Curing What Ails Us

Why Universal Health Insurance Isn’t the Answer


Our Health “Insurance” A Misnomer

The only sustainable answer to our health care dilemma is to put the concept of insurance back into health insurance. For decades now, the term “insurance” has been a misnomer when applied to our health care policies and programs. Rather than being true insurance, our health care reimbursements have operated more like subsidies or entitlements.

There are several features that characterize insurance in the classic sense of the word:
1) The event for which an insured person seeks reimbursement must take place in a specific location and from a known cause. For example, life insurance is paid in the event of death. There’s nothing as specific and delimiting as death.
2) The insurance beneficiary should not have contributed to the loss for which a claim is filed. So the claimants have to be able to affirm Billy Joel’s assertion, “We didn’t start the fire…”
3) Premiums must be affordable in relation to the magnitude of the loss being covered. It doesn’t make sense to pay almost as much in premiums as you might anticipate losing.
4) Losses must take place with some statistical predictability and must be quantifiable when they do occur. There can’t be compensation for vague, billowing losses or for open-ended, on-going losses.
5) Most important of all, the size of the loss for which the insured is making a claim must be a significant part of the beneficiary’s overall picture. A small claim can cost an insurance company much more to administer than it pays out. So small claims are rarely worth the trouble for either the insurer or the insured.

Our modern health “insurance” doesn’t meet any of the above criteria, least of all that essential one calling for a loss to be substantial before a claim can be filed.

Early forms of insurance most often covered merchants for the loss of whole consignments of their goods. The Hammurabi Code (1780 BC) stipulated that the State would compensate shippers whose goods were lost or stolen in transit. The claimant had to swear before the ancient Sumerian Gods that he had in fact suffered the grievous loss. In BC China, the principles of insurance took shape around the loss of commercial vessels plying China’s treacherous rivers.

Ancient Greek and Roman guilds did introduce the concept of health and life insurance. Guild members would pay premiums into the guild coffers, then they or their relatives could draw from the pooled funds in case of illness or death. These arrangements were more like benevolent societies though. For the most part, true insurance policies continued to center around the risky business of maritime ventures.

After the Great London Fire of 1666, insurance companies started to more commonly expand their coverage to include such disasters. Ben Franklin is often credited with starting the first official insurance company in the United States, concentrating on insuring against loss by fire. Franklin refused to insure any wooden houses.

Insurance practices, including the formulation of actuarial tables, became a science. The study of statistics was refined throughout the 1600’s and 1700’s in order to calculate the likelihood of losses. Coverage was extended to other kinds of disasters. However except in rare cases, the principle that a loss had to be severe in order to be covered remained the bedrock of standard insurance practice. Payouts weren’t made for splintered masts – only for sunken ships. That’s the concept of insurance we have to get back to in the realm of modern health care.

Current health insurance operates somewhat more like those old guild benevolent societies did - except the pool of money that is available to meet member claims is woefully inadequate – money is meted out routinely for minor claims – and the dispersing agency is distanced from the claimant by layers of bureaucracy.

So our system is the worst of both worlds. It compensates according to minor, minute demand as a guild chairman might have once been prevailed upon to dole out for a fellow worker’s non-emergency needs. But it does so without the old benevolent society’s first-hand knowledge of the individual claimant. The modern insurer has no way of knowing what losses any claimant actually suffered or what services he might actually need to receive in remediation of his loss. All this far-away third party payer can do is try to fit claims to a series of Procrustean beds of categories. The various service providers are correspondingly motivated to define their services so that they fall into the most capacious of these beds. As a result, the pool from which compensation is drawn is strained and drained.

On the other hand, our current system does not operate in the abstract, self-balancing realm of the free-market. It has ended up being neither personally beneficial nor able to self-regulate itself through the constrained operation of supply and demand. It exists as an elaborate system of entitlements in a gray no man’s land where costs can escalate unbounded into the ether.


Paying for the Home Depot Nail

Imagine if all insurance were to operate this way. Imagine if the typical homeowner’s insurance policy were to routinely compensate holders for small repair expenses. People do occasionally put in claims for minor robberies and residential damages. But on the whole, people’s main purpose in buying homeowner’s insurance is to protect themselves against massive damage to a dwelling. They basically want protection against wholesale vandalism, razing fire, torrential rain and flooding, and gale-force winds. For the rest, most homeowners understand that they must be responsible for the expenses entailed in routine home maintenance - for the drip, drip, drip of daily repair in addition to some more costly projects that have to be periodically undertaken. They have to be prepared for the “It’s always something” of home ownership.

If claims were to be made for every faucet washer or nail needed to make a household repair, the cost of these items would spiral out of control in the same way that the cost of health care products and services have spiraled out of control. We’ve all heard the “joke” about the $100 aspirin administered in a hospital. If an individual went to Home Depot to purchase a nail, and instead of paying for it directly then and there, filed an insurance claim for it, that claim would be launched on the same kind of tortuous voyage through channels that the aspirin now makes, accreting barnacles of additional expense with every lap. The result would be a joke about a $100 nail that was all too literally true.

The only, the ONLY, way to retreat from the $100 aspirin and to generally return our health care system to equity, solvency, and practical constraint is to bring it back into the realm of traditional insurance – insurance geared toward paying out only in the event of major, unpredictable losses or losses that would otherwise threaten to seriously compromise an individual’s financial picture. We have to make health insurance operate more like homeowner’s insurance, more like true insurance.


High Deductible Policies Are the Answer

This means that policies with high deductibles should become the standard once again. Whether these policies are made available through government sources or through private institutions, they cannot pay out for near first-dollar losses. It’s difficult to specify exactly how much of a deductible would return a current health insurance policy to the intent and meaning of “insurance” in the classic sense of the word. Naming any figure is likely to date an article immediately. However, for the years 2009-2010, a deductible of $25,000-$50,000 seems reasonable.

I can hear the gasps now. Health care professionals often are shocked if a client has a policy that carries a $1,000 deductible, asserting that such a policy is tantamount to having “no insurance at all.” So I can imagine most people’s initial reaction to any proposal that standard policies have deductibles fifty times that amount.

However, a couple of considerations might temper that reaction a little. First, $25,000 is really only about the cost of a new car now, and if the average working family can manage to finance a new car – they could reasonably expect to finance $25,000 out-of-pocket expense in the event a family member suffers a severe medical problem. Then too, policies with high deductibles would require smaller premiums or withholding – so individuals could start out with considerably more in their pockets when being asked to pay out-of-pocket.

Also, a policy designed along classic lines, operating in the way that true insurance policies are meant to operate, would provide much more protection for individuals in the long run. High deductible policies kick in at exactly the point where people need them the most. They pay when people experience serious health problems that threaten to eat up most of their incomes and savings - that threaten to put them in debt for years.

This is in sharp contrast to the kind of protection provided by most of our current, more favorably perceived policies. Our seemingly more generous first-dollar coverage policies often actually end up abandoning people at the time of their greatest need. A person will find his policy has paid minor claims leading up to the serious problem. It has paid for routine check-ups and examinations. It has paid for all sorts of initial diagnostic procedures, for opinions and pills and probes. But then when the individual finds himself in the midst of some full-blown crisis, his insurance company will often find a way to limit the policy in relevant ways, or to cancel it altogether. The policy might not be renewed because of “prior conditions.” Or it might provide no further compensation because the maximum payout allotted for that condition has already been made. Or the insurance company will involve the individual in such a thick Gordion knot of red tape that not even Alexander the Great could slice his way through it. These scenarios run contrary to the purpose of insurance. Again, true insurance is or should be designed to protect individuals against devastating financial wipeouts. Insurance policies that take people up to the precipice but that then let them plummet down on their own without parachutes – are NOT true insurance policies.

When our politicians speak about enabling every person to have health insurance, they should be thinking in terms of enabling individuals and families to protect themselves against the economic devastation of severe health problems. No one should have to go into debt for significant periods of time in order to pay for health care. No one should be called upon to deplete a life’s savings. No one should have to sell essential assets such as a home in order to pay for health care. Political initiatives should focus on making available the kind of insurance that will protect people against the expense of severely acute conditions or draining chronic conditions. Therefore, whatever insurance arrangements the government fosters should have high deductible policies as their cornerstone. These Government-sponsored health insurance policies should be conceived separately from aid programs. What’s more, if people are to continue buying insurance from private suppliers, they should be awakened to giving priority to policies with high deductibles.


The Real Way to Bring Down Medical Costs

However, the ultimate benefit of putting the true concept of insurance back into our health insurance programs is that ALL medical costs will consequently start to come down to earth again. The vast bulk of our medical complaints are minor complaints involving sprains and aches and rashes. By returning these to the Home Depot world in which the buyer of the nail pays for the nail - we will return those routine medical goods and services to their intrinsic cost of manufacture and application. If the individual who receives the aspirin, the bandage, the splint, or the appendectomy, pays for it directly rather than submitting a claim for reimbursement to a distant, necessarily unwitting insurance agency – those basic medical treatments will once again start to be priced according to their true market value.

Our political officials and most insurance policy holders seem to have lost sight of how it’s primarily the very ubiquity of first dollar insurance that has caused medical costs to spiral out of control in the first place. It’s not the acquisition of high-tech pieces of equipment that has been principally responsible for driving up medical costs. In the real economic world, the more widespread high-tech solutions become, the cheaper they become. Cell phones and computers are prime examples. Nor are doctors and medical personnel particularly greedy, driving up medical costs with exceptional avarice. No, the main engine of inflation in the medical sector over the last decades has been the increasing recourse to near first dollar insurance reimbursements. As third party payers have been called upon to pay more and more of the sum total of medical charges, as billing has gotten further and further removed from oversight by the individual who received and who can best assess the value of the services received - prices have skyrocketed accordingly.


The Time Before Insurance Reimbursements Set the Standard

Let me illustrate the process with an example from my own family experience. My mother was diagnosed with uterine cancer in 1960, although actually, the diagnosis was intimated more than it was ever spelled out. In the end, we were never really sure if she had cancer or not. But either way, a hysterectomy was the routine solution, as it still is now for women suffering almost any “female” disorder. A few days before she was to be released from the hospital, she was presented with an enormous bill and the news that she would have to undergo a lengthy regimen of cobalt treatments (the raw element used for radiation therapy at the time). These twin horrors sent my mother reeling in shock and despair. She registered her distress about the astronomical bill to one of the members of the medical team doing follow-up on her case. She said she frankly didn’t think she could come up with that sort of money in the foreseeable future. That Doctor shrugged off her concerns. He said, “Why should you care? Your insurance will pay for it.”

When my mother told the Doctor that she didn’t have insurance, it was his turn to reel back in shock. In 1960, admission to hospitals was often much more informal than it is today. My mother’s family physician had ordered a room for her based on symptoms he’d noted, and she had been duly admitted as a patient without having her financial situation thoroughly assessed, as it would be today. However, it was common enough even then for people to carry insurance, either through their employers or independently, that the doctors and the hospital probably just assumed my mother carried it. However in 1960, billing hadn’t yet become automated. Billing still had an element of personal discretion about it. So just before my mother was sent home, she was presented with a “revised” bill for her operation. It was about one-third the original bill. What’s more, her family physician took her aside and told her that her medical team had decided it wouldn’t be necessary for her to have any follow-up cobalt treatment after all. “You know,” our family Doctor whispered, “they have these machines, and they like to use them.”

My mother went home and lived another thirty years without any cancer reoccurrence – or occurrence. The new, lower bill that had been calculated for her clearly wasn’t a matter of charity. That revised bill just reflected the more realistic costs that had been involved in performing a hysterectomy. Now however, it would be virtually impossible for any patient to have such a more realistic, down-to-earth tally made. Billing is a strictly mechanical procedure. It is compiled out of sight and out of mind of any individual doctor, any hospital staff member, and the individual patient.

Even though, as our politicians worry, not everyone has medical insurance now, still the amounts that can be billed to insurance companies for procedures have become the computerized, automatic standard. A patient can perhaps have her bill adjusted for errors. She can protest that certain procedures that her insurance company was billed for weren’t really performed, or certain medicines weren’t really administered. But hardly anyone can question the price of services actually rendered. And despite all efforts at cost control, these prices are padded, re-named, re-classified, then padded again until they bear little relation to what that service would cost if its flesh-and-blood recipient were paying for it rather than it being forwarded to some distant, anonymous third-party payer for whom all services appear as disembodied abstractions.


The $1,800 Cup of Orange Juice

Almost all of us can cite recent examples, beyond that typical jesting example of the aspirin, of how minor hospital or doctor services get translated into major medical procedures when they are presented to Medicare, Medicaid, or a private insurance agency to pay. A friend of mine had a lumpectomy several years ago. She was treated on an outpatient basis. She went into the hospital at 7:00 and was out by 2:00 P.M. She was somewhat exceptional only in that she happened to get an itemized bill showing exactly what Medicare was charged for that day. The charges initially came to over $20,000 – and there was more to come after follow-up appointments were taken into consideration.

It’s difficult to argue with the charges made for the medical expertise of the doctors and technicians who actually performed the procedure. Perhaps a lumpectomy really does call for years of study, extraordinary skill, and recourse to extraordinary emergency equipment. However, there were some aspects of the bill that could be judged in terms of everyday experience. For example, after the procedure, my friend was ushered into a “recovery room” where she was asked to stay for two hours. She didn’t feel she needed to recover in any way, but she complied. The room was a regular pared down hospital room. It had an adjustable bed in it, which she was encouraged to occupy, although there was also a rather tattered lounge chair she could have simply plunked down into. Then a nurse came in with some paper slippers for her to put on and a paper cup about half full of orange juice. My friend and I stayed chatting on our own in this somewhat dingy room for the requisite two hours without being attended by any other medical personnel. Then we went home. For this “recovery room” service, Medicare was billed $1,850.

Recovery room experiences such as the one cited above have fostered another common joke. People often exclaim that at those prices, they could have “recovered” in the Presidential Suite at the Waldorf-Astoria for a day – with full room service.


The Cruelty of Price Caps

Of course our officials have also long been aware of how padded most charges made to Medicare and all insurance providers tend to be. So there was a period when the Government tried to put strict cost controls in place. But all cost controls and caps have two profoundly negative side effects. First, the oversight stipulations tend to lead to cruel curtailments and inflexibility just at the point where individual treatment and subtle human judgment is most needed. When my mother went into the hospital that thirty years later, this time with terminal emphysema, she was allotted just a certain amount of time in intensive care and then just so much time in a regular hospital room. After that, on the morning of her last day, she was briskly jostled onto a gurney and removed to what was obviously a “dying room” at the end of a hall – an outpost no staff member ever visited except for one nurse who would perfunctorily enter every other hour or so to take vital signs to see if my mother had died yet. It was heart wrenching to see my mother uprooted and almost literally shoveled into these bleak surroundings for her last hours. But this premature burial was necessary because Medicare had stipulated that a patient entering the hospital with her diagnosis would be allotted only so many days and hours in a “full-service” hospital room. After that, if the prognosis remained unchanged – the patient had to be either discharged or evicted to low-rent quarters.

Unlike my mother’s 1960 hospital experience, there was hardly any way in 1990 to temper or revise either treatment or billing to fit individual circumstances. There didn’t seem to be any practical urgency about moving her, since the hospital wasn’t at “full census” at the time. So, hoping my mother could be allowed to stay in her regular room being attended by the regular nurses she’d become familiar with for a few more hours, I rushed around, beseeching anyone who’d listen to, “Forget about Medicare! We’ll pay cash!” But another joke – Doctors and hospitals wouldn’t take cash.

They wouldn’t have known what to do with it. The entire system had become geared to the receipt of insurance reimbursements for those who had Medicare or other coverage. There was no life outside what insurance would pay for.

Since that period in the early 1990’s, the cost control stipulations have been eased quite a bit. Some of the dangers of allowing distant insurance adjusters to specify what kinds of treatments are justifiable and therefore covered have been recognized. Now medical personnel have again been given more discretion about what kinds of tests to order, what treatment to pursue and how long to pursue it. However the people who recently caused such a commotion at town hall meetings, raising the specters of “rationing” and “death panels” - might have been harkening back to some of those earlier practices. Their protests might have been exaggerated, but still might have had a kernel of cautionary truth in them. Skyrocketing costs always usher in a need for cost containment and cost caps. My mother was caught at a moment when these cost caps were particularly rigid. It happened once; it could happen again.


The Inevitable Failure of Third-Party Payer Systems

To return to the main point about our current pseudo-insurance arrangements though - wherever a third-party payer system is in place, price inflation is the inevitable result. This inflation in turn leads to pressure to institute price controls. Price controls not only have the potential to create the sort of bleak, impersonal treatment my mother suffered at the end – but they deform the entire economic sector where they are operate.

The whole experience of the former Soviet Union’s economy testifies to that. The Central Committee’s specification of prices led to black market gouging, corruption, general inflationary cycles, and a continuous mismatch between the goods that were needed and the goods that were actually supplied. Within our own more immediate experience, we might look at how New York’s rent controls more often lead to exorbitant “move-in” fees being paid to building superintendents than to any actual relief from exorbitant rental prices. You can sit on one end of a large balloon, but that only deforms it and creates explosive pressure at the opposite end of the balloon. And so it will be with the attempts at cost containment that must follow in the wake of expanding insurance coverage for routine health care. Our dependence on widespread, first dollar insurance coverage has created a sort of planned economy in the health care sector, and has brought with it all the woes commonly associated with planned economies.

When our leaders and when individual policy holders cringe away from the idea of high deductible policies, they are thinking of the present cost of even the most routine services rendered in the health care sector. Since having a broken toe set, either in an emergency ward or in a clinic, now can be expected to cost a couple thousand dollars – people reject the idea of high deductible policies because they envision having to shell out chunks of thousands of dollar several times in the course of a year in order to receive care for even the most minor of problems. They envision having to pay almost $25,000 a year, every year, to have their most basic health care needs met. And they are right to anticipate that constant steep drain unless insurance reform is effected across the board to become what insurance was meant to be.


Health Insurance Raises Prices, Breeds the Need for Yet More Insurance

To summarize - the widespread existence of near first dollar policy coverage has removed both responsibility for payment and capacity for assessment from the hands of the individual recipient of the service and has placed it in the realm of distant, automated reimbursement agencies. The padded billings that doctors and hospitals are able to achieve in this environment become the implacable standard prices that can be charged for that service in that location. There can rarely be any more adjustments made for those who do not carry insurance, as an adjustment was made to my mother’s bill in 1960. Everything proceeds on automatic pilot now. If a broken toe can be re-defined in such a way that it can be managed as part of a complex system of entrained treatments – then it can be billed to the tune of several thousand dollars. And that exorbitant price tag becomes the set sum billed for every broken toe in that area. Then as the cost of a broken toe becomes prohibitive, pressure on our leaders to provide means of obtaining still more comprehensive insurance coverage builds. The price inflation caused by prevalent first dollar insurance coverage breeds the need for still more comprehensive coverage. And round-and-round, and onward and upward the spiral of medical costs go, as we have been witnessing.

More widespread, more comprehensive coverage for still more people is not the answer. Across the boards, first-dollar coverage, amounting to a health care subsidy, is not the answer. Only when our health “insurance” once again becomes true insurance - that is, insurance against major loss – can goods and services received in the health care sector be brought down to earth. Only when the individual himself is put in a position to see and to assess the value of particular services rendered to him by paying for those services himself – can the system be brought back to sanity. Only when that happens will an hour spent in a room with a tattered lounge chair and a paper cup of orange juice stop costing thousands of dollars and be priced according to its true worth.

David Goldhill wrote an excellent, eye-opening article published in the September, 2009, issue of the Atlantic Monthly that similarly demonstrates the need of making high deductible insurance policies the cornerstone of our personal and our Government’s health care policy. Mr. Goldhill also outlined a well thought-out system of additional provisions that includes individual savings plans and accommodations for lower-income individuals. I highly recommend this article to anyone interested in reforming the health care system, and I hope many of our elected officials will read it and consider its proposals.


Postponing Treatment Might Not Be Bad

One more problem needs to be addressed though before anyone advocating high deductible policies can hope to gain adherents. Most of those favoring universal first dollar coverage base much of their feeling of necessity on the need to “catch problems early.” They point out that if people are required to pay for basic health care out of their own pockets, they will postpone getting check-ups until small problems become big ones. Then both society and the individual will needlessly suffer.

The argument that society will suffer generally boils down to a concern that society will have to pay for an individual’s neglect of his or her health. Expenditures, ultimately likely to come from taxpayer coffers, will have to be made to reimburse health providers for the truly heroic measures needed to treat the now severely ill person. Also, a lot of productive capacity will be lost as the dilatory individual languishes in a wheelchair rather than being up and at work on the assembly lines. However, social programs that require an individual to act for society’s good, not with relatively limited precautions such as wearing a helmet while driving a motorcycle, but in broader and more constant anticipation of society’s greatest good – can become the seeds of a dangerous social ethic. Programs based on such concerns smack of the spirit of the Third Reich when posters everywhere exhorted people to remember that “Gesundheit ist Pflicht!“ (“Health is Duty!”). Tyranny always starts by putting people under such general social obligation.

Concern over the individual’s own well-being might seem to be a more legitimate reason to urge universal health insurance providing near first dollar coverage. That way, it’s argued, problems can be nipped in the bud. No one would be motivated to delay treatment to save money. No one would have to worry about some health problem arising when he’s low on funds, thus allowing a small problem to mushroom into a big one.

But should the rightful concept of insurance as something to be invoked only in cases of major disaster be perverted in order to accommodate people who can’t or don’t choose to save some money to have minor health problems addressed? It might seem cruel to suggest such a thing. And if Mr. Goldhill’s plan for establishing individual savings accounts to supplement the high deductible policies and to be drawn on for routine health care were to be put into effect, the problem generally wouldn’t arise anyway.


Katie Couric Notwithstanding

However there’s a more fundamental reason that such an argument in favor of first dollar coverage isn’t necessarily valid. We are bombarded at every turn with injunctions to have routine check-ups – colonoscopies, mammograms, prostate exams. If a woman is pregnant, sonograms and all kinds of “pre-natal care” are now seen as essential precautions. Media celebrities impress us at every turn with the efficacy, the necessity, of keeping ourselves under constant surveillance in this way. We hear these check-ups urged so often, that their saving grace is taken for granted by most people.

However, quite a few doctors have published statistical analyses showing that, unless a person has some specific symptoms, routine check-ups of this kind can do more harm than good. Even the most accurate tests produce a proportionally significant number of false positives, which then torture the individuals with worry while all sorts of invasive follow-up diagnostic procedures are performed. The original tests and then the follow-up tests each carry the potential for error and mishap. The risks of submitting oneself for routine check-ups often outweigh the benefits. Morbidity and mortality rates for groups of the medically mindful don’t differ significantly from those rates for socio-economically similar populations of people who don’t get the recommended regular check-ups, who don’t so diligently try to “nip things in the bud.”


The Terrible Toll of Medical Error

However, there’s one easy, overshadowing statistic that eclipses all these somewhat more tricky statistics. An article published in the April 15, 1998, Journal of the American Medical Association (JAMA) concluded that that over 100,000 Americans die prematurely under medical care every year as the result of adverse drug reactions (ADR’s). It can be assumed that many, many more die yearly from other iatrogenic causes, such as hospital-acquired infections. These findings naturally received some criticism because the study was actually a meta-statistical one. That means it reached its conclusions by piecing together the conclusions of a number of other, smaller studies. This overarching JAMA study therefore likely included, among other statistical distortions, some duplication and overlap of the victims of medical care that it was counting. However even critics of the JAMA study conceded that the methods of statistical analysis used might just as easily have resulted in an under-estimation of the numbers of medical victims as an over-estimation of them. Therefore, all-in-all, the figure of 100,000 needless deaths a year seems a reasonable one.

Although this finding of such a staggering annual death toll is occasionally mentioned, it still remains a largely hidden and unrecognized danger every time yet another commentator urges regular medical check-ups. A few organizations have formed to try to reduce this iatrogenic toll by such simple expedients as having coordinated, computerized print-out prescriptions replace the old hand-written scrawls – and by enforcing hand-washing and sterilizing practices on medical staff as they make their rounds. Mr. Goldhill in the article cited above himself urges these reforms, and President Obama has made the extension of such measures a notable adjunct to his health care reform plan. However despite these efforts, the figures probably remain much the same as they were at the time of the 1998 study, in part because of a still very limited awareness of or acknowledgment of the potential damage and risk entailed in submitting oneself to medical care per se.

That figure of 100,000 unnecessary annual deaths remains the 600-pound gorilla in the middle of the room. Not many have been willing to look at it or to consider its implications. Thirty times the number of victims of 9/11 are dying often horrible, needless deaths every year because they submitted themselves to routine medical procedures. So it would seem that for every person who prolongs life and health by nipping something in the bud – there will be many more whose lives are curtailed as a result of going for routine exams. Therefore, the initially counterintuitive and unpopular conclusion is that if requiring individuals to pay for basic health care out of their own pockets sometimes causes them to indefinitely postpone making doctors’ appointments – the net result will actually be a healthier, longer-lived population.

Of course, it’s a gamble. Although the above statistics might indicate that for every person saved by early detection, there might be several who are unnecessarily damaged – who wants to be in the group that might have been saved by early detection? As every poet has attested, a person will more profoundly regret and be haunted by the adverse consequences of what he didn’t do than by what he did do. So we will rue the little lump we neglected and let develop into an overwhelming cancer more than we will rue the routine check-up that resulted in necrotizing fasciitis. At least in the latter case, we can consol ourselves that we did the approved thing, the thing that by all rights in an ideal world should have protected us in the long run.

Either way, it’s a tough, lonely decision, one that each individual will have to make for himself or herself every time a symptom arises or a media personality persuasively urges some routine test or check-up as a preventative care measure. However, the availability of first dollar insurance to cover early detection exams doesn’t necessarily steer one in the right direction or insure greater health. If indeed, as statistics currently indicate, less is more when it comes to submitting oneself to standard medical procedures – it doesn’t matter whether one comes by that reduced consumption through conviction – or through a simple lack of funds.


False Assumptions Behind Universal Health Insurance

But this leads to the most profound and radical objection I have to the extension of health “insurance” coverage to more people for more conditions. This leads to the most important reason I would urge our public officials and our private advocates to re-examine their basic attitudes about what is and what is not necessary when it comes to being healthy. By advocating universal health insurance starting at or near first dollar coverage – our officials are advancing the assumption that each and every one of us needs to stand eternally poised as either actual or potential consumers of health care. They are perpetuating the myth that we can only expect to live long healthy lives if we remain continuously enlisted as patients on the rolls of various doctors and health clinics. It not only assumes that we will need to have constant recourse to medical care when we manifest symptoms – but it also assumes that our very “wellness” can only be managed, validated, and advanced through the ministrations of medical professionals. In short, the advocacy of universal health insurance/universal health care presumes we all need frequent access to medical care for both our good days and bad. It’s that assumption embedded in the drive for extensive health care coverage that I believe will most grievously propel us down the wrong road.

Again, an analogy with a related professional field might be useful. There is currently some effort being made to promote legal insurance policies. In some ways, these are often more like pre-paid plans, but they can legitimately be thought of as insurance. You pay your annual premium, then you will be covered for some estate planning costs, for one or more court advocacies, for some paperwork associated with real estate transactions, etc.

However, despite the earnest efforts on the part of some to market these legal policies, they haven’t gained much traction with the general public. Although attorneys are often seen as being bent on legalizing all aspects of our lives, on bringing every human transaction into their domain, under their aegis – in reality, most of us don’t need an attorney’s services very often. In fact the average citizen might never need an attorney, or might need one only a few times in the course of her lifetime – perhaps to write that Will, to intervene in a dog-bite case, when property is bought or sold, or in the eventuality of a contentious divorce. So most people resist buying these touted legal insurance policies because they believe, rightly in most cases, that they just aren’t likely to be able to consume enough legal service to ever recoup even a fraction of the costs of their annual premiums.

That sort of skepticism should be applied to the push for basic universal health care coverage as well. The average person might want to consider that he or she simply doesn’t need much medical intervention in the course of a lifetime, certainly not enough to warrant our government’s concern over putting into place a massive infrastructure of provisions to cover health care costs. However the medical profession has been much more successful than the legal profession in packaging and re-defining a vast range of human need in terms of a demand for its services. Our lives have become medicalized - from the array of technological interventions often standing ready or actually imposed at the moment of our births, through to the protracted array of interventions, proscriptions, and prescriptions imposed in our last years. So now, while many people believe they can buy and sell a house without the process necessarily being mediated by an attorney - very few believe that they can maintain even basic health without being under a physician’s care.


Our Medicalized Society

A number of philosophers have tried to illuminate how this increasing belief in the necessity of professional services has transformed our lives. Ivan Illich, in his book Medical Nemesis, made the case that consumerism isn’t confined to those of our shopping excesses that often get criticized at Christmastime. He found our worst addiction to consumerism to be based in our belief that we stand in constant need of the services of such professionals as medical personnel. We have come to rely on these professionals to package and “deliver” their goods to us as commodities. They make their essentially irrelevant, adventitious services increasingly in demand, therefore increasingly scarce and costly. And we buy into it.

Other philosophers such as Michel Foucault and Jean Baudrillard have similarly, although more obliquely, included ideas in their works about how natural human processes have increasingly been re-defined as institutional commodities or outputs that we’re told we all need to consume in order to maintain ourselves. However I don’t have to cite these sometimes abstruse philosophies in order to make a case for how artificially manufactured much of our perceived medical need is. Much of my opinion comes from personal experience - as a volunteer driver for senior citizens. I drove senior citizens to their doctors’ and hospital appointments for several decades. And more - I sat with them through most of the medical exams or procedures they were having done. So (the usual disclaimer), while I’m not a doctor, I have racked up perhaps a thousand or so visits to doctors in the company of my friends and colleagues and assigned “clients.” Of those thousand-plus visits, only four seemed necessary or helpful.

Those four visits that justified the difficulties of bringing the patients to and fro were all on behalf of one person. This person (I’ve disguised circumstances to maintain the patients’ privacy, but have retained the essential nature of the appointments) had been suffering from a fistula for over a year. An appointment or two was expended in assessing the situation. Then there was the day of the actual operation when the fistula was removed. Then a follow-up appointment. And, ah! Relief! But those were absolutely the ONLY appointments that could be considered to have accomplished anything. All the rest struck me as having been a waste of time, energy, emotion, and probably millions of dollars in Medicare reimbursements.

I do first want to stipulate that the services of the medical profession are no doubt crucial in the treatment of people who present with acute conditions - with injuries, war wounds, etc. – or of younger people with specific symptoms. Our medical profession does a wonderful job addressing specific stabs of conditions, if the patient can avoid those iatrogenic side-effects of treatment. But as far as the appointments that are merely routine attendances, the kind that seniors are often called upon to keep – these almost all appeared to my educated eye to be utterly pointless. And they account for the largest part of our domestic expenditure on health care.


The Vast Wasteland – A Typical Exam

A typical appointment that I accompanied a senior citizen to and through would go as follows:

The 80-year-old woman spent a sleepless night worrying about the exertions that would be involved in getting to her appointment the following day. She said she had taken a sleeping pill to finally get a little rest, but she believed this unaccustomed pill had made her feel a little extra woozy. But we bundled into the car and drove to the Medical Center where this woman’s Doctor was seeing patients. I couldn’t find street parking, so I had to drive into the high-rise parking lot, going all the way up to the 10th level on the roof before I could find an open slot. I asked the woman to wait while I searched through the parking facility, then all the way down into the Center lobby to find a wheelchair to take her the block-and-a-half to the actual wing where her Doctor had his office. I was lucky, and did find a wheelchair available on this occasion. (Many times, I would either let my febrile companion off at the door of the Medical Center to make her way into the lobby on her own, where she’d sit and wait for me to park. Or else she’d stay with me as I drove into the parking facility and, if no wheelchair could be found, we would walk together slowly, laboriously all the way from the parking facility into the Hospital. In short, a lot of difficult logistics and dishevelment were usually involved in merely getting to the site of any appointment for a check-up.)

Once in the Doctor’s reception area, we were given forms to fill out which once again called for a recounting of my friend’s entire medical history, including the hysterectomy she had in 1978, and a list of current medications she was taking. Oh, we had forgotten to bring all her pill bottles with us! Let’s see – how many milligrams of A… was she taking? We filled out the forms as best we could, then we waited for nearly two hours. My friend was getting really hungry, since she had been too nervous to eat breakfast. When her name was finally called, we were ushered into a cubicle examination room where a young nurse took some preliminaries – weighing her and taking her blood pressure. Her blood reading proved to be alarmingly low, something like 80/60! The nurse sent a distress signal back to the Doctor and we heard some mumbled exchange taking place in an adjoining room. My friend tightened more with worry.

Finally the Doctor swept in with brisk cheer. He glanced at the forms attached to his clipboard, put them aside, and looked intently at my friend. He took her blood pressure again, and this time got a somewhat higher than normal reading. Another mumbled exchange took place between him and the nurse who was hovering nearby. I gathered that because my friend was so thin, under 100 pounds, they needed a special sphygmomanometer to take her pressure. The standard one used by the nurse had been too loose on my friend’s arm.

This higher reading caused the Doctor to write a new prescription for my friend, upping the dosage of blood pressure medication she’d been taking. This dosage incidentally remained unchanged until several years later, when the woman was fading from cancer and her hospice workers got consistently very low blood pressure readings. When I mentioned this to the visiting Doctor assigned by the hospice, and questioned whether she should still be taking pills to lower her blood pressure – that Doctor scanned her charts anew, and perfunctorily agreed that the medicine ought to be cancelled.

But on the day of this typical visit to the Medical Center, there was no further review of my friend’s charts or of the forms we had so studiously labored to fill out. The Doctor looked jovially at her, asked if she had any questions. When she said “No,” he crisply dispatched the clipboard under his arm, shook her hand, and chirped, “See you in three months!” – then swept out of the room in full confidence that something had been accomplished.

I chauffeured my friend home again, driving the difficulties we’d had getting to the Center in reverse. But things were much more pleasant on this return trip. My friend could relax. She’d done her duty of reporting for her regular check-up and had presumably been given a clean bill of health – except for that worrisome high (or was it low?) blood pressure. She was looking forward to getting back into her apartment, to eating a big meal to make up for the breakfast and lunch she’d missed, and to easing down on her couch to watch “Wheel of fortune.”

I was less confident than either the Doctor or my friend that anything had in fact been accomplished that day. I didn’t see the bill issued to Medicare and AARP for this visit, but I’m sure it was steep, no doubt specifying “Complete Physical Exam – Check-Up,” or something that sounded similarly necessary and comprehensive.

And this, almost down to the last detail, was the content of about 75% of the appointments I ushered by friends through. There was always the commotion of getting the elderly person to the site of their appointment – the forms to be filled out – the waiting – the two blood pressure readings which almost NEVER agreed with each other (the first sometimes being high, the second low – or vice versa) – the loosely revised prescription – the tucked-away clipboard – the quick dispatch – the relief at having put a hurdle behind us, of having done our duty. Oh, sometimes the Doctor would have my charge lie back on the examining table and would briefly palpate some part of his or her anatomy – but that was rare. Sometimes there was a concrete point to the visit, such as a mammogram (which also usually produced equivocal results and had to be painfully repeated). Most of the visits though were exact repeats of the tokenism I described above.

However, about 25% of the appointments I accompanied friends to did involve more extensive exams or procedures aimed at addressing some actual physical problem the patient had manifested. But again, to my educated eye, even these presumably targeted rather than routine visits proved to be exercises in futility.


The Green Mile to Radiation Therapy

A 93-year-old man had noted a spill of blood in his stool and was ultimately diagnosed with rectal cancer. He was launched on a regimen of combined chemotherapy/radiation, and there were whispered intimations of re-sectioning and colostomy to follow. We went in for radiation treatment every weekday for six weeks. However, I could never get quite clear on this man’s behalf what the Doctors hoped to accomplish with this arduous treatment. At first we were hopeful that they were aiming for a cure. But after a lot of vague, wandering explanation, I gathered that no, the best that could be hoped for was some shrinking of the tumor. The Doctors assured us though that the treatment was necessary as the only way to shrink the tumor enough to stop the bleeding and dangerous blood loss. That might have been legitimate – except the man had happily reported to me during the week he’d spent in a hospital room before starting this chemotherapy/radiation regimen – that the bleeding had almost completely stopped! The doctors denied this and said he must have been mistaken. Well, maybe.

At any rate, the man miraculously got through the radiation therapy with remarkably few side effects. He did die of cancer when he was 98-years-old, with the bleeding having resumed so that he experienced about the same amount of bleeding every day that had originally caused him to seek treatment.

A woman in her 70’s who had completed a similar regimen of chemotherapy/radiation was then told to report weekly for epoetin shots, presumed to bolster some of the blood factors that get depleted by radiation. (I learned that some athletes also were secretly taking these shots because they believed they enhanced performance.) I accompanied this woman through nine appointments, nine shots. The blood counts for her various blood components never changed during the course of this treatment though. So we privately wondered if the shots were really doing any good.

This woman was also very slim and the large needle used for the injections caused considerable pain. The ninth and last shot she received might have damaged a nerve in her arm, because she complained about pain and limited movement in that arm ever after. Her GP confirmed that her symptoms were consistent with a needle-damaged nerve.

Epoetin was a very expensive hormone extract, and I saw that Medicare was billed $1,200 for each shot. Quite a flurry of consternation surrounded that ninth shot, apart from the especially severe pain my friend experienced receiving it. Although Doctors had confirmed that my friend should report for her regular appointment that ninth time, when we arrived, we were initially told that Medicare would no longer pay for the treatment and that the appointment was cancelled. (Now they tell us!) However ultimately, after some extensive conferring, a phlebotomist was brought forward to administer the shot. That was definitely the last one though. About a year later, we learned that one form of epoetin had been withdrawn from the market and a lawsuit had been launched because of some side effects.


Shock and Awe

Then there was the particularly sad case of the woman in her late 70’s whom I’d been assigned to drive home from the hospital where she’d spent a week being treated for flu-like symptoms, probably walking pneumonia. When I called her early that day, she was ecstatic at the prospect of being “released.” She was gleefully packing.

When her husband and I got to the hospital though, we were shocked to learn that she was in intensive care under Code Blue. She had suffered from anaphylactic shock as she wa preparing to leave, and had been intubated. I drove her husband to visit her every day after that. Her condition waxed and waned. She would improve a little and was miraculously weaned from the breathing machine. She’d just be rallying, when she would suffer another attack of shock and would have to be intubated all over again. After eight weeks of what was overall a torturously downward spiral, she died. Staff members were never able to discover what had triggered these episodes of anaphylactic shock. I suggested the Latex in the hospital gloves might have been the culprit (I’d read that some people have a hypersensitivity to Latex). But the doctors believed they had ruled Latex out as the cause. So, it remains a mystery…


Do the Most First

Another one of my clients had complained of a sore throat. She was living in subsidized senior apartments and mentioned this to the visiting nurse. The nurse in turn phoned the regular Doctor who visited and attended the seniors in this building. He immediately set up an appointment at his Hospital for my friend to have an endoscopy. I was taken aback because this more difficult probe had been ordered before anyone had even cursorily peered down my friend’s throat with a simple, old-fashioned tongue depressor. “Say ‘Aaaaaaaaaa.’” But so be it.

My friend received a sheet of instructions telling her not eat for 12 hours before the test, and listing other precautions she needed to take in preparation. Her appointment was confirmed. After we arrived at the Hospital though (with the usual difficulties involved in getting a barely mobile 90-year-old anywhere) and had completed those perennial pro forma medical history forms, we learned that the procedure was NOT going to be performed that day. This appointment had been made merely to set a date for the main event! It was an appointment to make an appointment! However Medicare was billed for a full check-up exam for the day.

All that was really done that day though was to go through the usual weigh-in and blood pressure check. Nevertheless, I was initially relieved that the endoscopy wouldn’t be then. I thought this would give the doctors a chance to reconnoiter the problem with that low-tech tongue depressor. I was hopeful such a basic inspection would obviate the need for an endoscopy. But no. After the blood pressure check, we were sent home, still with no one having imply glanced down the woman’s throat. The order for an endoscopy stood – for another day. This meant another fast for my friend (who looked forward so much to her midnight snacks). It meant another arduous pilgrimage to the medical center, this time through deep snows, wheels spinning. We narrowly avoided getting stuck in the deep snowdrifts on either side of us all the way there.

The endoscopy revealed nothing out of the ordinary. The doctors toyed with setting up a deeper probe of my friend at a future date. However we never had to take that step because my friend’s sore throat went away after she switched back to the old brand of inhaler she’d been using to relieve her occasional mild asthma attacks.


A Hard Day’s Night in the Emergency Ward

Another woman just shy of being a centenarian got the sniffles and a sore throat, which then developed into a more pronounced cough. The visiting nurse in her seniors’ building called me to immediately take the woman to the emergency ward. I was more than a little dubious about jumping directly to this extreme recourse. I wondered if the building’s Doctor couldn’t make a visit instead, or if the nurse could just arrange an appointment with the woman’s regular GP. But no, the visiting nurse was firm about the immediate need of the emergency ward. And once any qualified member of the medical profession would utter anything, even if it was just an off-handed guess at the right course of action -that utterance became mandate, in the eyes of the patient herself and of the world at large. I couldn’t presume to contravene it.

So off we went to the emergency ward of one of the most respected hospitals in the U.S. We arrived at 11:00 AM. My friend hadn’t eaten breakfast or lunch in the midst of this consternation about how to deploy her, but we assumed she could get something at the hospital. After about forty minutes, she was assessed by the triage nurse. This nurse apparently felt that my friend’s condition warranted hospitalization, especially since this happened at the tail end of a scare about a serious pandemic flu. However her condition wasn’t deemed serious enough to grant her high priority for admission. So we languished in the anterooms of the emergency ward.

After another hour or so, she was taken back into the thick of the emergency room action with the exam cubicles off to one side and commotion all around. She was briefly examined in one of the cubicles and was then sent back out into the general stream of emergency room action. Hours passed. She wanly asked if she could have something to eat. A nurse rushing past promised to scout something. More hours passed. She asked another angel of mercy on the fly. This nurse said that the dinner hour was over, but that maybe she could get something from a vending machine. She promised to come back with something very soon. More hours passed. A gurney was brought out so my friend could lie down and rest. The aisles of the emergency ward were already so crowded though with other people lying on gurneys and with various apparatuses and dispensaries – that my friend’s gurney kept getting pushed toward the back entry doors. As the night deepened, more ambulance drivers and paramedics kept rushing in and out of those doors with victims of shootings, bludgeonings, stabbings, as well as with heart-attack victims and people sinking into diabetic comas. Every time one of these more serious patients was rushed into the ward, more cold night air also rushed in to chill my friend lying there on the gurney. I tried to push the gurney to warmer quarters, but it kept getting jostled back by the doors in the general on-rush. Finally someone brought my friend a blanket to ward off that cold night air. But still no food.

We discussed just getting up and going home. But a nurse, overhearing our plans to defect, strongly advised against that. She said my friend really should be more thoroughly assessed as an in-patient. The hospital was at full census – but “Just a little longer.”

Finally, a little past midnight, they found a room for her. It was an isolation room with a little foyer where any later visitors would be expected to change into protective clothing. I didn’t have to change though since I’d been with the woman all day. She was settled into the bed where she droopily asked if she could get any food. The attending nurse was doubtful, since it was past the time for nighttime snacks. But she said she would try to drum up something.

I stayed with my friend until she dozed off in the wee hours. As I quietly slipped out to go home, there in the little foyer I saw a covered dish on a rolling table. I lifted the lid and saw – a cold hot dog on a bun. I hadn’t thought to look out there! I presume my friend got the regular hospital breakfast, but that would have meant she went over 36 hours without food. How a nearly 100-year-old woman with the flu was able to stand that gaff of no food and repeated blasts of cold night air - I don’t know. I, who was much younger, would have been unlikely to survive.

However my friend came through this in remarkably fine fettle. She was kept in the hospital about five days, during which time they determined that she only had a common garden variety of flu. They tinkered with her blood pressure medication a little and the dosages of a heart pill she had been taking for some years. And then she was out – with an adventure to narrate, but with very little of real substance to show for the ordeal as far as I could see.


Hold the Compresses!

Finally, I’d been accompanying a man in his 70’s to a never-ending series of doctors’ appointments at a big medical center. The man was on Public Aid and he had what seemed even from the start a poorly coordinated host of specialists in attendance on him. One day he’d see the endocrinologist. Later that week, it would be the cardiologist. Then it would be his assigned GP there, and on to the gastroenterologist.

It was concretely established that he had inherited a gene for Leiden Factor V, which causes abnormal blood-clotting and consequent thrombi, which most painfully affected his legs. He was on high dosages of blood thinners.

Then it was decided he needed a stent to open an artery. He was informed of the risks involved in this operation and he actually planned for the worst, meeting with an estranged daughter, for what just might be the last time. He had reduced his intake of blood-thinners to almost nothing I got to his apartment at 4:00 AM because they said he had to be at the hospital to complete the check-in process by 7:00 AM. It was a cold and lonely drive through the rainy pre-dawn streets to the Hospital. But he was duly admitted, given preliminary sedation, and prepped for the operation. We chatted while we waited for him to be wheeled into the operating room. More to make conversation than for any specific reason, I asked if his regular cardiologist knew that this procedure was being performed. I’d heard the names of all sorts of new doctors and surgeons mentioned in connection with this operation, but Dr. S.’s name hadn’t been mentioned.

My friend said he didn’t know. That’s right, he wasn’t sure Dr. S. was in on this. So when the next Doctor/intern team came in to further prep my friend, we asked if Dr. S. would be in the operating room, or if Dr. S. even knew this operation was being performed. The Doctor looked puzzled. He made a note on his chart. A short time later, my friend was wheeled to the operating room.

I prepared to wait several hours to see how the operation turned out. I thought I might be asked to move to a recovery room soon to free up this regular hospital room. So I was partially packing up when I heard the loud clattering of a gurney coming down the corridor. There came my friend, on the gurney, being jostled zigzag back into the room. What? Why?

We never got a clear explanation from any one staff member. But we got snippets of explanations from a variety of interns and nurses. It seemed after our mention of Dr. S., the operating team had realized that my friend’s regular cardiologist had in fact been left out of the loop during the planning of this procedure. When the scheduled surgeon had phoned to apprise him – Dr. S. had urgently ordered that the operation be called off! He said even though my friend had virtually stopped taking blood thinners for the last days, there was no way a stent insertion would be safe. He’d bleed to death on the operating table! The operation was aborted just seconds before the anesthesiologist started to administer the final knock-out drops.

So several hours later, we drove home again. It was still raining.


Blue Zones

Again, these are typical of the appointments I kept with the senior citizens I drove. I haven’t selected the most dramatic or telling of my experiences with the medical profession. Each of these appointments was just “all in a day’s work.” I firmly believe this litany of uselessness is representative of what almost ALL senior citizens and many others without very specific, delimited symptoms experience as they become enmeshed in the medical system. Medicare and other comprehensive insurance coverage reimbursements have promoted this sort of needless consumption of medical services. But beyond that, the belief that health can only be achieved or maintained through the mediation of health-care professionals is what keeps people coming back for more – and more…

Last season Oprah had a show with Dr. Oz that featured the lifestyles of people living in what they called “Blue Zones” around the world. These are patches of communities where the residents seem to be enjoying extraordinary health and longevity. A disproportionate number of residents here were said to be living to 100+, remaining active and productive.

Well, this assertion might also call for a little skepticism. I remember the enthusiasm over the presumed longevity of the residents of Georgia, Russia, several decades ago when these citizens were featured in a variety of yogurt ads. It turned out that their claims of living routinely to 110 and 120 years of age turned out to be false. Birth records weren’t available in most cases, and people’s memories were faulty.

Nevertheless, assuming that the Blue Zones featured on Oprah’s show were a little better researched, or that the residents there live at least as long as the average U.S. citizen – that speaks volumes to how much health care it is necessary to purchase from health care professionals in the course of a normal lifetime in order to remain healthy.

One of these Blue Zones was Loma Linda, California. We can assume that the residents there might be consuming health care services generally up to usual U.S. standards. They’re probably on the rolls as patients at “wellness” centers and get most of the recommended tests and routine check-ups. However the other three featured Blue Zones were in rural or semi-rural areas where traditional lifestyles centered around family and farm and community still existed and where it was unlikely that the residents had not been observing any health regimens even remotely like those advanced as necessities here. These other Blue Zones were in: Nicoya Peninsula, Costa Rica; Okinawa, Japan; and Sardinia, Italy.

Dr. Oz was shown trekking to the Costa Rican site and scything down chafe in competition with the near-centenarian native there. The centenarian at least held his own, and probably outdid Dr. Oz in strength and endurance. But it seemed likely that this elder man would have been completely innocent of the ministrations of modern medicine. Like our great-grandparents, he might have had occasion to consult a local doctor there only a few times in his life – or perhaps not at all.


The Good Life

And so it should be for the average U.S. citizen. Unless a person has a crippling genetic disorder or suffers some specific grievous illness or injury along the way – all our elaborate medical interventions should be irrelevant to him. He should not base his identity on the roll of “patient.” He should not accumulate diagnoses like Boy Scout badges that allow him to advance through successive stages of an elite fraternity. “I received my diagnosis on April 12, 2007.” He should instead rest assured that, again barring unusual misfortune, he too can live most of his life without colonoscopies, endoscopies, pills, sagging sphygmomanometers, continuously fluctuating blood pressure and cholesterol readings, radiation, and rushes to the emergency ward.

Of course we are not living the “simple” lives of a Costa Rican farmer, but that doesn’t mean we can’t be naturally centered in our own environments – balancing some indulgences and joy with difficult, dedicated work – balancing solitude with some embracing fondness.


The Need for Basic Services

But even with that sort of intrinsic wellness, wellness not mediated by any teeming medical establishment - there are still all the little “slings and arrows” of life that we might occasionally seek some comfort against and some help with. For these we should bring back the old-fashioned family doctor, a person who makes house calls and who remains consistently enough on the job to get to know us without having to request that we fill out four sheets of medical history in preparation for each visit. We need to pepper the country with a generous number of small, low-tech, low-cost clinics that are open around-the-clock and that are staffed by one fully qualified doctor and by a variety of paramedics who can stanch a bloody nose, set a broken bone, and reduce the pain of a sprained ankle without enlisting us in lengthy, elaborate, lifelong attendances on any medical establishment. For the rarer, truly major medical problems that arise, we need to enable everyone to have high deductible insurance policies that cover the catastrophe. And we need concomitant watchdog groups to make sure that small problems aren’t therefore routinely inflated into major medical status.

However, we do NOT need to institute a system of medical reimbursements costing billions of dollars. We do NOT need to institute first dollar, universal health “insurance” that carries with it the assumption that we all constantly stand poised in need of medical enrollment, medical defining, and medical intervention.


Disillusionment and Hope

Few, if any, of the people I accompanied through the medical maze became fundamentally skeptical about the necessity of attending the next check-up, and the next… despite the seemingly obvious futility of the exercise they’d just been through. However, after several decades of this volunteer driving, I decided to substantially quit the job. I stood one day looking up at the high-rise parking lot attached to a major medical center and saw tier-on-tier of cars filling every level up to the roof-top. Based on my experience, I imagined the vast majority of those cars had carried people to hours of needless waiting - to needless exams producing equivocal, misleading results - to needless, complicated procedures performed before the simple gesture of one person looking with empathy and personal interest at another person had been given a chance to achieve a diagnosis. I saw a mountain of needlessness. And I thought – we have to do something else!

To the White Castle Diner We Go

I had a rather subdued Valentine’s Day. I made my fifth trip back to the auto supply store down the street in an attempt to get a battery that would fit my car. Since my 8-year-old battery had finally died in Chicago’s latest cold snap, I’d been on an all-consuming quest for another battery that would fit my car.

The first new battery the store clerk sold me, after consulting the computer, proved to be way too small. My car’s battery hold-down bar arched over this new installation like a bridge over troubled waters - with several inches to spare. So I could clearly expect no restraining action from the bar. What’s more, the battery was much too small for the battery pan where it rested. Between these two misfits, it seemed that the battery would be all too likely to slosh around under my hood, fly off its pan platform, and go smashing into any and all the other mechanisms there. I pictured a punctured radiator, torn fan belts, a cracked engine. Nope. No good at all.

When I went back to the auto supply store though, the clerk pooh-poohed my concerns. He said that he’d read a recent study proving that battery hold-down bars were superfluous. “Not necessary at all.” He assured me that my battery would rest firmly in place – unless of course, I was prone to driving over 60-miles-an-hour and hit a bump. That closing proviso caught my attention.

“Well, yes,” I asserted. “I am likely to go over 60. You almost have to go over 60 on the expressways. And there will surely be bumps in the road. You know life. There are always bumps in the road,” I tried to cajole with philosophy.

“Oh, you don’t look like you’d speed,” the young man said, obviously categorizing me with all those mythic little old ladies who drive just on Sundays, and then only to go a mile down their side streets to the local pharmacy.

This assumption roused me to go almost overboard in my objections. I stood firm in my assertion of a need to have a way of securing my battery in place while participating in the Indianapolis 500. The young man finally acceded to my special necessity of a bolted-down battery while taking curves at jet-propelled velocities.

He reluctantly scuffed off and got a “universal battery hold-down bar” for me. By using that, I could keep the smaller, lighter-weight battery he’d sold me. I’d consequently save on gas. Well, that idea appealed to me. He’d switched from pegging me as a snail’s pace oldster – to a green advocate Yuppie. I’d moved up a notch in status, and so on a number of counts, I accepted this compromise solution and went home with the new plastic hold-down bar.

But it didn’t come near to fitting the new battery in my car. So started my long campaign of exchanging batteries and hold-down bars. What should have been a chore taking only minutes – turned into an endless occupation. And what made this task all the more ludicrous in proportion, was the means I chose to ferry batteries back and forth from house to store. I preferred to do each successive replacement in the comfort of my own garage, rather than switching batteries out in the chill exposure of the store’s parking lot. So each insufficient battery had to be removed and transported in turn back to the store, and each new candidate for installation had to be transported home.

Batteries are heavy! I didn’t want to carry them back and forth even the short distance between my house and the store. So I loaded each one in turn into my baby stroller and off I went. (A shopping cart wasn’t an option because the wire grid at the bottom of those carts didn’t seem strutty enough to hold the prodigious weight of a battery.)

The use of my baby stroller made my excursions quite a spectacle. I became aware that I was probably making myself the subject of a lot of disapproving speculation. Nadia Suleman was bad enough with the octuplets she had just given birth to. But at least her children were real human beings. As I strode along the street, pushing an auto battery in a baby stroller, I presented an even more irrational picture of frustrated motherhood. Poor thing. She doesn’t even have a cat or a dog to love. She has to wheel a car battery around in a stroller.

I must admit, it was a temptation to play into such speculation. I was tempted to tie a little pink bonnet around the battery and beamingly sport it along the avenue, while I exuded parental pride.

For this last trip I took to the auto supply store though, I abandoned the baby stroller and did just drive my car so I could make the exchange in the store parking lot. I did this in spite of the signs that had recently sprouted all around that section of the lot – signs that blared “No Auto Repairing Allowed Here” - and that seemed to be saying “This means YOU!”

The store finally sold me a larger battery, one that conformed to the contours of my original hold-down bar. Their clerk rushed out, dropped the new battery in place under my hood, then disappeared. He probably wanted to leave me alone to break the law against doing parking lot repairs. So I quickly made the requisite reattachments by myself, in the blustery cold. Then I started up the car, and ahhhhh, at last – one task accomplished.

I thought I would celebrate by stopping in White Castle for one of my occasional tasty, but probably not-very-healthy meals there. When I got to the White Castle door though, I saw a pink sign hanging there, announcing their special Valentine’s Day festivities, which required reservations. I remembered – it was Valentine’s Day! It was 5:00 P.M. – the hour their special dining arrangements started.

I peered through their window, the classic outsider looking in, the waif with her nose pressed against the toy store window. There was a roseate glow about the whole interior. I saw red plastic tablecloths, a vase with a red rose on every table, pink drinking cups and pink streamers. Then I noticed couples were beginning to arrive in the parking lot and head into the diner. Some of these couples even looked as if they had dressed for the occasion. A few of the converging women were wearing corsages. I suspected that the White Castle server appointed as greeter for the occasion would probably bestow additional corsages and boutonnières to each new arrival.

It was clear that there was no room for the likes of me, a single person with traces of motor oil on her jacket, at the posh place the White Castle had become on this special day. I peered in with a trace of longing for a little while yet, before I turned away, resigned to the rejection of “no room at the inn.”

Jay Leno made short work of the concept of spending Valentine’s Day at the White Castle. He said if that’s all a girl’s date is willing to spring for, he’s clearly “just not that into you.”

But I don’t know. That rosy casualness looked sort of appealing to me. If I’d had a date for the day, I think I would have been happy to be treated at White Castle. No wine lists to try to fake my way through. No need to gird up in pantyhose and cinched waist. No judgmental wait staff who would have to be tipped despite bringing the wrong soup and no extra butter.

I was reminded of my childhood, of all the times my mother and I headed to the suburbs for some gathering with the family on Holidays. My father wasn’t able to drive us, so just the two of us would bundle up and go by bus and train. Along the route, we’d pass several greasy spoons where a few down-and-outers would already be scarfing down thin slices of turkey swimming in what was obviously glutinous gravy out of a can. Once when we passed a begrimed restaurant window and saw a particularly grizzled diner sitting alone in there on Christmas - my mother looked pityingly at the scene and said, “How sad – to have to eat in such a place on Christmas.”

But I thought then of the assemblage awaiting us in the suburbs. I thought of my aunt and her unremitting games of withering one-upsmanship. I thought of my cousin Harry whose handshakes always lasted too long and always involved his pulling us toward him into protracted hip-to-hip contact. I thought of all the distraction of these parties – with my uncle swearing at the malfunctioning stereo - swearing at the dog someone had allowed to come bounding into the living room – swearing at his losing football team on TV. And my aunt was sure to inject herself into this already fractured picture – with scoldings to my uncle as she’d catch him eating a potato chip. She’d dourly remind him how he was thereby jeopardizing his cholesterol count and risking imminent heart attack. If somehow, against all odds, a slightly more heartfelt conversation got started amidst all this incident, she would break off her warnings about myocardial infarction, would sigh heavily about how she couldn’t prepare the meal all by herself, and would ask the conversants if they would please come and help her in the kitchen.

There was never so much as an iota of family cheer about these gatherings – much less love. I had pointed this out to my mother, summarizing my brief against all these people we were forced to foregather with simply because of an accident of blood. And my mother was brought up short. She realized how she’d been indulging in a mythologized, Norman Rockwell painting of Holiday parties. She had been superimposing this Saturday Evening Post picture over the reality. So when I said I actually wished I could join that unshaven reject there in the greasy spoon – she reversed her former commiseration – and agreed with me. In there, we’d have had the freedom of both our togetherness and our own thoughts. We could have eaten potato chips and heavy gravy without reminders of escalating cholesterol counts. We could have celebrated the spirit of Christmas, a spirit of silent essentials.

And so it was as I gave one last look back through the window of the White Castle, wishing I had a date who’d take me there, where we could sit over one of those red plastic tablecloths – free of the swirling snootiness of restaurants with pretensions. We could sit there and look at each other, and look out the surrounding windows at the passing people and traffic, none of them at cross-purposes with us.

But I didn’t have any such date. I had to content myself with the lesser triumph of a car battery that fit in place under my hood – and that started my car. I got back in that newly reappointed car, and drove home to a TV dinner in front of a Seinfeld re-run.

Dampening Blagojevich's Spirits

Illinois citizens’ high spirits over the election of our Senator Barack Obama as President - have been somewhat dampened by the disgrace of our Governor Rod Blagojevich. Have we gone from the sublime to the ridiculous? We are the laughing stock of the world. And the Governor’s recent appearances on TV shows haven’t helped.

Although Governor Blagojevich lives only a couple miles from me, I’ve never met him. However I have met his father-in-law, Richard Mell, the powerful Chicago Alderman whose influence helped get Rod Blagojevich in office in the first place. Shortly after Blagojevich was elected, the two men had a falling out over who had unfairly profited from granting control over a large landfill acreage in the State. There has been a strained silence between the two men ever since, with Alderman Mell’s daughter left awkwardly in the middle between father and husband.

However Rod Blagojevich was re-elected for a second term as Governor, and Alderman Mell remains one of the most influential senior members of Chicago’s City Council. Mell has his big ward offices just down the street from me. I occasionally drop in there when I have a comment or question about ward services. Then there was that time Alderman Mell dropped into my residence. The visit had some very unpleasant consequences – for Alderman Mell.

I’d always had my living quarters adjacent to and actually mixed in with my family printing business. When I finally phased out my business, I rented space in the building to a young man bursting with enthusiasm over launching his own printing business. I’d assumed he would enlist his wife and two children to help him occasionally run the office, in the same sort of let’s-pull-together family conviviality that I had enjoyed growing up. But that didn’t materialize. Roberto was clear about not wanting his children to have to participate in what he considered the menial tasks connected with printing and mailing. His wife also kept generally absent from the operation. So I didn’t get to see any home-learning, family business perpetuated on my premises, as I’d hoped.

Nevertheless, Roberto jumped in by himself with gusto. He was very charming, so he was successful at getting a stream of people to come in here with their business. He would schmooze with them, gleam joviality and brightness, and give them confidence that he would execute their work orders with dispatch. He was in fact so charming, that people hardly ever seemed to notice when their jobs came out either horribly botched, or else never came out at all. The people would still flock to Roberto and his beaming glad-handing – again and again. I had thought to sort of casually keep my hand in the printing trade vicariously through his energy. I had thought I might circle on the periphery of his business, learning some of the new computer techniques being applied to graphic design and printing. However, all too often, I got drawn into the vortex of Roberto’s ineptitude.

In due course, Aldermen Mel came in here as one of Roberto’s customers, and he also fell into the vortex of continuous mishap. Mell probably wanted to throw some work to a local minority business. Whatever brought him in here, I was impressed to see Alderman Mell standing at the office counter one day, being schmoozed by Roberto. Mell was asking if Roberto could do a special job for him. He wanted some invitations to a Democratic fundraiser printed. He would supply his own paper, some very expensive gilt, deckle-edged linen cards. Roberto of course assured Mell he was the man for the job. And as Mell looked into Roberto’s eager, intelligent eyes – he became sure too. Mell proceeded to haul in boxes of the special stock. The two men parted in beaming mutual reassurance of the wonderful gold filigree invitations that would soon emerge.

But it was not to be. Robert was Roberto. He was a master at raking in the business. But when it came to actually doing a job, he was out and away and nowhere to be found.

Roberto could think up no end of distractions to defer actually having to start doing any work. He always wanted to add services to his basic printing operation. He asked me if he could install gumball machines and maybe even some video game machines on the premises. One minute, he entertained “diversifying” into printing T-shirts, and then on into tie-dying fabric. The next minute he thought he might sell money orders and telephone cards. He considered adding a translating service to his business. He would translate letters and telephone calls for those of his Hispanic customers who didn’t know much English.

Most of these mushrooming dreams never took root. They went up in a powder puff of dispersed spores. However Roberto did succeed in foisting one adjunct business onto my premises. Not long after he’d established himself here, he decided to breed dogs as a sideline. He brought a bouncy male boxer appropriately named “Rocky” into the building, to be available for round-the-clock stud service. However, Roberto was rarely around to train or feed or walk Rocky. When I couldn’t take up the slack, the dung and disarray would start building up around the printing presses.

Roberto’s legitimate customers naturally got lost in this rain of distraction that Roberto precipitated on the scene. Their jobs were neglected. Most particularly, Alderman Mell’s guilt-edged paper languished in a corner. As the days wore on, I kept reminding Roberto that he HAD to get busy with Mel’s order. Mell’s deadline was approaching. If Roberto would just make good on this account, he would no doubt get loads of additional work from the ward offices and from the Chicago Democratic machine in general. He’d be made in the shade.

But Roberto postponed and postponed, as he always did – running out and about soliciting yet more business over lengthy lunches around town. Finally, the night before Mell was scheduled to come in and pick up his printed invitations, Roberto grudgingly came in here late and set to work. He fell into the usual foul mood that overtook him whenever he was forced to actually execute any of the jobs he’d netted. In this case though, I could tell there was some additional frustration eating at Roberto as he revved up the press and started slapping ink onto its rollers.

When Mell arrived the next day to pick up his presumably dazzling gold-filigreed invitations – I heard what had happened. Roberto sheepishly confessed that his dog, Rocky, had urinated all over Mell’s cartons of paper. But ever one to turn a negative into a positive, Roberto immediately perked up. He assured Mel that he had rescued at least a quarter (maybe even a full half!) of the paper. He had gone ahead and run the slightly damp paper through his machines, risking damage to his press feed rollers in the process. But he had done it - as a special favor to Mell. I melted away anonymously into the background – so Mell could never connect me with this disaster, with this patently absurd reframing of who was damaging whom.

Mell took it in good part. He didn’t let his practiced politician’s smile crack even a splinter. He and Roberto joked in the vein of “dogs will be dogs.” Mell said it would be all right – that he might have enough invitations to go around. Or else he could make up any deficit in some makeshift fashion. They parted amiably. But of course Mell never came back.

I sighed with infinite regret. There went Roberto’s big chance. There went my big chance – to have a going business on my property again – or even just to have a tenant who could pay his rent.

Roberto finally folded and moved out in abject failure – leaving all sorts of corruption in his wake. Rocky’s stains are still in evidence here and there, permanent reminders of the whole sodden episode.

Now all these allegations of corruption have been leveled against Alderman Mell’s son-in-law – Rod Blagojevich. I get the feeling that a high percentage of the Illinois electorate would like to resurrect Rocky – to do to Blagojevich what he did to Mell’s gilt-edged paper.

Barack Obama - A No-Girlie Man

It was inspiring to watch the Obama inauguration. Those two million people in Washington, so moved, so joyous at having finally “overcome” – made me sort of wish I could have been there and have fully gotten into the spirit of it all. And I do think that Barack Obama will make a good President.

I think he’ll be more of a true statesman than we’ve had in a long time. He has the right temperament for the job. He won’t go off the deep end, feeling a need to assert our American supremacy over other countries and cultures. He won’t make rash, pressured decisions. To piggyback clichés – I trust that, as much as is possible, Obama will steer the ship of State successfully through rough waters and keep it on an even keel.

Having said all that, I hate to be a naysayer by raking up anything negative about Obama, especially since my objection might at least initially appear to be a quibble. However Obama said something along the way that gave me a glimpse into a prejudice he’s harboring and that really saddened me – because I believe it’s a prejudice we must to work harder to eradicate.

When Barbara Walters was interviewing Obama and his wife, she brought up the jolly topic of the dog he intended to adopt for his daughters. Since there are allergy problems in his family, he initially said a shelter dog probably wouldn’t be an option. With that, Walters suggested a few breeds such as poodles that don’t shed, but that are incidentally rather petite animals. A dismissive look came over Obama’s face, and he said that anything like that would be “too girlie” for him.

My heart sank. In that moment, I knew for sure we still have a lot more to overcome. It might seem I’m making a mountain out of a molehill when I take someone to task for dismissing a dog because it is too “girlie.” But in that remark, I do see a mountain that women still have to climb before they can stand on an equal footing with men in this country and in the world.

Just imagine what would have happened if Walters had suggested some breed of dog that has long black strands of hair, and Obama had dismissed the idea of getting any such breed because it was “too pickaninny.” A wave of shock and protest would have rolled around the world. And rightly so. Whether you dismiss something as “girlie” or as “pickaninny” – you are applying a diminishing, infantalizing term to a whole group of people, and you are floating the presumption that it’s OK to feel disdain for that group based on such a stereotype. Both “girlie” and “pickaninny” carry connotations of being laughable and lesser.

When Arnold Schwarzenegger refers to someone disparagingly as a “girlie-man,” I might be inclined to take it more in stride, considering the source is a former bodybuilder who no doubt had some habitual competitive reason for sneering at anyone less muscular. However, the usage is never really acceptable. Every female is or was once a girl, just as every black person is or was once a youth. So to use slangy, demeaning terms for that state of youth in whole segments of the population can’t do anything but reflect and perpetuate prejudice.

The only difference between “girlie” and “pickaninny” as pejoratives is that the former is so ubiquitous a usage, we accept it and have largely become deaf to the dismissal inherent in it. That fact that Michelle Obama and millions of other women sit by in cheerful, accepting silence when men disdain something because it’s “girlie” - i.e. because it has the assumed frivolous, feeble, second-class qualities of a girl – is testimony to how embedded this form of prejudice is in our culture. We’ve become deaf to the barb in the usage. We’re inured to it. Men automatically get away with using the term, and women themselves will play along and even bandy the term among themselves, although usually in a slightly different, “Hey, girlfriend,” context.

I’m not accusing President Obama of having any deep antifeminist streak. But I did feel that pinprick of disillusionment - that “Oh, no, not you too” regret when I heard Obama toss away poodles as an option because, being girl-like, they were beneath him. And his off-handed comment reminded me of the larger battle women have had to fight to attain some degree of equality. I was reminded of how historically in the U.S., women have had to wait, and wait, and wait, and wait… to gain respect. They have again and again deferred their dreams in order to allow black men to advance theirs. Black men have preceded women in being recognized as full human beings – in law, and in language.

Before the Civil War, it was primarily women who spearheaded the abolitionist movement. However, these women often felt they were fighting for a package deal. They felt that when slaves gained their freedom and were given the vote, women would automatically be included in this enfranchisement. They felt that with abolition would come an across-the-boards recognition of human rights. Elizabeth Cady Stanton and other suffragettes organized the Seneca Falls Convention in 1848 with high hopes that their arguments would be heard and that all the oppressed would soon be liberated in unison. Women, especially Southern women, joined hands with African-Americans (in spirit if not always literally), to march forward toward this goal of universal suffrage.

However, there was a lot of pressure on the women to take a back seat. It was felt that if they pushed for their rights, they would trivialize the whole effort to extend civil rights to others and would jeopardize the more crucial abolitionist movement. Many women reluctantly did defer to this sentiment. They agreed that slavery was the greater evil and that they shouldn’t do anything to jeopardize the eradication of that institution. If the world thought that women’s demands for the vote were silly, just so much more “girlie” nonsense, it would be counterproductive to link those demands to the more legitimate claims of black males.

Elizabeth Cady Stanton and other more militant suffragettes continued to press for equality, even in the face of all the urgings they received to “cool it.” But indeed they were headed for disappointment. The 15th Amendment to the Constitution, granting black American males the right to vote, was ratified in 1870. Women’s claims, still deemed by the majority to be ridiculous, were ignored. Worse yet, the black men who had been women’s comrades throughout the years of struggle for abolition and equality - almost all abandoned women after 1870. Once they got the right to vote, most of them never looked back. They didn’t extend any helping hands back to women in their on-going struggle.

Some say it was that betrayal that hardened the hearts of many activist Southern women against blacks – and that ultimately fed into what became the South’s uniquely virulent form of discrimination against blacks. On the whole though, it wasn’t so much bitterness that the women felt, as disappointment, depression, and even heartbreak. Although Stanton and Susan B. Anthony and others continued to write, speak, and organize on behalf of women’s suffrage, many women just gave up after the Emancipation Proclamation and the 15th Amendment so pointedly failed to include them in the new liberties. Much of the fighting spirit went out of the movement.

It wasn’t until the turn of the century that the movement was re-energized by a new wave of feminists. Then women such as Alice Paul in the U.S. and the Pankhurst family in England started a radical assault on the bastion of male supremacy. They chained themselves to pillars; they marched. In the U.S., they appealed to President Wilson over and over again to consider their claims.

Woodrow Wilson was another intelligent, essentially decent President who fought for an end to all imperialist presumptions – our own and those of other countries. He gave his all to trying to establish the League of Nations on a sound footing, with U.S. participation. However Wilson had this one blind spot. He couldn’t see women as true equals. He probably never used a word such as “girlie.” That wasn’t a word in such currency then. But records show that he at least privately thought women’s claims were “frivolous, flibbertigibbet, ludicrous.” He consistently refused to even give the suffragettes a hearing.

It took a long time to wear away his reluctance enough to get him to lend his support to the push to grant women the vote. It wasn’t until 1920 that women finally, finally won that right – with the 19th Amendment. This was a full 50 years after black men had been granted the legal right. I’m not so old, but my mother was the first woman in my family who could vote when she turned twenty-one. My great-grandmother and grandmother, although born in the U.S., could not.

And although women now have the right to vote and a variety of other legal rights, they are still pervasively devalued in so many social ways. Black men seem to have preceded them once again in commanding respect.

If a man were to complain, “I just can’t figure blacks out. I don’t know what they want,” there’d be a riot of protest. He’d no doubt be roundlytaken to task for the remark. Since he’d be assuming that all blacks are alike, all inscrutably erratic and whimmed, he’d probably receive a lot of lectures about the need to remember that black people are individuals and that any right-thinking person would know to consider them on an individual basis, not to lump them as a homogeneous mass.

However if the same man complains, “I just can’t figure women out. I don’t know what they want,” it’s taken as a perfectly acceptable piece of barroom philosophy. In that case, he probably receives a few commiserating pats on the back and responses of, “I hear you, buddy.”

Similarly, if a little boy were to announce, “I hate blacks! They’re icky! They’re stupid,” he’d no doubt receive some swift attitude correction, if his parents were the least bit modern and liberal in their thinking. However, when the same little boy announces, “I hate girls! They’re icky! They’re stupid,” most parents think it’s cute. They view such an attitude as a normal phase, one that every boy passes through on his way to taking the obverse view of “liking the girls” and vigorously pursuing them – all of them - one big, fabulous, indivisible conquest for him.

Which brings us back to the original point. If a man were to disdain something because it was “too pickininny, too Buckwheat, too blackie,” he would probably be branded as a racist and ostracized by most informed people. However, when he disdains something because it is “too girlie,” almost no one even notices, least of all the woman sitting next to him through life.

It’s not that I want to add another brick to the heavy load of political correctness that we’ve been hauling lately. I’m all in favor of wild, offensive, irreverent talk that’s recognized as such. I’m in favor of agreeing with and playing into stereotypes in order to float them up there for all to see and puncture. But when diminishing references are passed off and passed over as commonplaces, when they are scattered over the ground as prosaic as pebbles – that’s when I object.

So Barack Obama’s election signaled a major victory against prejudice. However, there are other battles against prejudice to be fought. There are all the casual, deprecating references to women, to old people, to other groups of people that are still routinely acceptable. And victory in all these other battles seems as if it might elude us for a long time to come.