In the good parts of town you hardly ever see them, but in the bad parts they are still everywhere. Brown, greasy, horizontal lines on the walls of rotting, mildewed buildings, reminding us even now of the Great Flood. If you look at the lines carefully enough, you may notice that they, though multiple, often visually coalesce into three broad bands. The bands tell a story. The highest band marks the high point of the water hours after the levees broke and the storm surge poured into New Orleans. After a day or so, the water receded to a lower level as Katrina passed inland, creating the lowest band. There it stood for almost a month, which is why this lowest band is usually the darkest and most distinct. A month later Hurricane Rita brushed the city on its way to landfall in Texas, bringing a new, smaller surge with it, and raising the standing water by a foot or so in some places. Thus the third, and middle band.

In New Orleans, water lines tell us something about a building. They tell us how much water the building took on, and more importantly, that the building has been untouched for the last two years. One of the first things people do when they start to rehab a flooded property is scrub off the water lines. It isn't surprising that, after two years, the city is still recovering from Hurricane Katrina, but it is surprising that there are so many houses with water lines, so many unreconstructed houses. Katrina is still one of the leading issues in the local news broadcast every single night, and makes the front page of the local paper every single day. Every story, every crime, every social problem is somehow linked to Katrina. Southeastern Louisiana is not stuck on August 29, 2005, but it seems to be stuck sometime in the spring of 2006. Stuck in a stage of early recovery, marking time like the recovering drunk who wakes up each morning and tallies up another day of sobriety. There is no looking ahead; there is only today. Let's just get through today.

The problem is, it has been this way for almost two years. The average person likes to look forward, to have a future, not to scratch out an hourly existence like an aborigine in the desert. But now, in the heart of hurricane season 2007, day-by-day is all the New Orleanian has. The levees are not what they should be. Another Katrina now would end things once and for all, and everyone knows it. The Army Corps of Engineers has a plan to protect New Orleans against a hurricane of Katrina's intensity, but plan will not be reality until 2011. There will be a lot of tropical disturbances between August 2007 and 2011. And the Corp's plan at this moment is nothing more than a promise from the federal government. I think we all know what that is worth nowadays.

In the months after Katrina, the initial stages of shock and grief were gradually replaced with a mixture of despair and hope. The despair is obvious, but the hope needs explanation. Many of us thought that in death there could be renewal, and we hoped that this disaster might clear out the bad as well as the good. Death is not all bad. It makes way for the young and the fresh sprouts of spring; it forcibly does away with old ideas and calcified customs and brings sunlight to the new.

The storm, for example, reduced the murder rate in the city to zero for a time. Some of us dared to hope that the drug dealers were gone for good, or at least could be kept out. Perhaps, we dreamed, the drug gangs and their supply systems were as hopelessly mangled in the flood waters as our bridges and homes were. With careful rebuilding, the thinking went, we could exclude this evil for a time, maybe for ever. As it turned out, we were terribly, terribly mistaken. The criminals came back, and the drugs came back. Flooded and abandoned houses are now crack houses. The crime is worse than it has ever been, and the police and justice system seem helpless to do anything about it.

The storm also blew away the New Orleans public school system. The New Orleans School Board was absolutely the worst elected body I have ever seen in the United States; prior to the storm it was millions of dollars over budget and for all its overruns was nonetheless one of the worst-performing school districts in America. Sixty-eight of the 108 public schools in the city were rated as "academically unacceptable" by the State Board of Education in 2005. Forty-eight percent of high school students dropped out, and many of those who stayed in school couldn't read anyway (One New Orleans school had a valedictorian with an ACT score of 11. The national average score is about 17.). The State Board was considering a complete system takeover before Katrina hit. The system's finances were already ordered into a form of receivership, and were being managed by the New York accounting firm Alvarez and Marsal. Accountants from that company were calling the school systems books among the worst they had ever seen. Louisiana ranks in the bottom 5 nationally in most educational surveys. So if the state of Louisiana considered the New Orleans educational system unacceptable, execrable is likely a more accurate word.

Katrina, however, put an end to this awful system. Individual schools were reopened as independent charter schools. In November of 2005 the state took 107 schools away from city control and created a state-run Recovery School District. The RSD seems to have done a reasonable job of finding responsible administrators to organize schools and get them running again. The city offered bonuses for out-of-state teachers to come in and help out with the recovery, and hundreds of promising and idealistic recent college grads answered the call.

There was also hope, and continues to be hope, that Katrina will help blow the corruption out of our beleaguered state. The trend towards clean government started before Katrina, and has accelerated since. In 2001 former Governor Edwin Edwards went to jail. In 2004 he was followed by Ronald Bodenheimer, a local judge who was convicted of framing a man for drug possession. About the same time the home of Jacques Morial, the brother of former Mayor Marc Morial, was raided by federal investigators. The ex-Mayor's uncle, Glenn Haydel, was sentenced on corruption charges in 2006. There are widespread rumors that the ex-Mayor himself may see his day in court. All this was followed by the raiding of the home and office of Congressman William Jefferson, and his indictment for bribery. A few months ago a former member of the New Orleans School Board pleaded guilty to corruption charges, and just last week City Councilman Oliver Thomas did the same. U.S. Senator David Vitter has his neck on the block for prostitution. Some might argue that this is simply evidence that Louisiana is as corrupt as its reputation would have it, but it is also proof that a proper accounting is finally underway.

Another helpful post-storm change: The multiple political boards that divided duties of levee upkeep were, after a huge effort, consolidated into two districts. Instead of being run by political appointees, the new Levee Board will now consist of scientists and engineering experts -- the kind of people who should have been managing the levee system all along.

Mardi Gras has come back, and appears to be alive and well. The Saints returned for last fall's football season, and this year the New Orleans Hornets will be playing basketball here, too. The port of New Orleans is back in full operation, and seafood production, especially shrimp and oysters, appears to be rebounding. According to New Orleans restaurant critic Tom Fitzmorris, there are 853 locally owned restaurants open in the city, up from 809 prior to the storm. (Figuring importantly among those are R&O's, Mandina's, and Clancy's -- my most beloved New Orleans restaurants.) Hotel capacity is rising to pre-Katrina levels. And this past week, Waldorf-Astoria bought the old Roosevelt hotel and intends to spend $100 million to bring it up to world-class status.

Those are the bright spots. Darkness, however, abounds. After the brief period of non-existent crime after Katrina, the murder rate has skyrocketed. And the city government seems completely unable to cope. Since his improbable re-election last year, Mayor Ray Nagin has vanished from public sight, saying little or nothing about crime except that the police are working hard to stop it. Meanwhile the District Attorney's office has only secured 3 convictions for the 161 murders that took place in the city in 2006 (that's right, three), and the DA has the nerve to claim that he is being scapegoated for systemic problems. (That's the one thing New Orleans has in abundance -- excuses.) The city is still without a crime lab, as FEMA holds up funding earmarked to help reconstruct the staggered police system in red tape. The DA's office can't try a lot of cases because it does not have the money to hire enough lawyers, and worse, the city cannot find enough defense attorneys for defendants.

The city's recovery plan has yet to struggle out of the gate, and this has forced citizens to make decisions without knowing what the government intends to do. Thousands are still waiting for assistance from the Road Home Program, a government grant project that was supposed to provide funding for individuals to rebuild. Thus far, only $2.8 billion of over $6 billion allocated has been spent. Only 37,000 grants have been made for  160,000 claims. As the money trickles in at a painfully slow rate, some citizens who intended to rebuild at first are now slowly moving away. The Road Home program is currently $2.9 billion short if it pays out all qualified claims, not because of corruption but because the need is so much greater than originally thought. George W. Bush's response has simply been to say New Orleanians have gotten enough money already. Donald E. Powell, Bush's coordinator for the Katrina recovery, has been a little more specific, arguing that the shortage has occurred because Louisiana officials have been basing awards on need, instead of excluding wind damage as the Bush administration required . Imagine that. A federal hurricane recovery program that excludes wind damage. Only the Bushes would think of something so harmful and stupid.  

Which brings us to another disappointment. Many of us dared to hope that, after the horribly botched federal disaster response, President Bush would, out of a self-proclaimed Christian man's sense of shame, make an extra effort to atone for the early errors. Hardly. On August 29, 2007, our leader makes his 13th appearance on the Gulf Coast since the hurricane. By comparison, over the course of his presidency, he has spent 319 days on vacation as President, or 20 days for every day he has spent in New Orleans. And by the way, he went on vacation the day before Katrina hit.

I have focused my comments on the City of New Orleans because New Orleans, as sorry a state as it is in, is vital enough yet to come back. Before Katrina I lived in St. Bernard Parish, just east of New Orleans and closer to the eye of the hurricane. St. Bernard was a blue collar community of 68,000 before the storm, composed mostly of fishermen, craftsmen, and oilfield workers. Today about 20,000 are left. Probably 75% of the buildings in the parish are still unrepaired. The only hospital has been razed. Of the 30 or 40 doctors that worked there, only 8 remain in a single clinic, a cluster of FEMA trailers in an old Wal-mart parking lot. There is talk of possibly opening a new hospital in 2011. This is a community that was completely shattered by the storm, and I have begun to doubt that it will ever come back. In my old subdivision only about a fourth of the houses appear to be occupied, and we used to live in a relatively wealthy area. In the poor sections, there is no one.

Two years after Katrina, the New Orleans area has reached a crossroads, if not an outright crisis. Progress has been slow, and after a while, even the most patient and determined people will tire of the endless struggle and quietly shuffle away. The city population has been increasing, slowly. The New Orleans population has reached about 60% of its pre-storm level. St. Bernard is probably at about 30%. Overall the metropolitan area is about 80-85% of pre-Katrina levels. This is not terrible, given everything that has happened, but it belies a slower, more alarming trend of educated people slowly leaving town. That 11,300 homes were up for sale in June and only 1,029 were sold suggests that more middle and upper class people are headed out than in. The oil business, which has been slowly consolidating in Houston for decades, is leaving town faster than ever. The port of Orleans has lost some ground to the competing ports in Houston and Mobile, Alabama. Very little big business is coming in to replace the lost jobs.

New Orleans' greatest problem is that, two years after Katrina, there has not been a definite commitment to recovery. Local and state leaders have floated ideas, but it seems that no one has the political courage to make the very hard decisions that need to be made, such as which neighborhoods and schools should be abandoned, or what new building codes need to be enacted to minimize hurricane damage. Even a recent property tax reform intended to spread the tax burden more equitably has led to considerable grumbling.  If people resist simple property tax re-assessments, how will they handle real reform?

The federal government has done some things, but its commitment has not been encouraging. Consider that the White House has agreed so far only to restore the levee system to pre-Katrina levels. In theory, the levees before the storm were supposed to protect the city against the equivalent of a Category 2 or weak Category 3 storm. Stronger storms than that frequently appear in the Gulf, so this announcement has heightened concerns rather than calmed them. There is funding for a study to determine what it would take to strengthen the levees to Category 5 hurricane protection, or a 500 year flood, but that is all it is -- a study.

Businesses won't relocate to New Orleans over a mere study. And former residents (myself included) will not consider rebuilding without credible assurances that Hurricane Katrina will not happen again. Without adequate flood protection it will be impossible to obtain affordable flood and home insurance, and this uncertainty is strangling the rebuilding process. A real commitment to strong levees on the federal level would ease those concerns and make the city a more attractive investment opportunity.

Some would argue that New Orleans, given its location, should not be protected against a Category 5 storm. Economists pointed out only days after Katrina (it still offends me that they could not wait a respectful length of time to make this observation!) that strengthening flood protection only encourages people to build in high risk areas, and thus creates the potential for more disasters in the future. This may be true, but if so -- if America thinks New Orleans is not worth rebuilding -- New Orleanians deserve to be told this honestly. This state of half-commitment is killing the city slowly and horribly, and that is not right.

I confess that I am sensitive to the efficiency argument. Business and good government are all about allocation of scarce resources, about getting the most out of what you've got. No one likes waste. But efficiency can become a substitute for morality, an excuse for hurting people when the only motivation is personal greed. Thus an auto manufacturer can fire 10,000 American workers, move a plant to Mexico, in the name of efficiency. No one questions the suffering involved, or who gets the saved dollars.

If the money saved by abandoning New Orleans went to end malaria worldwide, or to improving schools in the poor rural South, that would be one thing. If it is used to buy more DVDs and flat panel TVs, or worse, fattens the paychecks of Fortune 500 CEOs, what is the benefit? If I thought for a moment the efficiency proponents would take the money saved not building levees and use it to establish universal healthcare in the U.S, I would give them serious pause. But that will never happen, and we all know it. Our country will always be awash in petty luxuries like DVDs, and our streets will always be clogged with the luxury cars of millionaires, whether New Orleans has decent levees or not. But universal healthcare? Let's not hold our breath. Before the hurricane, St. Bernard was a relatively poor community. I do not doubt that if St. Bernard were simply abandoned in the name of economic efficiency, the thousands that live there would simply go be poor somewhere else. That vaunted efficiency may help someone, but it won't be them.

I have lived in New Orleans on and off for most of my life. It is hardly the perfect place. But it is a place apart from most of the United States. Increasingly, our country has been homogenized, and the pace of this homogenization has been accelerating. Our nation is turning into a sprawling suburbia of strip malls, overpasses, and Wal-marts, and not enough of us care. If someone dropped you on street corner in Atlanta, in Dallas, in Los Angeles, in St. Louis, how long would it take you to figure out where you are? If you were in a mall, you never, ever would. The radio would be no help; TV would be of litte help. Even local newspapers increasingly look alike. Most Americans do not live in the town they were born in, and many have lost the attachment to place that is everywhere in New Orleans.

According to the 2000 census, the American city with least transient population was Vacherie, Louisiana, a small town on the river between New Orleans and Baton Rouge. Among the 50 states, Louisiana ranked second, after Pennsylvania, among states with the most native-born citizens. People who live here want to stay here. They love the food, the culture, the music, and their heritage. They don't want to leave it and move to a "nice" place. The world is full of nice places, but only one place is home.

If New Orleans was different before Hurricane Katrina, the storm experience has bound the city together like nothing before. No city has endured this same collective experience in recent memory. This experience, this collection of stories, could generate a remarkable spirit of confidence and cooperation if the recovery kicked into high gear. Instead, all this potential for unique, creative energy is being wasted through indifference and incompetence.

America will not survive as a nation because all of its citizens are alike. We will survive because we are diverse. From diversity comes creativity, fusion of ideas, and revolution. From similarity comes sterility, rot, and failure. We should be actively encouraging individuality, encouraging cultural diversity, because this has always been our strength. I find our indifference to diversity as perplexing as our sometime hostility to immigrants, who have also contributed mightily to what we are today.

Diversity is not efficient in the economic sense. Yet it is the way of nature. Evolution, after all, is wasteful. Thousands of organisms live and die so those rare few with competitive advantages can survive and flourish. How many proto-humans walked on all fours before a very few stood up? How many nation-states failed before the first democratic republic took root? If nature favored only efficiency, there would be no such thing as intelligence because admiring statues and mapping the stars is hardly efficient. A tiger is efficient. A cockroach is efficient. A ballet dancer is not.  

In the last year, many have expressed concern over the plight of the honey bee. Perhaps you have heard this story -- throughout the United States bee hives have been disappearing. Not simply dying, but disappearing. Twenty-two states have reported drastic, and sometimes catastrophic drops in bee populations, with some beekeepers losing more than 90% of their hives for no obvious reason. The bees do not die, they simply abandon the hive and disappear. This phenomenon has acquired a name -- Colony Collapsing Disorder, or CCD -- and recent evidence suggests that the problem may be a complete breakdown in the bee's immune system. Some have suggested that it is an AIDS for bees.

I, like many scientifically conscious people, was distressed by the news of CCD. I have always liked honey bees, and find them beautiful and fascinating creatures. When I was about 10 a hive of bees swarmed my back yard. I was afraid of the swarm, until my father assured me that this was a natural process and that bees are much more docile and useful than their reputations suggest. And in fact this turned out to be the case; the bees took up residence in an old cyprus in the marsh behind our house, and quietly lived there for years. Many times I came within a few feet of the opening of this hive and watched with fascination as the bees harmlessly and busily slipped past me.

In my reading on CCD, I was surprised to learn that bees are very nearly extinct in the wild. I had no idea, and I am certain most people do not know this. People who claim to have been stung by honey bees are usually the victims of other stinging insects or bee look-alikes, such as the hornet or the wasp. What most people see in their gardens are not bees, but bumblebees. If you see a bee in your garden, this means almost certainly that there is a beekeeper in your neighborhood. Wild bees have been virtually extinct in the U.S. since 1994.

It is remarkable that an insect that most people are convinced is common in fact only exists in captivity. How could we be so mistaken? And how could we go on for so long without even noticing the extinction? And bees are not the only animals that are disappearing before our eyes. Frogs, and in fact most amphibian, populations are declining rapidly. The Audubon Society estimates that songbird populations have fallen by 50%, and in some cases by nearly 90%, in many areas of the country since the 1950s. I don't think very many people have noticed this either.

Which brings us back, oddly enough, to New Orleans. I feel New Orleans is endangered the way frogs, bees, and songbirds are. Its culture, and the culture of the Cajuns who live nearby, is dissolving before our eyes, and no one seems to be paying attention. Human cultural diversity is just as important to our survival as animal diversity is, and we are losing both. Deniers abound: people who think the data is phony, people who think declines are cyclical and nothing to worry about, and people who think species die as a part of the natural order of things. There may be a grain of truth in all of these objections. But all three ignore the basic truth that diversity is required for innovation and survival. A people that has lost its diversity is simply waiting around for extinction.

Our original national motto, E pluribus unum, means "out of many, the one." Our founding fathers chose this motto because they understood the meaning of diversity, even 100 years before Darwin. The many is a necessary precondition for the existence of the one. Diversity first, then unity. If we do not preserve that which is unique among us, there is not much more to be said about our identity.

Preserving New Orleans should be part of our national mission, because first of all, we can, and second of all, if we can justify letting it die in the interest of national economic efficiency, we can justify letting practically anything go for the same reason. We don't really need national parks, or clean rivers, or an educated majority, or even racial equality for that matter. None of these are paying propositions. Some of our most productive years, economically speaking, were at a time when the rights of blacks were actively and unapologetically suppressed. So why do right, except for the inconvenient fact that we are sinners if we don't?

I do not want to be part of a country that turns its head in a few decades and realizes that the wild New Orleans as it was is gone with the honeybees. To find that what is left of that unique culture exists in captivity here and there around the country, and in numerous textbooks, but that the real place is now a fossil. Maybe not completely lifeless, since the French Quarter could always be converted into Colonial Willamsburg or Main Street at Disneyworld, but abandoned in spirit, and no longer a renegade sprig on the American bough.

Two years since Katrina, and recovery is nowhere near complete. In many areas, it has yet to start. On this the second anniversary of Katrina, a ragged few will be making the rounds, hat in hand, once again asking for help. I know everyone is tired of hearing about it, and believe me, we are tired of having to ask. Before long, this asking will stop, either because the rebuilding is complete and all is well, or because the city has died and no one has come by to check the pulse. I wish today I had the confidence to tell you which way it will go.

Attorney General Alberto Gonzales resigned this morning. He gave no definite reason for his resignation, but that is in keeping with his standard operating practice, which is to act without providing justification for anything.

I am sure cheers are coming from every corner of the liberal world, but you won't hear it from me. I am disappointed that Gonzales is gone. Gonzales was the focus of much hatred in this country, and he was the one person I thought the emasculated Congress might actually impeach. My hope was the Congress would impeach Gonzales, and that in the impeachment proceedings useful information would come out. Gonzales was so godawful that he was the one person a majority of Republicans would vote to remove from office.

My next hope was that, once emboldened with the Gonzales impeachment, Congress might take aim at Cheney. According to polls, the majority of Americans think Cheney should be impeached, so this would not be a leap.

My opinion is that we need a showdown in this country. I watched Sen. John Warner of Virginia discussing the Iraq War on "Meet the Press" yesterday, and while I sensed that Warner is frustrated with developments in Iraq, I was frustrated to see the Warner was not ready to publicly oppose the President. It was all "let's have faith in the process" stuff.

The only process stuff I want to see is impeachment hearings. Congress needs to confront the President right here and right now and make him understand that he is not Dictator-in-Chief.

I worry that this resignation will diffuse some of the anger and buy Mr. Bush some time. In fact, I am certain this is why Gonzales hung on so long. The Bushes calculated that if they waited long enough to cut Gonzales loose, they could temporarily delay impeachment talk by allowing the Gonzales side show to absorb all the heat. If Gonzales held on long enough, by the time he resigned there wouldn't be enough time left on the clock for impeachment hearings to play out. The President is no longer counting on resurrecting his popularity. He is wasting time, our time, until the clock runs out and he can write pardons for all his friends (and maybe for himself) and skip out of town.

(Here's a cynical scenario for you: Bush waits until the last day of his presidency, then issues pardons to all of his cronies in the White House. Then, at 5 minutes to inauguration, he resigns, Cheney takes over, and pardons Bush. Unlikely, but possible.)

The rumor is that Gonzales will be replaced with Michael Chertoff. I have no end of expletives for this choice. Chertoff was in charge of the Katrina rescue effort. When Katrina landed, Chertoff was in Atlanta at a meeting on the influenza epidemic. Chertoff was ignorant about what was happening until the third day after the storm, when he checked his email and saw requests that he get further involved. This idiot is GW Bush's idea of the best candidate to be Attorney General.

Nice. Bush should be impeached just for thinking that.

In his book The Problem of Pain, C.S. Lewis observes that whatever we think of pain, it nonethelss serves humanity in one useful way: It forces us to act. Without pain, we humans have a natural inclination to sit back and let evil creep over us. Often, only suffering shakes us from our drowsy malaise and spurs us into action.

Pain is not only immediately recognizable evil, but evil impossible to ignore. We can rest contentedly in our sins and in our stupidities; and anyone who has watched gluttons shovelling down the most exquisite foods as if they did not know what they were eating, will admit that we can ignore even pleasure. But pain insists on being attended to. God whispers to us in our pleasures, speaks in our conscience, but shouts in our pain.

Lately there have been hints that we medical people are about to be shouted at. In newsletters, magazines, and emails of late I have been hearing an increasingly frantic message. The federal government is about to cut Medicare physician's payments by 9.9%.

For years, Medicare has used a complex formula to calculate physician reimbursement. The formula bases reimbursement on how doctors as a group utilize medical services, and it was intended as a carrot-and-stick mechanism to keep physicians from running up health care costs. The idea was that if doctors spent increasing amounts of money on diagnostic tests, reimbursements would go down. If they spent less money on tests, reimbursements would go up, or at least stay the same.

This formula, whatever good intentions it may have engendered, has been a dismal failure. Every year since 2001 the formula has mandated a salary cut for doctors. And every year, to correct the cut, American doctors, and particularly the AMA, have successfully lobbied Congress to override the formula and restore the cuts. This year, however, could be a different story because 10% is the largest the cut has ever been. Congress is struggling to find money to finance a certain foreign military action the White House feels is more important than the health of elderly Americans. When all the military contractors are paid, there may not be enough borrowed money left lying around to make up the ten percent. There is a chance that the cut, or at least a good part of it, will go through. Making the situation even worse, the formula projects further budget cuts each year through 2015. If all of these cuts go through, Medicare could be paying doctors 40% less by then.

Everyone agrees that health care costs in the U.S. need to be controlled. But that is no excuse for allowing a formula to passively run U.S. health policy. Medicine is not a static field that can be circumscribed with mindless rules. Medicine constantly changes, and allowances have to made for new practice guidelines and treatments. You can't just plug X, Y, and Z into an equation and expect to find the answer to spiraling health costs. Not unless you want to be stuck with the medical technology we had in 2001 forever.

A 9.9% fee cut will make a significant impact in the medical community. Medicare is the largest insurance carrier in America, and most doctors depend on it for a significant percentage of their income. There are very few businesses that could endure a 10% cut in income without making significant compromises in the quality and type of services they offer. Doctors, however, are in a particularly difficult position -- despite the cuts, they will be expected to provide the same level of care as before. The ethics of medicine do not allow physicians to lower their standards, regardless of the size of the check in the mail. But without a major technological advance, it is unclear how doctors could (or would want to) deliver the same care for 10% less. How would you feel if your boss called you in to his office at work and told you (1) you will be paid 10% less and (2) you will be disciplined if your quality of work drops off? And that your salary will be cut again each year for the next 7 years, but by the way, don't you dare think about slacking off after those cuts either?

The AMA's position is that the 9.9% cut will severely harm health care in the U.S. There are a few naysayers who think the AMA is only whining, but I don't think so. I have listened to a lot of doctors complain about insurance reimbursement for a lot of years, and I think we are reaching the point of no return. If this cut sticks, this baby's gonna blow.

Here is what could happen. There are a number of doctors in their 60s and early 70s, nearing retirement, who will look at the cut and decide to hang it up. This group has already made its money in medicine and will decide that the aggravation of a significant pay cut is not worth the trouble. Another group of slightly younger but well-established doctors will decide that it has enough Medicare patients and will not accept any more. Others will cut loose the Medicare patients they already have. An AMA survey suggests that 45% of doctors will cut the number of Medicare patients they see if the cut goes through. Though some critics call this a bluff, I think the numbers could eventually be worse than that.

When doctors who do not need new Medicare patients start refusing them, a large pool of patients looking for doctors will form. At first, younger doctors building their practices will soak these patients up, but eventually they too will have their fill. They will start refusing Medicare patients too. In the end there will be a considerable number of Medicare patients who cannot find a doctor. And why I think this will happen? Because that is what has happened with Medicaid patients as Medicaid reimbursement was pared to nothing. Nationwide, only 25% of doctors will see Medicaid patients. Most doctors get tired of seeing patients with multiple medical problems that suck up time and pay very poorly. What has happened to Medicaid could very easily happen to Medicare.

Then the pain really starts. Angry voters show up in Washington, or at their local representative's office. They bring torches and pitchforks, and threaten to burn the place down if something is not done. Hopefully, and this is wishful thinking on my part, leaders will seizes the opportunity not simply to reinstate the cuts but to fix the problem permanently.

But we can't stop there. The AMA, in its sniveling ways, is likely to try to fix Medicare only, instead of using the momentum of the moment to fix everything at once. This is where we have to hope that enough doctors and hospitals and patients are hurt enough that they will not settle for that. That they will say, "No, this is not going to happen ever again. We want the whole system reformed, not just Medicare, and if you don't do what we say a lot of politicians will feel our pain."

I have been burning candles and wearing out rosaries in the hopes that the cut sticks, and that doctors revolt. I hate to pray for pain, but in this country we are like C.S. Lewis's gluttons, are fat and happy, and not caring what we are eating. The only way out of this is if there is enough suffering all around that the suffers refuse to be satisfied with the usual bone thrown their way.

The sooner we get on with this pain the better off we are going to be. If we keep patching our sinking system instead of rebuilding, very soon our entire ship will be nothing but patches.

Medicare is a very good place for this reconstruction talk to begin. Medicare alone covers 14% of the population according to 2004 numbers, and together with Medicaid covers 27%. This is by far the single largest group of insured individuals. Collectively private insurance covers 59%, but this is a piecemeal group comprised of hundreds of carriers.  Medicare alone accounts for about 15% of all healthcare expenditures ($330 billion in 2006), Medicaid roughly 14% ($305 billion). When the millions of government employees who are on private insurance plans paid for by the government are added in, it is plain that the government has controlling influence over the U.S. health care sector, even without meaning to.

Patients who have private insurance may think they will not be affected by this fight, but they are mistaken. Doctors and hospitals routinely determine the services they will offer based on perceived profit margins. We might see fewer hospitals offering knee replacement surgeries or cardiac bypass operations because it is no longer profitable. Many home health companies could close, and inpatient rehab units could dwindle in number. One hospital I worked at lost two neurosurgeons in one year and had to stop offering neurosurgery services because there were too many Medicaid and uninsured patients in the payor mix. The surgeons got sick of not being paid and walked away. Add Medicare to the list of hated carriers and you may see your own doctor leave town if too many of your neighbors are retirees.

Healthcare reform in the U.S. has proceeded at an astonishingly sluggish pace, considering the stakes. I am now convinced that nothing is going to change until there is a serious breakdown that results in true human suffering. My only hope is that this breakdown is a flat tire and not a gasoline truck going over the bridge rail. That is why I hope the 10% cut sticks, and enough people lose their tempers that we can have this thing out once and for all, right now. Let's all get together and pray that she does blow, and blows very soon.

The other day I saw one of my regulars for a follow up visit. Cindy is a an attractive woman in her twenties, a young mother with several young children, who works long hours in retail to make ends meet. During the course of the examination, I leafed through her chart and noticed that she had no health insurance. Health insurance is a personal concern of mine, and when I meet a patient without it I often ply them with gentle financial counseling.

“Does your employer offer health insurance?” I asked.

“Yes. I looked into it, but it was too expensive.”

“How much was it?”

“They were going to take $300 a month out of my paycheck. I can’t afford that.”

I did not intend to persuade her to change her mind, but I wanted to plant the seed of an idea in her head. “I can appreciate that,” I said, “With the kids, money must be tight. Just keep in mind that insurance does nothing but go up. This is as cheap as it is going to get. And if you get sick, they could exclude your new condition, or deny you altogether.”

Then I talked to her about the CHIPS program, an arm of Medicaid especially for children. “The financial qualifications for it are pretty lax,” I explained to her. “Often working mothers can get it for their kids, so make sure you look into it.” I also told her that Medicaid loosens its qualifications for single mothers with more than one child, and that she needed to look into that for herself.

What I didn’t tell her was this: $300 is not all that bad a monthly health insurance premium. Some employers offer better, especially in situations where a union is in play, but for an hourly wage earner, $300 for a quality plan is at least competitive. If she was waiting for a better deal, she would probably be waiting forever.

This bothers me. It is one thing if a person has a job that does not offer insurance, or if the person has a pre-existing condition that precludes getting good insurance, or if the person is too sick to work at all. But when the insurance is there, and at a fair market price, and the person does not take it, what do we do about that?

I am in no position to say if Cindy could or could not afford $300 a month. Though it is worth noting that this $300 would be deducted from her paycheck pre-tax, meaning the cost to her would probably be less, maybe $250. Still, the offer is probably the cheapest she will ever get, unless she gets Medicaid. Complaining that a health insurance premium is $300 is like complaining that gasoline is $2.50 a gallon. You can complain all you want, but that is the price, and it is not going down.

If we have a class of people who will not buy health insurance even when the price is reasonable (and I think, considering the protection you get from health insurance, $300 is not all that outlandish), then it is clear that private insurance will never insure everyone. We need to throw that myth out the window.

Is it acceptable to allow people to choose to be without health insurance? I say no. There are too many common, potentially devastating medical illnesses lurking out there. If Cindy were to find a lump her breast, for example, she would probably lose her job and her health, go bankrupt, and eventually, after prolonged suffering, end up on Medicaid. She would also, with her pre-existing condition, be uninsurable for the rest of her life. It should not be the public’s job to pick up the pieces when an individual takes a risk and loses out. While one Cindy is a small risk for a society to take, a million of them is a serious risk, and one the public has a right to weigh in on.

Unfortunately, most people who choose to skip health insurance are people like Cindy. People who are young and have very little money; people who are in good health and do not feel they need regular medical care. This is the worst possible reason not to buy health insurance. The time to get it is when you are young and healthy. You have no pre-existing conditions, and you are free to choose a high-deductible plan that costs less money. If something comes up, you can usually switch plans with the same insurer. But if you don’t get your foot in the door and something happens, you are excluded forever.

Waiting until you get sick to get health insurance makes about as much sense as waiting until you smell smoke to get fire insurance.

What do we do? We can require people to carry health insurance by law. I am not a fan of forcing people to do things, but clearly society bears a great risk when people choose to go without insurance. If Cindy gets hurt and can’t work, we will pick up the bill, one way or another. It may be a fair argument to say that the price of living in society is that you must carry health insurance. We say the same thing about auto insurance now.

Another solution is to liberalize Medicaid so Cindy can get it, but then charge her at least nominally for the service. That puts Cindy on the taxpayer’s dime now instead of later, but at least it would give her access to health care. If she does get sick or injured, with prompt care she might avoid disability and get back into the workforce. An often-missed argument in favor of universal healthcare is that it means a healthier and more productive work force. People who get proper care do not languish on the sidelines the way people who get inadequate care so often do.

One thing is clear – tax breaks won’t work. Cindy is already in a low tax bracket, and her insurance would be paid with pre-tax money. This is not the issue. She could get a tax credit, but then the government would be paying her to buy insurance. This would spin off a new legal battle about how much of the bill the government should pay, and why not pay it for everyone? And it also assumes Cindy knows enough about tax law to claim this credit. This is not a given. It is estimated that 15-25% of people eligible for the Earned Income Tax Credit do not claim it because they do not know how. Since health insurance eligibility could be harder to prove than simple income, it might be more difficult to claim.

As a general rule, I have always opposed using the tax system to create health care policy. Taxes are supposed to be a way for the government to raise revenue, not an instrument for public health. God help us if the tax code is our hope for universal health care. There are simply too many opportunities for lobbyists and politicians to play with tax law and distort medicine for financial gain. My belief is that if the government is going to pay for health care for people like Cindy, it should treat health insurance like it does the police force. Just pay for it. Imagine what the police force would look like if it were a system of private contractors that were encouraged to do a better job through a system of tax incentives. 

Whatever the solution, for it to work Cindy has to pitch in. Either she pays for private insurance through her employer, we give her Medicaid and charge her for it, or the entire U.S. goes single-payer and everyone pays in taxes. The great problem with health insurance in the U.S. is that it is a complex shell game in which everyone passes responsibility on to the next person. Patients rely on employers to subsidize premiums. Employers lean on insurers to lower prices and cut benefits. Insurers raise copays and expenses for patients and try to dump high-risk patients on Medicaid and Medicare. The federal government supports Medicaid and Medicare (as well as tax subsidies for private insurance) by irresponsible borrowing instead of raising taxes.

Healthcare is not like a war. Eventually (0ne expects) a war will end, and war debts can be paid off. Healthcare is an ongoing expense, a cost that only goes up. We have to pay for it as we go. Borrowing to cover an ongoing, ever increasing expense is insanity. Like it or not, patients like Cindy have to be brought into the system and made to pay at least something. This puts them in the position of caring about the system, about wanting to get their money's worth, and about wanting to control costs. Too many people like Cindy sit outside the system, with no incentive to get in. And this costs us all in the end.

To read this serial novel from the beginning, go here.

The Game of Chicken 

 

Within half an hour, Cardinal had convinced the Head ELF to let him take over hostage negotiations. He really didn't care if the ELFs got what they wanted, or if the hostages got out. He only slightly cared if he himself got out. John Cardinal put himself in the middle of things because, live or die, he had to be in charge.

"To hell with it," he was shouting into the ELF's cell phone. "I'm just going to blow this thing. This is too much stress!"

"No, wait," the voice on the other end said, "We can work this out. There's no need to do anything rash."

"Rash? Rash? That's all you have to say while hundreds of innocent embryos lie in a permafrost prison at the Gulag you call a fertility clinic?"

"The embryos are coming. We are having problems with transport, that's all. They're frozen at thirty below zero. We don't want them to thaw out, and we can't just toss them into the average refrigeration truck. But I still don't understand what you are going to do with four hundred frozen embryos."

"Don't you worry about that. We have the necessary incubators. Four hundred women in locations known only to key members of the religious right."

Head ELF stepped up. "Mr. Cardinal, maybe I should handle this. You seem a little, um, volatile right now."

Cardinal covered the receiver on the phone. "Guy, we change negotiators and we're toast -- you get me? These guys are probing us for weaknesses, and a rotating team of spokesmen is a prime indicator of weakness. We switch off and you can kiss your sweet conceptions goodbye."

He continued to negotiate, but the agent on the line seemed to be stalling. After an hour of  back-and-forth, Cardinal turned to the ELF team and said, "They're not taking us very seriously, or things would be moving faster. Its time to prove that we're serious. We're going to have to throw a corpse or two out."

"We'll wha--?" Head ELF said. Cardinal waited for him to say more, but nothing came out of his mouth.

"Guy, you hijacked an airplane. You know, like, threatened to kill 200 people if you didn't get your way. They're calling our bluff, and we're going to have to demonstrate that we're pros. There are two kinds of people in the world --" Marsha, listening from her seat, had the feeling Cardinal had given this speech before, because it came out so easily, "those who will kill and those who won't. Those who won't have no negotiating power over those who will. Believe me, if they could get a clean shot at you, they'd take you out. So, you have to step up."

He looked up and down at the anxious rabble. "How about the blonde who came with you?" Ah, testing him.

"Love to help you out, pal, but she's housing one of my own personal embryos, if you know what I mean. It would run counter to our stated mission if we pulled something like that, don't you think?" Marsha groaned in her seat.

Head ELF leaned close and whispered. "We appreciate what you're trying to do, but we're not up to killing someone to prove a point." He paused, adding, almost ashamedly, "We're just not."

Cardinal paused a moment to fill in the last blank in his assessment of this case. This wasn't a band of killers, no way. Worse, if he hadn't come along, they probably would have lost their nerve and been pruned away by snipers a long time ago.

"All right then, plan B. Get one of the passengers to strip. Preferably an attractive woman. Stuff the clothes with newspaper, pour on a jar of ketchup, and dump it out the door. That'll get their attention. But do it quick."

"Won't they see through the trick?"

"Not at this distance. And especially not if you set it on fire. And another thing, guy. You confiscated all the cell phones, right?"

"Uh, no."

"You fool! Don't you realize somebody is texting the Feds about our every move right this second!" Cardinal ran over to the window in time to see a SWAT truck pull up on the runway. A dozen hunched men were filing out and  taking positions in a half circle, facing the main hatch.

"Dammit!" Cardinal roared. He kicked open the airplane door, removed his shoe and hurled it out. Then he took his revolver out and shot it in mid-air. The shoe exploded, rocking the plane. Quickly the SWAT team scrambled back into the van, and it mortifiedly slunk away.

"The shoe bomber was an amateur," Cardinal said. He turned to address the passengers. "I have one shoe left.  Whoever the hell is in contact with the cops, you tell 'em that." Then he turned to the stewardesses, trembling in the food prep area. "Girls, serve us up a meal. And pour me a scotch, neat. I'm not paying any damn $5 for it, either."

Next Episode: Here We Go. Embryo