Taking Note

Dr. Atul Gawande on the “Fight for the Soul of American Medicine”

McAllen, Texas likes to think of itself as the Square Dance Capital of the World. McAllen doesn’t like to think of itself as the home of the most over-priced health care in the U.S.Yet it is, as surgeon/author Dr. Atul Gawande reports in the June 1 issue of The New Yorker. 

McAllen seems an unlikely spot for Gold-Coast Medicine.  “Lonesome Dove was set around here,” Gawande writes.  “McAllen is in Hidalgo County, which has the lowest household income in the country.”  Nevertheless, if you have the patience to pore over nationwide Medicare data, you’ll discover that “only Miami—which has much higher labor and living costs—spends more [than McAllen] per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average,” Gawande notes. “The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.”

Public More Supportive of Immigration Reform

A few weeks ago, this column featured a result from an ABC/Washington Post poll suggesting increased support for a path to citizenship for illegal immigrants.

This was a noteworthy finding on an issue with strong culture wars overtones. Indeed, we might have expected tough economic times to inflame cultural prejudices, thereby promoting intolerance of immigrants. Instead, the reverse seems to be taking place, as confirmed by new polling from the Pew Research Center.

Their just-released 2009 Values Survey shows that 63 percent favor “providing a way for illegal immigrants currently in the country to gain legal citizenship if they pass background checks, pay fines, and have jobs,” compared to just 34 percent who are opposed. That’s up from a 58-35 split on the issue in December of 2007.

Summer Hours, an IFC Hit

French filmmaker Olivier Assayas’ Summer Hours was called “a masterpiece” by A. O. Scott in the New York Times. Entertainment Weekly’s respected critic Lisa Schwarzman gave it an A. In its first weekend, it grossed $24,100 per theater (there were only two), which made it the most promising opening of a “specialty” film in months. It now has expanded to ten top markets and will be in twenty-five by the end of May, according to indieWIRE.

But you didn’t need to hunt for a theater to see Summer Hours. It was simultaneously available at IFC Films on Demand (carried by Time-Warner and Cablevision in the New York metropolitan area) for $6.95 per twenty-four hours. IFC Films on Demand is a service of the Independent Film Channel Network and is emerging as significant source of quality movies. In the past six months, it featured Steven Soderbergh’s two-part Che, about the Cuban revolutionary. “An epic,” said Scott of the New York Times); Gomorrah, a mafia portrait that Manohla Dargis in the Times said was “corrosive and ferociously unsentimental”; and Hunger, an account of hunger strikers during the Irish civil strife, which Scott wrote was “calm, deliberate . . . unnerving.” At the Cannes film festival last week, IFC secured distribution rights to Lars von Trier’s scandalous Antichrist, which starts with a child falling to death from an upper-story window and goes downhill from there, but Dargis reports, “this impossible movie kept me hooked from start to finish.”                   

The Bottom Line: Health Care Reform

President Obama has been strong and calm and reassuring.  Most voters like him and trust him.  But he still must play the risky hand he was dealt, and in the end his success will be measured by his accomplishments, not his image.  One central achievement will make or break his legacy: health care reform. 

Like FDR and LBJ, Obama is trying to use active government to improve the lives of average people.  President Clinton, after his health care fiasco, was content to run a thrifty but sound fiscal policy and to trust his legacy to the peace and prosperity the country enjoyed when he was president. 

Obama was dealt an economic crisis that required swift, substantial spending if only to assure people that he was at work.  As in the Great Depression, he has proposed a set of programs to put people to work and to give citizens hope.  Yet, as in the Great Depression again, it is not clear how fast a fiscal stimulus can bring back prosperity.

Demystifying Death

Did you know that when there is “no hope of recovery” there are still things for the patient to hope for? Did you know that a “living will” is not a legal document in New York State or Massachusetts?  Did you know that environmentalists have created nature preserves where you can be buried?

“What we are doing is basically land conservation,” says Dr. Billy Campbell, who has created a preserve along Ramsey Creek in South Carolina. “By setting aside woods for natural burials, we protect it from development. At the same time, I think we put death in its rightful place, as part of the cycle of life. Our burials honor the idea of ‘dust to dust.’”  Ramsey Creek is just one place where families can arrange “green burials.”

These are a few of the things I learned this week at a “Leadership Connection” lunch for women in business, politics and the non-profit sector.  There, New York Times health editor Jane Brody spoke about her new book: Jane Brody’s Guide to the Great Beyond: A Practical Primer to Help You and Your Loved Ones Prepare, Medically, Legally, and Emotionally for the End of Life.

Brown v. Board of Education at 55

This past Sunday marked the 55th anniversary of Brown v. Board of Education, but to the extent it was noticed at all, the case’s meaning was pretty well diluted beyond recognition.  Brown was about ending segregated schooling and upending the noxious legal principle laid down in Plessy v. Ferguson that “separate” schooling for black and white could be “equal.”  Today, however, Brown has become for most education leaders a loose metaphor for improving education for minority students and is utterly divorced from the original notion that so long as disadvantaged minority students attend schools separately from more advantaged white students, those schools will be unequal.

Indeed, most of today’s education reforms – charter schools, merit pay for teachers, private school vouchers, standards and accountability – accept de facto segregation by race and class as basically inevitable.  Some of these reforms make sense educationally, but they are in essence trying to make the old vision of Plessy work as best as it can.  With school integration taken off the table, the educational outcomes have been mostly disappointing.

Many Roads to a New Transportation Policy

Congress and the White House are about to begin discussion of the re-authorization of the nation’s transportation program.  Representative James Oberstar (D-MN) has promised a first version of a bill from his committee within a few weeks that will lay out how nearly half a trillion dollars will be invested in our roads and rail systems, after which a debate will begin that will likely stretch into next year.  As the nation takes on the question of what our highways, streets and transit systems should look like for the next decade, this re-authorization process is a chance to address challenges far broader than the ones that are the traditional focus of the debate.

 

As a nation, we have just begun to understand the connections between transportation and housing, for example, and the recent announcement of a collaboration between the federal departments of transportation and housing and urban development is a promising start.  Transportation’s contribution to global warming is well understood, if still barely addressed in our policy-making.  Housing and environmental advocates should be pressing the federal government to make sure that both of these issues will be part of the debate in the months to come.

Millennials Are a Progressive Generation

It’s a “New Progressive America” out there, as I argued in my recent Center for American Progress report, with a new demography and a new agenda. The new demography refers to the array of growing demographic groups that have aligned themselves with progressives and swelled their ranks. One of the most important of these growing demographic groups is the strongly progressive Millennial generation, whose demographics, voting behavior, and policy preferences are covered in detail in my new CAP report with David Madland, "New Progressive America: The Millennial Generation."

Between now and 2018, the number of Millennials of voting age will be increasing by about 4 and a half million a year and Millennial eligible voters by about 4 million a year. And in 2020, the first presidential election where all Millennials will have reached voting age, this generation will be 103 million strong, of which about 90 million will be eligible voters. Those 90 million Millennial eligible voters will represent just under 40 percent of America’s eligible voters.

Last November’s election was the first in which the 18- to 29-year-old age group was drawn exclusively from the Millennial generation, and they gave Obama a whopping 34-point margin, 66 percent to 32 percent. This compares to only a 9-point margin for Kerry in 2004. Behind this striking result is a deeper story of a generation with progressive views in all areas and big expectations for change that will fundamentally reshape our electorate.

How big are these expectations for change? Consider these results of a national survey on "The Political Ideology of the Millennial Generation," by John Halpin and Karl Agne, that was released by CAP at the same time as my new report. The survey included a battery of 40 statements, each of which was a positive expression of either a conservative or progressive argument, with an even mix between conservative and progressive arguments.

Overall, Millennials expressed far more agreement with the progressive than conservative arguments. Indeed, of the 21 values and beliefs garnering majority support in the survey, only four can be classified as conservative. Moreover, six of the top seven statements in terms of level of agreement were progressive statements. These statements included such items as the need for government investment in education, infrastructure, and science; the need for a transition to clean energy; the need for America to play a leading role in addressing climate change; the need to improve America’s image around the world; and the need for universal health coverage.

The Kindle Surge and Beyond

In elections, it is (usually) safe to project from expert exit polling what the final results will be. Something like that is happening with the still early numbers for the sales and use of Amazon’s Kindle e-reader. It looks like a winner. Since its launch in November 2007, and despite being out of stock for long stretches, about a million units of the two versions have been sold, according to the best estimates I’ve seen, barely more than a dent in the gadget marketplace. Yet, I am consistently surprised at how many people I encounter who are enthusiastic Kindle users. At a board dinner of the International Center for Journalists last week, easily a third of the eighty-five people there raised their hands when the question was posed, although many fewer said they used it for newspapers and magazines. Kindles are expensive, even if Amazon is deliberately underpricing most books, and my anecdotal survey supports the conclusion that Kindle readers tend to be older and find it especially useful for travel.

Insurers Get Some Marketing Advice

As more and more employers back out of the health benefit business, more and more individual consumers are shopping for health insurance these days. Yet sales have remained relatively flat. The McKinsey Quarterly reports in its most recent issue. “What,” McKinsey asks, “is preventing health insurers from effectively addressing pent-up demand?”

My first thought was that the answer might have something to do with the fact  that consumers are having a hard time finding insurance that offers good coverage at a price they can afford. But apparently I’m wrong. The article’s authors suggest that insurers just don’t know how to advertise their product: “Our research suggests that a primary barrier is [insurers’]  belief that consumers make economically rational decisions about health benefits. It’s a misguided view. Faced with more choice, complexity, and financial exposure for their health care in an increasingly uncertain world, what consumers are really seeking is peace of mind.”