4/17/2008 1:52:13 AM

Steve--I do like the "Election Reporting Report Card" idea. As we keep finding out, since we come up with lots of good ideas, it's all about execution, which takes commitment, which is too often lacking. This also would be a fairly labor-intensive project (to do remotely well), which means either a lot of people participating a little bit or one or two people really digging in. Anybody?

Jonathan Simon

4/17/2008 7:46:17 AM

Others are also appalled by the sophomoric calibre of our media:

MoveOn is starting a petition to complain to ABC:

pol.moveon.org/.../

Jana

4/17/2008 11:39:46 AM

I missed the debate, but there was an amusing summation by Dbdmjs1022 on Democratic Underground that supports your assessment.
www.democraticunderground.com/.../duboard.php


For those who didn't see, the debate in a nutshell


Mod: Senator Clinton, how do you feel about Iraq?
Hillary: I feel we should leave.

Mod: Senator Obama, why do you hate America?
Obama: I love America, it's been good to me.

Mod: Senator Clinton, do you feel that poor people should have more money?
Hillary: Absolutely

Mod: Sen. Obama, when was the last time you and Reverend Wright plotted to blow up an Embassy?
Obama: Can't we just talk about the issues instead of this tabloid stuff?

Mod: Senator Clinton, what is your kitten agenda
Hillary: I feel kittens are soft and fluffy and should be cared for.

Mod: Senator Obama, someone you went to grade school with was arrested 8 years ago for kicking a kitten. Why do you hate kittens?
Obama: How is this relevant at all?

Mod: Senator Clinton, tell us exactly how brave you were in overcoming your husband's adultery?
Hillary: i was very brave. God helped me.

Mod: Senator Obama, it's all over the internet that you are an evil Muslim elitist terrorist. Why are you an evil Muslim elitist terrorist?
Obama: I'm not. And weren't you just asking me about my CHRISTIAN pastor?
Mod: The one you blow up embassies with?
Obama: What? Are you serious.

Mod: We have to take a commercial. Senator Clinton, we realize that we haven't paid enough attention to you and we deeply apologize.
Hillary: Quite alright.

Melissa Gonzales

4/18/2008 3:06:09 AM

Very clever DU post, but I didn't see the debate as biased toward Clinton so much as biased toward irrelevance – to what we might call Republican issues. (Gibson was also quite concerned with some real Republican issues – a possible increase in Capital Gains taxes and in eliminating the Payroll Tax cap, on both of which he made very misleading statements.) The difference would seem to be that whereas Clinton was comfortable in irrelevance and given her druthers would dwell there forever, Obama was clearly perturbed by the nature of the questions and said so.

Personally, I would have liked him to say so much more strongly. In one very important sense, Obama finally got the treatment he deserves. Defending his debate performance, George Stephanopoulos has explained that since the candidates are not far apart policy-wise, the core of the nomination fight has been about these so-called character issues.[1] One can take issue with why that’s so, and especially the media’s own role in making it so, but it is also true that Obama has used the world’s greatest stage to say remarkably little concrete about the fundamental problems of America, and what he would do differently from the Clintons. Indeed during the debate he praised the foreign policy of Bush Sr.

Now there may be good reasons why Obama does not take to task America and those that run America, why he praises Bush Sr and Reagan, why his first act as Senator was to affirm Bush Jr’s 2004 presidential election victory, and why he allowed the Democratic Leadership Committee to use his popularity to defeat progressive candidates in Democratic Party primaries. Maybe being a centrist or a “uniter” is what it takes to win. Perhaps if he were to say more, he would be killed. But whereas Kucinich, Gravel, Paul, Nader, or, to a lesser degree, Edwards, really did take up issues that separated them from others seeking their party’s nomination, Obama has not.

He gave a great speech on race and is, generally, a fantastic speaker. Hell, he seems like a great guy. Given the chance, he might be a great president. Maybe the greatest president ever. Might just save the world. I listen to him and am tempted myself to drink the Kool Aid. But, for chrissake, he’s had an extraordinary pulpit for going on four years, been running for president for sixteen months, and been running mano-a-mano against Hilary Clinton of all people for the past two months, and in all that time has said nothing of the real ails of America beyond the current White House occupant, nothing concrete even to distinguish an Obama presidency from the Clintons or for that matter, Bush Sr.

Maybe “Hope” and “Change” and “Optimism” is a winning strategy, but if Obama wants the media to focus on substantive issues, is it too much to ask him to say – substantively – why not Clinton?

[1] www.politico.com/.../...appropriate_questions.html

Steve Freeman

4/18/2008 3:51:26 AM

Steve said "...but I didn't see the debate as biased toward Clinton so much as biased toward irrelevance – to what we might call Republican issues."

Hmmmm... Republican issues are irrelevant? I think I can take issue with that as a devil's advocate. I agree that many of the points being brought up by the ABC team did seem like political trailer trash issues, but there are two important points that I argue make them quite relevant:

1. ABC didn't need the Republicans feeding them anything. Hillary's campaign has been quite adept at acting like the very politicians that they themselves hated and resented in the 1990s. Consider it the battered child syndrome, where the child resents being beat up by the father, but then does the very same thing to his children.

2. These 'irrelevant' issues are the only issues that seem to limit Obama's appeal to a super-majority of Americans. So, from a general election perspective, as well as the realities on-the-ground (where the vast majority of political emails do include the patriotism, muslim, wright, bitter memes swirling around Obama), these issues ARE relevant to our somewhat sick and twisted political culture in America. Yes, many of us would pin this solely on the Republicans. But, to some extent, I see it on both sides.

I think what we're seeing here is an example of ABC holding up a mirror to us as a nation, and the "some of us" who don't like how "most of us" look in totality blame the mirror for a bad reflection.

I know plenty of people from all party affiliations (including my father) who do not trust Obama primarily due to the symbolic value of all of these issues swirling around him. It is not racism. It's Obama himself not doing enough stiffening of his public persona to smack down these so-called concerns. If he were a stronger candidate, these things wouldn't stick at all. But they do, because he hasn't fully fulfilled his obligation as a national politician to create a brand that can withstand such attacks.

As a big Obama supporter and organizer, I can say that he is certainly not the perfect candidate. But that won't stop him from winning. He will likely win because he's good enough to win. He's just not good enough to win a historic, Reagan-esque super-majority to really transform politics. Or, at least, he's not good enough yet. If there's anything we've learned by observing him for the past year and 1/2, he seems to be a pretty quick study, and is smart enough to learn and adapt. Maybe by November he will have had figured out a way to dissolve the unpatriotic/muslim/militant/elite assertions.

Or, maybe we'll learn that there is enough truth in all of these assertions, and that this is just part of a great, yet imperfect, package of any human being, and that will still be OK.

Jon

Jon Deutsch

4/18/2008 5:56:47 AM

There is also the thread around how Sean Hannity gave George Stephanopoulos the tip on Ayers. So, now we have FoxNews "commentators" feeding so-called "legitimate" media on issues relevant to a campaign. FoxNews deserves the right be on TV (though I would argue the word "News" should not be allowed in their brand name), but I do not agree that Sean Hannity -- an entertainer -- has the journalistic credentials to be a part of such a serious political process.

In a similar vein, it would be like Charlie Gibson interviewing George Carlin to see what to ask the Republicans during their debates.

Jon

Jon Deutsch

4/18/2008 11:14:12 PM

Jon Deutsch wrote: As a big Obama supporter and organizer, I can say that he is certainly not the perfect candidate. But that won't stop him from winning. He will likely win because he's good enough to win. He's just not good enough to win a historic, Reagan-esque super-majority to really transform politics.

Jon: You should bear in mind that, at least according to our good friend and DNC consultant Cornell Belcher (responding to Steve's and my questions at the 2007 Media Reform Conference),unless a Democratic candidate is pulling super-majority support he ain't gonna even win. That is, they know that they need to be up by about 10% in their own polling (that is, polling which is not being adjusted to take into account the mysterious electoral red-shift that by now pollsters have to factor in if they want to stay in business) in order to eke out a victory. Especially true of a presidential candidate where they can rig the electoral votes they need where they need them. Cornell, sadly, didn't get it either, refusing (rather illogically) to even consider that that 10% discrepancy had anything to do with the fact that the votecounts, as opposed to their polling, might be "off." It's all on tape, to be found in the archives of unfathomable stupidity.-Jonathan

Jonathan Simon

4/19/2008 12:56:32 AM

"Obama has used the world’s greatest stage to say remarkably little concrete about the fundamental problems of America, and what he would do differently from the Clintons." This statement tells me that you have not LISTENED to Obama. The point is that change has to occur from the bottom up. That is what this man is promising, and we have not ever seen this at the federal level. At a local level, with a County Board of Supervisors, if you produce a chamber full of citizens who are well informed about a particular issue and are opposed to what the local developer community wants in the way of a zoning change, for example, the Supervisors will vote in accord with the citizens who are crowded into their chambers on every occasion that the specific issue is discussed. Obama has engineered many such outcomes in South Side Chicago. His primary campaign ought to provide all of the evidence needed to assure everyone that this guy knows how to organize a huge and complex undertaking. He now has more than 1.2 million contributors, very few of them anywhere close to giving him the $2300 maximum donation. He can tap this group for another $25, $50 or $100 each month and break another fundraising record. As he has said, this makes it very easy to budget each month.
As President, he plans to create a well-informed public opinion on specific issues by having the discussions that he is engaged in broadcast on C-span, so folks can listen and watch all of the players at the table on health reform, for example. Once that informed opinion has crystallized and found their way into a legislative proposal, Obama will be well positioned to ask his constituents to email their representatives and senators as things come up for a vote. Like packing the chamber in a county, perhaps 50 million or more emails will arrive at each congressional office expressing support for the President's proposed legislation. Where will the K-Street lobbyists stand at that juncture? You need to listen, Steve, and use a bit of imagination. This man is offering us something never seen before, but very doable. Hillary and McCain, on the other hand, are telling us what they intend to do FOR us. Barack is asking us to enable him to make it possible for ordinary citizens to effectively use their power to bring about real and sweeping changes on the basis of well-informed and widespread public opinion on any given issue. Unless we understand this reality, the golden opportunity before us may be missed. Best wishes. L. O'B

Larry O'Brien

4/19/2008 2:35:30 AM

Larry,

I completely agree with you, and I wish more people could see that what Obama is running on is not merely a set of policies or a collection of personal values, but rather a fundamental and innovative approach to politics. He's looking at politics at the systems-thinking level, and offering us a change in organizational approach.

I think what Steven (and many, many others) might be missing is the dimensional shift that Obama is offering us. I know many very intelligent people who -- possibly due to the pure number of political cycles they've lived through -- are simply unable to see what Obama is offering; they are unable or unwilling to stop-and-shift their perspective on what politics can be in America. And they are unable to see what exactly it is that Obama is offering us as a candidate.

And I don't intend to say he is offering us something different in the trite "change" and "hope" sloganeering way. When I say he's offering us something different, I mean in a politically multi-dimensional way. Let me try to explain what I'm thinking here in more detail (and please bare with me, this is the first time I'm putting these thoughts to text)...

National politics has generally run on what I would like to call "two dimensional politics."

The first dimension: Character/Leadership

Character is defined by the values, approach, style and beliefs of the candidate. Republicans have typically focused on this first (or primary) dimension as the defining characteristics of a leader. And this is why I would argue Republicans have the upper hand in national politics. This first dimension is the basic, primal, tribal, natural dimension. It's the one that we rely on when there are no other higher-order issues that can or are able to be considered. And, when people are in fear and as a result get more conservative, this first dimension of politics becomes of primary importance to the voter. This is also the dimension that demonstrates raw leadership capabilities... not the ability to think, but the ability to take charge. These traits are instinctively attractive to people who feel they need to be protected. It's only when people have the ability to get beyond day-to-day survival (or at least they believe that they can rise up and consider higher-order things in their lives), does the second dimension of politics become relevant.

The second dimension: Policy/Strategy

The policy dimension is the dimension that Democrats typically run on. This is the more intellectual dimension of politics because it goes beyond the day-to-day survival needs and focuses on long-term, systemic and ideally non-linear relationships of causation. To wit, "trickle down economics" is linear economic theory. Whereas "progressive taxation" is non-linear. Therefore, the idea of progressive taxation is more complex to explain and more complex to comprehend. When running a national campaign to a public that is generally too busy to be bothered with anything but a 5 minute update on the evening news, these non-linear proposals have a more difficult time resonating with the masses. They just make less sense, and on the face of it, they seem to benefit "others" vs "oneself." If the median income of a family of 4 in this nation is $40k/year, guess which economic policy is going to resonate more -- the non-linear one that seems to help "others" or the simple, linear one that seems to help "oneself?" It should be of no surprise that Democrats and progressive policies seem to generally be more attractive to Americans during favorable economic and peaceful times in our country's history. There of course are examples where this generality does not apply -- like the New Deal. But the New Deal was kind of special as it was the very first real broad-based liberal policy experiment in this country's social history (if I have my history correct).

These two dimensions is where politics has been since, it seems, forever in this country. What some of us see in Obama is actually an introduction to a third dimension -- organizational dynamics.

The third dimension: Organizational Dynamics

For lack of a better term (and, I admit, I am inspired by the title of my Master's program at Penn, which is called "Organizational Dynamics" , OrgDyn is the dimension where a politician like Obama (and to a lesser extent, Howard Dean in 2004) offers a systemic shift in operations. Not just policy, ideas, strategy, but a shift in how the organization itself - America - gets things done. Only a brilliant operational/organizational mind could have the audacity to consider this third dimension -- a dimension not on the ideas that drive the strategy, but a dimension on the ideas that drive the *implementation*. It's the difference between an MBA at Wharton (where management strategic thinkers are supposedly developed) and an MS in OrgDyn at Penn (where we're taught about the value and reach of concepts like innovation, design, administrative problem solving, religious and cultural impacts on values, how the idea of law and order varies by culture, etc. -- essentially, the advanced study of inter-relational models and how they directly and indirectly affect outcomes).

In the era of internet communications and collaboration changing how people and cultures can participate in dialog, discussion, and activities, Obama is offering us a change in political implementation strategy. This is why I would assert he can be so indifferent to the specific policies of each political party -- both parties represent entrenched political strategies that are about dividing and conquering the slim majority of the popular vote. Its entrenched ideological warfare, and we're so used to it that all we can hope for is someone from "our side" who is better at the "first dimension" of politics to drive our 2nd dimensional policies through the Washington bureaucracy.

From Obama's organizational dynamics platform, the specific policies mean less than the organizational design. Why? Because a properly designed political process will yield the most fair and representative policies, resulting in a purer democracy. A democracy that better represents the people of our country. The new tools and technologies that Baby Boomers in their 50s and 60s crow about ('I have a blog! I have a wiki! I Googled that last night!' ), are what the mid-40s Obama sees as tools that can transform the organizational design of America's political process to help bring fairness and equity to our society.

How? Well, as Larry pointed out above, the Obama campaign is already using the internet to change the model of political participation. Not only can anyone donate money to his campaign (which makes Obama accountable to his millions of individual supporters instead of thousands of elites), but anyone with internet access can submit an idea for consideration for his platform. In addition, not only can anyone post a blog on barackobama.com, but anyone can create a community or group within the Obama campaign to self-manage in any way he or she sees fit. This distributed resource aggregation and management -- combined with a sense of trust and respect for the individual contributor -- represents a significant shift of how a national candidate sees the individual in the political process. For the first time in my life, I see a candidate and a campaign that is interested in more than my dollar and my vote -- he is interested in my ideas and my participation.

At a fundamental, organizational dynamics level, Barack Obama believes that this "bottom up" approach to politics is the only real way to ensure that government is truly accountable to the people. Now that the tools and technologies are available for an unprecedented percentage of people to participate and have their voices heard, he is being audacious enough as a candidate to trust us with these tools, and to organize his candidacy around the idea that *we* are the political process if we choose to be. Under an Obama administration, if the government doesn't represent the people effectively, the people will no longer have an excuse for being disenfranchised: it will be our decision to be disenfranchised because Obama will provide us with the opportunity to participate in ways that we have never experienced before. He has alluded to this several times in his rallies: "If you want -- and are willing to work for --- better schools, you'll get better schools. If you want -- and are willing to help build -- better communities, you'll get better communities." This is a substantial break from the liberal platform of "the government's job is to help" and is journeying into the realm of "government as a grand organizer to help you get your own work done." This approach, by the way, is exactly the approach his campaign has taken. So, it's built into the DNA of his candidacy already. It's not just rhetoric.

So, for all of those who are looking for policy differences between Obama and Clinton, and for those who are looking for Obama to be an anti-Republican: I suggest that you are looking at the wrong dimension. He's not running in the second dimension of the political sphere. He's running on the third dimension -- the dimension of the organizational dynamics of the political process itself. As a result, he is actually not running against Hillary or McCain -- he is running against, as he puts it, politics as usual. Which, in the context of my framework laid out above, is two-dimensional politics.

Jon Deutsch

Jon Deutsch

4/19/2008 3:04:21 AM

Jon: I'm extremely pleased that my writing stimulated you to produce such an excellent discussion of the organizational dynamics drive that energizes Barack Obama in everything that he does. Great piece. Of course, if Steven did not have this site, this discourse would not be possible. Larry O'Brien

Larry O'Brien

4/21/2008 2:03:39 PM

Hi Steven,

Thanks for the response. Intriguing perspective. Allow me to try to answer it without debating, because I do not think what you are asserting has as much to do with a difference of opinion as it does a difference in dimension.

First, you say "I’d like to learn more about the many such outcomes he has engineered in South Side Chicago, and actual articulation of and examples of Obama’s “organizational dynamics platform.”"

I completely agree. I wonder about the concrete examples out of this period in his career as well. To me, it smells a bit like trumped up legend that is more of a savvy political tool than it is a substantive set of accomplishments. But just because it may be a savvy political tool doesn't mean it lacks value in the third dimension. For instance, look what Obama has done with this legend:

http://my.barackobama.com/page/s/fellowsapp

He has taken this legendary community organization experience of his, and turned it into a platform that others may "plug into" at a massive scale across the nation. Now, this kind of movement-building project could raise an eyebrow or two, especially if you don't trust the man or his motives. But, what this does support is the assertion that he is working to bolster the democratic fabric of the nation by creating a new level of organization at the grass-roots level, on a massive scale. Is this new level of organization going to be designed to only serve him and his political agenda? Well, it's certainly a program launched by his campaign, so it's clearly designed to support his campaign goals. What comes of it next? An interesting question to ponder.

You then say: "But unfortunately the evidence I’ve seen indicates he does not represent democratic process at all. First, most of his positions – unalloyed Gulf War I approval, Gulf War II funding, endorsement of and campaigning for DLC candidates opposed by progressives (e.g., Lieberman v. Lamont, Duckworth v. Cegelis), $8 billion worth of corn subsidies in 2006 alone, opposition to single-payer health care, and joining Republicans to shut down many class action and medical malpractice lawsuits – represent powerful special interests rather than democratic constituencies. [1]"

Barack Obama is not going to be an "in the pocket" Liberal. The nature of the Democratic primary has of course ensured that his most liberal positions are at the forefront of his campaign, but if you look at his positions and his overall moderate persona, he's really not an ideologue on most policies. That's why he's able to say that he's running to bring people together. The only way to say this and mean it is not to be an ideologue, but rather to be a moderate who is able to compromise on even the most thorny of issues. Every time one side (be it liberal or conservative) "wins" it means another side "lost." And with that loss comes anger, frustration, and a re-newed energy to fight another day. It's these series of "fights" (which create lobby groups, raise money, create red herring issues for voters) that Obama believes has led this country's body politic astray.

So, if you're looking for an "in the pocket liberal," you're not going to find one this season. Hillary is a DLC moderate, and Obama is a policy moderate because, as I see it, he believes that the "big prize" is building up the third dimension of political organizational dynamics.

You then say "...why isn’t he out front on election integrity? Obama knows as well as, or better than any of us in this group know that US elections are rigged, and rigged not just by money and media and fiddling with voter registration, but beyond that, rigged wholesale by voting machines that produce no evidence at all that votes are counted as cast. Yet has he spoken out? Not at all."

Well, I'm not sure it makes the most sense for a candidate running for President to bring up electoral integrity prior to the election. Can you imagine as black (ok, half-black) candidate 'wining' and 'complaining' about a 'rigged system' that he himself is counting on in order to win? Do you not believe it would be self-destructive for Obama to tell Americans that the voting process is rigged and then ask them to vote for him in Nov. anyway? Yes, he represents "change," but change is a poor man's revolution. And the American people are not looking for revolution... at least not yet. It would appear to me that it would be political suicide to bring this issue up prior to the election.

You then say "His first act as Senator, in January 2005 was to confirm fraudulent Ohio electors despite racist disenfranchisement of African American voters, which gave Bush & Cheney a second stolen term. And he has said nothing since about continued election fraud, even when he has been the victim of patently fraudulent results."

While you and the folks here are certainly focused on this issue and see it as a critical, systemic problem facing our democracy, it is not a front-burner issue in our nation's politics this season. I equate it to global warming: it was a side issue for decades until Al Gore took up the mantle and rolled out a game-changing feature film. You need "your Al Gore" to turn this issue into a serious problem that gets on the national the radar. Only then will you see the candidates take on this issue with the fervor you're looking for.

But more realistically, wasn't the objection to this tally overruled by 1-74 by the Senate? I don't think singling out Obama here is necessarily fair. As a brand new senator, I too might hesitate to start off my career challenging the outcome of the Presidential election. Sure, there is plenty of validity to the objection, but we're up against the momentum of a machine that serves all elected officials better who respect it and let it lumber on unchecked. It's rare when someone -- nevertheless a newcomer to congress -- is raring to go to buck the country's ability to pick its own President. I do not think Obama is that kind of leader, but then again, I don't think America will ever elect a leader who could be seen as radical in this way.

You then say "How exactly is Obama going to use popular opinion to influence legislation if that popular will is never measured properly, but rather falsified to legitimate the will of those who control the machines and the government?"

Popular opinion is typically captured in polls. I thought you asserted in your book that polls were the benchmark being used to measure election hijacking? Of course, the wording of the polls can push results, but no process is perfect. In addition, Obama's third-dimensional politics is not about polling and 'finding out' what people want. His politics is to get people active in the problem solving process. Measuring interest with action.

You say "We know there are reasons why politicians may not want to take a lead on election reform and why they may have to compromise on any number of issues. But where is any evidence that Obama is different? Rather he is more, albeit often better, of the same: Patronized by the wealthy, and speaking vague promises of hope and change to the masses."

I recommend reading or listening to Obama's speeches and interviews throughout the last 15 months (right up to today's interview on NPR, in fact), where there is copious evidence indicating that he is promising transformational change, not merely policy change. A mindset that challenges the very notion of America as a warring nation. A mindset that challenges us not to think about red states vs. blue states, but rather to compromise and work toward a united set of states. A set of values that is about using empathy as a tool for understanding. A perspective that listening and learning are prerequisites for deciding. A natural leadership ability to attract some of the brightest minds to join his campaign that has single-handedly re-invented modern campaigning.

And none of this even gets to the more tactical yet meaningful symbolic attributes of his candidacy which initially attracted me: the huge symbolic shift he'd represent from the guns-blazin' Texan-in-Chief to a bi-racial, Constitutional Scholar, oddly-named guy that will remind the world that America is *part* of the world and not *owning* the world. Hillary and McCain are certainly different than Bush, but they are each variations on the "Rich, White Westerner" persona that the world will view us through.

In conclusion, these are all good points to debate, but I do not feel they get to the crux of the third dimensional nature of Obama's politics. This third dimension is innovative, neither progressive nor conservative, and aligns brilliantly with the fundamental American Values espoused in our founding documents. Obama's candidacy is so much more than what he thinks of "hot button issue 1, 2, or 3." It's about re-engaging Americans back into their own democracy; a belief that the more of us that are involved in decision making, the better decisions we will make for ourselves in this democracy. It's about what Michael Moore said in his recent endorsement:

"There are those who say Obama isn't ready, or he's voted wrong on this or that. But that's looking at the trees and not the forest. What we are witnessing is not just a candidate but a profound, massive public movement for change. My endorsement is more for Obama The Movement than it is for Obama the candidate."

So, even Michael Moore, the very person that is quoted in your sources to demonstrate that Obama's healthcare solution is bad because it plays along with the existing healthcare industry, sees past his very own hot-button issue to endorse Obama and his approach (i.e., his 'movement').

I recommend you and others who are still not convinced to participate or simply read the best reasons to vote for Barack Obama at http://HopeAgainstTheMachine.com.

Jon Deutsch

Jon Deutsch

4/24/2008 3:11:44 PM

Please substitue this comment for the previous submission by me. The prior comment went out lacking the contextual remarks. Larry
________________________________________________

For Steven and Jon:
Perhaps a decent way to get the points about Barack's "third way" across more clearly would be to take a major problem that we have been talking about solving since HST was in the White House, one that we have not only made scant progress in solving but have taken many actions making things worse instead of better. I'm referring to the "health care crisis." I'll outline below what the fundamental problems is, which won't be forthcoming from the experts, and hopefully suggest to you both why the power needed to bring about this kind of radical change can only be generated by mobilizing an engaged public to push the issue and force appropriate change. Look through all of Barack Obama’s speeches for the word "power" and you'll find that it is never related to what he will do for us, but is always found near the word "mobilize" and usually near a warning from him that effort by the citizenry will be essential to make any significant change.

The following example of what Barack might help the population achieve is drawn from thirty years of my own direct experience in the medical care field. The simplemindedness of calling for a "single payer system" overlooks the root problems that have to be put right before any system can benefit real people in meaningful ways. Apologies for the length -- it is a long story.
__________________________________________________
A Different Approach to Reforming Medical Care in the US

“For any democratic society, the only legitimate purpose of a medical care system is to optimize the prevalence of good health and minimize the toll of ill health for every citizen.” (Charles M. Croner).

Three realities about American medicine prevent the achievement of this noble purpose:

1) Physicians cannot profit financially from fostering optimal health in their patients. Profit flows from treating illness or injury, and from related testing and ancillary procedures.
2) Physicians regulate the demand for their own services. The laws of supply and demand are turned upside down: supply regulates demand, not the other way around.
3) The physician workforce is twice as large as would be optimal to promote and protect the health of the entire population.

Current forecasts suggest that Medicare will be bankrupt by 2019. “Market forces” clearly cannot solve the crisis, because no market exists. If patients knew the difference between a colonoscopy and a colposcopy they would certainly not know the fair market value of either procedure. When negotiating to buy a new car the dealer knows that you can walk off at any moment. A patient cannot walk off, cannot negotiate price, and can’t determine the quantity of the services they need. Physicians regulate the level of demand for their own services, and there is now an enormous oversupply of specialists. Doctors are driving expenditure increases with no end in sight. This is the central problem in American medical care, and it is not good for the health status of the population or for the economic and financial health of the nation. It is essential to recognize that the problem is definitely not cost inflation.

A central issue that must be faced with complete integrity is that the cost of services is not the problem – it is the ever-increasing level of expenditure for physician services that is being driven and, in fact, dictated by the unsupervised suppliers of the services, usually specialist physicians, and not by the patient – i.e., the customer.

Perhaps the most pivotal reality that must be frankly confronted is the complete absence of general management in American clinical medicine. The general physician has been relegated to the bottom of the medical totem, instead of providing the key management judgments that are generated at the point of first contact. Unless effective general management of clinical medicine by generalists is introduced across the board, any addition of more money to the expenditure pot can only worsen the current mess and increase the dangers for the population in terms of the harm that is manifestly being done today by the provision of too much medicine.

Medicine at the point of first contact, primary care, is THE science of medicine. Barbara Starfield, MD from the Public Health faculty at Johns Hopkins defined primary care in a 1992 book as follows: “Care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness.” In the USA today, we do not have this, or anything even close.

During the past century of specialist domination in the United States, primary care has been denigrated and virtually ignored by the rest of the profession with disastrous results for the public health. With the emphasis on producing specialized and sub-specialized physicians, the nation now has twice as many of these as would be “optimal for the well-being of the population as a whole.” (Cf. Pew Commission Medical Workforce Report, issued under the chairmanship of Senator George Mitchell).

The innovations being proposed here would enable primary physicians to treat every patient in need of non-emergent primary medical attention whether that person was insured or not, and whether that patient could pay the doctor’s fee or not – and to perform this way without the slightest hint of being driven by commercial interest. Qualified primary physicians would know what to expect in the way of annual income and would thus be freed from monetary considerations and enabled to make medical decisions aimed strictly at doing the right thing, in the right way, at the right time, using the right resources for each of their patients. There would be no financial barrier to spending patient time encouraging the patterns of behavior that would prevent illness or injury. It is essential to recognize that preventive medicine requires time – lots of time, and that the primary care setting is the most appropriate setting in which prevention can be effectively addressed by physicians and other practitioners.

The decision to refer a patient to a specialist, or to not refer them, would have no financial or other commercial implications for the referring primary physician. The only consideration would be to secure the appropriate diagnostic and treatment services for a specific patient.

The key purpose of the proposed reorganization is to free primary care physicians from the perversity of being suppliers of service who regulate their own demand, as is the case with most specialist physicians. This purpose can be accomplished by assuring primary physicians of an annual income equivalent to three-fourths of the AMA’s published median income for specialist physicians in return for their providing optimal care for a sizeable group of patients.

To bring about a sweeping change of this kind, new legislation would be necessary to provide for the use of the federal tax system as the best vehicle to provide a guaranteed income for every licensed physician in active, full time primary or general practice who is Board Certified in one of the primary care disciplines: Family Practice, General Medicine, Internal Medicine, Pediatrics, Gerontology, or Disease and Injury Prevention.

These physicians would be bound to use a problem-oriented medical record system in place of the traditional source-based record system, employing the problem list as the pivotal foundation of all communication with a specialist physician designated by the primary physician (PCP) to provide services to one of their referred patients. The primary physicians would also commit to full participation in an outcome-reporting system based upon the electronic collection of data from each and every contact between a PCP or a nurse practitioner (NP) and a patient. A database approach would permit reporting of all encounters by diagnosis and by individual PCP. Patient identity would not be revealed except for age, sex, and geographic region of residence. These outcome reports will provide an effective management tool for tracking and trending clinical behavior and its results for the population being served.

A primary care team should be led by a PCP and include two NP’s, a nutritionist/diabetes educator (RD/CDE) and a mental health social worker. Salaries and benefits of the NP and RD/CDE team members would be shown in the PCP’s IRS return along with other administrative and business costs of the practice, in the manner of sole proprietorships.
Each team or practice would continue to bill insurers for the covered services they provide, including Medicare and Medicaid; collect any co-payments due under a patient’s benefit program; and keep complete records of all services provided to persons who cannot or do not pay for the medical and health care they receive.

At the end of each taxable year, based upon the participating PCP’s taxable income on the tax return, the federal government would write a check sufficient to raise a qualified physician’s reported taxable income to 75% of the level of the latest median income for specialist physicians as reported by the AMA. (Currently, this would be about $230,000 per annum). Whenever the taxable income of a PCP exceeds 75% of the AMA’s median figure for specialists, no IRS payment would be made to that particular primary physician.

One significant result of implementing this proposal would be that everyone who resides in the United States would be covered for primary care services in the area where they live and work, with enough PCP and NP patient contact time available to provide meaningful preventive care, as well as care for acute or chronic problems.

At present, average primary care ambulatory visits for the population are under three per year. Total visits should therefore not exceed 2100/year/practitioner (3x700), or 10.5/work day. A workday of 8 hours equals 480 available minutes, therefore each primary care practitioner would have an average of 45+ minutes per scheduled patient, including time for preparation, examination, consultation, and recording of results. (The current average time per patient is closer to 10 minutes in most systems).

1. This proposal would cut the current differential approximately in half by establishing an annual income guarantee of $230,000 in 2008 dollars for PCPs.
2. The panel of active patients managed by a primary care team would not exceed 2100.
3. The panel of active patients handled primarily by a PCP would not exceed 700, although the PCP would see any of the 2100 patients in the practice as needed.
4. The average number of patients assigned to a NP would not exceed 700.
5. For each team, the equivalent of 100% of the total cost of PCP, NP and RD/CDE salaries and benefits would be added to the team budget as overhead, to cover the salaries of other staff and all other administrative costs. (Overhead in medical practices has usually been 60% of total professional compensation).
If total annual costs per team equaled $1 million – half for salaries and half for overhead, including benefits -- to care for a total of 2100 patients, this would amount to $475 per year per patient, or $40 per month. (This figure indicates vividly what is wrong with the current “system”).

It would take 143,000 primary care teams to cover the needs of the entire population of 300 million, thus the total cost of the innovation would be $143 billion. If the average IRS payment to each primary care team amounted to 25% of the total cost of the team practice, with all other costs being covered by the revenue collected from patients and insurers, the total federal outlay nationally under this approach would be just under $36 billion. (There is a strong probability is that the annual IRS payout would be lower than 25%).

Expenditures for medical and hospital care reportedly reached $2.2 trillion per annum in 2006. The estimated average federal expenditure of 25% of the budget for all primary care team practices, to reimburse 143,000 participating primary care teams so as to insure the PCP head of each team a net annual income of $230,000, would equate to slightly under 1.7% of the total 2006 outlay for medical and hospital care of $2.2 trillion, leaving over 98.3% of that total for all other medically related services – inpatient, outpatient, emergency or urgent care, specialist, and prescribed drugs.

If all of the PCP teams together collected zero dollars during a given year, the entire federal cost of this proposed approach to cover every resident of the United States for all of the primary medical care that they need -- $143,000,000,000 -- would utilize slightly under 6.5% of the total 2006 outlay for medical and hospital care of $2.2 trillion, leaving 93.5% of $2.2 trillion for all other medically related services – inpatient, outpatient, emergency or urgent care, specialist, and prescribed drugs.

These numbers reveal why Ford and GM cannot compete with foreign automakers: expenditures – not costs -- are out of control because there is no general management at the clinical level by qualified primary physicians, thus allowing specialist physicians to dictate and regulate the level of demand for the services that they provide. When supply regulates demand there is no market, therefore the often repeated claim that “market forces” will fix the continuously spiraling expenditures for medical and hospital services is empty of meaning. There is also no end point for expenditure increase in a system like the current one. More specialists come on line each and every year, and fewer graduating physicians opt for the primary care disciplines. Relatively speaking, there is no money today in primary care, just plenty of long hours and hard work. Bankruptcy is the inevitable outcome of the current approach -- national bankruptcy as the boomers reach Medicare age.

The AMA and its allies would fight changes of this kind tooth and nail – just as they fought against Medicare and Medicaid. A bottom-up effort to create a well-informed public opinion about what needs to be done is the only way that the current conditions can ever be changed. Think about it. No one on the horizon except Barack Obama has a clue about these realities.

With all good wishes, Larry

Larry O'Brien