James Fallows

Hundreds of messages and photos have arrived, in response to two previous items (one, two) about the transformation in the physical types Americans have gotten used to seeing in daily life. I will start with these two.

First, a reader who was raised in America but now lives in Australia (and has changed citizenship) sends this image from a record jacket. It's a scene from pre-WW II America:

An image from the Library of Congress, 'Race, 4th of July, 1941, Vale, Oregon' (the last stop on the Oregon Trail).  Note uniformity of physiques of children.

The people in this photo, if they're still alive, would now be in their 80s. Apart from the racial diversity, I wonder how photos of their grandchildrens' (or great-grandchildrens') school races would compare.

For what it's worth, Australia has its version of the same problem. The urban(e) young population of Sydney tends to be super-fit; Australians as a whole are getting very heavy.

2) A reader who is very familiar with Hawaii sends this cautionary tale:

In my youth [Baby Boomer era], poor people were skinny because they couldn't afford enough to eat.  That's part of how we recognized them.  Not so today.  If you see a skinny poor person today, you may think - as I initially do, fairly or not - that drugs are the explanation, not hunger... Obesity has become a matter of economic class - but with rich and poor having switched positions at the over-weight vs. under-weight poles.
 
A book published in 1971, by a Japanese-American living in Hawaii, tries to explain why Japanese-Americans have done so much better fitting in (and even dominating) Hawaiian society than on the Mainland.  One of his arguments is that Japanese people tend to have body types that approximate the Hawaiian ideal - which he illustrates, with a slender muscular man and a curvaceous but by no means Rubenesque beauty.  This was in 1971! 

Today it is an article of faith that Native Hawaiians are just naturally "heavy."  [JF note: the same assumption obviously is now made for Pacific Islanders as a whole.] This always amazes me.  The traditional Hawaiian queens were heavy, because they were not allowed to walk and they were fed all day.  But apart from that one exception, every Captain Cook-era engraving, every 19th Century photograph, and every 20th Century photograph up until the 1980s or even the 1990s shows the Hawaiians as slender, well-built people.  Obesity in Hawaii is an overnight phenomenon, something that has occurred within a few decades - surely someone has written about it; it is just so appalling that the mythology can so quickly spring up and condition people to believing the opposite.

As it happens, I know the book being referred to here. It is Jan Ken Po, by Dennis Ogawa. And the reader's recollection of an image in that book from 40-plus years ago is correct. Here is how the "local image of what is beautiful"  -- with the "slender, muscular man and the curvaceous but by no means Rubenesque beauty" -- was conveyed at that time. (Via a photo I took of a page in the book just now.)

 

I will soon get back into "false-equivalence" coverage of the filibuster and similar depressing themes (on which there is a very good update at 'Poison Your Mind,' including a link to this incredible piece). So let's forestall that with something different: updates on "adjusting our eyes."

One reader says:

I share your surprise at how we've re-calibrated the size of Jackie Gleason and Raymond Burr. But one actor of the period, who seemed fat even on the radio, was J. Scott Smart who played "The Fat Man," a radio detective series (late 40s) that produced one movie (1951), and he played the title role in both.
 
Here's a picture of him on the scale, a weigh-in that preceded each episode and that was carried over to the film. He's not in Henry's class, but he qualifies for the title of the series.

And about Jackie Gleason himself, whose relative svelteness even as the "fat guy" on The Honeymooners I had mentioned:

Your point about our evolving sense of what obesity looks like is well taken. But your reference to Jackie Gleason reminded me of the movie "Soldier in the rain" made in 1963, which really illustrates the dangers of being overweight. There's a fight scene where one is sure that Gleason will collapse from heart failure before it's over - it's difficult to watch. This link  features pictures of Gleason with Steve McQueen [including the one at right, as they sat between takes].

The weight contrast is clear.

Many people of the Boomer era wrote in to mention an early soft-drink ad. As one put it:

When I was young in the 50's the standard Coca Cola bottle was 6.5 oz. Pepsi Cola had a jingle, "12 full ounces -- that's a lot!"

Finally, about adjustment in the other direction, an American who has lived for a long time in China writes:

I work around a lot of fashion models over here, and it occurs to me that our eyes have adjusted to thin as well as fat.  That is, if you pull out a picture of a fashion model from the 40s, 50s and 60s, many of them look positively plump compared to a contemporary fashion model.  They would never get work today.  It's funny how our eyes can adjust to two contrary trends, one in real life and one in photos.  Maybe we're getting used to extremes?

And, fittingly:

"Our eyes have adjusted" is clearly the nutritional equivalent of the boil-the-frog idea. Except this time it's our children  who are in hot water and don't know how to get out before it's too late.

(Please see update below.) I am not going to get in the middle of the Mayor Bloomberg giant-soda-ban controversy, though I lean in favor of anything that might offset the public-health costs and human tragedies of America's obesity epidemic.

Here is why I bring this up. Today in the NYT, Frank Bruni quotes one of Bloomberg's allies on part of the reasoning behind the policy:

"Our eyes have adjusted over time," said Thomas A. Farley, the city health commissioner, during a phone conversation on Thursday, when he and Mayor Bloomberg were out explaining and defending the proposed ban amid threats of lawsuits from restaurant-association lawyers and a hue and cry from the body politic unlike any I've heard in a while.

What does Farley mean? Here's what, illustrated with pictures I used in an item a few years ago while still living in Beijing.

First we have Jackie Gleason, at the left in this scene in The Honeymooners from the late 1950s. I was a school kid then and remember that he was famous as a fat man whose comic schtick involved his incredible girth:



Fair enough. The two kinds of adjustment obviously complement each other. I'm still more amazed by the Jackie Gleason pics though.

(See UPDATE at the end.) Let me try to work through some items today, naturally in LIFO order. Here are some sample notes disagreeing with my argument that the Obama Administration had swung to the "anti-science" side, when HHS Secretary Kathleen Sebelius overruled the FDA recommendation to permit over-counter-sales of "Plan B" pills to young girls.  First the complaints, then my reply.

One reader says: 

It's not really accurate to say "Anti-Science" because a) it is not clear that scientific tests have been conducted on 10/11/12 year old's of reproductive age to see what the side affects are, b) the panel aren't making a decision based on science if they are using precedence of other powerful drugs as a reason to permit it and c) public policy is ultimately determined by Government.

Sebelius isn't saying that the science is wrong, she's saying that they haven't done enough of it. They have not conclusively proven that there will be no side affects for a girl of any age if she takes this drug.

Lastly, once the science has been solidly established that doesn't end the discussion, it then becomes a moral issue for society to digest. Science does not dictate public policy. People and their morals do.

And:

I must disagree with you and others about this charge of the administration and President Obama.  I'm a father and have a precious daughter who will turn two in less than two weeks.
 
I'm also a fan of the President and will vote for him in 2012; I agree with him on this decision.  While science may be right, I just don't feel comfortable with allowing my daughter to have access to this medication especially if she's a minor (or younger than 18).  The analogy that the President used, having this medication, "next to bubble gum or batteries" is 100 percent correct.  This is not a question about science but a question about parenting.

And:

I believe that some clarification as to how the FDA and HHS are viewing Plan B and drugs in general could help shed some light as to why Plan B being widely available OTC is different than other OTC drugs on the market.  It probably has less to do with politics and more due to a different standard being applied by the two agencies.  With a standard OTC there can be a general assumption that there is some level of parental involvement for children.  An 11-year old child has little reason to purchase a drug like aspirin on their own, so its expected that its use will be monitored by an adult.

Plan B is different.  If there is a parent involved, then the parent can purchase it themselves and administer it to the child.  If a prescription is given by a doctor, there is an adult that can explain the proper use of Plan B to the child.  However, if it's OTC the intended use population for the drug changes.  You'd expect an 11-year old going to the store alone to purchase Plan B is doing so because the parents are not involved in the decision.  That's why the maker of Plan B, Teva, had to prove to the FDA not just that Plan B was safe and effective, but that adolescent girls understood how to use Plan B properly and that it's not to be used as a primary birth control before the FDA would allow it to be sold OTC.

However, what Teva didn't prove is highlighted by the HHS.  Teva didn't prove that the drug could be properly used by 11-year old girls, and 10% of girls start menstruating at this age.  The HHS takes exception to this, while the FDA probably had told Teva that 12 or 13 was good enough for a general OTC.  The HHS believes that there may be a significant cognitive difference between an 11 year old and a 12 year old which is why they rejected the application as a general OTC.

I'm not saying that there are no politics at play here, since that would be naive concerning Plan B.  However, to say that the HHS reasoning is anti-science is not a fair label either.

One more from a former public health official, then brief reply, after the jump.

More »

Last week, advice on the miracle protector against/cure for poison ivy, Tecnu. (Uma Thurman's rendering of Batman-world character Poison Ivy at right.)

This week, readers' additions and clarifications. One writes:

>>Maybe you don't know it, but soap and cold water usually works if used quickly. Even more effective is rubbing alcohol. No need for Tecnu.<<

No "need," perhaps, but it's worked for me. Next, on the surprising fruit-world parallels to poison ivy:

>>I too am crazy sensitive to poison ivy. My family physician once told me that one of my outbreaks was the worst case he had ever seen.

You probably know this, but mangoes are in the poison ivy family (this was the next thing my physician told me).

A couple of summers ago I broke my mango fast and had a mango smoothy. I was hideously itchy all over my body for weeks. My wife nearly killed me because I was driving her nuts with my self-inflicted itching.

Stay away from mangoes!<<

Hmm. So far I have coexisted with them without harm. The Japanese angle:

>>No poison ivy here in Japan that I know about, but we do have lots of lacquer (aka urushi).  I found out the hard way doing some lacquer repairs that the active toxin in poison ivy and poison oak is called urushiol, which, no surprise, is present in copious amounts in uncured urushi.  I read somewhere that American troops returning from Japan after WWII with souvenir Japanese rifles--with the lacquered stocks--were coming down with mysterious rashes after killing time on the boat home sanding down their toys.  If only we all had Tecnu.<<

More low-tech alternatives:

>>Actually chlorine-free bleach works very very well for getting rid of poison oak! tecnu is many times more expensive.... I was skeptical at first. its a pretty wonderful trick. it does dry out your skin a bit at first.<<

And another:

>>Up here in northern MN, where I have now spent 63 summers, the standard treatment for exposure to poison ivy is Fels Naptha laundry soap, which comes in a bar.  It's brown, it's unattractive, it looks toxic, but it works, and has for a long time.  One merely slices off a small sliver of the soap and then uses it in the shower, just like any other soap.  Our household has been using the same bar of Fels Naptha for at least a decade, so it's economical, too.  I've used it when just exposed to poison ivy and I've used it when poison ivy has taken hold, and it has always been effective.  It has been around a long time.<<

Thanks to all; may this be of use. Back to politics, the economy, and language shortly.

I mean to bring this up at the beginning of every summer, and it always keeps getting put off. So I'll do it now: if I had my own Nobel Prize for chemistry to award, I would give it to Dr. Robert Smith of Oregon, in recognition of his genius in inventing Tecnu. [Update: I should say the late Dr. Smith, since he died at 88 last November. That would be disqualifying for the actual Nobel prizes but not for mine.]

If you don't care about poison ivy (or its western counterpart, poison oak) -- if there's none where you live, if it doesn't bother you -- you can stop reading now. Otherwise, gaze in admiration at the Tecnu giant-size bottle I keep on hand between April and November, shown below ready for action inches away from a bathroom sink, and follow along if you will:

I feel very lucky in the general health category, and perhaps in karmic atonement I am pathologically sensitive to poison ivy and similar plants. I don't even need to touch them; walking within a foot or so of their leaves can lead to trouble. One of the few public-health benefits for me of living in China is that poison ivy didn't seem to exist there. Or at least not in places I visited, since otherwise I would have known via instant outbreaks of boils and inflammation. The pictures at the gruesome Poison-Ivy.org site are not of me. But I know how the Job-like victims shown there feel.

Poison ivy (with its related Toxicodendron plants) is a specific challenge in some places I frequent around DC, notably the otherwise-perfect running paths along the C&O Canal. And it's on on the march nearly everywhere, thanks to greenhouse gases. Predictably, it thrives on extra CO2.
 

Several items from up North, in response to the "serious" Rep. Paul Ryan proposal to get rid of Medicare. Previous entries: why Ryan's plan -- approved by the House last week with only four Republicans voting against it -- would indeed mean the end of Medicare, and larger problems with controlling late-in-life medical costs.

First, a primer from a reader in Montreal (I think - or someplace up there):

>>Here is how health care is financed in Canada.

1- The state determines how much money is available for heath care from the budget of the year. Say $1.00 [billion] etc

2- The state then asks the various medical professionals for a price for say 50,000 broken legs to be repaired, 20,000 births, you name it. The statistics of the needs of the country are known from previous experience.

3- The medical professionals discuss between themselves how to divide the available money for the various procedures. They know that it takes 10 minutes to do this and two hours to do that.

4- They return to the state with a price list for each procedure.

5- The state then guarantees that every medical act will be paid according to the price list.

6- The medical professionals know that they will get paid immediately upon completion of services. The only paper to fill is a credit card slip of paper containing the identification number of the physician and the procedure with the agreed price.

7- That is it. No collection agency, no discussion with an insurance about the need to do an MRI etc.. Whatever is ordered by the doctor is executed. If a question arises, then it is the medical association that looks into the matter and decides. The association has the power to remove the license of the offending doctor.<<

In a follow up note, the same reader adds:

>>There is a social impact as well.   Since health care is free, when a doctor screw things up (yes it happens in Canada) fixing the problem is also free. Hence the patient does not develop the anger of paying his bills and losing his home for the mistake of somebody else.

Result: A Montreal friend orthopedic surgeon specializing in spine surgery told me that he pays $5,000 per year for malpractice insurance per year.  

Compare that with the $250,000 for insurance of the average surgeon in Dallas, TX. The doctor must recover the insurance fee by charging more, and you end up in a vicious loop.

Fairness and justice makes life easier for everyone.<<

Also in the North American Solidarity theme, note this passage from (Toronto-born) David Frum's recent essay on why Republicans have lost their political and philosophical bearing by treating society as an atomized chaos of Ayn Randian standalone economic units, rather than as an organic whole in which public programs play an important part:

>>I cannot take seriously the idea that the worst thing that has happened in the past three years is that government got bigger. Or that money was borrowed. Or that the number of people on food stamps and unemployment insurance and Medicaid increased. The worst thing was that tens of millions of Americans - and not only Americans - were plunged into unemployment, foreclosure, poverty. If food stamps and unemployment insurance, and Medicaid mitigated those disasters, then two cheers for food stamps, unemployment insurance, and Medicaid.<<

I am a proudly nationalistic Yank, but I look with respect to these pensées septentrionale.

To round things off, a view from a practicing physician right here in the USA:

>>The real winners in the Ryan plan are the same as for Obamacare: the insurance companies. 

As always, follow the money.  Who gives the most money to whom and whose lobbyists are writing legislation.

My father was also a doctor who originally was against Medicare, in fact, his partner at the time, Dr. Ed Annis was leading the charge against Medicare.
  
The real reason health care costs are out of control is how Medicare was set up to begin with.  It encouraged fee increases and paid for any and all new equipment.  Practically every time Medicare has come up with new rules and regulations to save money by screwing the doctors, doctors have found new and creative and mostly more expensive ways of practicing.  It's largely a great stupid expensive game.<<

The reference to Dr. Edward Annis shook up something in the childhood memory bank. It is worth reading about his extraordinary efforts, as a public speaker for and then the president of the American Medical Association, to oppose the creation of "socialized medicine" through Medicare. These included renting out Madison Square Garden for a big anti-Medicare doctors' gathering. American politics has been fractious for a long time.

I mentioned yesterday Merrill Goozner's contention that Rep. Paul Ryan's "serious" plan to undo Medicare should be considered the real "death tax." Now, some readers' views.

From reader AS:

>>We [already] have that de facto "death tax" in connection with nursing care.

Every family that doesn't have a spare 100k/year effectively rolls the dice regarding how much of an estate may be eaten up by nursing care at the end of life. The only private remedies are 1) LTC [long-term care] insurance, a highly uncertain and problematic product, and 2) strategies to offload assets to children while there's still time.

Perhaps this system is the best we can do right now. There's certainly no will in the U.S. to tax ourselves to the extent that would be needed to provide something like universal LTC coverage. (In an ideal world, how about this bargain: a massive [by US standards] estate tax earmarked for LTC coverage.) But as you suggest, adding near-complete exposure to medical expenses for the elderly would make this risk burden intolerable. I can't believe we're seriously considering it. And in fact, we're not (unless we get a GOP president and Congress before the party changes course...)<<

From a reader with similar experience:

>>Medicare provides a cushion from insolvency only in certain circumstances. If one has cancer or is hit by a truck, it's great. However, if one has Alzheimer's...tough luck.

My Mother had Alzheimer's. In a few short, but excruciatingly painful years, her total nursing home care consumed just under the $250K she had hoped to pass on to me.

I also had to refund MediCal, and pay accumulated legal fees from her trusteeship, another $25K, and was forced to sell the home she was able to pass on. Fortunately for her, she had no understanding of this happening, but the consequences for me and my children have been significant. We need an expansion, not any contraction, of what Medicare will cover..<<

From GP, a scientist:

>>Imagine the tax on a Dr's office staff to manage billing to 23 different insurance plans. That's how many different billing systems my immunologist's receptionist deals with.

My ENT stopped taking anything but Medicare and cash.  He said that his staff was overwhelmed with learning the intricacies of dozens of plans when he decided enough was enough. Medicare doesn't reimburse the most, but billing is simple and they pay promptly. The same cannot be said for private, for-profit insurers. He did the cost benefit analysis and he's been running his practice this way for 2 years.<<

Another reader:

>>Here is what I see happening if the Ryan plan is adopted:

1. As you note, trying to purchase insurance upon retirement will be prohibitively expensive. I'd guess $25,000/ year for a healthy 65 year old. For someone with health problems or pre-existing conditions, impossible. How much of this will vouchers cover? Very very little.

2. Workers will negotiate-like-crazy to have employment-based health insurance extend into post-retirement years. This type of policy will be much more expensive than current plans, to be payed for by employers and workers. Not good.

3. The elderly will die really fast, and use emergency-room healthcare.<<

From an American working in the Middle East:

>>The most obvious question out there for Americans outside of the USA discussions, is "whatever happened to the more liberal version of Obamacare?"

As I understood it, the critical thing about the original White House health care proposal of last year (from the macroeconomics point of view), was to create a govt-managed alternative to private health care insurance, in order to create competition against the private sector and force them to keep rates low. In the polemic that followed, the false accusation of "death panels" arose to kill the initiative, and eventually Obama/Dems had to concede defeat and come up with a more lukewarm version. Which meant abandoning the "government alternative" [aka "public option] proposal. I recall at that time that some economic critics were pointing out that this was the most critical shortcoming in the compromise Obamacare solution, in that it failed to take the opportunity to cap the steady escalation in health care expenses.

We're now a year later and debate is SURPRISE coming up about escalating health care expenses, while in the meantime everybody seems to have forgotten last year's original "government health care alternative in order to cap the expenses". How can that "I told you so" point be brought to the public debate now?<<

Also, from TC:

>>Like yours, my father was a physician. Private practice in Southern California from about 1968 to 1973, then working for a Federal clinic until the big social welfare cuts in Reagan's first term, and then again in private practice in rural Oregon until his retirement a few years ago.

Like many others my father also took notice have when and where medical dollars were spent and to what effect, and I remember about 20 years ago he offered a novel solution to the cost of "dying American style" and it's implication for an aging population.

My father suggested that a elderly person could take a buy out, at (just guessing at a number) 50% of their actuarial benefit. They could travel the world, give to charity, leave to their descendants, or even spend all or some on the cost of dying.<<

After the jump, a dissenting view and a reply.

More »

See UPDATES below and followup items about doctors' views and about the Canadian approach.

From my days as a school kid I remember the original debate over creating Medicare. At the time, my dad -- a small-town doctor and at that stage a conservative -- was, like most doctors and the AMA as a whole, strongly against the plan, as a step toward "socialized medicine." After all, when his patients couldn't pay, he found ways to reduce or forgive their fees. The opposing argument, which in the long run convinced nearly everyone (including the AMA, and my father) was that leaving older people exposed to the threat of open-ended and potentially ruinous medical expenses, or dependent on individual doctors' charity, was harmful all around.

Controlling the open-endedness of medical spending is of course a major public and private challenge. To repeat: "bending the curve" of health-care expenses is absolutely necessary. But until recently it had been taken as settled wisdom, on both policy and political grounds, that insuring people against the risk of complete financial ruin from late-in-life medical expenses left everyone better off. Old people, their families, doctors and the medical system too. Our health care system is out-of-control and unsustainable in countless ways. But very rarely has anyone argued that removing universal coverage for older people would make things better rather than worse.

That's the understanding being challenged by Rep. Paul Ryan's "serious" budget plan. I've been trying to find the way to convey what it would mean to go back to the pre-Medicare era in which each family had to prepare for unknowably large late-in-life expenses. Merrill Goozner, on his GoozNews site, has just now put it in the way I was looking for. He writes (emphasis added):

>>Here's the real argument young and middle-aged people need to hear, and the real reason why the "more skin in the game" argument can never work for seniors or other vulnerable populations, including them when they reach that age. Seniors and the poor account for over half of health care spending. Within those groups, 5 percent of the population accounts for 50 percent of health care costs; and 20 percent of the population accounts for about 80 percent. These costs come for the most part at times when economic incentives have no influence at all on medical decision-making: in medical crises; in treating chronic conditions; and, for most Medicare patients, in the last six months of life.

That's why a voucher program for Medicare, which will shift an increasing share of those inevitable costs onto the elderly themselves, can fairly be categorized as a 100 percent estate tax or death tax. People under 55 need to know that if the plan crafted by Rep. Paul Ryan were passed, most of them will never have a cent to leave to their children. It will all go to the health care industry to support the American way of dying.<<

Here's a bit of real world evidence supporting that view: Why is the savings rate so unbelievably high in China -- as much as 50 percent of the GDP? There are many reasons, crucially including exchange-rate policy. But a very powerful individual motivator is each family's knowledge that there is no Medicare-like system for their older members. Health care is on cash-payment basis there, and so every family must save like crazy against the risk that the parents or grandparents will require very expensive late-in-life care. More savings would be good for America, but that's not the right way to induce them. It's hard to believe that the Republicans will seriously embrace a plan to undo Medicare.
___
UPDATE: Two points I thought of making, but skipped, earlier today.

1) If one major goal is containing overall health spending, it is flat-out delusional to think that older people, in their role as patients or individual purchasers of insurance policies, can be more effective negotiators than Medicare in its entirety dealing with the health system as a whole.

Doctors gripe about Medicare, but they hardly love the private insurers. And every bit of real-world evidence suggests that private insurers are worse at containing total costs, and of course administrative overhead, than Medicare or especially the VA. I won't give all the details now, but Phillip Longman on the VA is a great place to start. Moreover, the people shopping for insurance will be in a terrible position: older, retired, many or most with preexisting conditions. In short, if you want to "bend the curve" of medical spending, this is exactly the wrong way to do it.

2) If another major goal is reducing the non-purely-economic costs and anxiety of disease and treatment, then this is also a terrible idea. It means that, potentially, every older person, plus his or her family, must factor in a risk they're not now exposed to: the "what if??" of absolutely ruinous medical costs.

In short: the overall economic price tag for medical care is likely to go up under this plan; and the number of people who will have to live with worry about ruinous medical bills will be much greater. This is part of the reason why, until very recently, no "serious" person proposed getting rid of Medicare. 

ALSO, a reader in New Mexico writes to say that it's not quite accurate to call this a "100 percent estate tax":

>>It's actually more ironic than you write. This 100% tax only applies to modest estates (ie, those of about 99% of the US population). No matter how hard a billionaire tried to hang onto life, he couldn't possibly spend his entire fortune on end-of-life care. Hence, this tax is something like 100% on estates under, say, $1 million. Above that, if the Republicans have their way, there will be no tax. That's about as regressive a tax as ever suggested.<<

Drop-down image credit: Reuters

As soon as I find a video link to President Obama's comments just now on passage of the health-care reform bill, I will put it up and say a little more about his theme and performance. (Hint: I will welcome and thank anyone who can send such a link.) Listening to it in real time, I was struck by the forcefulness of the ending, which was less about the health-care issue itself than about the overall question of how the American political system can deal with largest-scale public challenges. It was as passionate as I have heard this always-"cool" character ever sound on any theme. Update: thanks to reader Jeffrey Schroeder, the link is here, and an embedded player is below. The whole thing is effective, but the part I'm referring to begins just before time 14:00 and runs for the next two minutes. Very last words of the speech are unfortunate, but otherwise...

Visit msnbc.com for breaking news, world news, and news about the economy

The question is of interest to me because of the fundamental "Is America going to hell" issue I raised in this article -- and have discussed in a series of reader "going to hell" responses that I was posting last month. Until our "categories" feature is repaired, I can't do a link to the whole series; after the jump, and thanks to reader Joshua Cypess, a list of specific item links.

I have many more responses in the queue, which I'll rev up again soon.  For the moment, one more reader response. This is part of a note sent by a political veteran, now in private business, to his Democratic Congressmen, who has decided not to run for re-election and was one of the "undecideds" until the very end. The note was written just a day before the vote; a day after the vote, it's worth reflecting on this passage. It alludes to the late professor Richard Neustadt, the great theorist of presidential power. From the letter urging the Representative to vote for the bill:

What are the consequences for the country if the President and Congressional Democrats fail on tomorrow's vote? Professor Richard Neustadt did a good job teaching generations of students (including me) that the president's power to accomplish things in the future is always driven by his success or failure in getting things done today. It's terribly unfortunate that we find ourselves in the awful and presumably once-avoidable situation that we do today. It's terrible that the mess in Congress has driven out or otherwise cost us thoughtful Members such as you. But, having said all that, I can't see any good for the country coming from losing the vote tomorrow. I can see a whole lot of harm.  I'm sure you can, too.

It may be galling for you to "reward" the Leadership, the White House, the bill's proponents with your vote. But I hope you'd find it abhorrent to reward the other side.

This Representative finally voted "Aye."
________

More »

Two brief updates, on the substance and the politics. On the substance, I mentioned yesterday what I thought was the significance of the vote. A reader from Minnesota puts the point in more specific and personal terms:

When I was 15 I developed a chronic condition, and received excellent care under my mother's insurance plan. When I turned 23 and graduated from college, I lost eligibility. Tagged with a pre-existing condition, I was black balled from the private insurance market for life. Since then when my condition's gotten bad enough that I couldn't put off treatment, I've made myself unemployed to qualify for Minnesota's General Assistance Medical Care [GAMC] program, which has taken good care of me . . . because I live in a prosperous, progressive county and I know how to use the system.
 
Now Gov Pawlenty is trying to unilaterally kill GAMC. Until tonight, I have been a Democrat because of people like Gingrich and Bush, Palin and Pawlenty. After tonight, I am an Obama Democrat in the sense that my grandparents were Roosevelt Democrats. For all the problems with HCR, for all the compromises and deals and disappointments and inefficiencies, tonight the Democrats stood up and took a political risk to say that I deserve medical coverage, that it's no longer okay to treat my health as sad but acceptable collateral damage in a Social Darwinist system. That's why this moment matters to me.*

On the politics, I mentioned last month this exchange on the House floor during "negotiations" over last year's stimulus bill, sent in by someone who was there:

"GOP member: 'I'd like this in the bill.'

"Dem member response: 'If we put it in, will you vote for the bill?'

"GOP member:  'You know I can't vote for the bill.'

"Dem member:  'Then why should we put it in the bill?'

"I witnessed this myself."

As we have now seen, this was in essence how all "negotiations" over the health bill worked too. There simply was nothing that the Democrats could have put in the bill that would have made voting for it more attractive to Republicans than voting against it, with the implied promise of stopping Obama himself, his Administration's other objectives, and the general momentum of the Democratic party. In 1994, William Kristol's advice that Republicans should vote against the Clinton health care bill -- no matter what was in it, just to ensure a defeat -- was seen as shocking enough that Kristol put it in the form of a confidential memo. (More here, here, here.) This time, simply "going for the kill" was the quite open Republican strategy -- as advocated by Kristol here and by Republican legislators passim.

Fine: that's their strategy, they had every right to choose it, although as David Frum very eloquently argues, this time it didn't work.** I raise it now in response to a new wave of interpretive hogwash: namely, the idea that although Obama may have "won," he did so in a fashion that was polarizing, hyper-partisan, and extreme. Please. The quite open GOP strategy was that they were not going to vote for this bill. They had every right to that as a strategic choice. But they can't now claim that their bloc opposition to the bill is proof that the Democrats were too partisan. Rather, they can and will claim it, but they shouldn't be believed.

"You know I can't vote for the bill" -- the phrase by which this era in politics may be known. We witnessed it ourselves.
___
* A reader from Texas writes just now: "Because I have an individual policy following cobra/divorce and having breast cancer, my health insurance costs almost $30,000 a year.  They deny me dental coverage after cobra. Feel free to use this factoid."

** As Frum says, "At the beginning of this process we made a strategic decision: unlike, say, Democrats in 2001 when President Bush proposed his first tax cut, we would make no deal with the administration. No negotiations, no compromise, nothing. We were going for all the marbles. This would be Obama's Waterloo - just as healthcare was Clinton's in 1994.... This time, when we went for all the marbles, we ended with none."

We'll talk some other time about the political consequences, in 2010 and 2012 and beyond, of the health-care reform vote. (My guess: this will not seem anywhere near as poisonous seven months from now as it does today. Jobs jobs jobs is what will matter most then. But we'll see.)

We'll talk about the many things that will prove to be wrong with the bill, and the many more steps that will need to be taken as far into the future as anyone can see, so as to balance and rebalance the potentially-limitless cost of new medical procedures with the inevitably-limited resources that individuals, families, companies, and governments can spend.

For now, the significance of the vote is moving the United States FROM a system in which people can assume they will have health coverage IF they are old enough (Medicare), poor enough (Medicaid), fortunate enough (working for an employer that offers coverage, or able themselves to bear expenses), or in some other way specially positioned (veterans; elected officials)... TOWARD a system in which people can assume they will have health-care coverage. Period.

That is how the entire rest of the developed world operates, as noted yesterday. It is the way the United States operates in most realms other than health coverage. Of course all older people are eligible for Medicare. Of course all drivers must have auto insurance. Of course all children must have a public school they can attend. Etc. Such "of course" rules offer protection for individuals but even more important, they reduce the overall costs to society, compared with one in which extreme risks are uncontained. The simplest proof is, again, Medicare: Does anyone think American life would be better now, on an individual or a collective level, if we were in an environment in which older people might have to beg for treatment as charity cases when they ran out of cash? And in which everyone had to spend the preceding years worried about that fate?

There are countless areas in which America does it one way and everyone else does it another, and I say: I prefer the American way. Our practice on medical coverage is not one of these. Despite everything that is wrong with this bill and the thousand adjustments that will be necessary in the years to come, this is a very important step.

I will recommend to historians and semioticians very close study of the footage being produced right at this moment, on the Fox "News" Channel, as it covers the vote in the House on the health care reform bill. 

His address to the Democratic House members at the Capitol yesterday was another one very much worth watching. Of the 45-minute C-Span clip available here, the first portion is warmup and prelude by Nancy Pelosi, Harry Reid, and Stenny Hoyer. Obama takes the stage at time 15:00. At about time 20:00 he is mordant about the way the press has covered the issue, and at 23:20 we have an acid little line about "death panels." At roughly 30:00, he starts making the case about why the bill is still important, despite the things that aren't in it. At 31:50, a direct appeal to Democrats tempted to vote against it because of this or that shortfall. ("If you think that the system is working for ordinary Americans rather than for insurance companies, you should vote No on this bill.")

Real payoff is the "I know this is a tough vote" peroration, starting around time 35:00 (or, distilled version starting just before 38:00). The real point here is Obama's argument that even if the vote proves politically costly, the ultimate purpose of politics is to win office so as to do important things, rather than to avoid doing anything controversial or important so as to cling endlessly to office. Nice that it's done in a "we all understand the problem" way rather than with a "you are falling short" tone.  ("Every single one of you had that same kind of moment at the beginning of your careers.... Maybe that thing we started with has been lost. ")



What he says is also in keeping with the argument made by my Atlantic colleagues Ron Brownstein and Marc Ambinder, and which I discussed yesterday with Guy Raz of NPR: that Obama is doing what we always say we want but which politicians rarely can bring themselves to produce. He is spending political capital, trading popularity for a cause he believes in. And he is telling his party's House members that this is the duty to which they are called. Yes, it's easy for him to say that: he doesn't run for reelection for another few years, while the House members all face the voters this fall. But he says that whenever the voter-reckoning comes, the calculus should be the same. On this theme, it's also worth reading the recent WaPo essay by former Rep. Marjorie Margolies, who cast a "hard" vote for Bill Clinton's budget-balancing legislation in 1993 -- and was promptly turned out of office. "I voted my conscience, and it cost me," she wrote. "I am your worst-case scenario. And I'd do it all again."

Agree or disagree on the bill - and for the record, I support it, because it is a step toward the principle that for society's benefit and for individual protection, everyone should be insured -- Obama's presentation is a powerful piece of plainspoken rhetoric. Plus empathizing with an audience without condescending to it. And in case you're keeping track, not a damned teleprompter in sight.

In my copious spare time, I'm filling out forms for a non-tourist ("class 457") visa to Australia, for regular visits I'll be making as part of the new U.S. Studies Centre at the University of Sydney. That's a whole promising story for another time.  Here's the relevance now, during Health Care Reform Showdown weekend:

In all the piles of documentation to provide the Australian authorities, two required items got my attention. One was a copy of my marriage certificate, so that my wife and I can travel together. (Hmmm, ours was written in cuneiform. Where would that be now?) And the other is: certificated proof that we both are covered by an "adequate" health insurance policy. Otherwise, they won't let you in. It's part of the principle that, of course, for shared social risk and as a bulwark against bankrupting individual surprises, everyone must be insured.

Every so often there is a reminder of how unusual, in world terms, the lack of such an assumption and system has been in the United States. In the nearly two generations since the passage of Medicare, Americans have come to take for granted that of course there will be some safety net for older people with the inevitable maladies of age. Exceptions to that are seen as scandals. On the highway, everyone understands that it's irresponsible and anti-social, along with illegal, for people to drive without insurance. What if they cripple someone? What if they plow through someone's front yard and damage their house?

Whatever happens tomorrow, and it seems as if the Democrats may finally have 216 votes, I bet that a generation from now Americans will have the same "of course everyone needs it!" attitude about health insurance that we now have about car insurance and Medicare. Few people who weren't around in 1965 can imagine how bitter, emotional, and divisive the debate about passing Medicare was at the time. If anything the fears of impending socialism were greater than they are now -- because back then, there was no Medicare in existence about which people could say: "Well, that program's OK, but anything more would be socialist." I think the incredible fury of this year's debate will have the same hard-to-recreate quality once health insurance becomes as matter-of-fact as -- yes -- car insurance is now. As I mentioned when the Senate pulled together 60 votes last summer, this is a moment to notice and remember. And, I'll be watching the vote.

I was in high school in California when Congress wrestled with the Medicare bill in the 1960s. The temper of our town was extremely conservative, and I remember then the same combination of heartfelt, and eventually panicked and despairing, warnings by opponents of the bill that I have heard from opponents of the current health-care plan these past few months. Big spending, big deficits, big government, end of choice, destruction of the doctor-patient relationship, intrusion of the bureaucrat, erosion of the American way. The mood was just as committed, angry, impassioned, and beyond the reach of mere "let's talk about the facts" discussion as it is now. That background doesn't prove that fears about the current bill are ill-founded. But it needs to be remembered.

At the time I didn't register the significance of Medicare's passage -- something now so engrained as part of the American Way that today's Republicans have positioned themselves as its protectors (against the alleged ravages of the Obama plan). I think that these two quick-reaction TNR articles -- by Jonathan Chait, here, and Jonathan Cohn, here -- do a wonderful job of registering the significance of the Senate's 60-39 vote today in favor of the bill. Chait's is particularly thorough in parsing and addressing the main objections to the bill. These two writers, plus Ezra Klein of the Washington Post, have through the long course of this debate provided a clinic in how to explain the policies and the politics of a very important, very controversial, and very very verrrrrryy complicated public decision.

The Republican opponents of Medicare in my youth at least had something they were for. They had Barry Goldwater's Conscience of a Conservative; they had Ronald Reagan with his recorded addresses on how socialized medicine was the route toward socialism of all sorts. Even though in practice Reagan's pitch boiled down to flat-out opposition to Medicare, the idea-content of his opposition now seems about 100 times greater than what we've become accustomed to hearing from Fox News or at tea-party rallies.

The Republican coalition of that time had its "reactionary" elements, notably those white Southerners who were being peeled from the traditional Democratic coalition by their reaction to the civil rights era. The John Birch Society was of course already part of the team. But the conservatism of Goldwater and Reagan didn't seem to be the pure reaction, pure oppositionism, pure emotional outrage that to me comes through many anti-Obama speeches. Newt Gingrich was not Ronald Reagan's equivalent as a political leader nor Goldwater's as progenitor of a movement. But when he led the GOP's efforts to stop Clinton's health care plan and its subsequent takeover of the House in 1994, he very prominently offered "ideas" and a "plan." (Viz, 'Contract with America.')

When the most visible faces and most prominent voices of Republican sentiment are Palin, Limbaugh, Beck, McConnell, and Boehner, aggrieved oppositionism is possible, but a Reagan- or even Gingrich-scale movement is hard. They await their leader. In the meantime, it is a moment to note.

- TNR/McCaughey watch. As mentioned here numerous times, starting 14 years ago, The New Republic made Elizabeth McCaughey a public figure in 1994 and has been trying to mitigate the damage ever since. Concluding installment, under the circle-closing headline "No Exit" [also the title of McCaughey's original article], from Michelle Cottle here.

- Unknown gigantic cities watch. In my story last year about the surprisingly intense struggles within China to improve environmental protection, I mentioned a visit to Zibo, a coal-and-ceramics center in Shandong province. Zibo is one of countless cities in China that few outsiders have heard of but that are larger than, say, Chicago or Milan. The always interesting Moving Cities site, a Beijing-based effort to document urban design in fast growing cities, recently took a trip to Zibo to show what it looks like. Description and four photo essays about Zibo can be found here. (Note: for me, the Javascript on this site always stalled with Firefox. Worked OK with IE, Chrome, and Safari.)

Downtown view, with housing from the 1980s onward -- horizontal black bar is part of the site's convention for presenting photos: 
 

On the way into town:


Alley that I've walked down myself, with pre-1980s housing:



- Problems of the press watch. I am grateful to Jake Seliger, of The Story's Story site, for a retrospective of my 1996 book Breaking the News. He makes the discouraging but, I think, accurate point that the arguments and criticisms from back in that era are all truer now. I have thought several times about revising or updating the book but have held back for two reasons. One is the shark-like instinct that it's worth always moving ahead to new territory. The other, that the central points to make remain the same; the details would differ and be more depressing.

Yesterday I reported this exchange with a representative of the Manhattan institute, where Betsy McCaughey was based when she wrote her "No Exit" attack on the Clinton health reform plan:

 "I wrote back to Lindsay Craig asking which of these options the Manhattan Institute was saying:

"A: The Rolling Stone contention that tobacco companies collaborated with Ms. McCaughey and M.I. is totally false; there was no such contact or collaboration.

"B: We are confident that Ms. McCaughey's opinions were not influenced by tobacco companies, even though she may have worked with them.

"Her immediate response:
"A.   Betsy never worked with Phillip Morris." 

As a followup, I asked Ms. Craig whether there was any significance in the distinction between "tobacco companies" in the question and "Phillip Morris" in the answer. She said: No.  Her flat denial applies to "Tobacco companies (plural -- though the document in question is from Phillip Morris)."

Clear enough. So we now have documents, reported in Rolling Stone, in which a tobacco lobbyist claims in detail to have worked with McCaughey as she put together her articles -- and a categorical denial from the Manhattan Institute that she worked with tobacco firms. Yet again it would be helpful to have Ms. McCaughey address the specifics of the lobbyist's claim.

In response to a reader's comment that a pack of buffed-up CPAs "built like lumberjacks" took on construction workers and held their own, plus another about slimmed-down med students, this reponse:

"I agree with many of the observations from your med student correspondent. I work for a mid-sized management consulting firm comprised almost entirely of former Big Four consultants. We employee many CPAs and MBAs. Other people have different higher degrees. Though we have offices all over the Midwest as a group the employees are not merely trim but fit. Just in my office in Kansas City (traditionally considered one of the fattest cities around) we have several triatheletes, lots of marathon runners and long-distance cyclists. Having a personal trainer is not consider out of the ordinary.

"It is assumed that everyone has an athletic hobby. To be unfit would be a career-limiting trait. To be obsese would be career suicide. No one munches chips at their desks.

"Management consulting can be a bit of a macho world. Some guys compete, even place bets, when they participate in local charity runs. To lose is to invite gentle (or not so gentle) ribbing from other males. Our firm regularly competes in Corporate Challenge, which is taken quite seriously by the leadership. To win an event merits a mention at office-wide meetings.

"I think fitness is seen by the leadership as a proxy for discipline, self-control, and health. We are forbidden by HR from asking certain questions during interviews so questions about excercise and visual inspection of candidates can be used to gather important data about perspective hires. All things being equal, a big fat guy would not be hired.

"Most of us have to visit clients and it is believed that the appearence of fitness and vitality gives clients confidence in our skills, our ability to work long hours, our discipline.

"Not all of this is class. Many of the partners and employees, including myself, come from working class, rural or near-rural childhoods in small towns thoughout the Midwest or South. Some come from extremely small towns in western Kansas. A few were overweight or obese earlier in life and have worked hard to overcome that. I guess a lot of this is self-selection but I think most is a by-product of ambition and peer pressure. Somewhere along the way, we picked up the idea that to rise in the corporate world you had to have a certain look. This look includes being trim, having no facial hair, having enough muscle to fill out a suit but not so much you're conspicuous, and having nice teeth."

After the jump, a report based on compare-and-contrast observations in Kansas City and Chicago.
_____

More »

In response to this item today, concerning Rolling Stone's claim that Betsy McCaughey worked secretly with tobacco lobbyists when preparing her 1994 New Republic article about the Clinton health reform plan, I have just received this note from Lindsay Craig of the Manhattan Institute:

"Below is a letter to the editor of Rolling Stone from Lawrence Mone, president, Manhattan Institute for Policy Research.

"In his article "The Lie Machine," Tim Dickenson asserts that former Manhattan Institute scholar Betsy McCaughey's work was influenced by Phillip Morris.  This conclusion is false.  Betsy McCaughey wrote two articles for the Wall Street Journal on the Clinton Health Care plan and an additional article for the New Republic which was solicited by its publisher.  At no time were her ideas influenced or controlled by anyone but the author herself."

I have written back to Lindsay Craig asking for clarification on what, exactly, Mr. Mone is saying. The Rolling Stone documents say that Ms. McCaughey worked, in secret, with tobacco company lobbyists in preparing her articles. Mr. Mone's statement says that she was not "influenced or controlled" by anyone else. I have written to ask whether Mr. Mone is saying that she never worked with tobacco representatives (whether or not she was "controlled" by them); and whether the Manhattan Institute was aware of any such collaboration. More info as it arrives.

UPDATE:
 I wrote back to Lindsay Craig asking which of these options the Manhattan Institute was saying:

"A: The Rolling Stone contention that tobacco companies collaborated with Ms. McCaughey and M.I. is totally false; there was no such contact or collaboration.

"B: We are confident that Ms. McCaughey's opinions were not influenced by tobacco companies, even though she may have worked with them.

Her immediate response:

"A.   Betsy never worked with Phillip Morris." 

Is this a question of a lobbyist grossly exaggerating his "influence" to impress bosses and funders? That's a very familiar pattern in Washington. On the other hand, the lobbyist's detailed knowledge of Betsy McCaughey's writing plans suggests some interaction. I don't know the underlying truth here. It would be valuable if Ms. McCaughey, who has specialized in detailed textual analysis, would address in specific what these documents contend.