Tuesday, March 6, 2018

Judicial Fiat?

Madison's words are oft quoted by those opposing judicial activism,
 but he was actually referring to the courts expanding congressional authority
 beyond that specified in the Constitution.

A month ago I wrote about the Fair Districts movement in Pennsylvania and its lawsuit, led by the League of Women voters, seeking to have the absurdly gerrymandered boundaries of the Commonwealth's districts for the US House of Representatives declared unconstitutional.

That lawsuit succeeded: the Pennsylvania Supreme Court issued an order that the boundaries for the districts be re-drawn.

This has attracted national attention, as Pennsylvania is not the only state in which congressional districts have been a hot topic of political discussion.  North Carolina is just one other current example.

Last week (Monday, 2-26-18, to be precise), this subject was mentioned in the "Monday Political News Roundup" on the NPR broadcast of the KQED (San Francisco) Forum, a program hosted by Michael Krasny.  Krasny was talking with KQED's Senior Political Editor Scott Shafer, when Shafer referred to the decision as a "judicial fiat."

This was somewhat jarring to hear.  As you likely know, NPR is thought of as being part of the "liberal media" establishment, and San Francisco, home to KQED, certainly plays into that stereotyping.  Shafer is not known for liberal bias - and of course no political journalist should be - but a gay man from San Francisco is not someone I would expect to use a phrase that suggests a court is over-reaching its authority, given how the LGBTQ movement has relied so much upon the courts in seeking fair treatment.

The word fiat, taken in its most neutral sense, can mean simply an order to "make it so" (in the words of British naval officers, made famous by Captain Picard on Star Trek).  But the word is usually understood to suggest an arbitrary edict, in an authoritarian sense.

The purpose of this essay is not to take Shafer to task for his choice of words but to examine the question of whether the Pennsylvania Supreme Court was, in fact, over-reaching.

The Court found the gerrymandered districts unconstitutional.  So we should ask whether there is anything in the Pennsylvania Constitution or the US Constitution that provides a clear basis for that ruling.  The federal Constitution says simply that the drawing of district boundaries is the job of the state legislatures.  The Pennsylvania constitution, a much longer document (typical of state constitutions), contains specific language concerning the drawing of boundaries for state legislative districts but not congressional districts.

So what did the Commonwealth's high court do to find a basis for its ruling?

First, it declared that the language related to the drawing of state legislative districts - which specifies that districts should be compact and contiguous and should break up recognized entities such as counties and municipalities as little as possible (only where necessary to make district populations come out even) - to be entirely appropriate for extrapolation to congressional districts and to provide a "floor" - or minimum standard - by which these boundaries can be judged.

Second, it reviewed the political history of Pennsylvania, from colonial times through the drafting of the Commonwealth's first constitution and several revisions over many decades.  In an opinion exceeding 130 pages, the Court found that Pennsylvania has a history of trying to assure that its citizens have representation based on elections that are free and equal.  The consistent principle is that Pennsylvanians should not have less of a voice in their government because of where they live, or their nationality or ethnic background, or their political ideology.  Thus congressional district boundaries deliberately drawn to have exactly that effect are unconstitutional in the Court's view.

The state Supreme Court then reviewed the evidence presented by the parties to the lawsuit in support of or refuting the claim that existing boundaries were, in fact, deliberately drawn for the purpose of reducing the voice in government of Pennsylvania Democrats.  This evidence was somewhat limited by the refusal of Republican leaders in the state legislature to provide information about the methods they used in drawing the lines.

However, the strategy and tactics used by the Republicans have been no secret.  "REDMAP" is both what the GOP wants the US to look like (the Republican party's symbolic color red dominating the US map) and the acronymous name of its project for achieving that: the Redistricting Majority Project.  Just Google REDMAP, and settle in for hours of reading about how successful this has been in many US states, Pennsylvania prominent among them.  As I explained in last month's essay, Pennsylvanians distribute their votes for Members of Congress roughly equally between the two major parties, yet the state's congressional delegation of 18 in the US House of Representatives is not 9-9, but 13 Republicans and 5 Democrats (before the resignation of Tim Murphy last fall).  The situation is similar for the state legislature, which has strong Republican majorities in both houses.

So what are we to make of the Court's ruling?  It might seem even more like judicial fiat when you consider that the Supreme Court issued the new boundaries itself.  But its original order instructed the legislature to develop a new plan for congressional districts, send it to the governor for his approval, and then pass it along to the Court for its review.  The other branches of state government did not follow those instructions, knowing full well that Court-issued boundaries would be the result.  Legislative leaders of the two parties separately prepared new maps (on a partisan basis), and the Republicans sent theirs to the governor.  He did not approve, and prepared his own.  All of these were forwarded to the Court.  As no plan was submitted to the Court having been approved by the legislature and the governor, the Court, aided by its retained Special Master, drew up its own plan.

Just what is at issue here?  First, whether the state constitution, accompanied by state constitutional and legislative history, really affords a basis for the Court's ruling.  Second - given the US Constitution's provision assigning the task of drawing congressional district boundaries to state legislatures - whether the Court was sufficiently deferential to legislative authority.

Any time someone does not like a court ruling that is at odds with what legislators have done, the court can expect to be accused of "legislating from the bench" or of "judicial activism."

In the case of this Pennsylvania Supreme Court ruling, legislators have proposed impeaching the justices who voted in the majority, and the ruling has been appealed to a panel of federal court judges as well as to the US Supreme Court in a separate action.

Few things are of such keen interest to students of political science as a battle between branches of government over separation of powers.

If you are a "strict constructionist," you are likely to object to the Court's ruling, as it does not rely on the plain language of the state constitution (which does not specify criteria for congressional districts) and seems to flout the US Constitution (which assigns authority to state legislatures).  If you believe in the importance of examining constitutional and legislative history, which the Court does at great length in its opinion, you will reach the opposite conclusion.  Yesterday's Pittsburgh Post-Gazette offered a glimpse of this difference of opinion within the Thornburgh family.

Here is an update of the situation, published yesterday in The Morning Call, an eastern Pennsylvania newspaper.  At this point the pundits' consensus view seems to be that the federal court challenges will fail, and the new districts will be in effect for the primary to be held May 15th.  Right now congressional candidates across the Commonwealth are circulating petitions, gathering signatures to get on the ballot for that primary.  As one of those candidates, I would like the federal courts to stay out of this, as we have had so many screwball twists and turns in this election cycle already, we really don't need another one.  But stay tuned!

Friday, February 16, 2018

Guns & Mental Health

A teenager returned to the high school in Parkland, Florida from which he had been expelled for behavioral problems.  Armed with a semiautomatic rifle, he shot about 30 students, killing 17.  Many who knew him at the school knew he was deeply disturbed, and that he had guns, and they had predicted that he would do exactly this.

News reports said the FBI was warned but did nothing.

When I read online commentary it seems to me that opinion is divided into two camps.  Guns are the problem.  Or mental illness is the problem.  Of course American gun violence is a complex matter, and the availability of guns and the prevalence of mental illness are both important factors.

Are we going to do something to reduce dramatically the availability of guns?  All the evidence points to No.  We have more firearms in the USA than we have people.  We had a ban on semiautomatic rifles for ten years, but it had little effect on supply, and it sunset without evident effect on crime, partly because these weapons are used in a tiny fraction of incidents in which people are killed with guns, even though they are used in a sizable proportion of mass shootings.  We may have another ban on these weapons, as the public demand to "do something" escalates.  Or we may not.

If we do, I predict it will have little or no effect on mass shootings.  First, weapons like the AR-15 used by the Parkland, Florida shooter will remain abundant unless there is an Australian-style confiscation, which seems exceedingly unlikely.  Second, anyone bent on a mass shooting does not need an AR-15.

Ask a "gun nut" who owns an AR-15 with 30-round magazines and a Glock pistol of heavy caliber (say, .40 or .45 or 10 mm) with 15-round magazines this simple question: given either weapon, with twice as many loaded magazines for the Glock as the AR-15 (to yield the same number of total rounds), is there any real difference in how fast you could shoot and kill how many people?

The answer will be No.  And if your response is, well, then, we have to ban semiautomatic pistols, too, I can assure you that is a much bigger hill to climb, as they have been in US civilian hands in vast numbers for well over a century.  The same is true for high-capacity (meaning more than ten rounds) magazines.  Given the large number of such guns and magazines in circulation now, and the "non-starter" status of any attempt at confiscation, this approach is just not an effective solution.

So, I have a simple idea that might make a small contribution.  Small contributions have the disadvantage of being small, but sometimes they have the advantage of being feasible, so consider this one in that light.

In the spirit of full disclosure, there are three things I should tell you about myself.  First, I am a doctor specializing in emergency medicine, with a longstanding interest in public health, and I've read a lot about the public health perspective on gun violence.  Second, I am a gun owner, and I have read a lot about the American gun culture.  I can tell you how gun owners think and feel, and I can explain the positions of the NRA and the other gun-rights advocacy groups that take an even harder line (believe it or not).  Third, I am running for Congress, so I think a lot about America's problems, including social problems, from the "there-oughta-be-a-law" viewpoint.  If a voter asks me what I am going to do, if elected, about gun violence, "I don't know" is not an acceptable answer.

I live in Pennsylvania.  In my state doctors have a legal obligation to report to the Department of Transportation drivers who have medical problems that may cause them to have episodes of loss of consciousness that would be dangerous if they happen while driving.  This affects mostly people with seizures, but diabetics with repeated episodes of low blood sugar, people with fainting spells of various causes, and alcoholics and other drug addicts who lose control of a vehicle because of an overdose are all reportable.

So how about this?  Why not ask a doctor who encounters a patient with behavioral problems such that, in the physician's judgment, this person should not have access to firearms, to make a similar report to an appropriate government agency?

How would that work?  Here are a few essential points.

1.  Doctors would need guidelines.  So form a panel of experts to create them.  What are the signs a doctor can recognize that mean a person is potentially dangerous in ways relevant to having access to guns?  Require all licensed physicians to learn these guidelines.  State medical boards already micromanage our continuing education, like requiring all licensed physicians to take two or three hours of online education about opioid prescribing and addiction, or child abuse, so this would be easy to do.

2.  Reporting in good faith would be legally protected.

3.  A person who is reported would be investigated with respect to whether s/he should have the right to possess firearms restricted.  There would be built-in due process involving appropriate parts of our legal system, with the right to appeal and the right to petition to have gun rights restored.

Would this identify everyone who is emotionally unstable and shouldn't have guns?  Of course not.  But what do we do now?  The people who are disqualified are those hospitalized involuntarily because of mental illness, and those who are adjudicated mentally incompetent.  That is a small portion of the population of people who shouldn't have guns because they are a potential danger to themselves or others.  And the expansion of the "pool" adopted during the Obama Administration, and reversed by Trump, that would have added people judged by the Social Security Administration as incapable of managing their affairs (financially) was vigorously opposed by both the NRA and the ACLU.  That should catch your eye, because the ACLU does not recognize a Second Amendment individual right, even after the Supreme Court explicitly did.

We need creative solutions.  Lots of them.  And they have to be solutions that can get substantial buy-in from interested parties on various sides of the issue.  This is one.  I will be doing my best, if I am elected, to fashion more that I think can be enacted in the context of an American society that is starkly polarized on this issue.

Monday, February 5, 2018

Fair Districts Pennsylvania

Many voters are now aware that some people in Pennsylvania regard the way the boundaries of congressional districts are drawn in the state to be unfair.

Let's start with the basics.  Representation in the United States House of Representatives is based on population.  For more than a century the number of representatives grew as the population grew.  But in the early 20th Century it was decided that this could not go on forever.  So after the US Census in 1910 the number of Representatives in the House was fixed at 435, effective with the Congress that was elected in 1912 and took office in 1913.  This is a number that is now familiar to all who pay attention to the workings of Congress.  We don't really think about it.  But the census a century later showed the population had more than tripled.  If we had kept increasing the number of Representatives in the House, it would now be 1,456!  Most agree that would be unwieldy.

The number of people in a congressional district is currently a little over 700,000.  The boundaries are supposed to be drawn so that the number of people in each district is roughly equal.  This is done after each US Census, so the last time was in 2011, after the 2010 Census.  This decennial re-drawing is necessary because population grows and shifts.  The overall population grows, and the number of people living in any given state or any given district may increase or decrease.  The number of representatives in each state may decrease even if the number of people increases, if it increases less than the populations of other states.  This has happened with my state of Pennsylvania, which has seen its population grow with each Census but has had its number of Representatives in the House steadily decline because its population has grown more slowly over the last century than the population of the country as a whole.  After the 1910 Census, Pennsylvania had 36 Representatives in the House; after the 2010 Census, that number had been halved, to 18.

Now that you know something about how representation is determined, to make it proportional to population, you might ask whose job it is to do that.  The US Constitution says the state legislatures have that responsibility.  But the legislature may delegate that responsibility.  This is typically done to make it non-partisan and less political.  California, for example, has an independent commission that draws the boundaries for both its delegation in the House and its state legislature.  In Pennsylvania the legislature draws the boundaries for itself and for the congressional delegation.

Now the question arises: what makes district boundaries "fair?"

There are many ways of looking at this, but it is usually viewed through the prism of our two-party system, and the idea is that fairness should produce a congressional delegation that reflects the party affiliations or voting patterns of the state population as a whole.  So, if you look at the way the people of Pennsylvania vote - tally up all the votes they cast for their US Representatives - it comes out roughly 50-50 between Democrats and Republicans.  Yet the state's membership in the House consists of 13 Republicans and 5 Democrats.  That could easily be explained if the Democrats tend to be concentrated in certain areas, such that a few districts are very heavily Democratic, while the rest have a modest preponderance of Republicans.  But when you look at the way the boundaries are drawn, and at the odd shape of some of them, it is natural to wonder whether they have been drawn to achieve that relative concentration of Democrats in a small number of districts, when geography alone did not produce that pattern.

Some of these districts have shapes that are very odd, indeed:

The state legislature has access to very detailed data on voting patterns, and it is no secret that these data are used to draw boundaries that favor the party that has the majority in the legislature.  And the legislature, because it draws the boundaries for its own districts, can work that angle to keep its majority.  If the governor is a member of the same party as the majority of the legislature, or one party has a veto-proof majority, then there is nothing to keep this from going pretty far to favor one party over the other.

[By the way, this process is called "gerrymandering," after Elbridge Gerry, a US public official who served as Vice President of the US more than a century ago.  Gerry was governor of Massachusetts in 1812 when he signed a reapportionment bill that created district boundaries, based on the 1810 census, that favored his party.]

If you have no "dog in this fight," so to speak - you don't care which party has control - you might not like or dislike the idea of partisan drawing of district boundaries.  But you should understand that, whichever party the process might favor in a given state, it tends to create boundaries that are "safe" for one party or the other because they have strong partisan majorities.

What is the consequence of "safe" partisan districts?  Let's look at this both ways: good and bad.

One may argue that with safe partisan districts, voters tend to elect people whose appeal to the "base" of their party is strong, so that their political positions are more extreme, in either a liberal or conservative direction.  This can serve to make Congress more partisan and more polarized, so that congressmen find it more difficult to work together and to compromise.

On the other hand, one may argue that that same tendency favoring candidates for office who have views that appeal to their own partisan base will assure that we elect some congressmen who have strongly liberal or conservative views, thus assuring that those views are voiced and heard in the political process that plays out on Capitol Hill.

Imagine instead that a state like Pennsylvania - or the nation as a whole, in which voting patterns trend close to 50-50 between the two parties - had districts drawn to be 50-50.  Then every candidate would have to appeal to both Democrats and Republicans, both liberals and conservatives.  This would heavily favor "moderates" or "centrists," people who do not lean strongly one way or another ideologically.  Congress might then be less partisan, less polarized, with congressmen more willing to work together in a spirit of compromise.  Yet the voices to which I alluded earlier - the strongly ideological voices, favoring clearly liberal or conservative ideals - might never be heard on Capitol Hill.  We should ask whether that is a good thing.  And you may say we needn't worry about that, because this is done by state, and we will always have liberals from California and conservatives from Texas.  But it's an interesting and important question within each state.

Now, using Pennsylvania as an example, I am going to take you through some arithmetic to illustrate the difference between the notion of "fair districts" that reflect statewide voting patterns and what the legislature can do if it is determinedly partisan.  I will begin by telling you that the state constitution says districts should be "contiguous" - meaning there should not be a piece here and a piece there, not connected with each other - and compact, which militates against some of the very odd shapes you see in the map above.  It also says political entities, such as townships, boroughs, municipalities, and even counties - should not be broken up by district boundaries except where necessary to make populations come out roughly equal.  My district (PA-18) has voters from four different counties, and not one of those four counties is entirely within the district.  That's a pretty clear indication that the boundaries do not meet the constitutional standard.

So, here we go.  Don't worry about the actual numbers, because they are just for the sake of illustration.  I am using numbers just so that this will not be a set of equations full of variables, making you feel as though I am torturing you with algebra.  But although I am using real numbers instead of variables, this is generalizable to any 50-50 state.

Each district has 700,000 people.  We will then say that about 400,000 are registered voters.  (The rest are not eligible to vote or too apathetic to register.)  And now let's say we want to maximize the number of safe Republican districts and minimize the number of safe Democratic districts.  So we decide we want to create districts that are 60-40 Republican to Democrat.  That means a district has 240,000 registered Republicans.  Statewide there are 18 districts, with 400,000 registered voters each, half of whom are Republicans, for a total of 3.6 million registered Republicans.  If we put 240,000 of them in each district, we have enough for 15 districts.  The remaining three districts will then be 100% Democratic.

Now you may say this is ridiculous.  How could we draw districts so that 15 of the 18 are 60:40 R:D, and the other 3 are 100% D?  Well, of course we couldn't, if the districts actually had to appear to make some geographic sense when you look at them on a map.  But if the legislature can draw them any way it wants, you can do exactly this.

And that brings us to the Pennsylvania Supreme Court case, in which the Court says the districts are unconstitutional, because the state constitution says the boundaries have to meet certain standards of geography, and the Republicans in the legislature say the Court's ruling is unconstitutional, because the US Constitution says the authority to draw the boundaries belongs to the legislature, period.

The Republicans in the legislature are trying to get the US Supreme Court to intervene, to say the state legislature has the ultimate authority.  On the other side, the League of Women Voters and others who brought the "fair districts" lawsuit in the first place, are telling the US Supreme Court that the state court is applying the state constitution, and this is clearly a state matter.  We should hear from the US Supreme Court this week: will it, or won't it, get involved?

My money is on won't.  And that is a good thing, both as a matter of jurisprudence and of fairness.

If a partisan legislature can draw boundaries in the way I illustrated above, to favor their party 15:3, when statewide voting patterns suggest 9:9, then in every 50-50 state the legislature could draw boundaries that favor its own majority party with 83% of the seats in the US House of Representatives.

No matter how you look at it, those are just not fair districts.

Sunday, November 19, 2017

November 19, 2017 Convention Speech

In July 2017 I filed to be a candidate for the US House of Representatives in PA-18, planning to take on entrenched Republican Tim Murphy.

Then a scandal erupted and Murphy resigned in disgrace in the autumn.  The state Democratic party announced that its committee apparatus would select a nominee for a special election to be held March 13, 2018.  A convention of committee members from the district would cast ballots on November 19, 2017 in Washington, Pennsylvania.

Although I was not the choice of the party establishment that day, I delivered a speech intended to appeal to those who were driven by the issues that matter to Democrats - and, I think, to all Americans.  I was allotted five minutes.

Here is the text of that speech:

Fellow Democrats, my name is Bob Solomon, and I am here today because Pennsylvania’s 18th Congressional District needs a new representative who will serve the people: someone who will go to that other Washington and work every day to make their lives better.

I have spent the last 32 years taking care of people who visit hospital emergency departments.  They come to see me on the worst day of their lives.  They face serious illness or injury, and I work quickly to figure out what is wrong and set them on the road to recovery.  I have done this for every patient, every day, without regard for whether they look like me, or sound like me, and without regard for whether they have the means to pay their bills.

I have also spent many days on Capitol Hill, talking to Senators and Representatives, trying to use my expertise in health policy to influence decision makers.

Now I seek to become one of those decision makers and move from helping patients one at a time to helping Americans a thousand at a time, or a million at a time.

Voters who have gathered to hear the Democratic candidates for the nomination to fill the vacant Congressional seat in the special election next March have learned what I stand for.

My public speeches and answers to questions have left no doubt, because they are brimming with the ideals that animate true Democrats, and those ideals are voiced with clarity and passion.

I make the case for voters to choose Democrat over Republican in March, and again in November, based on a clear vision, and a mission to take the Democratic platform and make it work for the people of our district, returning government to its proper role as a servant of the people.

So often we hear candidates speak not in specifics but in platitudes.  We cannot count on voters to recoil in horror from the right-wing extremist chosen by the GOP.  They want to know what we will do, and they want specifics.

I give them specifics.

I will work to achieve universal healthcare: a system in which if you are a human being on American soil, you get high-quality healthcare, and no decision about seeing a doctor or going to the hospital is tinged with the fear of financial ruin.  Two thirds of Democrats support a Medicare for All approach to solving that problem.  Independents and Republicans will join us when we stand firm for our ideals.  That is political leadership.

I will work to put this nation on a path to an energy future that relies on sources that will not run out, like wind and solar.  Democrats know this is a matter of urgency.  The fossil fuels industries are telling us we should just “Drill, baby, drill!”  Some people seem to like that message, but they will join us in planning the transition to a secure energy future, protecting the environment, and dramatically slowing climate change, when we stand firm for our ideals.  That is political leadership.

I will work for an economy in which no one who labors 40 hours a week is living in poverty, needing entitlement programs like Medicaid and food stamps just to survive, because we have a living wage.  We will work with our traditional partners in organized labor to help make that happen.

I will work to assure tax fairness for workers, not tax cuts for the wealthy.  Republicans say cutting taxes for the rich will help regular folks, too, because of the trickle-down effect.  But the rich invest money to make more money, not to spur growth or create jobs.   Basic facts tell us consumer spending drives economic growth and job creation, so the money must be given to people who will turn around and spend it.  Voters will see that the Democratic approach is the right one for hard-working Americans when we stand firm for our ideals.  That is political leadership.

I will work to assure that government regulation does what we need it to do: protect the environment, protect consumers, protect workers’ rights, and voting rights, and women’s rights, and civil liberties.  Republicans always put the words “job killing” in front of “government regulation.”  We know that is wrong.  When we stand firm for our ideals, voters will recognize that government is our servant, and that we can, and will, and must use it to protect all of us, especially the most vulnerable of our society - and to be the agent of social progress we all know it can be.  That is political leadership.

There is a national spotlight on this special election.  Reforming the way we finance healthcare is at the top of the list of priorities for many Americans.  You can send to Congress a candidate with the experience and the policy expertise to shape the debate, and the ability to lead us to solutions that work for all Americans.  You can vote to put our district on the map, and I pledge to you I will make you proud that you did.

I am Bob Solomon and I ask you to give me what matters most today: your vote.     

Sunday, September 10, 2017

Medicare for All: Better, Cheaper

This phrase was used by the late Senator Edward M. (Ted) Kennedy, who advocated a system of healthcare financing for this nation that used a single payer.  The government-run Medicare program, established more than half a century ago, is not perfect, but it is well recognized as a remarkably efficient mechanism of paying for the healthcare services provided to seniors and the disabled.

Satisfaction with Medicare among seniors is high and compares favorably with what one finds among those whose health care is covered through any of the companies in the private-sector health insurance industry.

My sense of Ted Kennedy was crystallized by the speech he gave at the Democratic National Convention in 1980.  It was finely crafted and superbly delivered, and it was a grand exposition of the New Deal ideology, a political philosophy that holds out the promise of accomplishing great things by using government as an engine of social improvement.  Lyndon Johnson's Great Society also captured that vision, updated for the 1960s.

But in 1980 the American electorate had become deeply skeptical of government as a means toward the end of making America great, and it resonated with voters when Ronald Reagan told them government was the problem, not the solution.

It is time to rethink that way of looking at things when we consider the financing of healthcare.

We have money to spend on healthcare.  We give it to insurance companies, which are supposed to serve as a conduit, channeling the money to pay the doctors, hospitals, and other providers of health care to patients.  But the business model of the private health insurance industry is such that a portion of that money is not spent on health care.  Instead it is diverted to administrative costs that are substantially higher than we see for the government agency that runs Medicare and Medicaid, as well as marketing, return to investors, and lavish executive compensation.

Everywhere you look these days there are advertisements in the broadcast and print media and highway billboards saying "Aetna, I'm glad I met ya" and telling us that Cigna is in the business of caring.  Especially galling are the TV commercials for the "Medicare Advantage" plans, created to give the health insurance industry a cut of the Medicare dollar.  What was the rationale for that brilliant idea?  That private industry should be given a chance to show how it could do what Medicare does, only better.

Well, I am here to tell you this: it is not better; it is larceny.

Medicare's administrative costs are much lower, there are no investors expecting dividends, there are no executives pulling down millions, or tens of millions, of dollars each in annual compensation, and the marketing consists chiefly of little ads telling seniors to call 1-800-MEDICARE if they have questions.

Meanwhile, patients and doctors spend hours on the phone trying to get health insurance companies to pay for things they are supposed to pay for and jumping through hoops to get them to do so.

As if all this isn't reason enough to ditch the absurdly fragmented non-system we have for financing healthcare in this country, about ten percent of Americans are on the outside looking in, with no healthcare coverage at all.  They don't qualify for Medicare or Medicaid and they either are not eligible for employment-based coverage or cannot afford their share of the premium.  Some are self-employed and cannot pay the eye-popping premiums one finds in the individual market.

And many who do have coverage through the private health insurance industry struggle with copays and deductibles that are large enough to discourage them from seeking health care when they need it, because the costs will be largely or entirely out-of-pocket.

It is time to ditch the private health insurance industry.  It has had more than half a century to show that it can efficiently and effectively cover Americans whose health care is not financed through a government-run program, and it has demonstrated beyond any doubt that it is a failure.

Even for those who have been satisfied with employment-based coverage, that very satisfaction - and fear that something else won't measure up, or there will be a gap - is a barrier to changing jobs when such a move would otherwise be the right decision for career advancement.  Employment-based coverage came into existence at a time when employers were looking for ways to recruit and retain workers in an economy that was abundant in job opportunities.  Now it restricts career mobility and keeps people in jobs no longer satisfying because they cannot risk being without coverage in transition, with the cost of transitional ("COBRA") coverage being exorbitant, and fear that the next company won't cover a pre-existing condition.

We need a system that works like this: you are a human being on American soil, so you're covered. When you are born, you get a Social Security number, and you are also enrolled for healthcare.  For those of us who have already been on the planet for a while, it is easy to sign up.  If we don't take the initiative to do it ourselves, the first time we need healthcare, we get signed up on the spot.

Copays?  Deductibles?  Nope.

Copays and deductibles have two purposes.  The first is to get people to pay part of the cost of services that they already paid for when they shelled out money for premiums.  In a public system financed with public dollars, that rationale goes away, because there is no insurance company using it to boost its bottom line.  The second is to give people "skin in the game."  In other words, if you have to pay something, it will make you more sensible and responsible in your decisions about whether and when to seek health care.

There is no question that there is great variability among us in healthcare-seeking behavior.  Some of us seek professional health care for every little thing, and others do so only when they are very concerned that they have symptoms that could be something quite serious.  In my practice of emergency medicine I see people who have been in a car accident and feel fine, but they think they should come in "just to get checked out," while others are badly hurt and had to have worried friends or family badger them for many hours to persuade them to seek medical attention.

Yet there is abundant evidence that copays and deductibles discourage people from seeking health care that is very necessary, even urgently needed, as much as they are discouraged from seeking care that is of doubtful necessity.  Do we really want the 55 year old woman delaying going to the hospital for hours or days when she is having a heart attack, because the out-of-pocket cost encourages her to hope it's just indigestion?  I cannot begin to tell you how many times I have looked at an EKG and thought, "Well, no wonder the Tums didn't help."

I recently got an email from a conservative group, working to build public opposition to Medicare for All.  "Do you want government-run healthcare?" was the question it posed.

Great question, often paired with the assertion that the postal service - which we all love to ridicule - is an example of how the government cannot do anything well.

But Medicare for All is not "government-run healthcare."  If the government is paying all the bills instead of just the ones from patients currently in Medicare, Medicaid, and other government-based healthcare plans, it doesn't mean the hospital where I work, or the one in your neighborhood, or your doctor's office will be taken over by the government.  It just means they will be sending the bills to Medicare instead of to a slew of different companies, each of which has different rules and varying paperwork and employs an army of people to review claims and say, "No, we're not paying for that."

Imagine how much can be saved in costs by hospitals, doctors, and others who are dealing with one payer and one set of rules that are clearly understood by all.  And imagine a world in which patients get the care they need, and it simply gets paid for without their ever having to do anything except sign a form saying they received the healthcare being billed.

So, you may think, "No, I don't want government-run healthcare."  But you should want Medicare for All.  There is no good reason not to want it.  But the private health insurance industry will fight it with everything they have, because it will replace them.

It is time to replace them - with a system that works for all of us, and does the job right.

In fact, it is long past time.  

Sunday, August 13, 2017

Charlottesville: Erasing History?

Deadly violence erupted in Charlottesville, Virginia yesterday.  White nationalist demonstrators were protesting the possible removal of a statue of Robert E. Lee, the Civil War general who led the Confederate forces.

Charlottesville is the site of the University of Virginia, the institution founded by Thomas Jefferson.  Mr. Jefferson famously said of slavery that "...this momentous question, like a fire bell in the night, awakened and filled me with terror. I considered it at once as the knell of the Union. it is hushed indeed for the moment. but this is a reprieve only, not a final sentence."

Jefferson understood what must happen to the South's "peculiar institution" of forced labor of Africans brought to the Western Hemisphere in shackles under the ghastly conditions of slave ships.

Lee, on the other hand, was one of the men who went to war to preserve that institution.

The statue in Charlottesville is of Robert E. Lee mounted in military splendor upon his magnificent steed, Traveller.  Removal of the statue, according to those who support its being left in place, is an attempt to "erase history."

I know a little something about history - and the history of the South's "peculiar institution."  I have read biographies of all the early presidents who were slaveholders, notably including the four of our first five who were from Virginia.  I have also read extensively on the political history of the decades preceding the War Between the States.

Beyond the thousands of pages I have read on the Civil War itself, my personal library includes biographies of Jefferson Davis, Robert E. Lee, and Stonewall Jackson.

I can assure you, there is no "erasing history."

But there is something to think deeply about: if we do not want to forget Robert E. Lee, how exactly do we want to remember him?  And what sort of monument would facilitate that?

We are not about to forget that Lee led the Army of Northern Virginia against the Army of the Potomac, that he matched wits on strategy and tactics with Union generals and mostly out-generaled them.  Lee's admirers would say that ultimately his cause was lost because the North had more to work with in men and materiel, and in the final analysis it proved to be a war of attrition.

But the grand monument to Robert E. Lee in the saddle on Traveller suggests admiration for what he did on the field of battle, including exactly what it was he sought to accomplish: separation of the Confederate States of America from the United States of America, and the continuance of slavery.

And I believe that a monument to Lee's quest does not belong in Charlottesville, or anywhere else in these United States.

So let us not forget Lee.  If there is to be a monument, let it show Lee together with the Union general who brought Lee's quest to its proper end.  Such statuary is depicted at the beginning of this essay, showing Lee and Grant at Appomattox Courthouse.

In the spring of 2016 exit polling told us many voters in South Carolina thought Lincoln should not have issued the Emancipation Proclamation, and we would have been better off if the South had won the Civil War.  Monuments to Robert E. Lee serve to support such beliefs.  It may very well be that the names of Confederate Generals attached to US military bases, such as Fort Bragg in North Carolina and Fort Hood in Texas, do something similar.

So let us not erase history.  But let us make thoughtful decisions about having monuments to history that reflect today's values, not the shameful dehumanizing institutions of centuries past.

Sunday, July 23, 2017

Ethics in Politics: Reconstructing a Broken System

The year was 1988.  I was serving as chair of emergency medicine at a community hospital in a steel town in the Upper Ohio Valley.  A patient had a complex situation that raised issues in biomedical ethics.  The chair of family medicine was the patient's primary care doctor.  At the end of our discussion we agreed that our hospital needed an ethics committee to deliberate on such cases.  We recruited the director of the ICU, and his wife, a medical ethicist, and we formed a committee.

In the nearly three decades since I have been immersed in the study of ethics: not just biomedical and professional ethics, but the ethics of human societies.

This immersion has convinced me of many things.  One of these is that access to basic health care of high quality should belong to everyone living in American society.  Right now it doesn't.  We have an absurdly fragmented non-system for financing health care.  You can have employer-based health insurance.  You can be elderly or disabled and qualify for Medicare.  You can be impoverished and qualify for Medicaid.  You can be in the military service or a veteran and have access to care in that system.

But you can also have no coverage and no access.  The United States is virtually alone among First World nations in having a significant segment of its population in that last category.

Here is what I think the situation should be in a society with sound ethical values that are put into practice: if you are a member of our species, and you are on American soil, we take care of you when you are sick or injured.  You may worry that the world will flood America's borders with refugees desperately seeking health care, and you may want to find ways to prevent that.  But right now we have nearly 30 million Americans without health care coverage and access, and tens of millions more whose coverage and access are woefully inadequate.

Why don't we have universal health care now?  Is it because most Americans are cruel and heartless?  Is it because most of the 535 Members of Congress, our Senators and Representatives, are unethical beasts who care not a whit about the common man?

We have some among us, and some in Congress, to be sure, who care too little about the have nots of our society.  But a large part of this failure is the result of having a profit-driven health care system.

Think about it.  The most efficient way to take care of absolutely everyone would be to have a uniform system, like Medicare, that covers all Americans.  But that would eliminate the private health insurance industry, an industry that is very profitable.  It would surely clamp down on prices charged by the pharmaceutical industry - an even more profitable sector.  And those industries protect their turf by contributing to the election and re-election campaigns of the people on Capitol Hill who make these decisions.

The middle class family looking at eye-popping health insurance premiums, the struggling single mom who makes a little too much money to qualify for Medicaid, and the down-and-out homeless person living in a cardboard appliance box over a subway grate or sleeping under a bridge - these are all people with no political power because they are not part of the system of campaign financing.

These very same forces keep Members of Congress from doing the right thing in many other areas - including improving the environment and protecting consumers - because on the other side of those issues are corporations and wealthy and powerful individuals with their own agenda.  And their agenda and ours are completely different.

The member of the House of Representatives elected by the people of my congressional district is a fellow named Tim Murphy.  Over the years I have thought of Murphy as a decent and ethical fellow, even if he sometimes voted in a way that I thought was too friendly to corporations, especially those in the health insurance and pharmaceutical industries.

Then along came the American Health Care Act (AHCA) - the House version of the effort to "repeal and replace" the Affordable Care Act.  According to the best available data, the number of non-elderly people in our congressional district who would be tossed out of the Medicaid program, promptly joining the ranks of the uninsured, is 37,000 - among a population of about 700,000.

That's right: more than 5% of the population kicked off their health insurance. And Mr. Murphy voted for that.  I was shocked.  Then I realized I shouldn't be. Those 37,000 people don't make campaign contributions.  Heck, many of them probably don't even vote.

We must bring strong ethical values into our political system.  We want our elected representatives to make good decisions: decisions that are best for all of us; decisions that give us cleaner air and water, that avoid atmospheric changes that will bring calamity to global climate and acidify the oceans; decisions that protect consumers from businesses that, driven by profit, would abuse them in an unregulated free market.

I couldn't help but notice that Murphy had no Democratic opponent in 2016 or 2014.  Why should he vote anything except the Republican party line?  I thought about that question, a great deal.  And I decided I must do something to give him a reason.  I must give the voters of Pennsylvania's 18th congressional district a choice.

And so I have filed with the Federal Election Commission to be a candidate for the Democratic nomination for this seat in the House.  I have gathered smart, energetic, politically attuned people around me, people who are committed to bringing this kind of change to the system.  And, because no race for a seat in Congress can succeed without funding, I have begun raising money.  This is a grass roots campaign.  No money from the corporate world will be flowing into my campaign treasury.  There will be individual contributions and very little else. If a PAC that strongly supports universal healthcare wants to contribute, we will talk.  But I intend to serve the interests of the people, not the powerful, and that is how my campaign will be funded.

In the latter third of the 19th Century this nation attempted a Reconstruction to include in our political system people who were left out by our original Constitution: people who counted as three fifths of a person for purposes of determining a state's representation in the House but who were not themselves citizens and did not have the right to vote.  It is time for another Reconstruction, this time one that will bring back control of our government to all the people, and not only those who have the money to buy a share of it.

For more than three decades in the practice of my specialty of emergency medicine, I have been making human connections with people in crisis caused by illness or injury, from the well-to-do to the destitute, from Americans whose ancestors were among the earliest colonists to immigrants from Africa and Asia doing their best to communicate with me in very rudimentary English.  You will not find many in the halls of government who know the people of the district as I have come to know them.  I have come to know them, and I will do what is right for them in Washington, DC.

Please join me in this effort.  Give what you can, whether it's time, or money, or telling your friends about this candidate and this campaign.

Please visit the campaign's Facebook page to learn more about this candidacy.

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[The campaign website is under construction at solomon4pa18.com, but it will soon tell you all you want to know about what I am trying to do.]