Political Booknotes
Dash, James Carville,Joshua Sharfstein,John Heilmann,Leon
Political Booknotes The Prince Of Spin By James Carville AT THE HEIGHT OF HIS POWERS Lee Artwater attained a level of spin that made you stand in awe. He was just so good at it....
...Every minute counts in a heart attack, and by the time of diagnosis and treatment at the suburban hospital over an hour later, his heart muscle was irreversibly damaged...
...I’ve read All the Kings Men four times, and he didn’t like The Prince as much as I liked All the King’s Men...
...But in a book devoted to the threat of profit-driven managed care, these prescriptions are little more than a dignified surrender...
...If you stepped on a rusty nail, you prayed that you didn’t get lockjaw and put coal oil on the wound...
...They ate in a separate cafeteria with the black hospital staff...
...Anders’s solution is regulation, oversight, and vigilance...
...Then he sent him home...
...She’d be picking the family’s cotton crop come late September...
...I was having a heart attack, and all she gave me was three bucks...
...Rather than reward each test with a payment, employers decided to pay up front and let insurers control costs by limiting care...
...So at dawn, the entire family waded out into the cotton patch, searching for and collecting bolls that might have ripened early...
...An engaging mix of anecdote and statistics, Health Against Wealth makes a convincing case that many Americans are being betrayed by the new health care system...
...What going to college might mean for the future wasn’t that obvious to Daddy,” Elders remembers...
...It’s been proved over and over again that the public likes stories about process, and there’s some good inside baseball about Atwater’s early technique...
...I could hardly breathe...
...Even now that Medicare has begun to publish survival rates from coronary artery bypass procedures by hospital, many HMOs continue to force their patients into institutions with deadlier records (in some cases, close to twice the morality rate) but cheaper prices...
...On the other hand, Brody traces the development of Atwater’s “Southern Strategy” and “permanent campaign” concepts to a 1947 memo by Clark Clifford...
...HMOs also use legal and financial incentives to keep their providers from complaining about poor quality either to patients or to the press...
...Who knows if Atwater meant it...
...Part of the problem was that many American workers could not switch from plans that they didn’t like...
...The trick is getting there...
...In Elders’s fourth year of medical school, she met Oliver Elders when she had to give physical exams to the players on the high school basketball team he coached...
...Large families, teenage pregnancies, incest, abuse, lack of nutrition, scant medical care...
...Perhaps most profoundly, the market has failed to identify outright fraud in time to prevent its consequences...
...Haller Jones was desperate for her husband to let Elders go, and they bickered about it...
...At 18, she married 19-year-old Curtis Jones, whoalso had made it through the, eighth grade...
...I knew how they survived...
...Budget deficits throughout the European Union are higher as a percentage of GDP than that of the United States...
...When we went out to see, there was Daddy sitting on Old Jim holding Bernard in his arms, still bundled up in the blanket...
...Here you really get a sense of the kind of guy Lee Atwater was, and it all dovetails around the details of his death and the spinning of his legacy...
...In his new book on American government, Anthony King, Britain’s bestknown political scientist, casts himselfas the Martian, training his eye on “one big and very important thing that most Americans, because they are so accustomed to it, tend not to notice...
...Audiences at professional wrestling matches are the swing voters in election...
...I liked his approach to manufacturing a response to a candidate’s speech-strategically placing loudly enthusiastic supporters at home plate down in front of the microphone and then putting smaller pockets at first, second, and third base to create a home run effect on the rest of the crowd...
...Only in America are they forced to spend vast sums to get reelected, and to harvest those sums almost entirely on their own...
...There were no hospitals around there for any black children...
...unfortunately, relying on this course of action to obtain good measures of care for seriously ill individuals could take years...
...Now, really: Is there anyone who’s thought even half-seriously about American politics who hasn’t noticed this...
...Ignorant and without help...
...but the most fashionable of the proposed remedies-from town meetings to ballot initiatives to electronic plebiscites to, most popular of all, term limits-he considers flawed...
...A student then asked how the father had explained the long hospitalization to his employer...
...The only problem now was money: The family didn’t have the $3.83 bus fare to Little Rock...
...DO your best...
...Like my father riding off on the mule with Bernard in his arms...
...that’s good enough!’ Elders’s account of how she rose out of the rural hamlet of Schaal, population 98 (“ninety-nine when I’m home”), provides a textbook formula for others who would follow her...
...Sou,& Carolina Governor Carroll Campbell said, “He was a BS artist of the highest order,” but Brody does his best to wade through...
...Curtis Jones did not return with his son until late that night...
...To get there quickly, he cut through Boston,driving past five leading health centers with state-of-the-at emergency services...
...Designed by the HMOs themselves, the quality measures focus on easy preventive strategies (i.e., what percentage of members get their cholesterol checked) rather than on management of serious illness...
...Elders and the two other black medical students could not eat in the medical school’s white lunchroom...
...No hopes and no horizons...
...If you wanted to know that Atwater named his first political consulting firm Baker & Associates after a man whose portrait he had purchased at a garage sale and that its office was situated above a chicken-wing restaurant, here’s the goods...
...Up From Arkansas By Leon Dash JOYCELYN ELDERS, M.D...
...response to the oil shock of 1973 and the nation’s never-ending “war on crime...
...Elders is an example of what is possible, but on the national level, she was hardly given the opportunity to share with us how it can be done...
...Elders resigned herself to staying home...
...And ceaselessly...
...Kevin, the younger of the couple’s two sons, has had serious problems with alcohol and cocaine addictions, and was arrested (and eventually convicted) for the sale of cocaine when Elders was surgeon general...
...As Haller Jones’s children grew, house and farming chores were added to their school lessons...
...Elders was her mother’s first born, and one of her earliest childhood memories is of her mother teaching her to read, using a switch to add painful emphasis to Elders’s errors...
...Elders says she harbors no anger toward Clinton...
...Elders was the valedictorian of her high school class, and fortune stepped in with a full-tuition Methodist scholarship for Elders to attend Philander Smith College in Little Rock...
...But never were the children allowed to use the hard work all of them did as an excuse to slack off on their school work...
...Haller Jones, to whom the book is dedicated, passed on to Elders four bits of wisdom that could serve well any child in any American circumstance today...
...The latter statement was too much for Clinton, still reeling from the Republican Party victory in the mid-term congressional races, so he fired Elders in December 1994...
...Not surprisingly, he is at his best, and his most instructive, when comparing our system with the rest of the world...
...Brody had access to Atwater’s childhood scrapbook, his high-school letters to his mother, his incomplete doctoral thesis, his medical records...
...Elders did a lot more than that, however, and not just for herself...
...There are, to put it mildly, a few snags with this idea...
...Elders never learned what Grandma Minnie said to her father, but in early September, her grandmother told her to get ready to go...
...For where most American reformers, in King’s view, want to make politicians more responsive to the voters, he wants to make them less so...
...Elders’s proposal to establish school-based health clinics set off storms of protest in Arkansas, with antiabortionists accusing her of trying to set up programs that would take away parents’ rights to teach their children about human sexuality...
...You could trust Atwater to always act in his own interests...
...American officials, he shows, are not just highly vulnerable to what he calls, with customary academic flair, “the vicissitudes of electoral politics!’ By international standards, they’re peculiarly vulnerable-more so “than the politicians of any other democratic counw Only in America are the members of the larger house of the national legislature forced to face the voters every two years...
...What he seems not to realize is that those features are deeply embedded in that system-and that simply importing one or another of them isn’t likely to produce the desired effect...
...GREW UP in a 1930s Arkansas African-American sharecropper family so desperately poor that few would expect such a child-whose skin color legally marginalized her-to surmount the formidable barriers in front of her...
...Toward nightfall, Elders’s five-year-old brother Chester, stooped over after working since sunup, looked up at his sister and asked, “Min, do we have enough yet...
...These people talked about everything...
...If Jones had not died in her eighties in 1995, she could tell us in one word, as she told Elders six decades ago, the secret to Elders’s success: education...
...Not bad for a Martianbut not brilliant, either...
...With the help of Arkansas legislators, Elders won some of the battles around schoolbased clinics, the professional legacy of which she is most proud...
...My chest was killing me...
...Elders certainly faced dire circumstances...
...Early advocates of prepaid health systems pointed to well-established and effective not-for-profit health plans, including Group Health of Puget Sound and Kaiser of California...
...For all his details, Brody doesn’t have the answer...
...iiWe understood that the aim of this game was to get through medical school,” writes Elders about her reaction to the segregated facilities...
...How to help people out of poverty has perplexed and occupied this nation for many years...
...He wasn’t alone...
...All for a few bucks, my patient lamented, and he was right again...
...Haller Jones had an eighth grade education, a considerable achievement for a southern, rural black woman in the early part of this century...
...And consider that, at this very moment in King’s homeland, Labour Party leader Tony Blair has been running for Prime Minister, in effect, for two years now-a stretch of campaigning even longer than that waged by Bob Dole in 1995 and 1996...
...Wealth Maintenance Organizations By Joshua Sharfstein MY PATIENT WAS LYING IN THE Cardiac Intensive Care Unit, connected to continuous monitors and dripping intravenous lines, but he couldn’t stop thinking about his last tip...
...Had his boy been in an HMO, the man speculated, the diagnosis might not have been caught in time...
...While documenting these failures, Anders asks how the market in health care could allow them to happen...
...The book comes most alive when Brody is talking about Atwater’s personal affairs, the career-defining office politics that are the heart of Washington and the extramarital experiences that were an open secret...
...I carried this lady’s groceries up to the third floor,” he told me...
...After all, managed care took off in the late 1980s to counter the grossly inefficient and expensive excesses of fee-for-service care...
...Recognize the truth and speak out against wrongdoing...
...It’s fascinating that someone went to the trouble...
...The most compelling part of Elders’s life is her childhood of rural poverty, and her overcoming that to rise to a position in Arkansas to help those in similar circumstances...
...It’s not my role to defend the RNC, but I was dating my wife at the time, and I do happen to know first-hand that they paid for the staff that was attending to him at the end, his car, his driver, the hot tub that was built in his backyard, and his around-the-clock nursing...
...Elders and her second husband had their share of personal pain and trauma...
...Jones and her switches saw to that...
...But Curtis Jones needed his oldest daughter in the fields chopping the weeds coming up around the cotton and corn...
...JOHN HEILMAN is the National Affairs Editor at Wired...
...For example, he notes that in one Tennessee town, the two main Medicaid HMOs refused to pay for antibiotics necessary to stop a raging epidemic of childhood dysentery until public health authorities intervened...
...Between the poor whites and blacks there was no difference,” she writes about what she saw...
...Army’s Women’s Medical Specialist Corps, and entered the University of Arkansas Medical School in 1956 with financial support from the GI Bill...
...crime (other than violent crime) is often as high there as here, and unlike here, is rising rather than falling...
...So when opportunities expanded in Arkansas for African Americans, Elders and most of her siblings were prepared to take advantage of them...
...I‘ll never forget sitting in a firstyear medical school class listening to a heart-rending story from a man whose son nearly died of the eye tumor retinoblastoma...
...One consistent element within all of them is the absence of any understanding that a solid academic education can be a ticket out of their dire circumstances...
...Until this nation changes course, we all will have to live with this irony...
...As the nation’s top doctor, Elders’s plain-spoken manner stirred up one storm too many for the Clinton administration during her 15 months in the ofice...
...Brody also accumulated a tape deck full of unvarnished conversations among the major Republican players in the White House and on the campaign trail...
...Obsessive, bright, paradoxical, ambitious, a scheming but likable guy...
...Then she said that masturbation is a “part of human sexuality, and perhaps it should be taught...
...In a nutshell, King’s argument is that, because of the frequency and high cost of US...
...But an equally important problem, Anders argues, is that HMO rating systems are fundamentally flawed...
...The best decisions are seldom taken or implemented on a fast-moving rollercoasterl’ Anthony King has rendered a reasonable, if not terribly original, description of the rollercoaster, while failing to provide any promising idea as to how to slow the sucker down...
...JOSHUA SHARFSTEIN is a first-year resident in pediatrics at Boston Medical Center and Boston Children's Hospital...
...Or, as a retiring Republican congressman quoted by King puts it: “What kind of whore am I?” The consequences for policy are even less savory...
...A young white foster daughter and the young woman’s fiancee were both killed in an unsolved double murder...
...Near the end of his book, King writes that “the high-exposure, highrisk politics of the American kind is exceedingly time-consuming and exceedingly expensive, that it is degrading to those who actively participate in it and depressing to those who merely watch it and that, in policy terms, it results far more often than is necessary in fear, paralysis and fraud, ceaseless activity becoming a substitute for calm deliberation and effective action...
...She credits her strong-willed mother for all of her success...
...Consumers always should be on the lookout for poor care, but expecting them to do so during their most vulnerable moments is a cruel system of quality control...
...For-profit HMOs that reduced health care costs for businesses reaped unprecedented dividends for their investors and had little financial incentive to maintain quality...
...There were no hospitals for black people in the area around Schaal, and, if by chance you cut your foot while doing farm work, you put coal oil (the equivalent of kerosene) on it...
...But although King manages to avoid embarrassing himself, his sideways glance at our politics isn’t especially revealing...
...They were able to sell the cotton they picked for $5, enough to get Elders to Little Rock “with a dollar and change left to spare.’’ Elders, who adopted the name Joycelyn in college, married briefly after graduation, joined the US...
...Revealing perhaps the most calculating tradeoff between life and profit, Anders writes about how some popular East Coast and West Coast HMOs pick their cardiac surgery centers...
...set off for the small community hospital that his HMO had told him to head for in case of an emergency...
...Legal threats are also unreliable...
...He seems caught between the polar emotions of admiration and revulsion...
...a recent study showed that about half of American workers have their health plan chosen by their employers...
...JAMES CARVILLE is a founder of the political consulting firm Carville & Begala and the author of We're Right, They're Wrong...
...King cites five, all of them well rehearsed in recent years by a range of scholars and journalists: the pressure to deliver pork to powerful interest groups, the outsized power of the lobbies, the tendency to substitute symbolism for substance (see crime policy, etc...
...This in turn has damaging implications for public policy...
...Seeing these places was taking me right back to where I had come from,” Elders says...
...If you want to get out of the fields, get something in your head...
...Atwater’s political successes are well-documented here...
...My wife, however, takes vehement issue with Brody’s assertion that Atwater was abandoned by the Republican National Committee...
...Sounds good...
...Then President Clinton amointed her Surgeon General of the United States, the first African American to hold the post...
...He put the big red tube in there to drain the poison out of him...
...But when we took the blanket off, 1 saw a big tube sticking out of his stomach...
...Jones taught each of her children to read with the same fierce determination and a collection of switches...
...And indeed, the section on Washington is the most boring in the book...
...the best evidence indicates that about 2 percent of true medical negligence leads to a lawsuit, and about 80 percent of lawsuits have no basis in medical fact...
...Lee Atwater was a man who was obsessed with Lee Atwater, and now here’s this book obsessed with the same thing...
...Anders doesn’t address what Health Against Wealth convincingly demonstrates is the root cause of much poor care: health plans beholden to employers and to profit...
...Anders recalls the Medicaid scandals in Florida .and Tennessee, where hastily thrown-together HMOs made a mint without ensuring adequate access to care for hundreds of thousands of members...
...After losing a South Carolina Republican gubernatorial primary for General William Westmoreland, he had the dry heaves for two days (I can relate to that), but things went pretty much straight up from there...
...Actually, I’m self-employed as an investment advisor,” the man saidiadding “if any of you have any extra cash, buy HMO stocks...
...The writer asks, “Had he wronged so many others because he felt so deeply wronged himself...
...The doctor told Daddy Bernard’s appendix had burst...
...He wants America, in this respect at least, to be more like Europe...
...Don’t use up your future trying to recapture the past...
...Only in America do politicians also face the prospect of being challenged in primaries within their own parties...
...The dissatisfaction, King believes, is warranted...
...And I thought it was just Democrats who talked to reporters...
...Regulation to reduce financial and legal pressure on physicians and improve reporting would undoubtedly help...
...As King himself admits, despite reduced exposure to the “vicissitudes of electoral politics,” many European governments have hardly done better than ours at dealing with the sorts of problems he bemoans...
...It would have been a major achievement if Elders had just survived, worked as the store clerk she originally aspired to be, married, raised a family, and lived a God-loving decent life...
...Sometimes, the device works...
...For more than a month, Elders traveled around Arkansas visiting the state’s 106 health clinics in its 75 counties and quickly determined what their needs were...
...elections and the relative weakness of the two major parties, our politicians live in a constant state of fear for their careers, which causes them to campaign constantly at the expense of governing thoughdully (let alone courageously...
...Afterwards, King contends that Washington’s failures in these and other areas of policy have given rise to the bitter public dissatisfaction with government that has been the touchstone of national politics in the 1990s...
...Not that King has nothing to add to the debate...
...If a member just shows up at an emergency room and receives care, she better hope the condition is serious: If not, the HMO is likely to deny payment, even if the problem was a near-miss...
...They survived the same way we had survived...
...But as strong-willed as her mother was, Elders knew if her father decided he needed her on the farm, Haller Jones would not be able to convince her husband otherwise...
...Soon I was sweating all over...
...LEON DASH is a reporter for The Washington Post...
...I tell ’em I learned a lot about politics from going to wrestling...
...The clear solutions are for individuals rather than employers to choose their doctors and health plans (either through Clinton-style managed competition or, preferably, through a singlepayer system) and for Congress to bar investor-owned managed care companies from the market...
...And only in America do loters make their choices primarily on the basis of the candidate’s own performance rather than that of his or her p q . According to King, these differences between America and most other advanced democracies are bound up with two competing views of democracy itselE the view held here that politicians should act largely in accordance with the will of their constituents and the view held elsewhere that they should act largely in accordance with their own view of the national interest...
...But if King’s take on the causes of the United States’ electoral exceptionalism is open to debate, his assessment of the consequences seems squarely on the money: America’s politicians “run scared...
...At just 44 years old, the father of three small children, he was a man whose heart had paid a dire price for his HMO’s plan to trim the costs of emergency care...
...Elders gives a poignant description of her father carrying her very ill younger brother, Bernard, in his arms early one morning as he rode off on Old Jim, the family mule, to see the nearest doctor...
...And if you were bit by a dog, you might put coal oil on the punctures, watch to see if the “dog had had rabies in its bite,” and hope you didn’t get hydrophobia...
...When illness strikes, HMO members are often urged to call a special 800 number (rather than 911) and then are routed to particular hospitals chosen on the basis of price...
...Elders feels the opposition she stirred up in Arkansas followed her to Washington, where her stint was too short to let her make any lasting accomplishments...
...the fondness for shortterm solutions (see Social Security, Medicare), and the depletion of spine...
...According to a consumer survey cited by Anders, as many as 20 percent of HMO members have not been reimbursed for their own emergency care...
...Health Against Wealth reveals other systematic ways that some HMOs reduce costs but compromise quality: drastically scaling back mental health services, cutting off access to top specialists, increasing “the hassle factor” that makes it virtually impossible for a patient or provider to pursue a complaint, and making heroes of physician executives who deny patients expensive experimental care...
...At some length, King details how these defects have resulted in poor policy decisions, including the US...
...One was like a photo negative of the other...
...Now a pediatric professor at the University of Arkansas, Elders has not spoken with Clinton since...
...It was all the same...
...Atwater called some of what he did “strategic misrepresentation” and bragged that he read Machiavelli’s The Prince 23 times...
...They are hot...
...In his ideal world, consumers (and their lawyers) challenge HMO decisions at every turn, doctors speak out against abuses, legislators rein in the most outrageous practices, and regulators publish better report cards...
...Atwater had a whole staff to generate stories about himself, to spin his past in order to weave his future, and some of that whole cloth has apparently been accepted here as fact...
...From Bad Boy: The Lfe and Politics of Lee Atwater by John Brody emerges a portrait of a man who was all of these things...
...Despite all this, the truth is that King may well be right that America would benefit if its politicians operated under a less unrelenting (i.e., European) level of electoral pressure...
...Since the mid1980s, I’ve studied several families trapped in intergenerational poverty...
...Trustworthy...
...These travails and years of medical research on childhood diseases occupied Elders up to her appointment by Governor Bill Clinton as director of the moribund state health service in 1987...
...Right from the start we were far more concerned with that than we were with something like where we ate...
...I had lived through it...
...In addition, overzealous HMO marketers in several states have been charged with mail fraud, intimidation, bribery, and forgery in their attempts to sign up Medicaid clients...
...and entitlements (think of France) are similarly spinning out of control...
...All of this can be learned from Elders’s easily read autobiography...
...Through the birth of her eight children, Haller Jones “held tight to the conviction that if we ever wanted to ‘be something,’ we had better get educated,” Elders writes...
...We are all the poorer for her absence...
...Brody is the Jack Webb of political biography- “Just the facts, ma’am,”-and his book is relentless in its details...
...What’s more, legislators are sure to focus on the most politically engaging HMO practices (such as “drive through” deliveries and mastectomies) while leaving the remaining 99 percent of medical practice untouched...
...He didn’t read Machiavelli 23 times...
...Political Booknotes The Prince Of Spin By James Carville AT THE HEIGHT OF HIS POWERS Lee Artwater attained a level of spin that made you stand in awe...
...Despite the massive growth of for-profit managed care companies, when Consumer Reports rated the nation’s top 10 health systems, all 10 were not-for-profit...
...Brody asks, “Can someone who had so many flaws be considered great in the final analysis...
...She never claims to be more than a physician who saw the worst of rural poverty and racism and put it all behind her to become a committed health care advocate for the many neglected children of our nation...
...Her most significant accomplishment was her victorious battle to expand health care for Arkansas’s poor while state director of health services in the late 1980s...
...Machiavellian scholars haven’t read The Prince 23 times, and it would be very un-Machiavellian to admit it if you did: Bad Boy is most powerful when it’s most personal...
...She accepts what happened to her in Washington as the fate that awaits all who occupy high-profile political positions and are impolitic enough to say what they genuinely feel and believe...
...As Wall Street 301~marle porter George Anders documents in his new book, Health Against Wealth: HMOs and the Breakdown @Medical Tnut, many health maintenance organizations (HMOs) and managed care organizations systematically compromise the health care of their members in order to minimize costs to employers and maximize their own profits...
...This is, of course, a crude caricature...
...Of this last consequence, King writes, ‘American politicians’ extreme vulnerability makes it harder to make tough decisions: to court unpopularity, to ask for sacrifices, to fly in the face of conventional wisdom...
...Brody never satisfactorily answers that question, but he goes a long way in documenting the Atwater transgressions, both political and personal...
...He favors fewer primaries, stronger parties, and less money in politics...
...What King seems to want is for America to have all of the most desirable features of a parliamentary system...
...Not only does Brody tell you that James Brown attended Atwater’s funeral, he gives you the color of the Godfather of Soul’s shirt (black) and tie (white...
...By the time Elders entered school in 1938, she was reading...
...Brody presents the case that much of Atwater’s development can be traced to a tragic childhood accident that killed his brother and let him live...
...But by the late 1980s, there was too much money on the table...
...Emergency care is just one egregious example...
...But he was certain he’d be losing his work leader if Elders went off to Little Rock...
...admiration for a guy who really got the job done, revulsion for what Atwater did to the people he brushed up against in the process...
...Oliver Elders experienced several long bouts of such deep depression that Elders considered leaving him...
...Bernard looked the same as when he had left, huge-eyed and silent as death...
...But Elders hadn’t counted on her paternal grandmother, the woman she was named after, Minnie Jones...
...Running on Empty By John Heilmann IF YOU READ EVEN A SMATTERING OF ti 1co mmentary on American politics and society written by foreignersand particularly, for some reason, by the British-you will inevitably run across the conceit of the wide-eyed Martian...
...More often, it makes the author look like a rube-and a condescending one at that...
...To which the only reasonable response is: Don’t we all...
...And with a slavish attention to moneygrubbing, publicity seeking, and constituent strohng that suggests a variety of careers that don’t exactly qualify as public leadership...
...If a Martian were to land in Anytown, USA, in the winter of 1997 . . !’ a piece might start, and then go on to point out some truth about life in Anytown that its residents have never realized, but that the Martian, with his fresh perspective, finds comglaringly obvious and terribly significant...
...First, Elders suggested studying what impact the legalization of drugs might have on crime...
Vol. 29 • January 1997 • No. 1
