotte notes that the entire wasteful enterprise to make sure that some alien other never ever gets one dime of the hardworking Murcan taxpayer money ever is a totally moot point:

Mexican migrants working in the United States may soon have their own affordable health insurance program. According to Mexico’s Health Department, it is launching a pilot program designed to encourage migrants who work in the states to sign up for the Mexican government’s Seguro Popular health insurance plan.

In 2003, Mexico set out to achieve universal health care, and from what I understand, they’re on track to reach their goal of doing so by 2012. They’ve done such a remarkable job because they have---you guessed it---a public option that everyone who has a job can buy into. (Except public sector workers, who are covered by a separate insurance system.) They also have a system of federally run clinics to administer to basic health care needs, regardless of employment status. It would be this public insurance that would reach out to migrant workers in the U.S. and encourage them to buy in. Of course, covering bills incurred by Mexican citizens who go to U.S. providers will be very expensive for Mexico, especially since they’ve kept internal health care costs so low. (About 1/3 of what the same procedures cost in the U.S.) Still, it’s both the humane and fair thing for Mexico to do, because migrant workers in the U.S. are good for the Mexican economy, putting billions of dollars into their economy every year. Unfortunately, the economic crisis in America has significantly reduced the average income levels of migrant workers in the U.S., which has impacted the remittance income tremendously. So the Mexican government is starting this pilot program even as immigration is making them less money.

Mexican health care is not an optimal model for the US, but the philosophy behind it is light years beyond what our brigade of idiots in Washington can fathom. Instead, we're jumping through hoops and implementing costly verification systems when Mexican workers can sign up for their home country's public option and never touch any American system to begin with.

If the President wants to "own" these stupid and petty political compromises which benefit his opponents but make no sense from the standpoint of economics or human decency, he'd better be prepared with some good arguments about them. From what I see, naked fear of Republican extremism is leading him to act against the interests of the public.

Outrageous

The White House agrees with Joe Wilson, thinks it's a good idea to stop undocumented immigrants from buying things with their own money. Hopefully they'll extend this and stop them from buying over-the-counter prescription drugs and food without showing papers, either. They're at least talking about using SAVE, a much better verification system than the blunt instrument of proof of citizenship, but it's beyond stupid to force undocumented immigrants away from getting any health insurance (basically what this would do) and into emergency rooms as their primary doctor, with higher costs for everyone, because some backbencher yelled during a speech.

A White House spokesman, Reid Cherlin, said that the president’s proposals would bar illegal immigrants from purchasing private insurance through the new government marketplace, known as an exchange, and that verification of immigration status would be required for anyone seeking to purchase coverage [...]

The White House said that illegal immigrants would still be able to purchase health insurance through the private market, as they can now, but acknowledged that the private market was certain to shrink after the creation of the new marketplace.

Many illegal immigrants must now seek medical treatment in emergency rooms, which by law cannot turn them away. In recent years, the federal government has spent $250 million a year to reimburse hospitals for bills that go unpaid as a result. The White House said those reimbursements would continue.

Jellyfish run our government. By the way, watch abortion be next. They'll move to restrict all funding for a women's right to choose, even in private plans, inside the exchanges. You can see it coming.

Covering The Undocumented Is Cheaper, Actually

Rep. Joe Wilson gave a bumbling, stumbling response to his comments last night.



Once again the media has taken one sensationalistic remark and let it overshadow the entire speech last night, which was a political winner for reform. But it's worth digging down into the substance of the claims and the actual policy behind it. Right now, the way things are, undocumented immigrants (there are no illegal people) can go to an emergency room and get treatment. They can purchase their own health insurance. They can go to a free clinic. They can, in a variety of ways, access health care if they need it.

The plans on the table would provide more security for those with insurance, and provide exchanges for those without coverage. The undocumented can access those exchanges, because it would require them to pay for coverage with their own money. The bill would also provide subsidies to people who cannot afford coverage. The undocumented would not be eligible for those subsidies. It says that in every single bill draft. Rush Limbaugh, being a little more honest than usual today, says "It will cover undocumented aliens. Now it may not specifically say so in the bill... " He's talking about enforcement and verification statutes, which is a red herring, because a driver's license or some form of ID is typically required at the point of service if you have an insurance card. There are lots of checks in the system already.

That said, I agree with this:

The Baucus plan currently going around, of course, explicitly states that "[no] illegal immigrants will benefit from the health care tax credits" and limits the insurance mandate to U.S. citizens and legal residents. But Dana is right to ask whether undocumented immigrants should be covered in some capacity. Beyond potentially skewing employer hiring incentives, the exclusion of immigrants from the plan will create a financial burden on the system anyway -- which seems to be conservatives' big concern. By law, hospitals are not allowed to refuse care to anyone in an emergency situation, whether the person is insured or not. The cost of the uninsured then falls both on the hospitals and on the government, which provides $250 million annually as reimbursement through Section 1011 of the Medicare Modernization Act, which has been extended through this year.

So, tax dollars are already being spent on care for uninsured and undocumented immigrants. And hospital resources are being strained since the losses aren't fully accounted for, which can have an effect on the quality of medical care provided to the general population. Regardless of the system in place, coverage of undocumented immigrants is a problem that's going to need to be dealt with. Given that, shouldn't we be working toward a solution that's more transparent and just?

The President talked about the $1,000 hidden tax on everyone with insurance as a result of funding ER care. That would not change if immigrants had to use continue to use the ER as their primary doctor. That status quo is grossly inefficient and we all pay for it; in fact we pay more than if we just offered subsidies and brought everyone under the umbrella of universal care. In addition, having an underclass of people prone to disease without preventive care is a major public health problem.

In a general sense, this kind of "blame the brown people" argument will be consistently made until we deal fully with the undocumented within our borders, through both workplace enforcement and some legitimate path to citizenship. Until you do that, these political footballs will always surface, and cowardly Democrats will thunder "we will not pay for undocumented workers!" when we already are paying for them, and could lower that payment.

...I knew somebody would turn that into being Obama's fault.

Poor People Can Just Go To Free Clinics

I'm sure that the right thinks there's no need for health care reform because the system works great right now. If you get sick you go to the emergency room, and Bob's your uncle. Here's GoOPer Jack Kingston saying basically that. And here's Connecticut for Lieberman's own Joe Lieberman saying how great the current system working, meaning there's no need for a public option.

On Planet Reality, the only reason that the American system doesn't look like a total nightmare, I mean a people-dying-in-the-streets nightmare, is because of numerous local efforts to keep things afloat. The "just go to the ER" approach adds tens of billions to health care costs. But even that isn't being used to the extent it could, because of the existence of free community clinics. Which will cease to exist before long, on the current trajectory.

The Mission of Mercy, a group of traveling clinics that circulate through towns in Maryland, Pennsylvania, Texas and Arizona, is one of more than 1,200 free clinics across the nation that are feeling the effects of the economic downturn.

Their patient lists are growing as Americans lose their jobs and their health insurance, but as demand grows with rising unemployment, their donations are dwindling. This year, Mission of Mercy has $350,000 less than it did last year; it takes no government funds for its services.

"People are so afraid to give now, because they're thinking they could lose their job next," said Linda Ryan, the executive director of Mission of Mercy. "We're squished because we have more people in need; we need to grow now more than ever — who knows what will happen with health care?"

Over the past year, free clinics across the country have seen a 20 percent decrease in donations and a 40 percent to 50 percent increase in patients, said Nicole D. Lamoureux, the executive director of the National Association of Free Clinics. Last year, the clinics the association represents — which largely have been excluded from the health care debate — treated 4 million people. This year, Lamoureux expects, they'll serve some 8 million, 83 percent of whom come from homes in which at least one person works full time.

"Quite frankly, the need is so great at some point in time we'll hit a place where we have to say we need to start cutting," Lamoureux said. "We'd like to be a part of those discussions (on health care.) We really need to make sure that this legislation gives the people we serve access to quality health care."

The New York Times did a good story on one of these clinics, in Milwaukee, which is doing its best but cannot hope to survive given the increase in demand.

The current system forces many of the nation's poor, even people who have jobs, EVEN PEOPLE WHO HAVE COVERAGE through Medicaid or Medicare, to visit these community clinics, which just don't have the funds to survive. There are often no other options for primary care. These clinics are the last line of defense and they're failing. They're staffed by good people who selflessly seek to protect and care for everyone regardless of ability to pay. They won't exist in a decade.

And then everyone will TRULY see the consequences of a for-profit health care system, if no reform is accomplished.

The Cost Of Doing Nothing

I'll probably have a blizzard of health care stories up today, because there's a lot I want to highlight that I've seen over the last week. Most important, we're finally seeing some critical mass about the cost of inaction. That's always hard to quantify. The Congressional Budget Office doesn't score "do nothing" side-by-side with the policy at hand. But advocacy groups and even the media are starting to make noise about how the status quo would have real, definable costs.

First, Families USA today released a report about the hidden tax, the amount of money that insured Americans pay for uninsured Americans to receive emergency room treatment.

During 2007 and 2008, one out of every three non-elderly Americans—86.7 million people—went without health insurance for some period of time.1 When those who do not have health insurance get sick, their first response is often to avoid or delay seeking care due to the cost.

When the uninsured do obtain care, they struggle to pay as much as they can afford. Often, however, the uninsured cannot afford to pay the entire bill, and a portion of it goes uncompensated. To make up for these uncompensated care costs, doctors and hospitals charge insurers more for the services provided to patients who do have health coverage. In turn, the costs that are shifted to insurers are passed on in the form of higher premiums to consumers and businesses that purchase health coverage.

It turns out that American families pay about $1,017 each on this hidden tax, which would be mostly wiped away by reforms that would cover almost everyone. By the way, this is why I support extending coverage to everyone in America, because leaving any group out would keep the hidden tax in play. So-called "illegal immigrants" get sick too, and someone picks up the tab.

The Urban Institute did a study on cost increases over the next ten years in the absence of reform.

They find that, absent reform, individual and family spending on health care (the sum of insurance premiums and out-of-pocket costs) will rise approximately 40% per capita under a best case scenario of low unemployment and economic growth.

Under an intermediate or worst case scenario (in which fewer workers have jobs and comprehensive insurance, more uninsured burden the system, and health care costs continue to spiral upwards), they project individual and family spending on health care to increase 50% in an intermediate case scenario or almost 60% in their worst case scenario.

That would be just an enormous burden, especially on those making under the median income. But the costs borne by the individual are just as bad as the costs borne by the state. Without reform, 26% of total GDP, or $9 TRILLION dollars, would be spent by Americans and the government on health care alone. Now Mickey Kaus might think that's just swell, but he isn't much of a budgeter, since that expanse of funds devoted to health care would simply break the budget entirely. The government actually does other things, but if health care grows 10 times as large as defense, it would have no ability to do much else.

This is why, as Steven Pearlstein put it in an excellent column, those who use the budget to argue AGAINST health care reform are arguing in the opposite direction from reality.

The biggest threat from this budgetary obsession is likely to come up in the debate over health-care reform. Under pressure from budget scolds, Congress and the administration have agreed that any plan to extend health care to 47 million uninsured Americans and reform a $2.6 trillion industry will be "budget neutral" within the first five years after enactment.

There is, for example, general agreement that it will cost $100 billion to $150 billion a year to provide the subsidies necessary to allow all Americans to afford a basic health plan. But the Congressional Budget Office, the official scorekeeper on these matters, has been reluctant to certify the major cost savings that might come from various proposals to restructure the health delivery system, or reform the health insurance market to make it more competitive, or change the way doctors and hospitals are compensated so they have the incentive to use only the most cost-effective treatments.

It is, of course, the CBO's job to be skeptical, particularly after a number of past experiments in this area have yielded disappointing results. But it is also true that because nothing of this scale and complexity has been tried before, projecting the fiscal impact is next to impossible. This budgetary standoff will leave Congress with no choice but to try to finance its health-reform efforts by raising taxes or limiting payments to doctors and hospitals, possibly jeopardizing the entire project.

We can certainly applaud policymakers for their reluctance to enact another expensive and popular entitlement program without finding the money to pay for it. But it is folly for them to put themselves in a political and procedural straitjacket. In all of history, no revolution was ever made by budget analysts. Health reform requires leaders with the foresight and confidence to take a leap into the unknown.

There are ways to finance universal health care, though many have different beliefs on the most cost-effective or sensible. But one thing is clear - financing it 10 years from now would be a near-impossibility.

Past The Point Of No Return

There was a report out yesterday about climate change that basically said we've reached a point where dramatic changes to the climate, to sea levels and to weather patterns were irreversible, that even if we dropped everything and eliminated every single carbon emission it would take perhaps thousands of years to return to equilibrium. I feel the same way about California's finances. If every Yacht Party member suddenly turned into Paul Wellstone and we changed every revenue source and dysfunctional structural barrier, we'd STILL be in a world of hurt. A couple stories today make that clear.

First, a coalition of emergency room doctors has had enough and is suing the state for additional funding to stave off a total collapse of the ER provider network.

Frustrated emergency room doctors filed a class-action lawsuit against the state Tuesday, saying that California's overstretched emergency healthcare system -- which ranks last in the country for emergency care access -- is on the verge of collapse unless more funding is provided.

Across the state, scores of hospitals and emergency rooms have shut their doors in the last decade, leading to long waits, diverted ambulances and, in the most extreme cases, patient deaths.

Doctors say the situation is only getting worse. State officials, struggling to balance the budget, have proposed another $1.1 billion in Medi-Cal cuts.

"Are people truly suffering consequences? Absolutely," said Irv Edwards, one of the doctors represented in the lawsuit and president of Emergent Medical Associates, which staffs 14 emergency rooms in California. "This could happen to you or me. We could be traveling through San Francisco or San Jose, get in a car accident, have a broken leg and end up in the ER, where it takes hours to be treated regardless of our screams. Then we get to diagnosis, and they say, 'There's no orthopedic on call. I'm sorry.' "

ER doctors are required by law to treat whoever comes through the door, and rising ranks of the uninsured have stretched the system beyond repair. Further, specialists are frustrated with the low reimbursement rates and are taking their names off of call sheets for referral in case emergencies require their services. A physician on KPCC's "Air Talk" today described the suit as a "canary in a coal mine," warning that without increases in rates, not just restoration of funding but increases, there will be no emergency room network in California, period.

Then we have Standard and Poor's downgrading the state's credit rating for economic recovery bonds once again, meaning that investors will see a lower-than-expected return and will be far less likely to buy whatever else California sells in the future, which by the way is how we fund our state government.

Finally, you have two ignorant lawmakers, Arnold Schwarzenegger and Jerry Brown, asking the US to halt federal oversight of state prisons even though precious little has been done to manage the crisis. Brown and Schwarzenegger are more interested in saving a few pennies than the Constitutional rights of those incarcerated. The failure to understand this problem over 30 years have put these disgraced leaders in the position to lie to their own citizens because they can't face up to their responsibilities. And as the accountability for this shocking behavior is remote, there is no reason for it to stop.

State Attorney General Jerry Brown feigns to be shocked, outraged and appalled that a proposal to build prison facilities for older, chronically ill, physically impaired, feeble prisoners includes exercise rooms, TV rooms, gardens and natural light.

Taking all this away, as Brown surely knows, wouldn't save much money – but it would make life difficult for prison workers to manage the prison population. Hey, why not take away air conditioning, too? [...]

Brown whines that a federal court-imposed solution would violate "state sovereignty." Yet he knows perfectly well that the state could avoid any court-imposed solution if it would simply take responsibility for a solution on its own.

One such solution had been proposed by the governor and was supported by legislative Democrats, a bond package for facilities. Senate Republicans killed it last May.

And nothing stops the state from working with Kelso on a negotiated settlement that would reduce the population of older, feeble, chronically ill prisoners or build facilities to house them.

But none of that is happening. Despite all the complaining about the federal courts, the governor, lawmakers and Attorney General Brown seem quite content to let the courts decide – deflecting blame to the judges and away from themselves for the choices that have to be made.

Jerry Brown doesn't believe that prisoners are human beings and that they lost their Constitutional rights upon conviction, even if they are being held for the medical condition of drug addiction (which he ensured by opposing Prop. 5 in the most dishonest manner possible). His attitude is retrograde and horrifying and shows a complete failure to account for his own actions.

He's also the top candidate to be the state's next governor.

We are past the point of no return.

Limits Of The Imagination

There was a fairly amazing article in yesterday's Washington Post that I think hits on many of the features of this newfound effort to worry about the deficit and entitlements precisely at the moment when a Democratic President enters office facing a huge crisis requiring major public spending. The basic thrust of the story by David Brown, a doctor and science reporter, is that health care spending will inevitably expand forever, and there's nothing we can do to control costs, and pretty soon we're going to face a crossroads between wanting to live longer and healthier lives and being able to afford it. This was not in the opinion section.

This difficult truth, which has emerged over the past half-century, is leading the United States and the rest of the industrialized world into a new era of humankind [...]

Last year, 16 percent of the nation's gross domestic product went for health care, about $7,600 per person. In terms of human effort, health care is the new food. By 2016, when it reaches 20 percent of GDP, it will be the new shelter. If it grows at its present rate through the first three-quarters of this century, it will consume 38 percent of GDP by 2075. It will then be the new food and shelter.

This isn't a mistake. If it were, we might have a chance of stopping it. It's success -- the way things are supposed to be, and the way we want them to be.

"At the end of the day, when it comes to controlling health care costs, the enemy is us," said Drew Altman, head of the Henry J. Kaiser Family Foundation. "Americans want the latest and best in health care technology, and we want it down the street, and we want it now."

It sounds so simple, doesn't it? Americans greedily want to be healthy, and they demand the latest and greatest, and the costs skyrocket.

Now, nowhere in this analysis is any explanation of the method of delivery of the US health care system, and how its inefficiency may just be, I don't know, the source of the problem. I'm trying to remember when I barged into a doctor's office and insisted on an artificial heart because the guy down the street just got one. No, what happens is that I pay thousands of dollars in premiums to a for-profit insurer, and when I try to use my coverage, I barter with some customer service rep for hours on end trying to get them to sign off, and she gets paid along with a whole staff to keep treatment costs down, and her salary and the salary of the marketing team at the insurance company and the PR guys and the pharmaceutical reps bringing in free lunches for the doctors and the CEO's private jet all fall under that big number of "health care spending."

Also, health care spending grew at its lowest rate in a decade last year, mainly because the economy started slowing down, people started using CHEAPER generic drugs (I thought Americans wanted the best and they wanted it now?), and because of lower rates of growth for administrative costs in - wait for it - Medicare, the public not-for-profit alternative health care delivery system.

Now, it would be simply gauche to point out that the current health care delivery system sucks up all kinds of money for insurance industry profits and admin costs, and that the high cost of premiums force 47 million people to go without health care and use emergency rooms as their personal physician, jacking up costs prohibitively. That couldn't possibly explain all that growth in spending.

Except consider the current series of health care bills before Congress, and recognize that the plan which would cover the most uninsured and the plan which save the most money are THE SAME PLAN. Matt Yglesias has the charts to prove it, from this Commonwealth Fund report. As Yglesias notes, because that DFH Pete Stark wrote the bill that combines reducing the most uninsured with saving the most money, it's deeply unserious and outside the boundaries of conventional Beltway debate.

Stark’s is the best again. And yet there’s no chance whatsoever that we’ll actually do this because his plan, though the most practical, is also the most left-wing. Far too left-wing for the United States of America

Some folks, of course, will oppose the Stark plan because they’re right-wingers who don’t want to expand health care coverage. And some folks, will want to focus their energies on other, worse, plans because those plans have a better chance of passing. But what’s incredibly frustrating is that a lot of people who claim to want to change public policy to expand health care coverage and better control health care costs will nonetheless fail to embrace Stark’s plan or anything similar for no real reason other than ideological posturing. It just can’t be the case, as a matter of centrist dogma, that the best solution is actually the most left-wing solution. It’s a far more ideological stance than anything you’ll ever hear from Pete Stark or from me. But the people hewing to it will insist on being called pragmatists.

Pragmatists like David Brown, who says that we're all going to have to live with the costs of better medical care and drugs, and if it costs too much to save someone's life, well we just have to grapple with that Malthusian Spectre. It can't possibly be that bringing America's health care costs in line with every other industrialized nation on the planet would both help to fix the deficit and entitlement concerns AND deliver better quality and more affordable health care to every American.

That just cannot be. If it's such a good idea, why wouldn't we have thought of it by now?

This all reflects a very ideological problem, where the case for liberal government has either not been made or drowned out by the right for the past 40 years, and so the Very Serious People in Washington view that case as a pollyanna scenario. And in the exchange, we all suffer.

Just Go To The ER

None of this is going to come as news to anyone, but the need for comprehensive health care reform now is magnified by massive job loss, which also often means a loss of health insurance for those affected (which is typically not just the employee but their family), leading to the phenomenon of the pre-insured.

The crisis is on display here. Starla D. Darling, 27, was pregnant when she learned that her insurance coverage was about to end. She rushed to the hospital, took a medication to induce labor and then had an emergency Caesarean section, in the hope that her Blue Cross and Blue Shield plan would pay for the delivery [...]

“This shows why — no matter how bad the condition of the economy — we can’t delay pursuing comprehensive health care,” said Senator Sherrod Brown, Democrat of Ohio. “There are too many victims who are innocent of anything but working at the wrong place at the wrong time.”

Often, when I'm having arguments over health insurance with people, they will trot out the talking point that nobody goes without health care in America because anyone can go to the insurance room. Aside from that being the most expensive, wasteful and dangerous way to achieve "universal coverage" you can think of, it doesn't work as a matter of capacity. It's simply false that everyone has access to the emergency room.

Even before the recession became evident, many emergency rooms around the country were already overcrowded, with dangerously long waits for some patients and the frequent need to redirect ambulances to other hospitals.

“We have no capacity now,” said Dr. Angela F. Gardner, the president-elect of the American College of Emergency Physicians, which represents 27,000 emergency doctors. “There’s no way we have room for any more people to come to the table.”

What's more, patients entering ERs for routine care prevent doctors from treating those with more pressing emergencies, and frequently patients delay medical care until they have an emergency, making treatment more costly.

Again, anyone who has spent several hours in an emergency room waiting for a bed knows this. Anyone who's been laid off and seen what it costs to maintain coverage through COBRA knows this. That majority needs to be very present in making sure their concerns are met by any comprehensive health care reform. Of course, we've been governed the past eight years by people like this:

Being without health insurance is no big deal. Just ask President Bush. “I mean, people have access to health care in America,” he said last week. “After all, you just go to an emergency room.”—NYTimes.

This Ad Writes Itself

It got lost amid the convention and the VP picks, but a top advisor for John McCain calling the emergency room a form of insurance is a very memorable moment. It's also not at all new. I remember a Republican winger making this argument to me in 2003. They have such a disconnect with how those who struggle in the health care system that they actually believe destroying the nation's ERs makes sense on any fiscal or medical level.

But the numbers are misleading, said John Goodman, president of the National Center for Policy Analysis, a right-leaning Dallas-based think tank. Mr. Goodman, who helped craft Sen. John McCain’s health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

“So I have a solution. And it will cost not one thin dime,” Mr. Goodman said. “The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

“So, there you have it. Voila! Problem solved.”

The reason we have skyrocketing health care costs is because we funnel tens of millions of people into expensive ER care, resulting in a "hidden tax" on everyone with insurance. Goodman wants to perpetuate that. And McCain's campaign wants to tax health insurance as income for those who get it from their employers.

This is how Republicans think. They consider poor people "lucky duckies" for getting to sit in an ER for two hours, dying on the floor while clogging the facility where real emergencies are supposed to be dealt with.

The Emergency Room Nutjob Talking Point

So I guess this wingnut idea that "we have universal health care in this country, anyone can just go to an emergency room!" is making the rounds again, this time out of the mouth of the President, no less.

Echidne of the Snakes, writing at TAPPED, knocks down this nonsense:

Except that emergency rooms are not conveniently located in neighborhoods all over the country, emergency rooms are not well suited for the provision of primary care and tend to charge rather heftily for those services, emergency room care fails to provide the kind of continuous care that is really needed and the real intended customers of emergency care (people with emergencies) will have longer waiting times than necessary if the same places are also used for primary care.

Neither are emergency rooms going to provide preventive care or prenatal care for the poor, for example, and it is highly unlikely that the care the poor receive in emergency rooms is timed correctly from the point of view of best health outcomes. I suspect that people wait until they just can't take the pain any longer before going to an ER. This means that illnesses are more advanced and treatment less likely to succeed than if primary care was provided in the communities of the poor.

I had a Republican use this line of attack on me 4 years ago. It’s a standard wingnut talking point. It doesn’t quite square with “brown people are stealing our health care!!1!!” but who expects logic nowadays?

The fact is that reliance on ERs because no other treatment is available to tens of millions of people has crippled the system, particularly in low-income areas (see King-Harbor Medical Center, lady dying on the floor while orderlies mopped up the blood around her edition) and has sent costs soaring that are absorbed by everyone who pays taxes and for health insurance. It’s a universal system, just the worst one you could possibly devise.

King-Harbor on the road to shutdown

You never know when the traditional media will latch on to a story, but they've certainly raised the case of L.A.'s King-Harbor Medical Center to new heights by publicizing the tragic story of a woman who died while waiting in the lobby of the emergency room while hospital staff casually walked by her. It's become a powerful symbol of our broken health care system. In fact, King-Harbor has been troubled almost since the moment it opened in 1972, and the tales of woe emanating from the medical center are numerous.

Among the cases cited:

• One patient in King-Harbor's emergency room told a triage nurse on April 30 that he was seeing "aliens and devils" and that he was thinking about drinking bleach to commit suicide. He was left in the lobby for more than an hour and not seen by a physician for almost seven hours. A mental health evaluation was not completed for 17 hours after he arrived, according to the federal report.

At that time, the patient denied being suicidal and was discharged without receiving treatment.

• A female patient went to the emergency room on March 8 complaining of two weeks of stomach pain. She said she had nausea and rated her pain as a 10 on a scale of 1 to 10. "The patient identified that the pain she was experiencing was constant and that nothing provided relief."

Even so, she was given no treatment to alleviate pain or reduce her fever. Two hours later, she was checked again and again offered no treatment. She was not seen by a physician until nearly seven hours after she arrived. "The patient experienced severe pain throughout her [emergency stay]," the report said. Eleven hours after she arrived, she went to surgery.

• A patient went to the emergency room on May 11 complaining of spotting during pregnancy. An hour later, a triage nurse saw her, gave her a pregnancy test and sent her back to the waiting area. When staff called her name two hours later, she had left without being seen.

Three days later, the same woman returned to the hospital with complaints of vaginal bleeding and severe pain. A nurse didn't evaluate how much she was bleeding and had her wait four hours without pain medication. During an ultrasound, she had a miscarriage and was discharged a short time later.

So today, state regulators have moved to close the hospital. But is that the right thing to do?

Both the governor and a portion of the LA County Board of Supervisors seem resigned to King-Harbor's closure:

Two of the five members of the Los Angeles County Board of Supervisors said Thursday that they now support closing the hospital without delay.

"I think it's over for us," Supervisor Gloria Molina said. "I'm in fact terrified that somebody else might be hurt or neglected or abused at Martin Luther King hospital."

Supervisor Mike Antonovich agreed. "The time has come to put patients' lives before incompetent employees or political agendas," he said.

The state's decision, which was approved by Gov. Arnold Schwarzenegger, is subject to appeal. That process could take six months to a year.

So for the next year, King-Harbor would remain open until the process is complete. But what would be in place in the wake of any closure? In the CA-37 debate, the district which includes the area around King-Harbor, almost all of the candidates stressed the fact that there are few options for the low-income residents that King-Harbor serves. Most of them use public transportation and can't afford an ambulance to take them to the next closest hospital. And the trauma centers in the area are already overburdened, and another 47,000 ER visits per year (the approximate average at King-Harbor) could create the very problem regulators are seeking to avoid. If there is an extended, year-long process to close King-Harbor, plans MUST be made to provide for some replacement access for the citizens who would be left with practically no alternative should they become sick or injured. Community advocates are saying the same thing.

"We are playing with not only fire, we have gasoline in the other hand," said Lark Galloway Gilliam, executive director of Community Health Councils. "That emergency room, you can't let that go. Closure to me is not an option."

Finally, this really stresses the need for a better safety net for all citizens than a crippled emergency room system that acts as a faux-universal care apparatus. People deserve better than this. They need to have access to preventative care instead of going to the ER for a fever. King-Harbor's problems are part of the larger health care crisis in America.