Patty Wright: Newly blue Maine expands access to abortion

The Maine State House, designed by    Charles Bulfinch   , and built 1829–1832. Bullfinch also designed the famous Massachusetts State House, with its iconic gold dome.

The Maine State House, designed by Charles Bulfinch, and built 1829–1832. Bullfinch also designed the famous Massachusetts State House, with its iconic gold dome.

Via Kaiser Health News

While abortion bans in Republican-led states dominated headlines in recent weeks, a handful of other states have expanded abortion access. Maine joined those ranks in June with two new laws ― one requires all insurance and Medicaid to cover the procedure and the other allows physician assistants and nurses with advanced training to perform it.

With these laws, Maine joins New York, Illinois, Rhode Island and Vermont as states that are trying to shore up the right to abortion in advance of an expected U.S. Supreme Court challenge. What sets Maine apart is how recently Democrats have taken power in the state.

“Elections matter,” said Nicole Clegg of Planned Parenthood of Northern New England. Since the 2018 elections, Maine has its largest contingent of female lawmakers, with 71 women serving in both chambers. “We saw an overwhelming majority of elected officials who support reproductive rights and access to reproductive health care.”

The dramatic political change also saw Maine elect its first female governor, Janet Mills, a Democrat who took over from Paul LePage, a Tea Party stalwart who served two terms. LePage had blocked Medicaid expansion in the state even after voters approved it in a referendum.

Clegg and other supporters of abortion rights hailed the new abortion legislation: “It will be the single most important event since Roe versus Wadein the state of Maine.”

Taken together, the intent of the two laws is to make it easier for women to afford and to find abortion care in the largely rural state.

Nurse practitioners like Julie Jenkins, who works in a small coastal town, said that increasing the number of abortion providers will make it easier for patients who now have to travel long distances in Maine to have a doctor perform the procedure.

“Five hours to get to a provider and back ― that’s not unheard of,” Jenkins said.

Physician assistants and nurses with advanced training will be able to perform a surgical form of the procedure known as an aspiration abortion. These clinicians already are allowed to use the same technique in other circumstances, such as when a woman has a miscarriage.

Maine’s other new law, set to be implemented early next year, requires all insurance plans ― including Medicaid ― to cover abortions. Kate Brogan of Maine Family Planning said it’s a workaround for a U.S. law known as the Hyde Amendment that prohibits federal funding for abortions except to save the life of the woman, or if the pregnancy arises from incest or rape.

“[Hyde] is a policy decision that we think coerces women into continuing pregnancies that they don’t want to continue,” Brogan said. “Because if you continue your pregnancy, Medicaid will cover it. But if you want to end your pregnancy, you have to come up with the money [to pay for an abortion].”

State dollars will now fund abortions under Maine’s Medicaid, which is funded by both state and federal tax dollars.

Though the bill passed in the Democratic-controlled legislature, it faced staunch opposition from Republicans during floor debates including Sen. Lisa Keim.

“Maine people should not be forced to have their hard-earned tax dollars [used] to take the life of a living pre-born child,” said Keim.

Instead, Keim argued, abortions for low-income women should be funded by supporters who wish to donate money; otherwise, the religious convictions of abortion opponents are at risk. “Our decision today cannot be to strip the religious liberty of Maine people through taxation,” Keim said during the debate.

Rep. Beth O’Connor, a Republican who says she personally opposes abortion but believes women should have a choice, said she had safety concerns about letting clinicians who are not doctors provide abortions.

“I think this is very risky, and I think it puts the woman’s health at risk,” O’Connor said.

In contrast, advanced practice clinicians say the legislation, which will take effect in September, said this law merely allows them to operate to the full scope of their expertise and expands access to important health care. The measure has the backing of physician groups like the Maine Medical Association.

Just as red-state laws restricting abortion are being challenged, so are Maine’s new laws. Days after Maine’s law on Medicaid abortion passed, organizations that oppose abortion rights announced they’re mounting an effort to put the issue on the ballot for a people’s veto.

This story is part of a partnership that includes Maine Public Radio, NPR and Kaiser Health News. Patty Wright is a reporter at Maine Public Radio.

Nicole Braun: The GOP's war on democracy in the Heartland


For millions of Americans, there’s no “making it” if you fall beneath a certain social class line. And the Michigan GOP, which was roundly rejected in the last election, is determined to keep it that way.

In neighboring Wisconsin, Republicans decided to show voters there that their voices, votes, hardships, and pain don’t matter. They passed a series of lame-duck bills making it all but impossible for newly elected Democrats to implement their agenda.

Here in Michigan, the GOP quickly followed suit. Republicans pushed many bills through the legislature in their last days in office that hurt regular folks but benefit the elite, despite election results that show unambiguously what voters want.

Among many other things, these egregious bills ignore voter-approved sick leave protections and minimize wage increases, make it more difficult to vote, restrict campaign finance reform measures, and — for good measure — make it harder for voters to get future proposals on the ballot.

The GOP doesn’t care how tough many folks in Michigan have it, and there’s no apparent logic to their thinking except to make it tougher.

For instance, earlier Medicaid rules passed by Michigan Republicans say that folks need to work 20 hours a week. But often when you work 20 hours a week, you no longer qualify for Medicaid — even if you still can’t afford private insurance.

And when you work 20 hours a week without insurance and get sick, you’re out of luck — because Republicans just gutted a citizen-passed initiative to make sure workers have paid sick leave.

They also pushed forward a bill to drastically slow down minimum wage increases approved by voters. Studies show that no one in America can afford a two-bedroom apartment anywhere working even full-time for minimum wage, but Republicans watered down the voter-approved increase anyway.

Outgoing Republican Gov. Rick Snyder signed those bills. Sadly, many folks I talked to weren’t surprised.

Folks in Michigan have been suffering for years under GOP rule. We’ve seen blatant power abuses, including the undemocratic recall of elected officials. We’ve seen rising inequality, a rampant opioid crisis, poverty, corruption, and egregious failures like the Flint water crisis.

“Our governor has a body count — the kids he killed in Flint,” said Wil Gallivan, who lives outside Flint.

“Expecting him to all of a sudden gain some decency is just wishful thinking. We should all be wearing yellow vests at the Capitol, 100,000 people strong,” he added, referring to the “yellow vest” protests rocking France. “But who can afford to take time off their jobs to do that?”

Recalling Snyder’s purchase of an exorbitantly expensive cake just as news of the Flint water crisis was breaking, former bartender and Flint native Carol Frey reflected: “People who pull that usually lack the compassion and empathy chip.”

I teach sociology. It’s a given that the more inequality there is, the more violence, anger, despair, addiction, and hatred there is too. Inequality produces unhealthy humans and unhappy communities. No one can bloom in such unhealthiness.

By pushing forward these harmful bills even after a progressive wave, Michigan Republicans are saying that the people who voted them out don’t matter. So are their neighbors in Wisconsin and in other states across the country (like Florida, where lawmakers are trying to water down a voter-passed initiative to give people who serve time their vote back).

Still, more protests and acts of resistance are planned. Michigan people are strong, and we fight back — even if we’re broke and tired.

Nicole Braun is a sociologist in northern Michigan.

Peter Certo: GOP's mid-terms campaign depended on lies, fear-mongering and rule-rigging

This 1874 cartoon by Thomas Nast is considered the first important portrayal of the Republican elephant.

This 1874 cartoon by Thomas Nast is considered the first important portrayal of the Republican elephant.


I can’t be the only one who spent the night of the mid-terms tossing and turning. Though I managed to shut off the coverage and try to sleep, spasms of anxiety woke me repeatedly throughout the dreary hours.

Ultimately, Republicans picked off several Red State Senate seats while Democrats won back the House and at least seven governorships.

A Democratic House will serve as a badly needed check after two years of aggressive Republican monopoly, but I can’t help feeling uneasy. For one thing, I can’t shake the last days of the campaign.

For a while, Republicans “merely” lied about their policy agenda.

Rather than campaigning on the $2 trillion tax cut for rich people they actually passed, they promised a middle class tax cut they never even had a bill for. And after spending all last year trying to throw 20 million to 30 million Americans off their health care, they (unbelievably!) promised to defend Americans’ pre-existing condition coverage — even as they actively sought to undermine it.

But the lies took a much darker turn as the White House took hold of the narrative.

Led by the president, GOP propagandists turned a few thousand refugees — over a thousand miles away in southern Mexico — into an “invading army.” The White House put out an ad about it so shockingly racist and false that even Fox News stopped airing it.

Unashamed, President Trump kept repeating the obvious lie that the homeless refugees were funded by Jewish philanthropist George Soros — even after a refugee-hating extremist murdered 11 Jews at a Pittsburgh synagogue.

Such vile hatred may have been key to Red State Republican gains in the Senate. But where that wasn’t enough, it was backstopped by voter suppression and gerrymandering.

Suppression may have helped the GOP governor candidates fend off strong challenges in Florida and especially Georgia, where tens of thousands of voters were scrubbed from the rolls and lines in Democratic precincts ran up to five hours long.

And thanks to gerrymandering, it took an extraordinary effort for Democrats to win even a slim House majority. They’re up only a few seats despite decisively winning the popular vote by at least 9 points. Had it been “only” a 4 or 5 point win, Vox’s Matthew Yglesias estimates, the GOP might have retained its majority.

Also worth noting: Democratic Senate candidates actually racked up over 10 million more votes than Republicans, even as Republicans picked up Senate seats on a GOP-tilting map,

To me these results show that Republicans can’t win with their actual policy agenda — not even in many Red States, judging by some ballot initiative results.

For instance, Red State voters in Missouri and Arkansas raised their minimum wages against the wishes of state Republicans. Missouri also legalized medicinal marijuana, along with deeply conservative Utah, and Purple State Michigan voters brought legal recreational marijuana to the Midwest.

Along with Utah, ruby red Idaho and Nebraska expanded Medicaid under Obamacare, a big win for health care.

These progressive policies are far more popular than their right-wing alternatives. So Republicans rely on a potent combination of lies, fear-mongering, and rule-rigging to win.

If Democrats ever hope to really come in from the wilderness, they need to support a host of radical pro-democracy reforms.

In that they can take inspiration from a stunning movement in Florida, where voters re-enfranchised over 1 million of their neighbors with felony convictions. And from Michigan, Colorado, Utah and Missouri, which all passed initiatives to support citizen-led redistricting. And from Maryland, Michigan, and Nevada, which all made voter registration easier.

Uneasiness is part and parcel of drawing breath in 2018. But if I sleep a little better tonight, it’ll be thanks to movements like those.

Peter Certo is the editorial manager of the Institute for Policy Studies and the editor of

Judith Graham: Mainers to vote on expanding home health care, to be paid for by new tax



For Kaiser Health News

As Election Day draws near, a ballot initiative in Maine to provide universal home care is shining a spotlight on the inadequacies of the nation’s long-term-care system. The essential problem: Although most older adults want to live at home when their health starts to decline or they become frail, programs that help them do so are narrow in scope, fragmented and poorly funded. Medicare’s home care benefits are limited to seniors and adults with disabilities who are homebound and need skilled services intermittently.

State Medicaid programs vary widely but are generally restricted to people at the lower end of income ladder. Long-term-care insurance is expensive and covers only a small slice of the older population. That leaves millions of middle-class families struggling to figure out what to do when an older relative develops a serious chronic illness, such as heart failure, or suffers an acute medical crisis, such as a stroke. “We’re about to have the largest older population we’ve ever had, which is going to need exponentially more care than has ever been needed before. And we’re not prepared,” said Ai-jen Poo, co-director of Caring Across Generations, an organization working to expand long-term care services across the U.S. Maine, with nearly 20 percent of its residents age 65 and older, is exploring a radical response to this dilemma that’s being closely watched by other states.

Its ballot initiative, known as Question 1, proposes that home care services be available to all residents, at no cost, regardless of income. If enacted, it would become the first such program in the nation. Adults would be eligible for the program when they need help with at least one “activity of daily living”: walking, bathing, dressing, eating, toileting, personal hygiene and getting in or out of bed. Services covered would include care from aides and companions; speech, physical and occupational therapy; counseling; home repairs; transportation; respite care; devices for people with disabilities; and even, occasionally, small rent subsidies. Stipends would be granted to family caregivers. Seventy-seven percent of program funds would be directed to home care aides, in a move to strengthen this workforce.

More than 21,000 people could qualify for home care services under the new program, in addition to about 5,600 people who already receive services through Maine Medicaid and other state programs, according to the most definitive analysis to date, published last month by researchers at the University of Southern Maine’s Muskie School of Public Service.

Funding for the new program would come from a new 3.8 percent tax on wages and non-wage income that isn’t taxed by Social Security: a threshold of $128,400 per person in 2018. Between $180 million and $310 million would be raised annually, according to various estimates. The program would be fully implemented by January 2022. The political battle over Question 1 is fierce, although no one questions the need for affordable home care for seniors and people with disabilities.

In AARP’s most recent “Long-Term Services and Supports State Scorecard,” Maine ranked last in the nation on affordability of home care. Among thousands of people affected are Rick Alexander of Blue Hill, Maine. 70, a retired school librarian, and his wife, Debbie, 64, who has multiple sclerosis.

“Since Debbie has a progressive form of MS, her needs are going to increase,” said Alexander, his wife’s sole, unpaid caregiver and a supporter of Question 1. “We brought in some paid help years back, but we couldn’t do that for very long: It’s too expensive.” Alexander wants to keep Debbie at home as long as possible, but he worries about the physical demands and emotional consequences.

“I have chronic clinical depression and periodically I go down into the dumps, a long way,” he admitted. “When that happens, it’s hard for me to motivate myself to do anything.” Also, it’s generally accepted in Maine that something needs to be done about a severe shortage of home care aides — a problem surfacing nationwide. Each week, 6,000 hours of home care services that have been authorized aren’t delivered by Maine agencies because of staff shortages, which are particularly acute in rural areas, according to the Maine Council on Aging.

Despite these areas of consensus, however, disagreements surrounding Question 1 are intense and most Maine health care and business associations oppose it, along with all four candidates for governor.

Taxes are a key point of contention. Question 1 supporters argue that a relatively small number of high-income individuals would pay extra taxes. The Maine Center for Economic Policy estimates that only 3.4 percent of people earning income in Maine would be affected, according to a September report. Citing ambiguous language in the initiative, opponents argue that families earning more than $128,400 would also be subject to the tax hike, significantly expanding its impact. A pressing concern is that higher taxes would discourage doctors, nurses and other professionals from moving to or remaining in Maine.

“We have a workforce crisis already, and this increase — which would make our income tax rate among the highest in the country — would be a disaster,” said Jeffrey Austin, vice president of government affairs at the Maine Hospital Association. The program is too expansive and expensive to be sustained long term, other opponents say.

“We have limited public resources in Maine and those should be dedicated to the people most in need, fiscally and physically,” said Newell Augur, a lobbyist for the Home Care & Hospice Alliance of Maine and chair of the “NO on Question One/Stop the Scam” campaign.

In a statement, AARP Maine, which has not taken a stand on Question 1, expressed reservations. “Using a payroll tax to pay for HCBS [home and community-based services] is an untested policy at the local level,” it noted. Also controversial is the board that would be established to operate the home care program. The initiative calls for nine members (three from home care agencies, three direct care workers and three service recipients) elected by constituent organizations to oversee the program.

“The board wouldn’t be accountable to the governor or the legislature, and Maine taxpayers would have no say over how their money is being spent,” said Jacob Posik, a policy analyst at the conservative-leaning Maine Heritage Policy Center. Supporters note that an advisory committee would include state officials from multiple agencies. The board’s structure is meant to be “responsive to the people providing and receiving the care,” said Mike Tipping, communications director for the Maine People’s Alliance, a grass-roots organization that’s spearheading Question 1 and that helped pass a 2017 ballot initiative expanding Medicaid in Maine, currently tied up in the courts.

For all these policy disputes, it’s clear that Question 1 has considerable emotional resonance. “I’ve never had people cry signing a petition and tell me how much something like this would have changed their lives,” said Kevin Simowitz, political director for Caring Across Generations. One of the people who’s spoken out publicly is the Rev. Myrick Cross, 75, of St. Patrick’s Episcopal Church in Brewer. Cross works part time at the church so he can pay for aides that care for his 38- year-old daughter with Down syndrome and his 95-year-old mother, who has suffered from kidney disease, falls, wounds that didn’t heal and pneumonia in the past several years.

Cross works part time at the church so he can pay for aides that care for his 38-year-old daughter with Down syndrome and his 95-year-old mother, who has suffered from kidney disease, falls, wounds that didn’t heal and pneumonia in the past several years. “I will do whatever I need to keep them home,” he said.

Originally, Cross looked to home care agencies for assistance, but with rates of $23 to $25 per hour “that was more than I could afford,” he said. Today, three local residents provide more than 50 hours of care a week for $12 to $15 an hour.

“I’m blessed that I’m able to work and to hire all these people to keep us going,” Cross said. “But several members of my congregation are older and don’t have the family resources that we have. This would make the quality of their lives better.”

Martha Burk: A sad birthday for Medicare and Medicaid




July 30 marks a very important anniversary in our modern political history.

Fifty-three years ago in 1965, President Lyndon Johnson signed Medicare and Medicaid into law, creating two programs that would disproportionately improve the lives of older and low-income Americans — especially women.

Fast-forward to 2018, and both programs are very much under siege. Nowhere is the struggle starker than in the House Republican budget — titled “A Brighter American Future” — now on Capitol Hill.

The importance of Medicare as a source of women’s health coverage can’t be over-emphasized.

Older and disabled women make up more than half the total beneficiaries, and two-thirds of those 85 and over. This budget from hell takes a giant step toward privatizing the program by allowing insurance companies into the Medicare marketplace, which means benefits could be caught in a race to the bottom and become too paltry to cover all but the barest of medical needs.

Medicaid is the joint federal-state program that provides low-income people with health care. The proposed Republican budget repeals the Medicaid expansion that came with Obamacare, which will cause 14 million to 17 million people to lose coverage.

The Medicaid remnants that survive would be turned into block grants, allowing states to pick and choose who gets covered and what kind of benefits they get — no doubt with little or no federal oversight. That approach makes it easier to cut the program without saying how many people would be dropped, or how much benefits would be lowered.

Since poor women under retirement age and their children are the biggest group of beneficiaries, it stands to reason they’d also be the biggest losers.

But there’s more. Because women have more chronic health conditions like arthritis, hypertension, and osteoporosis, they’re more likely to need institutional care. Since Medicare generally doesn’t cover nursing home care, Medicaid provides such care for those with disabilities and/or very low incomes — and 60 percent of those folks are women.

What’s not in the budget? Long gone is the Obama-era effort close the Gingrich-Edwards tax loophole that allows some high-income individuals (possibly including Donald Trump) to avoid Medicare and Social Security payroll taxes altogether, resulting in billions of lost revenue for both programs.

The House Republican budget probably won’t pass in its present form. But with Republican majorities in both houses of Congress, even compromises are sure to favor more cuts.

“A Brighter American Future?” Hardly. This summer’s 53rd anniversary of Medicare and Medicaid looks like a less than happy one for those that depend on them most — namely women, but really anyone counting on growing older.

Martha Burk is the director of the Corporate Accountability Project for the National Council of Women’s Organizations (NCWO) and the author of the book Your Voice, Your Vote. 

And handy for congressional insider trading

From Robert Whitcomb's "Digital Diary,'' in

Congress, at least in recent sessions, has not particularly cared about poor people with limited access to medical care. As Robert Pear noted in The New York Times, “They cannot agree on subsidies for low-income people under the Affordable Care Act or even how to extend funding for the broadly popular Children’s Health Insurance Program.’’ Many Republicans have often expressed a barely disguised distaste for Medicaid and the low-income people on it, while they’re leery of offending the generally higher-income and high-voting folks on Medicare, a much more expansive program.

Most members of the House and Senate are affluent and have few interactions with poor people who are uninsured and who can’t afford doctor visits or prescription drugs.

But the solons do love expanding funding for medical research, with a plan, for example to boost the funding of the National Institutes of Health by $2 billion in the next fiscal year. Mr.  Pear notes, accurately in my view, that a major reason could be that legislators think that the research could create cures for ailments that they, their families and friends might have. And of course, few legislators are young; ailments increase with age.

“{T}he cynic in me says it’s because of the prevalence of selfishness. We all want to know there’s something out there that will cure us if we need it, but many of us are quite reluctant to pay for somebody else to get cured when they need it,’’ R. Alta Charo, a law and bioethics professor at the University of Wisconsin, told The Times.

I think that there’s another element in Congress’s love of funding  medical research and development: Legislators may see this as a way of getting in early on investments in the drug and medical-device sectors.  Enjoy a bit of insider trading. For guidance on such lucrative activities, consult, for example, former Georgia Congressman and former Health and Human Services Secretary Tom Price, M.D.

To read The Times’s story, please hit this link.


LeeAnne Hall: Many have jobs BECAUSE they're on Medicaid


On Jan. 11, the Trump administration issued a cruel announcement: If you can’t find a job, don’t count on being able to get health care.

Under an unprecedented new policy, the administration will let states kick people off Medicaid for the crime of being unemployed. Instead of providing good jobs to struggling people, the administration is offering threats and tougher times.

Those hurt could include the Carrier plant workers from Indiana, whose jobs Trump promised to save when he was campaigning for the presidency. Last year, the company announced 600 layoffs.

Now the last of these employees are being pushed out the door. One worker says she’s “a lost paycheck away from homeless.”

Imagine telling her Medicaid won’t be there for her on top of everything else she’ll lose. The heartlessness is incomprehensible.

Still, her state’s governor is one of ten that’s jumping on the administration’s new proposal to require work or work-related activities. Kentucky’s plan has already been approved.

This is no way to treat people you claim to care about — especially when lawmakers can improve our lives with policies providing child care, paid family and medical leave, and living-wage jobs in a clean-energy economy, to say nothing of affordable health care for all.

Simple facts show that this work requirement isn’t about jobs. Most working-age adults who use Medicaid already work, and many of them have jobs thanks to Medicaid — not despite it.

That’s because Medicaid helps them get and stay healthy enough to work. After Ohio expanded Medicaid, three quarters of those who signed up said getting coverage helped them get work. In Michigan, more than two-thirds also said it helped better at a job they already had.

This policy is another blow for those facing racial or other discrimination on the job. It punishes people in job-scarce communities. It hurts people struggling to find work when they have a past criminal conviction.

And, while the administration says people with disabilities won’t be affected, that could be by only by the strictest definition of disability. Those who’ve been hurt on the job won’t necessarily be protected. Neither may many people struggling with addiction, mental health concerns, or physical conditions that make working difficult or impossible.

We can see from Kentucky’s plan what this could look like. New premiums for struggling families. Paperwork lockouts. A financial or health “literacy test” reminiscent of tests that barred African American people from voting. State officials say 90,000-95,000 people will lose their coverage.

Last year, Americans demanded we not go backwards on health care. Thousands of us showed up at town halls to block the GOP effort to repeal the Affordable Care Act and the gutting of Medicaid.

Everyone should get the care they need.

The expansion of Medicaid under the Affordable Care Act was a step in that direction. It gave many of us hope for the country we can be: one where a family’s fortunes don’t depend on the good graces of a giant corporation, and our lives don’t depend on the size of our wallet.

We still have a long way to go. Many are shut out of health care because of citizenship status, because coverage is still too expensive, or because our states refuse to expand Medicaid.

But the Trump administration and GOP Congress are moving us backward. This new Medicaid scheme is just part of it. There’s also the recent tax bill that will raise insurance premiums while giving huge cuts to corporations like Carrier — which, according to one employee facing layoffs, is “getting money hand over fist.”

Americans want health care expanded, not taken away. They can’t trick us with yet another scheme. Let’s raise our voices again and protect Medicaid.

LeeAnn Hall is the co-director of People’s Action and a member of the executive committee of Health Care for America Now. Distributed by


David Warsh: The sleazy Sacklers' lethal painkiller promotions and the need for a 'Health Fed'

President Trump has  declared the opioid crisis a public health emergency, rather than a national emergency, since the Federal Emergency Management Agency is over-extended in dealing with storm relief.  Unfortunately, the Hospital Preparedness and Public Health Emergency Funds are equally strapped for cash, running respectively at 50 percent and 30 percent below their peak levels of a decade ago. Congress will have to act.

It was, therefore, an especially good time for “The Family that Built an Empire of Pain,” to appear last week in The New Yorker. You can read Patrick Radden Keefe’s remarkable story about the wellsprings of the crisis for free online, more easily, if less pleasurably, than in the magazine itself. The sub-head states, “The Sackler dynasty’s ruthless marketing of painkillers has generated billions of dollars – and millions of addicts.”

Others have worked on the Sackler family story over the years, documenting its leading role in producing the opioid epidemic, including Barry Meier, of The New York Times, who first uncovered the extensive marketing efforts for OxyContin,  and the Los Angeles Times team that documented the "12-Hour Problem '' that Keefe describes. But none has achieved anything like the rhetorical force of Keefe’s article. Once it is reworked as a book, I expect that “Empire of Pain” will eventually  attain the status of Rachel Carson’s Silent Spring, Jane Jacobs’s The Death and Life of Great American Cities, and other classics of social criticism. It is an astonishing story. You might as well read it now.

The three brothers of the Sackler family — Arthur (1913-87), Mortimer (1916-2010), and Raymond (1920-2017) – are far better known as philanthropists than as pharmaceutical entrepreneurs.  All three attended medical school and subsequently worked together at Creedmoor Psychiatric Center, in Queens, N.Y.  Arthur put himself through medical school working for William Douglas McAdams, a small advertising agency specializing in medical markets, then bought the business.  In 1952, the three physicians bought Purdue Frederick, a little manufacturer of patent medicines in Greenwich Village (and no relation to the famous university). Each owned a third.

While Mortimer and Raymond built the company, Arthur took a more distant role, concentrating on medicine as editor in chief of the Journal of Clinical and Experimental Psychopathology from 1950-1962. In 1960, he founded a biweekly newspaper, Medical Tribune, which eventually reached 600,000 subscribers.

The Sackler family grew tolerably rich on the sale of Valium, which between 1969 and 1982 was the top-selling pharmaceutical drug in the United States. When Sen. Estes Kefauver (D.-Tenn.) investigated the rapidly growing pharmaceutical industry in the early 1960s, a staff member prepared a memo that read, in part,

"The Sackler empire is a completely integrated operation in that it can devise a new drug in its drug development enterprise, have the drug clinically tested and secure favorable reports on the drug from various hospitals with which they have connections, conceive the advertising approach and prepare the actual advertising copy with which to promote the drug, have the clinical articles as well as the advertising copy published in their own medical journals, [and] prepare and plant articles in newspapers and magazines.''

Enter Raymond’s son Richard Sackler (b. 1945), in 1971, fresh out of medical school. Starting as assistant to his father, during the next 30  years he presided over efforts to develop OxyContin and  turn  it into the best-selling pain medicine in the world.  How the company, re-named Purdue Pharma, managed that forms the bulk of Keefe’s 13,000-word account.

Simply put, thanks to  massive marketing efforts, the long-lasting narcotic came to be widely prescribed, not just for severe pain associated with surgery or cancer, but for almost any discomfort, including arthritis, back pain and sports injuries – despite its obviously addictive properties. Early versions turned out to be ruinously easy to abuse; later editions turned out to be a gateway to the use of cheaper heroin. More than 300,000 lives have been lost to overdoses of opioid drugs since 2000; perhaps 10  times as many have been shattered.

Arthur’s heirs sold their father’s share of the company to his brothers sometime after 1987. Mortimer moved to Europe to spend and save his dividends  Raymond ran the company day-to day for many years, and died only last July. Nine family members are among the directors of the private company.  Past president Richard Sackler was deposed last year, as part of Kentucky’s complaint that many of Purdue’s marketing methods were illegal. A battle to unseal his testimony has ensued.  Many more lawsuits are in train; their tactics resemble the campaign to rein in the use of tobacco. Congress can be expected to again hold hearings.

The editorial board of The Wall Street Journal also addressed the topic, uncharacteristically ignoring the supply side in favor of demand factors, in a piece headlined "The Opioid Puzzle'' (subscription required). The editorial board’s interest was piqued by “the government’s role is allowing too-easy access to painkillers, particularly among society’s poor and vulnerable.”

Medicaid recipients receive prescriptions for twice as much pain medication as those not covered by the government’s low-income plan, the editors wrote, citing government figures. And one out of every three Medicare beneficiaries received opioid prescriptions last year, half a million of them in extravagant doses. “The only way to explain this cascade of pills is an epidemic of fraud,” the editors concluded.

Better to put the two analyses together.  OxyContin sales are estimated to have been around $35 billion over the last 20 years.  An enormous portion of that was surely paid by the government as insurance subsidies.  Only when you see the two programs unfolding together do you begin to comprehend the nature of the problem – the entrepreneurial genius of the Sackler family on the one hand, developing and marketing popular mood-altering and painkilling drugs since the 1950s; on the other, the rise of government medical insurance since 1966, when the Medicare program went into effect.

Throw in the mostly unrecognized extent to which big pharmaceutical manufacturers have discouraged all manner of research on the painkilling applications of medical marijuana, and you have a real witches’ brew.

The U.S . health-care industry may be, in certain respects, the best in the world; certainly it is the most expensive.  As the opioid epidemic demonstrates, it offers a colossal field for mischief. The editorial board of the WSJ is right about this much:  innovation is the answer, to the opioid crisis, and much else among the medical sector’s many other ills.  In this case the desideratum is regulation – not Pentagon-style hierarchy, but rather the decentralized and consensual decision-making represented by the Federal Reserve System.

The blueprint developed 10 years ago by former Senate Majority Leader Tom Daschle (D.-South Dakota) in his run-up to a presidential campaign that was ultimately overtaken by that of the junior senator from Illinois, Barack Obama, is still the only model that make sense. Daschle imagined a dozen or so regional health-care authorities, sharing power among regulators, physicians, hospitals, insurers, device and pharmaceutical providers, governed by a federal board of governors insulated as much as possible from politics.

A Health Care Fed eventually will deliver efficiency –  and diminish freebooting – in the enormous sector, in much the same way the Federal Reserve Board stabilized the similarly turbulent banking industry a hundred years ago.  It’s just going to take more time – another generation or two, I would guess.

David Warsh, a long time financial columnist and an economic historian, is proprietor of economic principals. com, where this first appeared.

Patty Wright: Maine governor puts brakes on Medicaid expansion

Maine State House, in Augusta.

Maine State House, in Augusta.

Via Kaiser Health News

Just hours after Maine voters became the first in the nation to use the ballot box to expand Medicaid under the Affordable Care Act, Republican Gov. Paul LePage said he wouldn’t implement it unless the Legislature funds the state’s share of an expansion.

“Give me the money and I will enforce the referendum,” LePage said. Unless the Legislature fully funds the expansion — without raising taxes or using the state’s rainy day fund — he said he wouldn’t implement it.

LePage has long been a staunch opponent of Medicaid expansion. The Maine Legislature has passed bills to expand the insurance program five times since 2013, but the governor vetoed each one.

That track record prompted Robyn Merrill, co-chair of the coalition Mainers for Health Care, to take the matter directly to voters Tuesday.

The strategy worked. Medicaid expansion, or Question 2, passed handily, with 59 percent of voters in favor and 41 percent against.

“Maine is sending a strong and weighty message to politicians in Augusta, and across the country,” Merrill said. “We need more affordable health care, not less.”

Medicaid expansion would bring health coverage to about 70,000 people in Maine.

As a battle now brews over implementation in Maine, other states will likely be watching: groups in Idaho and Utah are trying to put Medicaid expansion on their state ballots next year.

With passage of the ballot measure, Maine is poised to join the 31 states and the District of Columbia that have already expanded Medicaid to cover adults with incomes up to 138 percent of the federal poverty level. That’s about $16,000 dollars for an individual, and about $34,000 for a family of four.

Currently, people in Maine who make too much for traditional Medicaid and who aren’t eligible for subsidized health insurance on the federal marketplace fall into a coverage gap. It was created when the Supreme Court made Medicaid expansion under the Affordable Care Act optional.

That’s the situation Kathleen Phelps finds herself in. She’s a hairdresser from Waterville who has emphysema and chronic obstructive pulmonary disease. She said she has had to forgo her medications and oxygen because she can’t afford them. “Finally, finally, maybe people now people like myself can get the health care we need,” she said.

Medicaid expansion would also be a win for hospitals. More than half of those in Maine are operating in the red. Across the state, hospitals provide more than $100 million a year in charity care, according to the Maine Hospital Association. Expanding Medicaid coverage will bolster their fiscal health and give doctors and nurses more options to treat their formerly uninsured patients, said Jeff Austin, a spokesman with the association.

“There are just avenues of care that open up when you see a patient from recommending a prescription drug or seeing a counselor,” he said. “Doors that were closed previously will now be open.”

But voter approval may not be enough. Though a legislative budget analysis office estimates Medicaid expansion would bring about $500 million in federal funding to Maine each year, it would also cost the state about $50 million a year.

The fate of the Medicaid expansion will now be in the hands of the Legislature, where lawmakers can change it like any other bill. Four ballot initiatives passed by Maine voters last year have been delayed, altered or overturned.

But state Democratic leaders pledge to implement the measure. “Any attempts to illegally delay or subvert the law … will be fought with every recourse at our disposal,” Speaker of the House Sara Gideon said. “Mainers demanded affordable access to health care yesterday, and that is exactly what we intend to deliver.”

Patty Wright is a journalist for Maine Public.

This story is part of a partnership that includes Maine Public, NPR and Kaiser Health News.

Jill Richardson: America's service workers need healthcare



Our country  has a powerful myth that anyone can succeed as long as he or she works hard.

That’s the story of Alexander Hamilton that has swept Broadway: how a “bastard orphan” can become “a hero and a scholar.” According to the lyrics he did it by working harder, being smarter, and being a self-starter.

If that’s all you need to do to succeed, then it’s your own fault if you’re poor.

And White House spokeswoman Kellyanne Conway has no sympathy for you. If you’re sad the Republicans want   to take away your Medicaid, she says  you can go get a job. Because your poverty is your own fault.

 To quote Ernest Hemingway at the end of The Sun Also Rises, “Isn’t it pretty to think so?”

The reality isn’t as nice. We don’t live in a society where anyone can get ahead just by working hard. It might feel that way if you grew up middle class, but that’s not the reality that millions of Americans live in.

Sociological research confirms this unpleasant truth again and again.

As for the people on Medicaid who should just “get a job,” odds are that they already have a job. Maybe two jobs.

We as a society want people working in restaurants, cleaning our hotel rooms, checking us out and stocking shelves at stores, and doing any number of low-skilled, generally low-wage jobs. Some people even oppose giving those workers a raise because it would either cut into corporate profits or raise prices.

Well, we can’t have it both ways. We can’t benefit from low-wage labor while simultaneously blaming low-wage workers for their own poverty.

And if you’re truly callous enough not to care if the working poor have access to affordable health care, consider how their plight affects you.

Suppose for a moment that 22 million Americans lose their health care, which is what the Congressional Budget Office predicted would happen if the Senate passed the dead-for-now Republican healthcare bill. What happens?

Those 22 million people no longer go for preventive check ups. They don’t treat medical problems when they occur, before the problems get worse. They wait until they have no choice, and then they go to the emergency room.

If they cannot pay the bills accrued at the emergency room, the hospital eats the cost. But hospitals must balance their budgets somehow, so they raise prices for everyone else.

If you’re insured, then you’re not paying the hospital directly, so the higher prices go to your insurance company. And they pass it on to you in the form of higher premiums.

Thus, if you aren’t moved by the human suffering caused by depriving the working poor of health care, perhaps you’ll be moved by your own pocketbook.

Unless emergency rooms start declining treatment to anyone who can’t pay, turning cancer patients and gunshot victims onto the streets to die, somebody is going to pay for the care of the uninsured.

The question is whether they’ll be able to go for preventive check-ups and treat problems early, or whether they ‘ll go to the emergency room after they can no longer avoid it.

For those who rely on Obamacare for their insurance — myself included — the prospects of losing their healthcare is terrifying. I have several friends with cancer who are literally afraid they will die if a repeal bill passes. And that’s not hyperbole.

It’s time we stopped telling ourselves that anyone who’s struggling only has themselves to blame. And as the wealthiest nation on earth, it’s a travesty that we aren’t willing to help them.

 Jill Richardson is the author of Recipe for America: Why Our Food System Is Broken and What We Can Do to Fix It. 

Peter Certo: Forget Russia, what about Trump's collusion with U.S. corporations?


I've always been a little skeptical that there’d be a smoking gun about the Trump campaign’s alleged collusion with Russia. The latest news about Donald Trump, Jr., however, is tantalizingly close.

The short version of the story, revealed by e-mails that The  New York Times obtained, is that the president’s eldest son was offered “some official documents and information that would incriminate Hillary” and “would be very useful to your father.”

More to the point, the younger Trump was explicitly told this was “part of Russia and its government’s support for Mr. Trump.” Donald, Jr.’s reply? “I love it.”

Trump Jr. didn’t just host that meeting at Trump Tower. He also brought along campaign manager Paul Manafort and top Trump confidante (and son-in-law) Jared Kushner.

We still don’t have evidence they coordinated with Russian efforts to release Clinton campaign emails, spread “fake news,” or hack state voting systems. But at the very least, the top members of Trump’s inner circle turned up to get intelligence they knew was part of a foreign effort to meddle in the election.

Some in Washington are convinced they’ve heard enough already, with Virginia Sen, (and failed VP candidate) Tim Kaine  suggesting that  meeting might be called “treason.”

Perhaps. But it’s worth asking: Who’s done the real harm here? Some argue thatit’s not the Russians after all.

“The effects of the crime are undetectable,” the legendary social critic Noam Chomsky says of the alleged Russian meddling, “unlike the massive effects of interference by corporate power and private wealth.”

That’s worth dwelling on.

Many leading liberals suspect, now with a little more evidence, that Trump worked with Russia to win his election. But we’ve long known that huge corporations and wealthy individuals threw their weight behind the billionaire.

That gambit’s paying off far more handsomely for them — and more destructively for the rest of us — than any scheme by Putin.

The evidence is hiding in plain sight.

The top priority in Congress right now is to move a health bill that would gut Medicaid and throw at least 22 million Americans off their insurance — while loosening regulations on insurance companies and cutting taxes on the wealthiest by over $346 billion.

As few as 12 percent of Americans support that bill, but the allegiance of its supporters isn’t to voters — it’s plainly to the wealthy donors who’d get those tax cuts.

Meanwhile, majorities of Americans in every single congressional district support efforts to curb local pollution, limit carbon emissions, and transition to wind and solar. And majorities in every single state back the Paris climate agreement.

Yet even as scientists warn large parts of the planet could soon become uninhabitable, the fossil fuel-backed Trump administration has put a climate denier in charge of the EPA, pulled the U.S. out of the Paris Accord, and signed legislation to let coal companies dump toxic ash in local waterways.

Meanwhile, as the administration escalates the unpopular Afghan war once again, Kushner invited billionaire military contractors — including Blackwater founder Erik Prince — to advise on policy there.

Elsewhere, JPMorgan CEO Jamie Dimon and other architects of the housing crash are advising Trump on financial deregulation, while student-debt profiteers set policy at the Department of Education.

Chomsky complains that this sort of collusion is often “not considered a crime but the normal workings of democracy.” While Trump has taken it to new heights, it’s certainly a bipartisan problem.

If Trump’s people did work with Russia to undermine our vote, they should absolutely be held accountable. But the politicians leading the charge don’t have a snowball’s chance of redeeming our democracy unless they’re willing to take on the corporate conspirators much closer to home.


Peter Certo is the editorial manager of the Institute for Policy Studies and the editor of 


Trump's 'pluto-populism'

Adapted from an item in Robert Whitcomb's "Digital Diary'' in

The Trump budget proposal is filled with so many bogus assumptions and so much creative accounting it’s hard to take any of it seriously. Indeed, people in both parties on Capitol Hill are treating it as a joke.

But there is a central, cohering direction – make America’s put-upon rich people even richer while sticking it to poorer people, many of whom, deluded by Trump’s demagoguery and such right-wing propaganda organs as Fox “News,’’ voted for the mogul. (Meanwhile, many Democrat-inclined people were too lazy tomake it to the polls.) You have to give the  hateand fake-conspiracy peddlers at Fox credit – the network has very good production values.

Of course, the richer the rich get, the more they control the government and the more that they’re able to further enrich themselves in a vicious or at least lucrative circle.

An essential part of the Trump budget is the assumption, or, rather, assertion, that it will somehow be paid for by increased economic growth – more of what George H.W. Bush used to call “voodoo economics.’’ The promise is that annual gross domestic product growth will rise to 3 percent, even as the nonpartisan Congressional Budget Office projects only a 1.9 percent rate. That’s because the CBO technicians wisely take into consideration, among other things, our aging population and falling productivity.

Most administrations – including Obama’s – havecooked (or massaged?) the books and often projected considerably higher GDP growth than happens. But the assumptions in the Trump plan are particularly egregious given the Niagara of retiring Baby Boomers and the big proposed tax cuts.

For  many Boomers, by the way – especially the richer ones -- Trump is relatively kindly. Older white Baby Boomers vote heavily Republican, and he has vowed not to touch gigantically expensive Medicare or regular Social Security – by far the two biggest entitlement programs – which of course benefit them.

He promised in the campaign not to cut Medicaid. Now he wants to slash Medicaid, Food Stamps and Social Security Disability Insurance. That isn’t to say that Medicaid can’t use some major improvements, such as reducing the amount of unnecessary care and in some cases including work requirements for recipients. And Social Security Disability Insurance has long been rife with abuse. But the fact is that most of the people who benefit from these programs are honest and truly needy. Indeed, most are far more honest than Donald Trump.

Martin Wolf, a Financial Times columnist, described Trump’s “ideology’’ well when he called it “pluto-populism” -- “policies that benefit plutocrats, justified by populist rhetoric.”


The GOP eyes gutting Social Security

Adapted From Robert Whitcomb's "Digital Diary'' in

There's a move underway by some Trump advisers and Republican lobbyists to eliminate payroll taxes used to fund Social Security and Medicare Part A. (Medicaid is financed from general budget funds), with the ultimate aim of throwing more people on the tender mercies of Wall Street to finance their retirements.

Associated Press writers Josh Boak and Stephen Ohlemacher reported: “This approach would give a worker earning $60,000 a year an additional $3,720 in take-home pay, a possible win that lawmakers could highlight back in their districts even though it would involve changing the funding mechanism for Social Security, according to a lobbyist, who asked for anonymity to discuss the proposal without disrupting early negotiations.’’

Well, yes, that might be an initially popular way to destroy Social Security. The George W. Bush administration tried to give Wall Street  lots of Social Security cash. But the public, understandably doubtful that people in the financial-services industry would put customers’ interests first, pushed back. Then came the Great Crash of 2008….

Philip K. Howard: Congress needs to clean out the stables of long-outdated laws

Government is broken. So what do we do about it? Angry voters are placing their hopes in outsider presidential candidates who promise to “make America great again” or lead a “political revolution.”

But new blood in the White House, by itself, is unlikely to fix things. Every president since Jimmy Carter has promised to rein in bureaucratic excess and bring government under control, to no effect: The federal government just steamed ahead. Red tape got thicker, the special-interest spigot stayed open, and new laws got piled onto old ones.

What’s broken is American law—a man-made mountain of outdated statutes and regulations. Bad laws trap daily decisions in legal concrete and are largely responsible for the U.S. government’s clunky ineptitude.

The villain here is Congress—a lazy institution that postures instead of performing its constitutional job to make sure that our laws actually work. All laws have unintended negative consequences, but Congress accepts old programs as if they were immortal. The buildup of federal law since World War II has been massive—about 15-fold. The failure of Congress to adapt old laws to new realities predictably causes public programs to fail in significant ways.

The excessive cost of American healthcare, for example, is baked into legal mandates that encourage unnecessary care and divert 30 percent of a healthcare dollar to administration. The 1965 law creating Medicare and Medicaid, which mandates fee-for-service reimbursement, has 140,000 reimbursement categories today and requires massive staffing to manage payment for each medical intervention, including giving an aspirin.

In education, compliance requirements keep piling up, diverting school resources to filling out forms and away from teaching students. Almost half the states now have more administrators and support personnel than teachers. One congressional mandate from 1975, to provide special-education services, has mutated into a bureaucratic monster that sops up more than 25 percent of the total K-12 budget, with little left over for early education or gifted programs.

Why is it so difficult for the U.S. to rebuild its decrepit infrastructure? Because getting permits for a project of any size requires hacking through a jungle of a dozen or more agencies with conflicting legal requirements. Environmental review should take a year, not a decade.

Most laws with budgetary impact eventually become obsolete, but Congress hardly ever reconsiders them. New Deal Farm subsidies had outlived their usefulness by 1940 but are still in place, costing taxpayers about $15 billion a year. For any construction project with federal funding, the 1931 Davis-Bacon law sets wages, as matter of law, for every category of worker.

Bringing U.S. law up-to-date would transform our society. Shedding unnecessary subsidies and ineffective regulations would enhance America’s competitiveness. Eliminating unnecessary paperwork and compliance activity would unleash individual initiative for making our schools, hospitals and businesses work better. Getting infrastructure projects going would add more than a million new jobs.

But Congress accepts these old laws as a state of nature. Once Democrats pass a new social program, they take offense at any suggestion to look back, conflating its virtuous purpose with the way it actually works. Republicans don’t talk much about fixing old laws either, except for symbolic votes to repeal  the Affordable Care Act. Mainly they just try to block new laws and regulations. Statutory overhauls occur so rarely as to be front-page news.

No one alive is making critical choices about managing the public sector. American democracy is largely directed by dead people—past members of Congress and former regulators who wrote all the laws and rules that dictate choices today, whether or not they still make sense.

Why is Congress so incapable of fixing old laws? Blame the Founding Fathers. To deter legislative overreach, the Constitution makes it hard to enact new laws, but it doesn’t provide a convenient way to fix existing ones. The same onerous process for passing a new law is required to amend or repeal old laws, with one additional hurdle: Existing programs are defended by armies of special interests.

Today it is too much of a political struggle, with too little likelihood of success, for members of Congress to revisit any major policy choice of the past. That’s why Congress can’t get rid of New Deal agricultural subsidies, 75 years after the crisis ended.

This isn’t the first time in history that law has gotten out of hand. Legal complexity tends to breed greater complexity, with paralytic effects. That is what happened with ancient Roman law, with European civil codes of the 18th Century, with inconsistent contract laws in American states in the first half of the 20th Century, and now with U.S. regulatory law.

The problem has always been solved, even in ancient times, by appointing a small group to propose simplified codes. Especially with our dysfunctional Congress, special commissions have the enormous political advantage of proposing complete new codes—with shared pain and common benefits—while providing legislators the plausible deniability of not themselves getting rid of some special-interest freebie.

History shows that these recodifications can have a transformative effect on society. That is what happened under the simplifying reforms of the Justinian code in Byzantium and the Napoleonic code after the French Revolution. In the U.S., the establishment of the Uniform Commercial Code in the 1950s was an important pillar of the postwar economic boom.

But Congress also needs new structures and new incentives to fix old law.

The best prod would be an amendment to the Constitution imposing a sunset—say, every 10 to 15 years—on all laws and regulations that have a budgetary impact. To prevent Congress from simply extending the law by blanket reauthorization, the amendment should also prohibit reauthorization until there has been a public review and recommendation by an independent commission of citizens.

Programs that are widely considered politically untouchable, such as Medicare and Social Security, are often the ones most in need of modernization—to adjust the age of eligibility for Social Security to account for longer life expectancy, for example, or to migrate public healthcare away from inefficient fee-for service reimbursement. The political sensitivity of these programs is why a mandatory sunset is essential; it would prevent Congress from continuing to kick the can down the road.

The internal rules of Congress must also be overhauled. Streamlined deliberation should be encouraged by making committee structures more coherent, and rules should be changed to let committees become mini-legislatures, with fewer procedural roadblocks, so that legislators can focus on keeping existing programs up-to-date.

Fixing broken government is already a central theme of this presidential campaign. It is what voters want and what our nation needs. A president who ran on a platform of clearing out obsolete law would have a mandate hard for Congress to ignore.

Philip K. Howard, a New York-based lawyer, civic leader and writer, is the founder of the advocacy group Common Good and the author, most recently, of The Rule of Nobody.



Paul A. Reyes: Jeb Bush has had freebies his whole life

The Republican Party has struggled for years to attract more voters of color. In a recent campaign appearance, candidate Jeb Bush offered yet another useful case study of how not to do it. At a campaign stop in South Carolina, the former Florida governor was asked how he’d win over African-American voters. “Our message is one of hope and aspiration,” he answered. So far, so good, right?

“It isn’t one of division and get in line and we’ll take care of you with free stuff. Our message is one that is uplifting — that says you can achieve earned success.”


With just two words — “free stuff” — Bush managed to insult millions of black Americans, completely misread what motivates black people to vote, and falsely imply that African Americans are the predominant consumers of vital social services.

First, the facts.

Bush’s suggestion that African-Americans vote for Democrats because of handouts is flat-out wrong. Data from the Joint Center for Political and Economic Studies shows that black voters increasingly preferred the Democratic Party over the course of the 20th Century as it stepped up its support for civil rights.

These days, more than 90 percent of African Americans vote for the Democratic Party’s presidential candidates because they believe Democrats pay more attention to their concerns. Consider that in the two GOP debates, there was only one question about the “Black Lives Matter” movement. When they do comment on it, Republican politicians feel much more at home criticizing that movement against police brutality than supporting it.

Bush is also incorrect to suggest that African-Americans want “free stuff” more than other Americans. A plurality of people on food stamps, for example, are white.

Moreover, government assistance programs exist because we’ve decided, as a country, to help our neediest fellow citizens. What Bush derides as “free stuff” — say, Medicaid, unemployment insurance, and school lunch subsidies — are a vital safety net for millions of the elderly, the poor, and children, regardless of race or ethnicity.

How sad that Bush, himself a Catholic, made his comments during the same week that Pope Francis was encouraging Americans to live up to their ideals and help the less fortunate.

Finally, Bush’s crass comment is especially ironic coming from a third-generation oligarch whose life has been defined by privilege.

Bush himself is a big fan of freebies. The New York Times has reported that, during his father’s 12 years in elected national office, Bush frequently sought (and obtained) favors for himself, his friends, and his business associates. Even now, about half of the money for Bush’s presidential campaign is coming from the Bush family donor network.

And what about those corporate tax breaks, oil subsidies and payouts to big agricultural companies Bush himself supports? Don’t those things count as “free stuff” for some of the richest people in our country?

It’s also the height of arrogance for Bush to imply that African Americans are strangers to “earned success.” African-Americans have been earning success for generations, despite the efforts of politicians like Bush — who purged Florida’s rolls of minority voters and abolished affirmative action at state universities.

If nothing else, this controversy shows why his candidacy has yet to take off as expected. His campaign gaffes have served up endless fodder for reporters, pundits, and comics alike.

Sound familiar?

As you may recall, Mitt Romney helped doom his own presidential aspirations by writing off the “47 percent” of the American people he said would never vote Republican because they were “dependent upon government.”

In Romney’s view, they’re people “who believe that they are victims, who believe the government has a responsibility to care for them, who believe that they are entitled to health care, to food, to housing, to you-name-it.”

Sorry, Jeb. The last thing that this country needs is another man of inherited wealth and power lecturing the rest of us about mooching.

Raul A. Reyes is a lawyer  and columnist based in New York City.Distributed by 


Robert Whitcomb: Oregon points to better Medicaid

  Unsurprisingly, Rhode Island Gov. Gina Raimondo is getting pushback from interest groups against her goal of “reinventing Medicaid’’ – the federal-state program for the poor. The Ocean State’s Medicaid costs are America’s second-highest per enrollee (Alaska is first) and 60 percent higher than the national average.

Many in the nursing-home and hospital industries will fight the governor’s effort to cut costs even if it can be shown that her plan can simultaneously improve care. After all, the current version of Medicaid has been very lucrative for many in those businesses. The Affordable Care Act has brought them even more money.

As we watch her plan unfold, let’s be very skeptical when we hear lobbyists for the healthcare industry and unions asserting that reform would hurt patients. Lobbyists are adept at getting the public to conflate the economic welfare of a sector’s executives, other employees and owners with its customers’. Ambrose Bierce called politics “a strife of interests masquerading as a contest of principles.’’ Often true!

So “nonprofit’’ Lifespan, the state’s largest hospital system, has just hired eight lobbyists to work the General Assembly to defend its interests. (And beware healthcare executives’ citing their businesses’ “nonprofit’’ status. Many of these enterprises take their profit in huge executive compensation.) Some unions are also on the warpath. They worry that reform to reduce the overcharging, waste and duplication pervasive in U.S. health care might reduce the number of jobs.

But economic and demographic reality (including an aging population, widening income inequality and employers’ eliminating their workers’ group insurance) make Medicaid “reinvention’’ mandatory as more patients flood in.

Oregon provides a model of how to do it.

There, in an initiative led by former Gov. John Kitzhaber,  M.D., an emergency-room physician, the state has both improved care and controlled costs. It did so by creating 16 regional coordinated-care organizations (CCO’s). The state doesn’t pay for each service performed but gives each CCO a “global budget’’ of Medicaid funds to spend. The emphasis is on having a range of providers work with each other to create holistic treatment plans for patients that include the social determinants of health (such as access to transportation and housing quality) as well as patients’ presenting symptoms.

Oregon’s “fee for value’’ approach rewards providers for meeting performance metrics for quality and efficiency and punishes them for poor outcomes and increased costs.

Oregon CCO’s have great flexibility in spending Medicaid money. For example, they could use it to buy patients air conditioners, which may make it less likely that they’ll show up in the E.R. And Oregon CCO’s pay much attention to how behavioral and mental problems can lead to the more obviously physical manifestations of illness. After all, many in our health-care “system’’ “self-medicate’’ through smoking, drinking, drugs, eating unhealthy food and lack of exercise. You see many of these people again and again in the E.R. –wheezing from smoking and obese.

In Rhode Island, 7 percent of Medicaid beneficiaries account for two-thirds of the spending; many of these “frequent fliers’’ have mental and behavioral health problems best addressed through Oregon-style coordinated care.

Unlike the Oregon approach, the “fee for service’’ system that’s still dominant in U.S. health care encourages hospitals and clinicians to order as many expensive procedures as possible, prescribe the most expensive pills and do other things to maximize profit – and send the bills to the taxpayers, the private insurers and the patients.

But “evidence-based medicine’’ -- as opposed to “reputation-based medicine’’’ -- has helped to show that doing more procedures does not necessarily translate into better outcomes; indeed overtreatment can be lethal. I recommend Dr. H. Gilbert Welch’s book “Less Medicine/More Health’’.

Meanwhile, Oregon points the way:

Among the Oregon Medicaid reform’s achievements: a 5.7 percent drop in inpatient costs; a 21 percent drop in E.R. use (which is always very expensive), and an 11.1 percent drop in maternity costs, largely because of hospitals not performing elective early deliveries before 39 weeks of pregnancy. Thus Oregon officials assert that the state can reach its goal of saving $11 billion in Medicaid costs over 10 years.

Rhode Island can achieve similar successes.

Robert Whitcomb (, overseer of New England Diary, is a Providence-based editor and writer and a partner  in Cambridge Management Group (, a national healthcare-sector consultancy. He's also a Fellow of the Pell Center for International Relations and Public Policy.

Hospitals must help create new community networks

  Health-system markets are being pushed toward a volume vs. value-payment tipping point. This is driven by the confluence of states’ moving Medicaid and state-employee health benefits to value-based (risk) contracts, corporations’  securing national contracts for high-cost care episodes and commercial payers’ creating tiered health insurance. Successful population-health (value-payment) programs, whether fixed-price bundled services for individual patients or comprehensive services for a specific population, as with ACO’s, require action based on these insights:

  • Outcomes depend on patients’ behaviors over their lifetimes. Thus, patient and family participation must be increased. Success depends on getting “upstream” of medical-care needs.


  • Broad local and regional communities, not individual institutions, can best allocate resources to improve the social determinants of health.

Indeed, improving community health depends more on the interactions among the parts than on individually optimizing the parts themselves. Hospitals and health systems have a time-limited opportunity to help develop community-health networks, the backbone organizations for improving population health.

To get started, leaders of hospitals, public- and private-sector social-service organizations, payers and representatives of the broader community must first frame the discussion from a policy perspective and then map linkages across the community.

Our experience with community health networks underscores the importance of social determinants of health, teamwork within/across collaborating organizations and accepting risk within global budgets. Sustained system thinking across the community’s health assets, shared insights, and much generosity and patience from every sector are critical factors for success and flow from visionary hospital leadership and community/political leaders. Case studies from Oregon and Connecticut, among others, show what can be done.

To get started, leaders would do well to convene a perspective-and-policy-setting discussion to frame context and mutual dependencies. Complex, foundational change is emotionally and organizationally disruptive. Thus establishing a fact-driven and respectful dialogue is an essential first step. We recommend that community leaders, especially hospital leaders, convene a community conversation and use linkage mapping as way to structure the conversation for progress. Based on readiness, one or more work streams would be selected to explore and improve the interactions between the parts.


This  is a summary of an Oct. 13 presentation developed by a Cambridge Management Group team led by Marc Pierson, M.D., Annie Merkle and Bob Harrington for the Society for Healthcare Strategy & Market Development's Connections conference. Oregon State Sen. Alan Bates, D.O., provided invaluable information and insights from his work as both a primary-care physician and community/political leader enlisting colleagues in all sectors.