The Health Care Reform Debate In Perspective

As everyone paying attention has seen, I've done a lot of writing about health care. A lot of it has been in much the same vein as every other liberal-to-socialist blogger on the blogosphere: criticism and polemic on the debate itself. As I've noted before, there's a lack of excellent writing on the substance of the debate. I've decided to try to address the substance again, partially because new readers who find me 'more liberal than radical' may not have seen my earlier commentary on the substance of the debate and partially because I'm still not terribly satisfied with the final form health care reform is taking despite my pleasure that it looks like some basic problems will be addressed.

First and foremost is the substance of the reform actually being discussed in Congress. The right-wing advocates of market reform and the left-wing advocates of national health care policy have both been excluded from the debate. As I (and others) have said before, what is being debated in Congress now is insurance reform. Insurance reform is better than no reform at all. It certainly addresses the real problems of health care in America better than market reform as advocated by the right.

Those problems, which I have also written about before, are basically three-fold:

1.) High consumer costs generated by the inefficient pooling of costs in multiple payment pools. This means multiple partially funded systems of payment and no single fully-funded pool of shared costs. This is entirely opposite to the principle of shared cost. Whereas other insurance can survive this way because it covers against the unexpected, everyone will need medical care at some point in their lives. Thus the inefficiency of the cost-sharing method has a mushroom effect on consumer costs. When one adds to this the cut the insurance companies must take from the consumer to make a profit it only gets higher. So while medical costs really do rise as technology changes, the consumer costs created by our insurance system are the biggest cost problem.

2.) Access to proper care is restricted in a variety of ways. The uninsured frequently forego all but the most urgent care (which is much more expensive) for financial reasons. Insurance companies frequently make their customers jump through hoops to make full use of their benefits, or deny payment entirely if it suits them to do so. Medicaid is difficult to receive (indeed, many of the people who need it are ineligible because of the family requirements) and offers inferior service. Medicare and the Veterans Administration only serve specialized portions of the economy. Thus many people cannot afford to see a doctor, believe they cannot afford to see a doctor, or choose not to see a doctor because they prioritize other financial needs before medical care. Even when one has coverage, there is no guarantee the insurance company will provide full access to necessary care under the current system.

3.) The current health care system puts a tremendous burden on American business. The majority of people with insurance who are not covered by Medicare or Medicaid receive health insurance benefits through their workplace. This infringes their economic freedoms (because their benefits tie them to their job) and it also shifts much of the cost of health care onto the business sector as a de facto tax burden. This latter aspect is worth taking into account among the many problems with American economic policy. I'm no friend of corporate culture, as anyone who reads my stuff knows, but forcing the corporate sector to underwrite what most of the world considers a national issue and a government responsibility is... of questionable capitalist virtue.

The current health care reform proposals in Congress primarily address problem #2. They would require insurance companies to open access to more care to their customers and restrict them from simply dropping their customers or refusing to pay for a variety of reasons. This is a huge improvement not to be ignored. However, it is key to remember that the first and third problems with our current system are only addressed tangentially if at all.

The focus on costs is on medical costs, not consumer costs. While medical costs are a real issue, they are secondary. A better system for paying consumer costs would lower them dramatically without the need to focus on medical costs that can probably not be cut to the degree believed by the advocates of insurance reform. The creation of a competitive, national insurance exchange will probably lower consumer costs somewhat... but it is difficult to say how much and it is possible it won't have a real impact because of the increased standards of quality may keep consumer costs higher than desired. A competitive, robust public option might help to drive costs down somewhat... but it is again very difficult to say how much this will help the guy who already can't afford to buy private insurance.

The economic problem is ignored entirely. First (and perhaps worst) it is assumed that everyone with employer-paid insurance is happy with their coverage and that there is no need for reform of this market. My partner's experiences following surgery have shown, to me, the facts are very different. Employer-paid insurance is in much the same state as private insurance, whether the premiums are lower or not. The public option, as it stands now, would not be available to anyone receiving employer-paid insurance.

In addition, liberals appear to believe that corporations can and should foot the bill instead of government. They advocate increasing employer's responsibility to provide insurance to their employees and punitively taxing those who do not. This may serve the needs of PayGo, but it is aggravating rather than solving problem #3.

None of this is intended to suggest that the insurance reform being discussed in Congress is not better than our current situation. It is. Nor is it meant to rally opposition to said insurance reform. If nothing else can pass, insurance reform needs to pass.

It is meant to put the problem in its proper context and to instill an understanding that this reform is not the 'end' of health care reform. It is a first, shaky step in the right direction. The issues of consumer costs and economic burden will remain to be addressed, and the left must not forget that. We must continue to raise and address these issues to affect future policy debate as much as possible.

To put it more simply, we need massive reform and even the 'liberals' in Congress are not approaching the problem from a sufficiently radical direction. We should support them, but we should keep pushing in the wake of their success.

Energy Policy, Environmental Policy, and National Security

Climate change is a real, ongoing phenomenon and human action has contributed to its aggravation. That is a scientific fact. I want to get that out of the way before I begin to ramble in twelve directions at once. There are real environmental dangers facing the world and it is important that we are able to confront them; either we must find real ways to minimize our impact on our world or we must find real methods of dealing with the consequences of our mucking up the world. No sane or intelligent person should doubt or deny this.

That said, no one really has any idea how to successfully go about this. Not really, not yet. We know the problem but not the solution. This has created the usual dichotomy in such circumstances. On the right hand we have the people who deny, publicly at least, that there even is a problem or say that we can't do anything about it without more information. On the left hand we have the panic driven activists who suggest anything and everything to stave off global catastrophe.

Southern Beale has been writing about 'astroturf' fronts for the oil companies fighting the administration's cap and trade proposals. Her last three pieces (here, here, and here) have all been on the topic of the environment, the oil companies' attempts to create 'grassroots' opposition to the administration in order to protect what they perceive as a threat to their bottom line, and what environmentalists are doing in return. All of this has had me thinking about the issue a great deal. It occurred to me, during my one hour break between my two stretches of work this morning, that I haven't written a really obnoxiously wonkish and geeky policy piece for a little while.

So all the new readers over the last couple days (high guys!) get to suffer through this for the first time. Forgive my malicious laugh.

I am going to start, as I always attempt, with a statement of the real problem in critically realistic terms:

Climate change is happening.

Not my deliberate phrasing. I did not say 'climate change will happen', 'climate change is happening but', or 'we can prevent climate change by' or any other similar phrasing parsed to fit an agenda. This not about the advancement of agendas, this is about the critical appraisal of the reality of the problem.

Climate change is happening. Now. There is no reset button, no miracle cure, no magic whistle. That bird has flown and all that is left in the cage is the guano. Anyone, right or left, who tells you differently is selling something. There may or may not be ways to reduce the affect we continue to have on climate change in order to ameliorate the actual problems it creates or we may have to start planning to respond to those problems now. I am thinking both is the best bet. In other words, if you've been writing about polar bears drowning to get people aware of the melting ice caps, stop now. Start writing about donating to the World Wildlife Fund and creating a Russian/Canadian/American conservation program to save the polar bears. The ice isn't going to magically refreeze because we switch to solar panels tomorrow.

It is not my intention to take a deliberately fatalistic approach to the problem, but the simple fact is that the problem is not 'how to stop global warming.' Climate change is happening and one cannot just stop it or reverse it, human science does not have that power at this point in time.

This is not to say that we should not explore alternative energy. We should, for a wide range of reasons. First and foremost is the fact that while we may not be able to stop or reverse climate change we might be able to affect the degree of damage the process does to the world.

However, green activists need to keep quite a few facts in mind. There is no (and, more importantly, will never be) technology available to support modern civilization with zero impact on the environment. It doesn't work that way. Hybrid car batteries save fossil fuels and reduce air pollution. Their manufacture also creates toxic waste that must be safely disposed of, and the batteries themselves become toxic waste when exhausted. Hydrogen fuel cells are not an energy source, they are merely a means of energy storage and transfer. This means that a hydrogen car runs entirely clean... but the fuel cells must still be manufactured using electricity, gasoline, nuclear power, or some other primary energy source. Which means that there is still an environmental impact. Solar power requires a great deal of space for solar panels, takes a great deal of time to generate energy, and is difficult to easily store/transfer. Wind power is quicker, but it still requires a lot of space and has the same storage transfer problems. Both require technology that produces significant industrial waste. Hydroelectric power is amazing and versatile... but it has a massive environmental impact on watersheds and wildlife.

I think everyone gets my point. We have to either start the Luddite Revolution now, which I think would be awfully silly, or admit to ourselves that we are going to continue to damage our environment no matter how we finally decide to power our civilization. There is no 'green revolution' because nothing we, as humanity, develop will be truly green for at least the next few centuries.

Before the oil companies start donating money to keep my blog going, however, I have even harsher reality for them. The world's oil supply is finite. One can believe or disbelieve in the precise predictions made by specific economists and geophysicists using various models, but the fact remains that oil is not a renewable resource. This means it is absolutely necessary that the world adopt alternative energy models and that the United States adopt a comprehensive energy policy and plan for transition away from oil and coal as the primary energy supply for the economy for reasons entirely economic. Environmental benefits accrued from such a transition are difficult to predict for certain. It is possible that the effects of climate change could be moderated to some degree but impossible to predict that degree.

This all brings me to policy. For all the right wing claims about innovation in the free market, much of 'free market' innovation has been driven by government research grants, government contracts, or both. Television, as we know it, was developed by defense contractors before the military licensed the technology to private corporations and the original developer of commercial television technology for RCA worked on the government project first. Other television pioneers also received grants from either the US or foreign governments for their work. The number of valuable commercial patents that have been sold to private corporations by NASA is staggering.

Yes, all the innovation comes from the free market. Really.

We need a robust program of government grants for alternate energy sources and plastics technologies that do no require crude oil. Period. Natural gas, hydroelectric, solar, wind, geothermal, nuclear, everything; we particularly need to finance hydroelectric, geothermal, and fusion research as there is still untapped or undeveloped technology in all these areas. Nuclear fission may be useful and necessary in the short term, as part of a transition away from oil and coal, but it is a dead end because of the expense and difficult of safely disposing of radioactive waste.

The corporate research labs spend their time on what is profitable now or will be profitable when easily perfected. They do not 'waste' time on what might be profitable in twenty years without incentive. They are making too much money one existing technologies to explore new technologies without incentive.

As much as possible, additional grants should be made available to scientists not affiliated with corporate labs in any way. If the government wants to sell the patents later, I suppose that's a price that may have to be paid (though I don't like it), but we need to have scientists who do not serve a corporate agenda working on matters this serious.

More than for any other crisis facing the world, the the energy and environmental crises are directly the fault of corporate profiteering. I don't think it's radical to suggest they might not be as interested in solving them as the rest of us.

Should we be scared of 'Socialized Education?'

Of course this is a silly question. While we retain free market options for those who can afford them and wish to make use of them, the bulk of our national education system is already 'socialist.' It has been since the Progressive Era.

On a completely unrelated note, it's very likely that a system of 'socialized medicine' would look very much like our system of socialized education. Good and bad with 'free market options' for those unsatisfied. Just thought it should be said.

The real question is this: can we reform socialized education to correct the flaws the current system has created?

Arianna Huffington thinks so. While I have been critical of Ms. Huffington's writings on health care (here and here) lately, this piece deserves praise as well as analysis and criticism. Her idea is certainly bold and sweeping. Ms. Huffington's idea is to break the monopoly that district schools hold on their students by a simple device:

"In a single-payer health care plan, the federal government provides coverage for all U.S. citizens and legal residents. Patients don't go to a government doctor -- they just have the government pay the bill.

And that's how it would work with education. In a single-payer education plan, the federal government, in conjunction with the states, would provide an education allotment for every parent of a K-12 child. Parents would then be free to enroll their child in the school of their choice."

She also argues, with a certain degree of legitimacy, that this would not be a significant increase in out education budget:

"The single-payer health plan would be financed by a payroll tax. In education, the annual cost per child -- equalized for urban and suburban school districts across each state -- would come from the current education funding sources."

So it's really all simply and straight-forward. Which is good, policies should be as simple as possible. However, this may be too simple. Ms. Huffington leaves several questions unanswered.

1.) Does the phrase 'the school of their choice' mean the public school of their choice or any school of their choice?

There are a couple of reasons for asking this question. The first is the obvious one. If the law were defined to mean 'any school of their choice' it would essentially be school vouchers writ large. All of the arguments for and against school vouchers would then apply to this proposal as well. As school vouchers have been advocated in the past, their cons have outweight their pros. This would be present a far greater threat to the public school system than school vouchers alone. If school vouchers take money away from public schools and put it into the private sector, how much worse would a subsidized private school education for any middle class kid whose parents want it be for the public system? We'd risk turning the public system into a bureaucratic ghetto comparable to Medicaid.

It's worth noting that there are countries that do contribute the same set amount of allotted funds for either private or public school and those countries successfully maintain both systems; but those countries have a higher income tax rate than the US. I do not oppose a tax hike to help pay for private school for those students who choose it, but it would be necessary to avoid cutting public school funds to pay for private school tuition.

2.) If the phrase 'the school of their choice' is restricted to public schools, does this mean conventional district schools or does it include charter schools that currently require students to meet strict standards of entry?

This is a hugely important question. Charter schools are frequently waved about by some educators as the solution to the public education problem. Certainly they offer an ability to innovate beyond the standard public school format. The problem is that charter schools' current success is artificial. Charter schools cherry pick the best students with grade requirements, admissions tests, or test score requirements. This guarantees they will 'succeed' while contributing to public school 'failure.' For charter schools to truly work, they have to be open to every student who wishes to go there and more public schools have to use a charter school system to grant academic freedom to the teachers and administration to run the school that works best for its students. This will be necessary for schools to compete in a free system.

3.) How will schools be allowed to compete to avoid overcrowding?

I already answered this question, but I'll raise the problem anyway: freedom to choose any school one wants will inevitably trigger a rush from the worst schools to the best if the current system remains unchanged. This requires reform allowing public schools to successfully compete with private schools and each other be implemented before opening up the system. The obvious answer is to make every public school a charter school. This allows administration and faculty to tailor their curriculum to their students for maximum results and the ability to at least try to reach every kid.

This, after all, is the real problem with American public education: the stultifying effect of the system on the classroom. We run our schools the way we run our prisons and make inmates out of our children. As long as this is the case, making our kids spend more time in school is like making innocent people spend more time in jail.

Ms. Huffington's idea has a lot of merit. I have addressed it with a critical eye less in the interest of deconstructing it than with the intent of improving it. I hope someone else does the same with my own analysis. This is the kind of attempt to solve real problems that Congress should be taking under advisement.

Some Thoughts On Health Care Debate and Policy --- Again

Everyone is writing about health care. I normally do not write about what everyone else is writing about, thought I do occasionally offer criticism of the things others write. However, as anyone who has read this blog knows, health care is one the issues foremost in my mind. I believe that American health care policy is in need of a near total overhaul and I've said so before. Then, I outlined many of the problems with our system that need to be fixed and attempted to attack those problems specifically in my ideas.

Much of the health care writing on the web and in print right now is centered on the health care debate itself rather than health care policy. This is somewhat dangerous. Indeed, much of this writing attacks or defends the process in Congress or the administration without advancing constructive ideas. There is also, of course, well measured and intellectual criticism of specific problems with the compromises being made in the Senate Finance Committee in the name of bipartisanship. This second quote piece is from Ron Chusid of Liberal Values, who is likely one of the most sensible and sober writers on the issue on the net. Not only is Ron a doctor, and thus possessed of a knowledge of the subject not always present with the rest of us in the blogosphere. He has a great deal to offer both on the debate itself, and in support of many of the reforms currently on the table, in addition to the aforementioned critique of the finance committee bill. He's not so far out on the left as I am, myself, but who really is?

I'm not going to write, this time, about the debate. I agree with the majority of Ron's comments about the debate (I believe passing the current reform agenda in the form most palatable to liberals and most likely to pass muster is extremely important, even if not the final word), though I do believe that those on the left criticizing current proposals have important views that should be heard as well. I believe the left has been shut out of the debate on a more meaningful level even than the right, and I think it's inappropriate that so much sound thinking on the left was merely dismissed.

Instead, I am going to offer something tangible: a new American health care policy. While it is unlikely anything on this scale will be included anytime soon, it is important that such ideas be presented and circulate for the future.

I am going to start by identifying what I think are the most serious problems with the current system, and offer specific solutions to those problems. I will then attempt to predict the problems such a system might create, and create ideas to attack those problems as well.

1.) The chief problem with our current system is financial. This is not the problem of 'health care costs' as described by the pro-reform voices in the debate, but rather the high consumer costs created by the utterly inefficiant means of paying those costs. Rather than pool all the available health care dollars into one pot to pay the total health care costs those dollars are divided between individuals (both those wealthy enough to pay for most health care out of pocket and those too poor to pay any other way, as well as the dollars paid to insurance companies... as well as Medicare taxes), corporations (both through employee benefits and workplace liability laws), insurance companies (who collect money from both individuals and corporations, take their cut, and then pay health care costs), and the government (through Medicare and Medicaid... and also into insurance companies for government employees.) So there are four different entities who pay into multiple pools. In the case of individuals, the government, and corporations those involved all pay into at least two pools and sometimes more. For example: the same person pays Medicare taxes and insurance premiums, while also paying co-payments out of pocket. That person is paying three times for the same amount of health care. Employers pay into insurance pools while paying corporate taxes that go into the budget to pay for Medicaid, and also pays any workplace liability claims. The government funds Medicare and Medicaid and private insurance costs for government employees. That's a horribly sloppy division of costs and is practically impossible for all of that money to be properly applied the way it is spent.

The solution to this is obvious. Eliminate all the pools but one. Every individual pays a dedicated tax, based on the Medicare tax, into one pool of health care dollars. The insurance companies are eliminated. They are only a drain on the system anyway. Their administration costs and their profit requirements merely serve to suck money that could be paying for health care out of the health care pools. The drain on resources to pay for health care that they create does far more damage than the benefits they provide. While there are some excellent companies that would provide a useful model for a single-payer system or national health service (Kaiser Permanente, despite real flaws, would be excellent for the latter), even the best companies drain money out of the health care pool by their business models. The goal is to eliminate co-payments and deductibles for medical care and confine costs to one dedicated payment that would replace health care premiums.

Medicare and Medicaid would also be discontinued and this system would replace Medicare and be extended to cover Medicaid recipients as well. Importantly, this would eliminate the additional expense of Medicaid eligibility testing. An entire bureaucracy would be shaved off, the money saved to supplement the new health care system as necessary.

2.) Access to health care is, by far, the second biggest problem with the current system. This takes two forms: access to actual care and access to care of sufficient quality. The first is actually a set of several subgroups: those who are refused coverage by insurance companies because of pre-existing conditions despite the ability to pay, those who cannot afford to pay for health insurance and thus do not seek medical care under most normal circumstances, and those who have health insurance but whose provider refuses to pay for care for a variety of excuses. The second group consists of members of all the subsets of the third group: those who generate sufficient debt due to the cost of health care that their physicians will no longer see them until they have paid off their bills.

This problem is solved by the previous solution. Everyone is paying directly into the same pool and so everyone has access to health care when they feel the need to exercise that access. This increased access and the increased ability of health care facilities to receive compensation that results from increased access should also have the benefit of including the quality of care to which many people in the second group have access. The reforming of the Medicaid ghetto into part of the mainstream health care system would give people now on Medicaid access to a better quality of care. This would cause those clinics currently providing services to Medicaid recipients on a nearly exclusive basis to improve or be replaced by better facilities. In this sense (and in that of many people on low quality private insurance) this increase in consumer choice would actually encourage a more 'free market' competition between medical facilities and practices. If patients can go where they please with fewer limitations, then facilities must compete for patients more aggressively with better services and care.

3.) One of the major weaknesses of our current system is one that few people on the left or center properly appreciate, one of the few areas where the right is generally correct in their assessment: the economic burden paying for employee health care costs places on business. Many small businesses cannot afford to pay for health care for their employees at all, while more and more corporations are ceasing to provide health benefits or dramatically shifting the burden of paying for those benefits onto employees. The lifting of this burden would do American business far more good than any corporate tax cut. Current health reform proposals seek to shift more of the burden of paying for health care onto American business and to make it more difficult for corporations to opt out of paying employee health care costs by requiring those that do not to pay punitive taxes. Not only is this punitive taxation potentially a bill of attainder and thus legally questionable, but it aggravates what is already a major economic problem.

The system outlined eliminates this problem entirely. There's no need to add much more than that, and this one of the strongest arguments in favor of single-payer or a national health care system. It lifts a huge de facto tax burden on American business.

4.) Insurance companies and medical facilities currently compensate many medical specialists at a rate far beyond what Classical economists would consider 'market value.' Classical theories of labor, based on utility, would argue that the most important medical practitioners would be primary care physicians. However, because of the inordinately high compensation offered to specific specialists (cardiologists, endocrinologists, neurologists, oncologists, psychiatrists, and specialty surgeons all come to mind), the most necessary facet of medical practice is grossly underrepresented while specialty practice is overrepresented. Specialties like geriatrics and internal medicine are also frequently underrepresented, despite the incredible need for doctors in those fields.

The new, single pool for which to pay for medical costs would allow medical study of the need for specialists in various fields to be done to restructure more reality-based compensation for both general practitioners and specialists. Increased compensation for primary care physicians and underrepresented specialties would draw more doctors to those fields. More reasonable compensation for less necessary, but overrepresented specialties, would help to impose some small degree of basic cost control on the system.

There are at least two problems that such a thorough-going reform could create, which must be anticipated and addressed.

1.) Successful medical programs grow in cost precisely because they are successful. This has been witnessed most specifically with Medicare. The huge change it has wrought in the lives of American seniors has steadily increased the cost of the program because of the increased availability of medical care for seniors and the fact that seniors living longer because of increased access to better medical care means that there are more seniors needing medical care. It is only natural and logical to make a baseline assumption that improved access to medical care for all Americans would have a similar effect on the budget of such a system.

There are several things, however, that can be done about this. The most obvious is that purely elective procedures and medications (plastic surgery not directly necessary for reconstructive purposes, Lasik surgery, abortion in any case where the termination of a pregnancy is not necessary to protect the health or life of the mother, elective hysterectomies and vasectomies, ED treatments, etc) would need to still be based on the ability to pay. If this sounds unfair, then perhaps it is, but there is such a thing as economic necessity and that the more efficient allocation of health care dollars should allow the health care industry to lower the costs of elective procedures to a level where more people can afford to pay those costs.

Second, and perhaps most importantly, is this: the current SS/Medicare tax is capped and income over a maximum level is not taxed. A dedicated tax to pay for national health care costs should not have this cap. All income earned above the current cap should be taxed to pay for health care. Such a tax would still be lower, in all likelihood, than the insurance premiums/deductibles the highest paid Americans are already paying for their insurance, simply because of the need for insurance companies to funnel a percentage of their inflow into profits.

2.) Increased access to health care presents the problem of demand outgrowing supply. This used to be the right wing nightmare scenario, before they decided 'death panels' were even scarier. The image of flooded emergency rooms full of the miserably ill waiting their turn was flaunted by the GOP during the 1994 health care debate.

While there are definitely areas where this will be a problem, some of it is actually highly exaggerated. Emergency rooms are already flooded because of the inability of those without health care coverage to simply make an appointment and go to a doctor's office when they have non-emergency health care concerns requiring attention. The increased ability to see a doctor would reduce the strain on emergency rooms rather than increase it, particularly now that 'urgent-care clinics' have become the ongoing medical fad. The recent profusion of urgent-care clinics would relieve much of the current strain on emergency rooms without overcrowding the new clinics. Emergency rooms, more and more, would only be patronized in the case of actual emergencies. That would relieve the system of a tremendous burden.

The area where demand is likely to outstrip supply is primary care. The shortage of primary care practices could mean longer waits until new doctors enter the field. However, demand creates supply. An increased demand for primary care physicians would naturally generate more primary care physicians to meet that demand. The restructuring of medical compensation to pay primary care physicians more equitably would speed this process. There would be a short-term period in which appointments would need to be scheduled further in advance and waits at doctors' offices would be longer, but this would gradually normalize as new doctors entered the primary care field. PAs and nurse practitioners currently fulfill many responsibilities in this area and the expansion of both fields should be encouraged as well.

Besides, in the simplest possible terms, a medical system in which the biggest problem was the office wait for routine care would be a massive improvement over the current mess.

The Health Care Topic Not Everyone Considers: How should we pay our doctors?

One of my frequent sources for outside opinion from the left, Ron Chusid, made me think about the aspect of health care I had not considered most closely before. As something of a policy wonk with strong feelings on this particular aspect of policy, my focus on health care has been the individual's access to quality health care and the cost to that individual. I have not considered, one way or the other, just how doctors should be paid. This has changed a lot over the years.

In the past, many doctors were the 'country doctors' and 'town doctors' of storied movie and television lore. Such doctors were an early form of 'socialized medicine.' They did not punch a clock, but rather were on permanent call should someone need emergency medical assistance and either kept regular offices hours during the week, made regular rounds, or some combination of the two. In return, they were supported by the community. Some of them lived in a home built or paid for by the community, others moved from guest room to guest room, sleeping with one family and then another on a rotating schedule. All were frequently dinner guests at the homes of their patients, some ate all their meals in community homes. If the doctor was paid in hard money at all (and not all were) it was from a community fund into which all the members of the community paid. One could not get more 'socialist.'

Urban doctors (as the phenomenon of urbanization took deep hold in the US) usually worked in hospitals. Hospitals were either public institutions, supported by local tax money, or private charities supported by philanthropists or religious groups. These sources of funding were much stronger than in today's 'for profit' hospitals, and the individual charges to patients were much lower. Doctors frequently lived in the hospital, particularly younger doctors (this is the source of the term 'resident' in medical parlance), and often ate there. Doctors in private practice, usually older doctors, were paid by their patients on a per visit basis.

Health care reform and the largely mythical question of 'cost control' (mythical in the sense that the thesis 'many medical costs can be controlled at the supply end of the spectrum' is questionable at best, many things can be done to control consumer costs) frequently focuses on medical procedures (the much villified 'unnecessary procedures' and the more genuinelyrather than doctor compensation. When doctor compensation is mentioned at all, it is used as a fear tactic by conservatives claiming that the US medical system will suffer a brain drain if doctors cannot get rich. It should be noted that since younger doctors at the low end of the profession are as underpaid and overworked as established doctors at the high end of the profession are underworked and overpaid, the question of how doctor compensation affects health care costs and how health care reform might or should affect doctor compensation becomes an important consideration.

Ron quotes Ezra Klein, blogging for the American Prospect, talking about just this subject. The primary resource for Klein's article is a poll by Kaiser/NPR. Klein, citing the poll and showing a nifty graph, demonstrates that 25% of the people polled believed their doctor should receive a yearly salary while a whopping 70% believed their doctor should be paid for each visit with patients. Klein than says:

"Honestly, I'm surprised patients even have an opinion on that. And it might be a very weak opinion. But for now, the public prefers that doctors get paid for each thing they do than on a salary basis. They prefer, in other words, that doctors have an incentive to do more rather than do less."

It can be taken that way, if one wishes to read it that way. Except that, under the current system, the final word on your medical care is not your doctor. It is either the isurance provider that pays for your care or the HMO or hospital that pays your doctor. This is an important distinction. It is also important to remember that there are times when it might be in your interest for your doctor to do more rather than less. Ron notes:

"Many have experienced the horrors of the HMO era in which doctors were actually paid based upon how little care they provided. Many also see the difference between the more old fashioned model of doctors in private practice as opposed to the increasing number of doctors who are employees paid a salary. They have seen the difference between a doctor who is motivated to work long hours to care for their patients and salaried doctors who check out at 5:00."

Ron makes a very important point for basing doctors' pay on service provided to patients rather than service to the clock. I work for myself, and in 'private practice' I am paid for the work I actually do, not for my time on the clock. While one can argue that a doctor in a hospital might deserve compensation for his availability, I agree with Ron that a doctor's primary compensation should not be for punching a clock.

To repeat an example I gave in my comment on Ron's post, compare the way doctors are compensated with the way lawyers are compensated. An associate in a law firm (the rough equivalent of a resident in a hospital) is paid a salary, because they are an employee. However, their pay is greatly affected by their billable hours (more productive lawyers are paid more) and most law firms pay extra compensation for courtroom hours. Lawyers in the same position as doctors of equivalent experience are incentivized to work more rather than less. What is more, lawyers who do not meet firm standards of billables will see their pay drop and may be fired. While this exact model may not be the perfect choice for medical compensation, it outlines a stark difference between the employment models.

I should note that prescribing more drugs (something many liberals bash, as the model which incentivizes doctors for prescribing specific drugs is clearly mistaken) or ordering more procedures (which some hospitals and doctor's offices do indulge in when they know a patient has a plan that will pay for it) are not what I am talking about. These are certainly corrupt practices which liberals rightly bashed. I am talking about the time and care the doctor gives a patient. Prescription incentives and procedure incentives may be fat in need of trimming, but doctors should be incentivized to give the highest quality care to the patient rather than worship the clock.

The major problem with health care reform is the obsession with 'medical costs' as if some miraculous reorganization of the system will magically make things cheaper. If one obsesses with 'medical costs' than one rapidly becomes confronted by the fact that the newest medications and medical procedures will always cost more. The cost of innovation will always be applied to the cost of care. Liberal discussions of trimming wasteful costs and conservative paranoia of 'rationed care' are equally removed from the real problem.

The real problem is the cost of medical care to the consumer and the fact that high consumer costs reduce access and quality of care. The uninsured bum in the emergency room is not given the same quality of care as the teacher with state insurance, and the teacher is not given the same quality of care as the millionaire who can afford to pay every cost out of pocket. This is a very real 'rationing' problem that exists in our current system, and economic rationing will not be solved by bureaucratic rationing. The added 'rationing' effect of provider corruption, which is all but required in order to make a profit, only makes it all worse.

There is no easy solution to the problem of medical costs, and liberals who say the government can solve it all and conservatives who say the market can solve it all are equally wrong. The government cannot lower the costs of the best medical research. In fact, the kind of quality controls that the government needs to impose on prescription drug research and marketing and medical technological research might very well increase the costs of those processes. Lying about this or hiding from it is only counterproductive to health care reform. The market cannot improve the situation because free enterprise must make a profit to remain viable. As long as research companies, medical providers, and hospitals are driven by the need to make a profit then consumer costs will continue to rise and Americans will continue to be denied access.

The only problem that can be addressed is consumer cost, and this problem can be addressed in at least two ways. It can be addressed by spreading consumer cost as equally as possible among the largest number of consumers and subsidizing the rest (which our current system attempts to do and fails) or it can be addressed by addressing the profit motive of corporate health care. France and Germany have gone a very long way toward solving many of the problems discussed through the latter method, with some of the former. Sweden has done even better through the former method, with some of the latter.

Which brings me back to policy. First and foremost, physician pay needs to be restructured: doctors must be incentivized to serve the needs of their patients, not the needs of HMOs or hospitals. This will have a definite effect on the overall quality of care. Second, a way must be found to address consumer costs and individual access. There are plenty of possibilities, but I admit to having particular pereferences.

I admit to favoring a system in which everyone receives access to a primary care physician of their choice and that physician and the indivual patient have the responsibility for health care decisions. I do not believe bureaucrats should make such decisions whether they work for insurance companies or the government, whatever system we choose we must be certain that neither corporate nor government interests can restrict access to treatment nor countermand the most informed decision made with the advice of medical experts.

Economic access, however, is as important as bureaucratic access. As employers increasingly slash benefits in difficult economies and small business owners have never been in a position to effectively provide benefits to their employers, I believe greater government involvement in the payment process is necessary. There should be dedicated, government subsidized health care plans for small business owners and their employees, in which the costs normally borne by the employer are borne by the government. This would dramatically increase the ability of entrepreneurs to compete in the national marketplace. I've said before that the current two-payer system, in which American business subsidizes a significant portion of the nation's health care costs to save American taxpayers a buck is a far more crippling economic burden than any corporate tax. Those costs should be picked up by the government as well. Any necessary tax increases to pay for health care would be entirely compensated by people receiving health care. While these two steps, by themselves, are not the entire process of reform they are a far bigger step we have taken along the right road since Medicare.

If I sometimes appear a broken record on the topic of health care it is because this is the single most crucial area of American life in need of truly radical reform.

Money For Nothing: is the Best Education Policy No Policy at All?

Now stop a moment. Don't let the title scare you. I haven't switched parties, I am not going to write a piece about gutting or disbanding the Department of Education (if we are going to start slashing cabinet departments, Homeland Security is the only genuinely expendable department that immediately occurs), and I am certainly not going to talk about defunding public schools. I believe there needs to be a federal involvement with education and that we should certainly not be spending less money. I'm simply not sure I believe in education 'policy.'

President Obama started outlining his education plan all the way back in March, but I did not write a piece on education then because I wrote two pieces on foreign policy, one on health care, and a couple polemics against GOP attacks on the EFCA. I've continued to be primarily occupied with political polemic throughout April, however, and I feel a pressing need to get back to the kind of meaty policy wonkery that motivated me to start writing in the first place. The most important issues (in my mind at least) may be health care and the economy, but I have written on both those topics quite a bit and I haven't tackled education aggressively yet.

I'll start with some of President Obama's ideas, which include: incentivizing teacher pay based on student performance, ending state limits on charter schools, and lengthening both the school day and the school year.

As it happens, I have reservations about the first two and outright oppose the latter two.

I am all for raising teacher pay across the board, improving the pay scale for experienced teachers, and adding incentives for the best teachers choosing to go to the worst schools. I think all three of these things are good idea. Nor do I have a real problem with ending or modifying teacher tenure, though I do believe this must be looked at carefully. There are benefits to tenure as well as negatives and a more judicious granting of tenure and a more aggressive willingness to weed out bad apples before they are tenured might be far more appropriate than simply ending tenure. Still, the question of whether to retain, eliminate, or modify tenure is not the pressing issue to me that it is to either teachers' unions, top-to-bottom reformers, or hard-line conservatives opposed to spending money on education.

My biggest reservation is the idea of incentivizing teacher pay based on 'student performance.' Now if you are one of today's current crop of gung ho back-to-basics school reformers, this may offend your sensibilities on a vast scale, but it needs to be said: None of the currently en vogue methods of measuring 'student performance' has anything to do with actual education. Neither classroom grades nor test scores measure what a kid has actually learned. The former measures the child's ability to go through required motions to pleasure authority and the latter measures the child's ability to negotiate modern standardized tests. What is more, in the case of the latter, there is the very real and valid concern that teachers are teaching the test rather than educating students. This is already a concern because of No Child Left Behind, and it was a serious concern among many teachers and parents even before that.

Standardized tests do not measure students' level of education, they measure a student's ability to take a test. As a great example, former New Jersey Senator and basketball star Bill Bradley had a miserably average SAT score... and yet he was a Rhodes scholar. Take a moment to think about that: if standardized tests were really an accurate measure of education then such a thing would not be possible. Yet our educational culture relies more on standardized tests than ever, not less.

As for grades, many elementary, middle school, and high school grades are based on completing and returning homework more than any other factor. Much of the homework is tedious and redundant to students who are actually learning in class and the brightest, most successful classroom students are the least likely to feel a pressing need to wade through pages and pages of the same books they covered all day at school. They blow off the homework and their grades suffer. Yet they have actually learned more than anyone in the classroom, which is precisely why the homework is so tedious for them.

Consider as well that many of the quasi-literate, dumbed down, historically ignorant high school graduates of whom we all complain have successfully navigated their time in school without failing. They all got decent grades and decent test scores and managed not to learn anything despite it all. Not so easy to track 'student performance' as it first appeared, is it?

Charter schools are a more difficult issue still. The conservative knock on charter schools is that they are expensive, while the liberal knock on charter schools is that they drain money and talent from 'regular' schools. Many charter schools are highly successful and I understand why the urge to eliminate limits on such schools is so appealing. But the final word on the issue is this: if charter schools are really so great, why the bloody hell aren't all schools charter schools?

If charter schools work, which they appear to, why is it a question of simply building more? Why are we not converting all of the schools in the country to the charter school model? If such a thing were done, then the liberal knock on charter schools would vanish. They would not drain money and talent from 'regular schools' because there would be no 'regular schools.'

The dirty secret is that charter schools are primarily so successful because the deck is stacked in their favor. The admission process is extremely selective, students who are not considered likely prospects for academic success are not allowed through the door. Students who do not meet the performance standards are not kept in charter school programs but instead dumped back into 'regular' schools. Thus much of the success of charter schools is manufactured.

This not to say that transforming the school model from the traditional system in place today to the charter school model is not worth doing. It can be argued that the working model of the charter school is far more versatile and fosters a far better atmosphere than the standard school model. It is simply important to understand that not every student is going to get straight As, regardless of the school model. Regardless of grades, however, every student can learn. This is the real issue, and the obsession with grades and test scores has obscured this. Many of the reasons public education fails so many of our students can be found in traditional public schools, particularly in poor communities. Changing the model has always shown great promise. The problem is that no one has ever changed the model, they have simply built schools using a different model and allowed the same old problems to continue with the rest of the system.

So you see, more charter schools is not genuinely meaningful until we are willing and able to convert the entire public school system into the freer model.

Which brings us to the two portions of the White House education plan which strike me as the most counter-productive: lengthening the school day and the school year.

We are warehousing our students as it is. Parents get less time with their kids, kids get less genuinely free social time (instead having their socialization experience replaced with regimented, formalized experiences which can affect their entire social outlook for the rest of their lives), and a great deal of non-productive time in which kids are simply sitting in school being bored by minutiae already serves to beat our kids down. I went to public school and can heartily attest to the effects of institutionalized bullying (and let no one tell you differently, the school system create an environment that encourages bullying and punishes the victims rather than the bullies, because it is the victims disturbing the faculty and administration routine), teacher apathy (and the powerlessness of non-apathetic teachers to to act on their better judgement), and administrative group-think. Subjecting our kids to more of all that is not going to improve the situation. It is going to aggravate it. School violence will increase significantly.

The biggest problem with the American school system is not in the schools, though it colors nearly every aspect of the schools. The biggest problem with the American school system is the idea that children can be standardized. Every child is a unique individual with unique needs. While huge class sizes, overworked or burnt out teachers, standardized tests, and reams of homework may be real problems that aggravate the attempt to treat kids like interchangeable spare parts, they are the symptom and not the disease. The disease is the belief that education can be systematized, that one magic system can apply to every kid, that individual effort and attention are not necessary, and that the student has no part in the education process. This is an institutional, cultural problem embedded deep in school administration. In the mind of the workers in the average school district office, they are the education system and the school and students are an afterthought. My mother tells a story in which, during tough economic times, a school district made the decision to cut teachers' salaries... and then outfit the district offices with the newest and most expensive copy machines. This kind of thinking, the notion that kids and teachers are supernumaries, is at the root of the problem.

Much of this is rooted in the idea of 'education policy.' Education policy is all too often geared to the idea that systems can be applied to all children and produce immediate, miraculous results. Fads, conceptual gimmicks, and just plain silly ideas have been espoused with rabid devotion, all without understanding that in a free society we are mentally and spiritually whipping the capacity to operate in a free society out of our kids. We have corporate schools to fit the corporate economy, and frequently it becomes difficult to tell the place of work in adulthood from the school in childhood.

The federal government should set academic standards, set teacher standards, police school district programs to make sure that children learn real science, real history, real math, and real literacy rather than broad conceptual images of these things, and above all else it should make sure the public school system can afford to operate. But setting policy from the top down has proven increasingly ridiculous.

The best people to decide education policy may be the teachers in each indvidual classroom, and in a free society the best thing we can do may be to give them the freedom to do it and get out of their way. Maybe, then, we can blame the teachers' unions if we don't like what we get. As it stands now, we have only ourselves to blame.

Crime, Corruption, and Fascism: The War on Some Drugs

While it is old news now, most people are aware that President Obama laughed off a question about marijuana legalization with a joke and a dismissal. At the time, Norm Stamper (a retired Seattle police chief and an advocate of drug policy reform, particularly medical marijuana) wrote a firm and direct article on Huffington Post, chiding the president for the joke. Mr. Stamper is a firm advocate of legalization, having seen the failure of the drug war from the front lines during his career in urban law enforcement. It is worth commenting that he has some street cred on the topic. He is motivated not merely by his views on the pragmatic failures of drug policy, but also by ideological advocacy of legalization through his involvement with the medical marijuana lobby.

I read his article at the time and strongly agreed with his position, though I thought he waved the bloody shirt a little bit. The anecdotal story about John or Jane Q. Public and their tragedy has never been my favorite political tactic, even before Joe the Plumber made it a sick joke. On the issue, however, Stamper is dead on.

Stamper's reaction was not the only reaction on HuffPo, nor was reaction limited to HuffPo. That same week, Ron Chusid wrote (quoting the SanFrancisco chronicle) about the DEA raiding a medical marijuana dispensary in San Francisco and on the topic (quoting Daniel Larison and Andrew Sullivan) of whether it is helpful or counter-productive for advocates of legalization to preface their comments with 'I don't smoke pot, but...', both pieces sparking their share of discussion. The second, particularly, sparked reaction from Jeremy Pober about the issue of pragmatic support for legalization vs philosophical support for legalization and whether or not the debate between the two points of view was counter-productive for the legalization campaign. Norm Stamper wrote about the reaction to his original piece and laid out the debtate between those who felt it was wrong for the president to shrug off the question of legalization and those who felt it was politically wise. The most recent piece by Stamper rekindled my thoughts about the previous pieces mentioned above.

Before I go any further, I will note that both sides of the debate Stamper mentions have factual grounding. It is true that the legalization of marijuana (and the larger issue of the Sitzkrieg that is the 'War on Drugs') is a very important issue that deserves serious consideration and not jokes. Dismissal of the pro-legalization side of the argument as a bunch of pot-heads not worthy of serious consideration is a big part of the strategy of the drug warriors. Even if this was not President Obama's intent, his joke mirrors those used by the drug warriors.

President Obama won several red states where voters take a hard law and order line, and he may believe it is politically inexpedient to advocate drug reform too aggressively because of the risk it may pose to those gains. He may very well be right.

Nevertheless, drug reform is too important an issue not to push, regardless of its political expedience. I will say that again, so that my clarity of meaning cannot be mistaken: drug reform is too important an issue not to push.

The so-called 'Drug War' is better characterized as 'The War on Drugs We Don't Like on Behalf of Corporations We Do Like.' That's awfully long to type, so I will just call it the 'War on Some Drugs', though I can't take credit for that phrase. Drug reform, real drug reform, is about a lot more than legalizing medical marijuana at the federal level or even entirely repealing federal marijuana laws. Real drug reform is about improved regulation of prescription drugs, improved enforcement of that regulation, ending the 'War on Some Drugs' entirely (by legalizing presently illegal drugs and legally regulating those in need of such regulation on a case by case basis), and applying a tax and duty policy to drugs (both those presently legal and those presently illegal) across the board. Medical marijuana is a tiny tip of a huge iceberg, and the entire iceberg must be successfully circumnavigated.

The 'War on Some Drugs' was sold to the public as an agressive campaign of law and order against gangsters and thugs who sold drugs to innocents. It has become, instead, a selective war against the poor and minorities justifying massive violations of civil liberties. The people in the actual business of selling drugs are doing better than ever, while their 'victims' (whom the policy was allegedly enacted to defend) are treated as the enemy.

At the turn of the century, it should be noted, cocaine, opiates, and marijuana were all legal. Marijuana was grown throughout rural America, particularly the South. Cocaine was in soft drinks. Morphine and codeine were sold over the counter, and heroin was in toothache pills, throat lozenges, and cough drops. Drug related violence was impossibly low, by today's standards. These drugs were outlawed roughly at the same time as Prohibition was imposed on alcoholic beverages, as part of the same Progressive Era moral reform movement. Prohibition ended, but the restrictions on illegal drugs were not lifted. Initially, as the big business in organized crime was still gambling and prostitution (which had naturally accompanied bootlegging), things went on as normal... until organized crime realized the money that could be tapped in the market for illegal drugs. Then the drug business bloomed as never before.

The public health argument for prohibition of drugs is laughable. Nicotine and alcohol, both legal, are extremely dangerous drugs when used irresponsibly and nicotine may be impossible to use responsibly. Yet neither are illegal. By comparison to nicotine, marijuana and LSD are as safe as aspirin and both are far less addictive. Even addictive and dangerous drugs like heroin and cocaine cannot compete with nicotine for addiction rates and death rates, and the overdose rates for both drugs may be artificially high because prohibition completely removes any possibility of regulation or quality control. Methadone, the preferred method of treatment for opiate addiction, is far MORE addictive than any of the opiates it replaces and far more dangerous to the health of the user. Yet it is used to treat addiction to heroin without a second thought. Most chemical treatment patients end up addicted to methadone for life and risk deadly withdrawal if they try to quit. Legal prescription drugs frequently have addiction potential and harmful side effects on par with heroin and cocaine as well. The 'public health' rationale for the 'War on Some Drugs' is completely incoherent.

The 'law enforcement' argument is worse. If drugs were not illegal, drug related crime would drop. Drug related crime is so high because drug prohibition relegates otherwise law abiding drug users to criminal status and puts the business entirely in the hands of criminals. Pragmatically speaking, the 'War on Some Drugs' creates far more crime than it stops and the majority of the 'criminals' persecuted under the policy are the victims of the drug cartels rather than their leaders.

On a purely philosophical level, the moral hypocrisy of the WoSD is simply impossible to completely communicate. Recreational users of dangerous drugs are persecuted as criminals... unless they are recreational users of alcohol or nicotine. Mandatory minimums for drug offenders frequently carry heavy racial undertones, such as differences in sentencing for possession of powder cocaine and possession of free-base cocaine. Laws against other drugs, such as heroin and methamphetamine, primarily target the poor. Well-to-do abusers of illegal drugs or prescription drugs frequently end up in treatment programs without facing criminal charges.

The pragmatic benefits of taxation and regulation have been argued by others, and I am not going to repeat them here. My fundamental objection to the WoSD is philosophical, though I agree entirely with all the pragmatic arguments.

One of the greatest flaws in the WsOD, however, is the treatment of prescription drugs. Just as recreational drugs, medical drugs are big business. Dangerous, experimental drugs are marketed before they have been fully verified as safe and effective. Multiple drugs are frequently marketed for the same conditions with no other purpose than to sell another product. Corporate advertisements tell us to solve our problems with drugs every day, and some medical conditions (ADD and ADHD come to mind, but are not the end of the story) have arguably been invented in order to justify selling dangerous drugs to 'treat' them. Once upon a time the purpose of drugs was to cure disease and treat pain, but now the purpose of drugs is frequently to manage chronic symptoms without affecting the underyling condition responsible. This is simply corporate drug dealing, no different than selling heroin on the street. Scores of hugely dangerous products are sold legally to people who may or may not benefit from their use every day.

This situation is too insane to be allowed to continue, the only reason it continues is money. People make money off drugs, legal and illegal, and that money would be threatened by the major overhaul our drug policy needs. Thus political expediency crushes real reform at every turn.

It is easy to understand why the president feels it politically inexpedient to challenge the current drug policy, even in as small a step as to respond to a question about the legalization of marijuana, but it is important that agitation on the issue continue. Our current drug policy, medical and criminal, divides America into two: a nation of addicts and a nationed of criminals.

Clearly, rectifying a crisis on that scale justified radical action.

Economic Reality vs Moral Imperative: Are they really incompatible?

After smug Twittering by Republican operatives that it might be so, it is now official: Arlen Specter (R - PA) has declared on the floor of the Senate that he will be voting against the Employee Free Choice Act at this time and won't reconsider 'until the economy returns to normalcy.' This is both an unfortunate decision by Senator Specter and an unfortunate choice of words with which to deliver it. I'll start with my substantive policy position on the EFCA, before veering off into political polemic about the choice of words.

The EFCA is a reaction to the harsh union busting tactics adapted by corporations, to control their employees' right to protest and bargain collectively in defense of their rights, with the license granted by 'right to work' state government policies and 'at will' employment policies.

'Right to work', in theory, protects the right of the hypothetical Working Joe not to join a union if he chooses not to do so. This sounds great on paper. The problem is that state 'right to work' laws always contain provisions that go beyond allowing Working Joe to refrain from joining a union if he so wishes. These provisions vary in their specifics, but they are remarkably uniform in their effects: they restrict the ability of unions to organize themselves, to bargain collectively, to strike, and to address employee grievances. Thus every individual is alone facing his employer when strolling into the human resources department, without an advocate or ally. Working Joe is free to refrain from joining a union if he wishes, sure, but if his coworkers manage to unionize they will not be able to gain any positive benefits from it. One is forced to wonder whether the purpose of such state laws, then, is really to protect Working Joe's rights or instead to eliminate Working Joe's rights by rendering impotent the only advocate he might have for those rights. Furthermore, 'right to work' laws are guilty of a particularly reprehensible intellectual dishonesty: they posit a counter-intuitive argument in which Working Joe's rights are threatened by a predatory union and safe-guarded by a benevolent employer.

I don't know what is more morally objectionable: the bald-faced arrogance of that lie, or the moral failure of many voters and politicians in both parties in either believing it or failing to properly expose it. This is not a case of Republican bad guys and heroic Democrats, sadly. Many Democrats have co-operated in advancing these swindles. Nor have we seen significant checks on these policies by either state or federal judiciaries. 'Right to work' violates the citizen's constitutional rights to speak and publish his views and to assemble freely in protest. The corporation, through 'right to work', is given fascist police powers that the government itself is denied by the U.S. Constitution. All those libertarians out there who interpret 'less government regulation' as meaning 'greater individual liberty' should have a much harder time swallowing that than they do.

This brings us to the second half of the one-two punch, the right cross to punctuate the left jab: 'at will' employment agreements. Once again we are addressing a policy grounded in a legal fiction. The 'at will' position assumes that employee and employer suffer equal restraint from a contractual agreement and receive equal freedom from restraint by the absence of a contractual agreement. An 'at will' employment agreement gives Working Joe the theoretical freedom to leave his job at any time for or without any reason, if something better comes along. However, it contains no protections allowing Working Joe to secure his benefits, last paycheck, or a good reference is he does so. Most companies require an employee to sign away his right to secure the return of deposits paid to the company or remuneration for unused benefits (such as sick time or vacation pay) should he quit without notice. So Working Joe is not really free to quit at any time.

More importantly is what Working Joe gives up in return for receiving his questionable right to quit at any time for any or no reason. He gives up his right to sue for wrongful termination unless he can prove discrimination covered by the 14th Amendment. This is because the 'at will' agreement gives the company the right to fire Working Joe at any time, for any or no reason, without notice or warning. This not just the freedom to lay Working Joe off if necessary, with recourse to union benefits or federal unemployment aid. This is the right to fire Working Joe and leave him without legal recourse, at the company's pleasure. Working Joe's very right to seek redress in court is contractually eliminated by an agreement alleged to give him more 'freedom.' When really read and considered, the typical employment agreement under 'at will' policies is not an 'at will' agreement at all. It is a pernicious one-sided contract that binds the employee while leaving the employer absolutely free. This rather blows 'equal protection under the law' out of the water.

It should be noted that none of this, neither 'right to work' state laws nor 'at will' employment regulations, serves any purpose but to increase the ability of an employer to control the life and limit the liberties of his employees. 'At will' employment agreements have justified firing employers for their political opinions, for the way they vote, for their internet activity at home, for personal activity far removed from the workplace, and a great many other personal areas into which the employer should have no power to intrude. These agreements are possible because 'right to work' inhibits the creation and operation of a union to oppose these policies. 'Right to work' is bolstered, in turn, by the most important right the employer gains from 'at will' agreements: the freedom to specifically fire an employee for union activity. Remember, the employer can fire the employee at any time, for any or no reason.

Which brings us to the EFCA. Labor unions offer the first line of defense against the kinds of abuses specifically legalized by 'right to work' and 'at will' laws and policies. Labor unions can (and have) organized aggressively against 'right to work' laws, and a strong union can prevent an employer from requiring and enforcing 'at will' employment agreements. When one really considers the minimal gains that Working Joe receives from these laws and agreements against the vast power the employer receives over him in return, it is impossible to claim that these laws are for Working Joe's benefit. They very specifically and explictly benefit corporations to the detriment of the civil rights of American citizens. Passing the EFCA would be a beginning (not the end, it is not radical enough to finish the job, merely to start it) of the restoration of the balance of power between business and labor.

Which brings me back to Senator Specter and into the political polemic portion of this post. His statement 'until the economy returns to normalcy' is fraught with conservative economic meaning. 'Return to Normalcy' was the campaign slogan for President Warren G. Harding, an affable newspaper publisher from Ohio who was driven into politics by a combination of naive political idealism and a lot of corporate money. At the time he ran for president, then-Senator Harding was a member of the reactionary wing of the Republican Party which had helped to destroy President Woodrow Wilson's second term in the wake of WWI. His nomination was a rejection of the more left wing 'Progressive Republican' policy positions of Theodore Roosevelt, William H. Taft, and Robert 'Fighting Bob' LaFollette (one of Harding's opponents for the presidential nomination) and an embrace of the conservative, laissez-faire stance for which President William McKinley's administration had been infamous during the beginning of the Gilded Age.

The meaning of the slogan, 'return to normalcy', was two-fold. The first and obvious meaning was that WWI was over, the peace settlement was settled, and the country would get back to business as usual. The second was a complete rejection of reformist politics, both President Wilson's Democratic 'liberalism' and a rejection of the 'progressivism' and 'gradualism' (both, as more than one historian has noted, were very close to the same thing) that had come to dominate the Republican Party under presidents Roosevelt and Taft. The people backing Harding believed nothing was wrong with the country and nothing needed to be changed. Temporary crises had been conquered and life would go on as it had before them.

This led directly into the counterfeit prosperity of the Roaring Twenties and the tragic economic collapse of the Great Depression. Temporary measures had clearly not been enough, meaningful reform of the system was still needed and had been rejected.

Senator Specter's use of the phrase now is even more egregious, because we are still in the midst of crisis. The ECFA is part of the means of defeating that crisis. Now, as during the Gilded Age, we are faced by jarring imbalances between the rich, the middle class, and the poor while the divisions between the middle class and the poor continue to break down. We cannot wait for matters to 'return to normalcy' before acting to face that crisis, we must move boldly to fix the broken parts of the system. Not only will that bring the current crisis to an end more rapidly, but it will secure us from future repetitions of the same. I firmly believe that the decline in real wages for the working class, the loss of blue collar jobs overseas, and the Bush-era gutting of the middle class all directly share portions of the responsibility for the current crisis. We must act to correct these problems as surely as we must act to correct the problems of the financial markets.

Senator Specter's argument is that in times of economic difficulty, major corporations should have more power to exploit their employees and employees should have less freedom to guarantee their livelihoods and civil rights from the most egregious exploitation. He may not realize it, but it is. The employer-employee relationship at the present time, under present conditions is as adversarial as the political system or the criminal justice system. The employee needs to be restored his legitimate ability to defend himself in that system. The current economic crisis makes that moral imperative all the greater rather than reducing it in any way.

Senator Specter is wrong to change his vote on the EFCA. I can only hope that he realizes he is wrong or that another Republican steps into the breach to fight for the right and the good in our time of crisis.