An Open Letter To Tom Coburn on Medicaid Expansion Money For Oklahoma

Dear Mr. Coburn, 10-7-2013

I recently read your editorial in the Tulsa World in support of our state leaders’ decision to turn down Medicaid expansion money.

I believe your reasoning is flawed in many respects.  You voice concerns in your piece about our state’s financial situation if we do expand Medicaid.   But let’s be clear - the federal government’s proposal is to send our state millions and millions of dollars.   These dollars would have provided medical care to the poorest among us.  But let’s also not forget, we are talking economics here after all, that these hypothetical dollars would not disappear into the ether after they are spent.   When medical personnel receive payment for their work, they in turn spend that money in their local communities.

What I am saying is that because we have turned down Medicaid expansion funds, local businesses in Oklahoma are missing out on millions of dollars in business.  This is money that would surely drive unemployment down and enrich our citizens.  It would almost certainly provide enough income for some citizens to lift themselves right off of the Medicaid roles.  Jobs and rising incomes are the answer for the large number of poor in Oklahoma.  And this decision to turn down money for healthcare, and therefore for local businesses, is going directly against that possibility.  

Small business owners, look around your store.  There would be more people in it if our state had accepted Medicaid money.    Governor Fallin’s decision has directly led to less use for your cash register.  And you are paying your federal taxes while other states (not ours) receive the economic benefit of federal dollars in return.

I can hear criticisms now:   “We don’t want money that was put here by federal spending.”     But you, Mr. Coburn, know that ALL money is put into the economy through federal spending.   That is where financial resources originate.  Dollar bills are not dropped from helicopters.  They do not spontaneously generate in our wallets.   They are introduced through federal spending.   Then we use those dollars locally to facilitate business.  (Banks also introduce dollars, but those dollars are owed back to them.  Federal spending introduces dollars owned free and clear.)

I have addressed the federal debt with you in previous letters.  However, I must point out that suggesting, as you did in your editorial, that a check from the US government could “bounce” is a falsehood.  You know this is not true, but you are stoking ignorance and paranoia in order to promote your political goals.

The United States government has run a continuous debt since 1837.  It always will, for its debt is simply the creation of money into the non-government sector.  The United States cannot, in principle, bounce a check, because all checks anywhere originate with federal spending.   You might as well suggest that the NBA might run out of points for its next game.    

In fact, the only way the US ever could come close to bouncing a check is if conservatives in Congress willfully choose to do it on purpose - which is exactly what they are threatening to do.   You and your colleagues are pronouncing fearful prophecies and then trying to self-fulfill them.  

But even if the federal government was not proposing a huge stimulus to care for our poor, our state would not go broke if we did it on our own.   Rather, we would need to spread our resources out in a different manner in order to provide more health care.  We could boost our overall productivity by hiring the unemployed, and if we need to divert some resources away from luxury cars, vacations, video games, etc. to provide basic humanity to the poor, then so be it.    

But the resources are there.   

Let’s talk about the working poor.  A childless person bagging groceries for $8 an hour cannot afford healthcare.  She is also not eligible for Medicaid, since she has no children and is under 65.  Governor Fallin’s decision to turn down the Medicaid expansion has made sure that this person still cannot qualify for Medicaid.

Do we need people to bag our groceries?   To cook and serve our meals at restaurants?  To pour our coffee?  To work our cash registers?   To care for our children?   

Then let’s not blame them for their station in life while simultaneously depending on them.  We need them.  Let’s get them health care.

I think that if you don’t want them to have health care - you will say you do, but without offering a legitimate possibility, this is a lie - then you should probably pour your own coffee.

We live in a world where people are more interested in the world obeying their particular political philosophy than they are in feeding and healing the poor.   But if the private sector were able to provide adequate care for the poor, then it would already be done.   Until churches routinely pay for heart surgeries, we need the public sector to be involved, as a public good.

I often imagine Jesus being asked - should we feed the hungry and heal the sick publicly or privately?       I imagine his answer to be   -    YES!

Perhaps the biggest weakness in your arguments against accepting Medicaid expansion money is what you propose to do instead.   Which is basically nothing.

What I read in your letter is essentially this - please stay away from the doctor, working poor.  

You make the line too long.

Mr. Coburn, I appreciate your intellect and your energy.   And I am sure that you are a wonderfully capable physician.   But on the issue of the Medicaid expansion in Oklahoma, you are guilty of both economic and moral malpractice.

Sincerely, your constituent, 

Steven Stark, Oklahoma City

www.stevenstarkmusic.com

A Violation of Religious Freedom or a Prevention of Religious Domination? - part three, Engaging A Catholic Argument

This is the last installment in this series of posts.  This issue has obviously interested me greatly, as I can understand why it appears, on the surface, to be a question of religious liberty.  But I do not think this is the case.  No individual is being required to take birth control, and no doctor is being required to prescribe it.  However under the Affordable Care Act, health insurance policies will be required to provide birth control free of charge (though, of course, people still pay for insurance policies).

Here is an argument against the Obama administration’s position.  I took it from a Facebook page called “Stand With the US Bishops Against The HHS”.

“...to make the case that the state can force the Church to pay for contraception for employees requires at least three premises to be true: 1) that all people have a right to contraception under natural law, 2) that all people have a right to receive that contraception free of charge, and 3) that employers have the duty to pay for the contraception.  The 1st premise is false because contraception violates nature by ceasing or altering natural bodily functions. The 2nd premise is false because no one can say that his rights must be secured by another. The 3rd premise is false because employers provide health care as a matter of convention and a part of wages, but it could also be that an employer pays enough for an employee to acquire independent insurance. Further, the 3rd premise is false because while employers do have an interest in the health of employees, they have no interest in the sex lives of employees, and contraception, which is a violation of the body's health, is about sex, not healthcare.”

Here are a few brief criticisms.

One:  If access to contraception is considered an essential part of a woman’s health care, then can we argue that a person has the right to it?   This seems to be the case, as the criticism of the premise offered is one that debates the validity of birth control as an aspect of health care.  They argue against this because the pill “violates nature....by altering bodily functions”.  

Death is a part of nature. Our bodies are programed to self-destruct over time. Is it wrong to “alter” this bodily function when you have the chance?  

Perhaps a better example is pain.  For instance, a woman’s body is designed to feel pain during childbirth.  Is altering this bodily function OK?

So health care is not about what one considers natural per se.  It is about promoting health and well-being.  When a woman is able to have an intimate relationship, setting the stage for the possibility of a family, but can also have access to education and career opportunities by delaying child-bearing, then this contributes to her well-being.  When she can wait to have children until she is financially ready, then this contributes greatly to her and her child’s well-being.  When a woman can choose to have a relationship but not to have children, then her freedom and well-being (and that of her partner) is enhanced. The list goes on and on.  When considering the status of women in less developed countries, access to birth control becomes an even more dire issue.

Two:  The individual mandate enacted by the Affordable Care Act supports the idea that all people must contribute to paying for their own health care.    Participants in health insurance are paying for their insurance policies.  Obviously these policies must offer  coverage for prescriptions that promote well-being.  Whether the policy covers a portion of birth control costs or all of it, the policy would still be paying for birth control.  So this criticism seems irrelevant to me.

Three: Here is where they may have a good argument.  I don’t think that employers should have to provide health coverage to employees.  I think it is a bad way to facilitate the coverage required by the individual mandate.  But this is how things are set up, so until (and if) it is fixed, health coverage must include birth control.

Here is an argument in support the administration’s position:

One:  All people have the right to life, which includes health care.

Two:  The government has decided that all people must contribute to the practice and the preservation of this universal right by taking responsibility for their own health insurance.  This is called the individual mandate.

Three:  The government must therefore decide what constitutes adequate insurance coverage to satisfy this individual mandate.

Four:  Access to birth control is recognized by the government, the public and the medical community as being an essential part of a woman’s health and well-being.

Five:  The government must therefore require insurance policies to cover birth control.

My conclusion is that most of the arguments about this controversy can be reduced to arguments about whether birth control is really health care, whether the invidual mandate is a good idea, and whether the individual mandate should be satisfied through employers.   Arguments about religious liberty are off point.

A Violation of Religious Freedom or a Prevention of Religious Domination? - part two, The Real Problem

The real problem which is causing the controversy between the Obama administration and some US Catholics is not one of religious liberty.  It is one of the public sector using the private sector to accomplish its purposes.  

There will soon be an individual mandate for health insurance coverage in the United States. Here is a small snippet of an exchange between Mitt Romney and Rick Santorum where Romney offers up a concise and effective argument for the individual mandate for health insurance coverage.

"If you don't want to buy insurance, then you have to help pay for the cost of the state picking up your bill, because under federal law if someone doesn't have insurance, then we have to care for them in the hospitals, give them free care," said Romney. "So we said, no more, no more free riders. We are insisting on personal responsibility. Either get the insurance or help pay for your care." 

"Does everybody in Massachusetts have a requirement to buy health care?" asked Santorum.

"Everyone has a requirement to either buy it or pay the state for the cost of providing them free care," Romney shot back. "Because the idea of people getting something for free when they could afford to care for themselves is something that we decided in our state was not a good idea."

But this is a bit of a side note, as whether we accept it or not, the individual mandate will soon be the law of the land.  And of course, if we are required to purchase health insurance, it must meet certain criteria for contributing to the health and well-being of the citizenry.  The individual mandate would be worthless if individuals  could satisfy it by buying insurance thats cost $5 a month and only covered a bottle of aspirin a year.  There must be standards as to what constitutes an insurance that adequately satisfies the individual mandate.

Access to birth control is widely considered to be an essential part of a woman’s health and well-being.  It was listed by the CDC as one of the top ten most important health advances of the twentieth century, and it is promoted by a myriad of mainstream science-based medical organizations. Therefore it must be covered under any insurance that would meet the requirements of the individual mandate.

According to a recent study by the Public Religion Research Institute, a poll quoted in USA Today, most Americans, and even most Catholics, believe that birth control should be covered under health insurance plans.

So the real problem is not that health insurance should be required to cover birth control.  The problem is the primary method the government uses to satisfy the individual mandate - the employer/employee relationship in the private sector.

If health insurance was done completely publicly, then we might disagree with a national health care system and/or birth control, but we all pay taxes and watch the government do things with which we disagree (because it represents us all).  But this will not happen in the foreseeable future.

However, if the individual mandate was satisfied by individuals purchasing insurance directly,  instead of having it provided through their work benefits,  then there would also not be a huge problem with the requirement that insurance must include birth control coverage.  Catholics who disapprove of birth control would still be purchasing insurance from a company whose benefits would almost certainly include someone else’s birth control.  But this different accounting scenario would eliminate the perception some have that Catholic institutions are specifically being forced to purchase something with which they have moral objections.

So the real problem here is that the government is maintaining the link between the employer/employee relationship and health insurance coverage.   There is a middle man that might disagree with what the government, the public, and the medical community deems a very necessary component of adequate health insurance coverage for women, and the perception then emerges, because the benefits they offer must meet these standards, that the liberty of these middle men is being violated.  

But unfortunately, this is the world we live in.  Therefore the government simply must maintain standards for what constitutes adequate health insurance coverage, or else the individual mandate loses its effectiveness.  

A Violation of Religious Freedom or a Prevention of Religious Domination?

The Obama administration has decided that large institutions run by religious organizations cannot be exempted from including birth control in the health insurance plans they offer.  The rule does exempt churches and other places of worship whose primary purpose is to facilitate the practice of religion.  However, if a religious institution runs a hospital, a university, or another organization that goes beyond religious services, thereby servicing and possibly employing many people outside that religion, then they must comply with this new ruling.  Making sure birth control is easily available to women is a feature of the Affordable Care Act.

The Obama administration’s reasoning is based on the position of many, many medical organizations that making birth control easily available to women is a good for the public health that cannot be compromised by an employer, even if the employer is affiliated with a religion that disagrees with the practice.  Once again, churches would be exempted, but not institutions affiliated with religion serving the greater community beyond the specific practice of religion.  Of course, the Catholic Church is very, very unhappy about this decision as they run many hospitals and universities which would fall under the birth control coverage mandate.

I had to think about this for a while.  Religious liberty is a foundation of our society and should never be taken lightly.  But after considering it for a couple of days, I agree with the administration’s position.

First, we must establish that there is a limit on the practice of religious freedom.  Few would argue that Native Americans should not be able to smoke peyote in their ancient religious rituals.  (Actually, I think anyone should be able to do this, but I suppose that is another subject!).   However, imagine a religion with an initiation ritual requiring five year old children to walk five miles barefoot in the snow.  Let’s call this religion Freezism.  And when practicing this Freezist ritual, hypothermia frequently sets in.  Would our society tolerate this tradition?  Probably not, because of how the religious practice would affect others - namely five year old children who are too young to choose this religious practice for themselves.   So this barefoot snow ritual would not be an exercise of religious freedom so much as it would be an exercise of religious domination because of the risk of severe physical injury to those too young to participate in a truly willing manner.

So religious liberty is not an absolute - just like freedom of speech does not cover threats of violence or yelling “fire!” in a crowded theater when there is no fire.

Now imagine a university or a hospital run by a religion that does not believe in treating heart disease.  Let's call this religion Coronism. Their theology posits that God’s relationship with man dwells physically within a person’s heart, therefore no medical treatment should directly interfere with a person’s ticker.  It is a danger to a person’s soul.  Now imagine that this institution, a hospital let’s say, employs many, many people not affiliated with Coronism, and the hospital tries to exclude heart disease treatment from the health insurance policies offered to its employees.

Surely this would be too great a burden on the public health to be allowed.  It would be religious domination rather than religious freedom.  The Coronists would be forcing their employees to go without heart disease coverage, or to pursue coverage elsewhere at much greater personal expense.  The Coronists would be forcing unwanted religious restrictions, or at least the hardship of bypassing (haha) them, onto employees, onto workers in the community.

By requiring the Coronists to include heart disease treatment in the health insurance policies they offer, no one is forcing any Coronist to receive heart disease treatment.  But no one is allowing the Coronists to make it difficult for their employees to get the treatments they may need and desire and which medical science tells us are associated with health and well-being.

Now imagine another religion that does not believe in fire alarms.  Pyroism? Surely if the Pyrists ran a hospital for the general public, they would not be allowed to subject their employees and clientele to that danger?

At the risk of changing the subject temporarily, I actually think the real problem with the Obama/Catholic conflict is the link between the employer/employee relationship and health insurance.  This link is terrible.  An employer should offer pay.  That’s it.  Then individuals should purchase their own insurance.  We would have greater job mobility for workers, and Catholics could create their own policies which do not cover birth control, while employees at Catholic institutions (Catholic and non-Catholic alike) could buy the insurance they want which provides the services they desire.

But that is not the world we live in.

So the issue of religious freedom means deciding when one person’s “freedom” infringes on the freedom of another.   And the Obama administration has decided that when a church operates an institution that goes beyond the specificities of religious practice, not covering birth control creates an undue burden on the health and well-being of employees.  It is not an expression of religious freedom, it is an expression, however big or small, of religious domination.

And I agree.  Do you?

Tea Parties, Health Care and Freedom

The modern day “Tea Party” movement is not modeling itself on the right rebellion. Patriots in Boston, throwing British tea overboard, rallied themselves around the cause of “No taxation without representation.” Fair enough.

Tea party revelers have representation today. They may disagree with many of their representatives’ decisions, but they are free to express themselves at the ballot box. They are also free to gather together and protest, which is a very American thing to do, but to draw inspiration from the Boston Tea Party - a response to a truly unfair situation - rings hollow.

Another recent “assault” on freedom is the new health care bill. It requires Americans to purchase health insurance. I will readily admit that this is a necessary evil. Government coercion always is. Stopping at red lights and paying taxes are also necessary evils, but they are the price we pay for civilization. We trade in some of our freedoms to realize other freedoms.

Requiring health insurance for citizens makes sense. How can we expect the health care system to work when tens of millions either can’t afford insurance or decide not to carry it? When they get sick, hospital emergency rooms are required by law to treat them. And when the hospital is not paid, the price goes up for everyone. As Mit Romney said during the 2008 election (paraphrase) - “We already have universal health care - but not everyone is paying for it.” And without encouraging preventative care and regular check-ups, many people wait until they are really, really sick to seek treatment. This isn’t smart - it’s a waste of human life both for the sick and for those who have to pay for it.

As long as hospital ER’s are required to treat people, regardless of their financial circumstances, then we all must contribute. If we had a single payer system our required “insurance” would be paid through taxes, but private insurance is the way of the land, and that is fine.

Does this infringe on our freedom? In some ways yes it does. We are being required to provide for our own health care by purchasing insurance. But there are other possible assaults on freedom. How free is someone when she is sick, or her children are sick, and she cannot afford a doctor? How free is a person waiting until he is sick enough to go to the ER, rather than making a doctor appointment weeks earlier? How free is the middle class person whose medical bills include the cost of all the free treatments provided by hospitals? How free is a person stuck in a dead end job that she hates because she needs the insurance for her family? How free is the man with asthma who cannot purchase health insurance on his own, so he gives up on his entrepreneurial dream and takes a job with a corporation large enough to insure him? How free is a person in physical pain, who doesn’t know what to do about it?

Can government go too far attempting to provide for its citizens? Of course. But we are not talking about cars, cell phones, or even housing here. We are talking about whether we should systematically do all we can to provide health care to our citizens - to ourselves and to our neighbors. The only other commodity as valuable is education, and we pay our property taxes to educate society. To not do this would be to effectively brainwash children. If we have the ability to provide education and health care to our citizens we must do it. If we do not, then calling this the land of equal opportunity has zero credibility.