Healthcare in France: Doctors Tell Us The Public And Private Sectors Can Work Together

Today we heard the disappointing news that key Senate moderates,like Rob Portman of Ohio, are gradually getting on board with the travesty that is the American Healthcare Act. One of the most concerning concessions they appear prepared to make is the end of the Medicaid expansion introduced by Obamacare. They are buying into the Republican narrative (shared, though for different reasons, by some in the Bernie Sanders wing of the Democratic Party) that Obamacare’s problems somehow prove that a mixture of public and private coverage cannot work together. The Republican solution is to make healthcare entirely private; many on the left want to make it entirely public. I think instead, we should take a look at the great work France has done to cover its people through a mix of public and private healthcare sources.

The French government has two roles in the healthcare system: it has a health ministry that sets a national healthcare strategy and imposes cost control regulations, and it provides a National Health Insurance program, or SHI. The SHI is financed by a variety of taxes, including employer and employee payroll taxes, income tax, tobacco and alcohol taxes, and taxes on insurance and pharmaceutical companies.  SHI covers French residents who are employed, recently unemployed, students, or retired persons. The state pays for insurance for long term unemployed residents and refugees. In addition to SHI, French residents can add voluntary health insurance, which, like in Germany, mainly covers additional benefits and the costs not covered by SHI. All employed French persons are entitled to some level of VHI. While the French do pay coinsurance for their medical care, these rates are generally extremely low. On the whole, the French system is incredibly effective, and what we can learn from it is that it has slowly evolved over time to cover more and more French people because French leaders were committed to covering everyone and limiting cost, while working with healthcare professionals to help them ensure they are adequately compensated. I asked Pomme Tarte, a translator who has lived in St. Germain en Laye, a suburb of Paris, for almost 40 years, to tell us about a conversation she had with a couple of French doctors about what it’s like to work in the French system, and how they feel about it. Here is her report, (edited for flow):

Are you a specialist or a general practitioner?

Guillaume is a retired family doctor (GP).

Marielle is a retired specialist (specialties: endocrinology, nutrition, diabetes mellitus)

Do you feel that you are able to provide care to your patients in a timely fashion?

Patients can get an appointment within the week. A patient can call if urgent and the secretary can determine if it really is urgent. If so, the doctor takes the call and decides what to do. It used to be that doctors made house calls. While they still do, they do so much less. There are fewer doctors setting up their own town practices, apparently. The administrative side and overhead are a disincentive. There exist health centers where staff is on the payroll. The patient can’t expect to see their particular doctor, so it’s not the same relationship.  (Note from Pomme Tarte: This may be a trend, but it is not very visible in Saint Germain en Laye).

To get an appointment with Marielle, or most specialists, one needs to wait three months or so. She spends half an hour with the patient. If an urgent call comes in, she takes the call or gets back to them and evaluates the situation.

She used to have a secretary with all the problems of an employer. Then she got a call service to handle her bookings and phone needs, which helped with costs.

What about Patients who fall ill on a night or weekend?

They go to the ER or call SOS Médecins to see a doctor.  Ours is:  There is an office of “SOS Medecins” (A French emergency service that serves as a sort of urgent care center/urgent house call provider) in a nearby town where you can see a doctor during the daytime hours on a weekend.  Otherwise, SOS Médecins will put you on their list and drive to you. It takes awhile, because they have to drive all over the place, but you can stay home and wait. You get charged more, but it is an option to avoid going to the ER.

Too many people go to the ER when it is not a real emergency (Note from Pie Face: apparently this is not just an American phenomenon!).

How do people get to see specialists in France?


Guillaume says his patients choose him to be their “médecin traitant” (primary physician). He is then the gatekeeper to the specialists. A patient has to go through the médecin traitant in order to see a specialist. Marielle noted that this saves the health system money. It used to be that a patient would decide on their own to go see a specialist, but see the wrong one, etc., or see several wrong ones.  The SHI pays its share of  23 euros for the GP instead of 150€ for a specialist.

There are kinds of specialists that a patient can see without going through the médecin traitant: GYN, opthamologist, psychiatrist, stomatologist.

If you have an emergency, you dial 15 and they decide what your course of action should be and send you emergency care or ambulance, if necessary.

The price of seeing your médecin traitant is 23 euros. That is the price reimbursed by the SHI. The reimbursement rate is 70%. You pay your doctor, the doctor files the paperwork with the SHI, the SHI covers 70% and your VHI  covers the 30% not reimbursed by the SHI.

Are advanced new drugs available to patients in your system?

Drugs are approved by the French authorities (like the US FDA). Once a drug is approved, it is theoretically available. A doctor might prefer to prescribe an existing medication that works perfectly well rather than a expensive new one.

For some types of drugs, the patient has to get them prescribed at a hospital. There is a framework regulating the prescription of certain types of drugs (anxyolitics, etc.) For instance, the drug for Hep B chronic is expensive and specialized, must be prescribed by a specialist. At a hospital, there is no limit on what a doctor can prescribe for HIV or cancer or whatever.

The French system sends out a rep to remind doctors about “best practices” from time to time. If a doctor in private practice has a question about, say, antibiotics, s/he can call the Service des Maladies Infectieuses at the hospital for information.

Does your system lead to any kind of rationing? What kind of compromises do you think the system has made in terms of patient care to make it more affordable?

It organizes, but does not ration. The obligation to go through the médecin traitant is an example. No compromises are imposed. Very old people are given care (operations etc.). Their age is taken into account for treating them. The doctor gives care to benefit the patient. I’m sure they consider cost/benefit, but cost/benefit is not imposed on them.

Do you feel able to provide the same care to patients on the social system as you do to those with private insurance?

Everybody can get health care through the system, even hobos on the street with the State coverage for the indigent and refugees (CSU). The SHI pays 100% for a “CSU” doctor’s appointment.

Doctors are organized in Sectors: (Sector 1: they charge the SHI rate.  There is an advantage somehow on the retirement end for these doctors. Sector 2 doctors charge more. The VHI has more to pay.

A doctor is not legally obliged to take on a patient with CSU. Marielle and Guillaume said the doctor has a moral obligation, but not a legal one. Both Marielle and Guillaume had CSU patients. But, at the end of the day, if the doctor has had too many CSU patients, s/he is not going to be happy.

  1. When you look at the rest of the world, what is the best part of being a doctor in France? What is the worst?

The best: Marielle and Guillaume said the average price in Europe for a consultation is 50 euros  v. 23 euros in France. They had the impression that in the UK doctors earned more and worked less (Note from Pie Face: English doctors DEFINITELY do not make more money. They are in real trouble at the moment due to funding cuts.). Also, a doctor can set up business where they want (there are rules about distance from another specialist, but basically it’s up to the doctor where s/he wants to practice). Pleasant places are full of doctors!

The most modern MRI in this area is ten minutes from St Germain, in Poissy. The hospital in St Germain has been partnered with Poissy for resource sharing purposes. We no longer have an ER at night. The maternity ward used to deliver 2000 babies a year, now it’s all Poissy’s excellent maternity ward or else you go to the local clinic (which has set up shop right next to the hospital). Apparently the opthalmology and endocrinology and infectious diseases people at St Germain are great, it depends on the department.

The worst: The hospital system is cumbersome, administrative, not flexible. In France, things could be improved, but they basically think it is a system to be proud of.









Your Comey Cheat Sheet: When Does An Abuse Of Power Become An Obstruction Of Justice?

I’m sure that, like me, many of you are dangling on tenterhooks in anticipation of James Comey’s testimony before Congress tomorrow. The internet has been all atwitter about the possibility that Trump committed obstruction of justice by asking Comey to drop the Russia Investigation, and then firing him, presumably because he would not do so. Although many experts agree there is a heavy aroma of obstruction in the air, most also agree that we haven’t quite found the smoking gun. So here’s my take on what we know, what the law says, and which issues you should be looking out for when your eyes are glued to Comey’s testimony tomorrow.

The deeds we know the Donald has done

James Comey has a reputation for meticulous recordkeeping and an excellent memory, and the man of the hour has helpfully provided us with a pre-interrogation factual background of his interactions with Donald Trump (his full statement can be found in the above link). Here’s what we know so far:

  1. January 6, 2017 briefing: Comey briefed Trump alone on the “personal” elements of “salacious” and “unverified” Intelligence Community review of elements of the Russia investigation. This appears to refer to the Steele Dossier.
  2. January 27, 2017 dinner: Trump asked Comey, who had already agreed to stay on as FBI Director, whether he would like to keep his job, noting many people would be eager to take it on. Shortly thereafter he said “I need loyalty, I expect loyalty.” Trump repeated his demand for loyalty, and when Comey promised honesty, Trump settled on “honesty loyalty,” and Comey agreed.
  3. February 14, 2017 meeting: Trump discussed at length his concerns with intelligence leaks and suggested he hoped Comey could drop the investigation into Michael Flynn.
  4. March 20, 2017: Comey testified before Congress that the FBI is investigating the Trump campaign’s ties to Russian election tampering.
  5. March 30, 2017 phone call: Trump told Comey the entire Russia investigation is a “cloud” hanging over his Presidency and asked if Comey could act to “lift the cloud.” He also raised concerns that Deputy FBI Director McCabe was too associated with the Clintons, and wondered again about the “cloud.” Trump asked Comey to “get out” (to the public) that Trump himself was not under investigation. Comey reported Trump’s request to end the investigation to the Deputy Attorney General for the Russia investigation.
  6. April 11, 2017 phone call: Trump calls Comey and says “the cloud” is still hanging over him. Comey said he had referred the issue to the Deputy Attorney General, and that would be the proper channel for Trump’s request.
  7. May 2, 2017: Trump says Comey is the best thing that happened to Hillary Clinton, because he “gave her a pass” for her “many bad deeds.”
  8. May 8, 2017: Trump tweets that the Trump-Russia is a “hoax” and asks when the “taxpayer-funded charade” will end.
  9. May 9, 2017: Trump fires Comey, and claims he did so because the Justice Department recommended it based on Comey’s mishandling of the Hillary Clinton e-mail controversy.
  10. May 11, 2017: Trump tells Lester Holt of NBC that he was going to fire Comey no matter what, because of his handling of the Russia investigation.

These are the known facts relevant to Trump’s interactions with James Comey. The question is, what do they prove?

The requirements for an obstruction of justice claim

Every crime on the books has specific elements or requirements that a prosecutor must prove in order to convict a defendant. Obstruction of justice is no different.  In order to prove obstruction of justice, the U.S. Attorney’s Manual requires that “(1) there was a proceeding pending before a department or agency of the United States; (2) the defendant knew of or had a reasonably founded belief that the proceeding was pending; and (3) the defendant corruptly endeavored to influence, obstruct, or impede the due and proper administration of the law under which the proceeding was pending.” Now, we can’t be certain Trump would be convictable were he not President – the court cases disagree about whether the relevant statute applies to the FBI (if you are interested in the details, please click the link above to read a great analysis on the Lawfare blog). Fortunately, Donald Trump isn’t in danger of getting prosecuted, he is in danger of getting impeached (pending the outcome of the 2018 elections), and the “high crimes and misdemeanors” required for impeachment need not refer to a line item in the US Code. They are whatever the House of Representatives says they are (a terrifying standard at any time). Since we don’t have a House definition of obstruction for Presidents, the best we can do is analyze Trump’s behavior in light of the statute Congress created to apply to everyone else.

Which elements have been met, and which haven’t?

Element #1: “There was a proceeding pending before a department or agency of the United States.” If we treat FBI investigations as a “proceeding,” there are two “proceedings” that could be implicated here.  The first is the larger Trump-Russia investigation being conducted by the FBI’s counterintelligence division. The second is the widely reported grand jury investigation into Michael Flynn. Interference with the Flynn grand jury would fall under a different statute, and since we are not positive about the nature of that investigation or whether Trump could have known about it at the time he asked Comey not to investigate Flynn, I’ll leave that out of my analysis.

Element #2: “The defendant knew of or had a reasonably founded belief that the proceeding was pending.” Trump knew Comey was investigating Russia’s interference in the election on January 6, at the very latest.  He became aware that his campaign’s connections to Russia were being investigated when Comey testified before Congress on March 20, at the very latest.

Element #3: “The defendant corruptly endeavored to influence, obstruct, or impede the due and proper administration of the law under which the proceeding was pending.” This prong is the key. There is already some indication that Trump intended to obstruct Comey’s investigation. After Comey’s March 20 testimony, Trump called him twice, on March 30 and April 11, to try to get him to end the investigation. Trump’s tweet on May 8 also evidences frustration with the investigation, and Trump’s admission in an interview that the Russia investigation inspired him to fire Comey adds yet more fuel to the fire. However, firing Comey because he didn’t like the Russia investigation doesn’t necessarily prove Trump obstructed justice.  The problem with that reasoning is Andrew McCabe, the Deputy FBI Director who has known Clinton ties. Trump clearly knew that Comey’s #2 was associated with Democrats; he raised that concern with Comey on their March 30th phone call. It’s difficult to call the firing itself an obstruction of justice if Trump knew ahead of time that the Acting Director wasn’t going to stop the investigation and it was going to be a while until he could get a new Director through the Senate. The question is whether Trump did anything before the firing designed to push Comey to personally change the outcome of the investigation.

Was there coercion, or wasn’t there?

So our task for tomorrow’s hearing is to look for clues to whether there was an implicit or explicit if/then threat from Trump to Comey. Did Trump make it clear to Comey that if he did not “lift the cloud” then Trump would fire him? If so,that is an unquestionable attempt to obstruct the investigation. If not, it’s too easy  for a good lawyer to characterize Trump’s talk about a “cloud” hanging over his head as toothless whining (though his personality and past conduct would suggest it was not). It’s easy to see an implied threat; after Comey confirmed an investigation into the Trump campaign, Trump called him and asked him to end the investigation and began talking vaguely about Comey’s Deputy Director. Much of the distinction will involve Comey’s impressions and state of mind. If Comey didn’t perceive a threat in Trump’s statements, it’s hard to prove obstruction, unless Trump tells us he was threatening Comey, which is never out of the realm of possibility with this guy. Hopefully Trump had Comey quaking in his boots. Happy hunting folks – let’s see if that smoking gun turns up tomorrow.

Blue States’ Rights: How California And Other Blue States Can Hold America To The Paris Accords

This week, Donald Trump decided (or by the tone of his speech, Steve Bannon decided) to withdraw the United States from the strictly voluntary Paris Accords.  This decision was a tragic abdication of American leadership, and it is entirely possible that it marks the end of the American era. Why would any country ever enter a long term agreement with us again if our word is worthless? It was one of the most ridiculous self-inflicted wounds I have ever seen, and Trump’s prediction that the world would end up laughing at us has already become a reality. However, Trump’s destruction of American’ leadership may not actually destroy the planet. California, New York, and Washington have created the United States Climate Alliance, and intend to work with other countries, regions, and provinces to meet the Paris Accords. If they play it right, these states, and others that will hopefully join them, can use their constitutionally protected right to tell Trump to eat coal and enact laws that will keep the US to its Paris commitments.

States’ Rights Aren’t Just For Living Confederate Monuments Like Jeff Sessions

Those of us who take a dim view of America’s history of slavery and segregation tend to recoil at the term “States’ Rights,” because the concept has most often been invoked to promote institutionalized white supremacy. However, the Tenth Amendment, which says all powers not granted to the Federal Government belong to the States, is an essential check on federal power. It is there to protect California’s right to control carbon emissions just as much as it was ever there to help South Carolina persecute its black citizens. California already has a cap and trade system in place as well as other progressive environmental regulations. A State’s right to regulate internal  carbon commerce has already been established.

The United States Climate Alliance may not be able to control all carbon emissions in the US, but they may just be able to offset the transgressions of the Koch brothers and other polluters in states they cannot reach, and curb some big polluters in the bargain. Most carbon emissions don’t come from the federal government (although the Tennessee Valley Authority accounts for quite a few); they come from people and corporations. Just imagine that Oregon, New Jersey, Connecticut, Massachusetts, Rhode Island, New Hampshire, Vermont, Delaware, and Maryland join the Climate Alliance. About 100 million consumers live in those and existing Climate Alliance states. No business wants to voluntarily give up that many domestic customers over a few environmental regulations. A third of the American population uses a lot of power and a lot of cars and a lot of plastic, all of which come from fossil fuels (at least for the moment). Any business wanting to sell to consumers or do business in those states will have to adhere to whatever regulations the alliance may impose. The great news is that most big polluters are big companies, and big companies’ policies can be manipulated by a minority of states thanks to the power of capitalism.

Large Corporations have to set policies based on all states in which they do business

Big companies tend to develop internally consistent policies based on the most restrictive state law they have to obey. Let me give you an example: If 1/3 of American states pass a law mandating that all small SUVs must have 35 mpg as of 2020, American car manufacturers are not going to make a Ford Escape that gets 25 mpg for Alabama and one that gets 35 mpg for California.  They are going to create a product (given the technology already exists) that they can sell in all states.  Streamlining their products and policies to comply with all applicable regulations is a better and cheaper way for them to do business. There are also non-product related examples. Before marriage equality was decided by the Supreme Court, many large companies offered health benefits to same sex domestic partners.  This was often because some states required it.  It is easier for HR departments (or any other departments) in large organizations to have 1 policy to apply to all of its operations than different policies for every jurisdiction. Exxon, BP, and every other major oil company sell gas in California and every blue state. After all, that’s where most of the people are. Seems like a fair bet to me that they will be unwilling to forgo 100 million consumers – more than the entire population of Germany – just to avoid a little carbon cutting.

It’s time to use the tools we have to achieve the ends we want

With a petulant toddler at the head of the Federal Government, we need to look for alternative means to achieve our goals, and California has the right idea. For a hundred years, the South used their state laws to achieve the horribly discriminatory policies they wanted, and they succeeded, despite the existence of a constitutional amendment designed to prevent those policies. We have no such impediment! There’s no reason we can’t use our state laws to try to save the planet, or anyone else who needs saving, for that matter. One excellent aspect of federalism is that people in other states generally don’t kick up a fuss about what the state next door is up to, as long as it does not fundamentally offend human dignity, and it took almost two hundred years to nip that one in the bud. It’s time for us to support the United States Climate Alliance and any other state-level initiatives that can move our country forward. The more states sign on, the more consumers fall under a climate-protective umbrella, and the more polluters have to listen to us. Let the era of Blue States’ Rights begin.

Loose Lips Sink Ships: The Difference Between Leakers, Whistleblowers, and Plain Old Criminals

The Twitter POTUS has filled his Administration with amateurs and old political hands with no direct loyalty to him. A combination of slip ups by the inexperienced and deliberate revelations by shocked professionals has produced a deluge of leaked information, the likes of which the Press has never seen. They, and we, have been delighted by the Trump White House’s informational unseaworthiness. However, since Donald Trump exposed an Israeli asset by sharing intelligence with the Russians, we have seen a slight shift in the public discussion of leaks. The Press has simultaneously glorified leakers of Trumpian misdeeds as patriots and condemned Trump himself  as a danger to international security for “leaking” intelligence to Russia. In the last week someone in the Trump Administration has also leaked information about the Manchester bombing of an Ariana Grande concert to the FBI, causing the United Kingdom to suspend intelligence sharing for 24 hours. The question is, has the Press been hypocritical in its treatment of leaks? The answer is no. The problem here is that we are using the same word – “leaks” – for a few different types of information dumps. There are three types of leaks going on here: personal leaks that irritate Donald Trump, leaks revealing government lawbreaking, and leaks revealing top secret information unrelated to government misconduct. Here are the differences, and why they are important.

Palace intrigue, or will Sean Spicer get fired this week?

Gossip, or “palace intrigue,” about what Trump is planning, thinking, or saying is what most people really mean when they say the Trump Administration has more “leaks” than past Presidencies, and they are the primary source of Trump’s fury. Here are some examples: in April Vanity Fair told us that Kellyanne Conway didn’t really have a defined job, and might be on her way out; we also heard that there is a behind-the-scenes war going on between Jared Kushner and Steve Bannon, and that Steve Bannon might get canned; now it seems that poor, abused Sean Spicer might be about to get the boot (after all, we’ve heard Trump didn’t like that Spicey was being played by a woman on Saturday Night Live).

The only person harmed by these revelations is Donald Trump, but he has very little ability to stop them, because the relevant information is not privileged or classified and the Supreme Court has made it almost impossible for a public figure, especially a politician, to sue the Press for defamation.  These leaks are completely harmless to the institutional stability of the United States, and they are source of gleeful schadenfreude to those of us who dislike Trump. However, the public discussion has failed to distinguish between these relatively harmless inside baseball reports and the types of information dumps that implicate the Press’s official role in our constitutional Republic.

Whistleblowing, or I don’t think we’re supposed to be bombing Cambodia

Whistleblowers are “leakers” who reveal information that is classified but alerts the public to some kind of government misconduct of which it is unaware. Accurately and responsibly reporting information provided by whistleblowers is the highest calling of the Press. New York Times v. United States, more commonly known as the Pentagon Papers case, made clear that the First Amendment allows the Press to print classified information it receives, so although it is illegal for a whistleblower to distribute the information to the Press, it is not illegal for the Press to distribute it to the people. Famous examples include Daniel Ellsberg, who leaked the Pentagon Papers, Mark Felt a.k.a. Deep Throat, who leaked aspects of the Watergate investigation, and Edward Snowden, who leaked information about the NSA’s surveillance of American citizens (he also belongs in the third category, though more on that later).

The hallmark of a true whistleblower is the revelation of an abuse of government power either against American citizens, or by one branch of government against the other. For instance, Daniel Ellsberg leaked the Pentagon papers because they proved not only that the Johnson Administration lied to the American people about whether Vietnam was winnable, but that Johnson lied to Congress, proving, to Ellsberg, the necessity of Congressional war powers.  Edward Snowden revealed that the NSA was collecting vast troves of data on American citizens without a warrant.  Mark Felt kept the Washington Post apprised of the progress of the Watergate investigation at the FBI, and was a huge part of Nixon’s eventual downfall. Imagine what would have happened if there had been no revelations to the public about Nixon’s dirty tricks, and he had been treated like a normal President? Do you think his henchmen would have flipped? I doubt it. It is the interaction of whistleblowers like Felt and Ellsberg with a Free Press that keeps our government as honest as we can make it.

Dirty leaking criminals, or guess who tapped Angela Merkel’s cell phone?

All leaks of classified information are crimes; when those leaks compromise the function of the US Government and our international relations, they can be catastrophically damaging, and the perpetrators should be treated accordingly.  It’s hard to discuss this issue without wading into the Edward Snowden controversy, so here I go: he’s not a hero, but he could have been, and he serves as a great illustration of the difference between whistleblowers and plain old criminals. There are about ten major revelations from Snowden. Two of them, alerting us to the collection of telephone metadata and PRISM, were legitimate blows of the whistle. Well done, Ed. The other eight (revealing the tapping of Angela Merkel’s phone, proprietary NSA technology, and spying by the British GCHQ in London) did not reveal government misconduct, they just told our adversaries how we operate and our friends that we can’t be trusted with information. These revelations perform no essential constitutional function; they are therefore inexcusable. The recent leak of information about the Manchester bombing falls into this category. There was no government misconduct there – the leaker was just delivering a scoop, and impeded a major counterterrorism action being undertaken by our closest ally. Trump’s revelation of information gained from an Israeli spy was hugely controversial for the same reason – he compromised an asset of a close ally for no reason.

Don’t let Trump lump leaks together

Going forward, it’s important to distinguish which type of leak is being discussed by the Trump Administration and in the Press. Does this leak involve classified information? If not, no one’s committing a crime, they’re just making Trump’s life difficult. If classified information or the contents of a criminal investigation are involved, is this information essential for an informed public to interact with government? All of the leaks and testimony about Trump’s involvement with Russia are important because the public needs to make electoral decisions with the full picture – it needs to approach Trump’s decisions vis a vis Russia with the proper context. However, if leaks of government information don’t serve the public, it’s important to support any Administration, even Trump’s, in rooting out the perpetrators. There is a difference between careful, deliberate revelations taken for the public good, and plain old loose lips. Loose lips can get people killed, and when there is no public good in the balance, deliberate revelations of classified information from allies is a serious crime, the prosecution of which we should all support.


Cancer Treatment In Germany: What Happens When The Government Doesn’t Want You To Die

A note from Pie Face: I am admittedly and unreservedly biased toward the German system of universal healthcare. You can read more about it here, but in sum it is a mixture of state regulated nonprofit health insurance organizations, or “social” care, and private insurers.  Healthcare providers are mostly private. German healthcare is cheap, fast (faster than here, usually) and of excellent quality. Maple Pie describes below what it’s like to navigate the German system as a cancer patient, including pre- and post- operative care.

By Maple Pie

I have two insurance policies for medical and dental care. The “obligatory” one is from a public health insurance company of my choice and gives me standard universal coverage for an income-based monthly fee. The optional one is from a private health insurance company, a so-called supplementary policy which covers me for semi-private stationary hospital treatment, i.e. a two-bed room and treatment by the head doctor or his authorised substitute. I can have a one-bed room if I pay the extra cost from my own pocket.

When a standard screening for bowel cancer turned up positive, my family doctor gave me an acute referral for a proctologist. The enteroscopy, given under sedation, confirmed there was a malignant tumour that needed to be removed in a hospital. The necessary referrals in hand, I went home and laid down for the rest of the afternoon while my husband phoned around for advice. It turned out an acquaintance was Head Visceral Surgeon and a Professor at a nearby University Teaching Hospital!

I was in hospital for further diagnostic work within about 10 days. The results were discussed in a conference of doctors from all relevant disciplines, which set up the roadmap for further treatment. A port was set just below my right shoulder to allow chemotherapy with a pump system (a very gentle method), a tumour marker was set and radiation appointments arranged.

A referral from a local oncologist entitled me to out-patient treatment in the hospital’s Oncology and Nuclear Medicine Departments. Regular blood work, medication,  chemo, radiology and regular feedback from doctors were all taken care of in the hospital and registered in my “Therapy Pass”. A good prognosis , co-ordinated treatment, regular feedback and the luck to have read Randy Pausch’s “The Last Lecture” before my cancer was discovered provided me with a positive attitude.

The Operation took place 3 months after the original diagnosis. After 24 hours in intensive care I was back in my room. A specialist  arrived to check the pain killer machine and a physiotherapist came with first exercises, e.g. how to get into a sitting position or to roll out of bed.

By the time I was released a good week later I had been set up with an ostomy therapist to help me handle my colostomy pouch independently and the hospital social worker had booked me for a post operative care measure in Bayrisch Gmein, a spa near Bad Reichenhall.  This is a three-week rehab sponsored by a private cancer treatment initiative and must be begun within 14 days after hospital release. Without going into detail, it was fantastic; an individually tailored and co-ordinated programme for medication, diet, physio- and psychotherapy, further colostomy pouch training,  and informative seminars on, for example, further relevant treatment and how to manage the paperwork involved. Free time was spent in the legendary spa, Bad Reichenhall, to which we had access.

Three months after the first operation the colostomy could be reversed.  I had access to the proctology department and my ostomy therapist took care of the paperwork necessary to set me up with necessary hygiene and medical aids. The public health care policies cover the cost of pouches, lingerie protectors, etc. up to a certain level. Patients pay a small per cent of the cost of such articles and must cover “extras” themselves.

Every three months after the colostomy reversal I have been called into the Oncology Department for regular blood checks and occasional CTs, enteroscopies, chest X-rays, etc.  The results are discussed with the oncologist who manages my case. This year I have graduated to a six-month rhythm.  Throughout the treatment my family doctor and I have received relevant documentation of tests and medical reports for our records. All in all, my treatment has been competent and comprehensive, and I am more than satisfied with the results.

After The Monuments: Coming To Terms With History And Hate

Yesterday the last of the much-maligned Confederate statues was removed from Lee Circle in New Orleans, ending a two year battle over how to deal with the city’s – and the South’s – veneration of its “Lost Cause.” Watching a city I love in the throes of an uncharacteristic battle between hateful white supremacists and aggrieved activists has brought home to me the degree to which America has failed to wrestle with a defining fact of its history: while it lost the argument about the supremacy of the federal government, the Confederacy won the Civil War. Terrorist actions all over the South and the cost of enforcing Union policies soured northerners’ taste for the Reconstruction that would have ended white supremacy. After that, Southerners got sharecropping, which was scarcely better or freer than slavery, and Jim Crow. They spread their propaganda all over the country with Birth of a Nation, which lionized the KKK. They argued for “states’ rights” so often the rest of the country forgot or ignored that it is a euphemism for white supremacist oligarchy. Even northern textbooks taught that the Civil War wasn’t really about slavery. And when black southerners migrated north in search of a freer life, they faced less obvious but still permanent racial restrictions. For over a hundred years our history has been written by unacknowledged Confederate victors. I think the movement to erase Confederate monuments from the public square is the expression of an unaddressed need for what the Germans call Vergangenheitsbewältigung, or processing and coming to terms with history. We can’t process our history by wiping the public square clean of the evidence of American apartheid. We have to use it.

Destroying evidence doesn’t help the victims of a crime

Confederate monuments all over the Southern and border States are evidence and must be used to teach the true history of the United States. Both sides of the New Orleans monuments controversy are wrong. Leaving these monuments up as they were doesn’t preserve history, it celebrates mythology. However, tearing them down and hiding them away somewhere like Beauvoir (the home of Confederate President Jefferson Davis) does not erase the white supremacy they represent any more than bulldozing Dachau would have helped erase the impact of the Holocaust. Americans need to be taught about the truth of the Civil War and its aftermath. We need to understand that it had many facets; it was a war about slavery, but it was also a war about whether states could challenge federal power. I would argue that the South functionally won the first question, while the North won the second – and unforgivably waited 100 years to enforce it in favor of black Americans, benefiting economically from Southern practices all the while. We need to understand the nuance that comes with all human history – that Confederates were not universally bad, and that some important ones evolved on the issue of civil rights. Most importantly, we all need to understand the length of scope of the oppression black Americans suffered after the war that was supposed to liberate them. The only way to do that is to use the evidence at hand – statues erected decades after the civil war to Confederate leaders and white supremacist terrorists – to prove that the American history we have been taught is upside down.

These monuments tell an important story about the reality of post-civil war America

The existence of all four monuments taken down by the City of New Orleans proves that the regime in charge 130 years ago revered and celebrated the Confederacy and its cause. Two of them also represent specific lessons about the good and the bad in New Orleans after the Civil War. This first important monument is to the Battle of Liberty Place, an insurrection by white supremacists against the Reconstruction government of New Orleans. This monument was nothing more and nothing less than a homage to racist terrorists who wanted to re-take the city in order to oppress a hefty percentage of its citizens. The fact that it stood, prominently displayed, in the middle of a modern American city until 1989 (and still stood tucked in a corner until 2017) says pretty much all you need to know about the degree to which the South’s commitment to white supremacy (and the North’s quiet enabling of it) has dominated American history. That monument needs to be displayed prominently in an educational context in a public place in the City of New Orleans to teach this history to future generations.

So does the monument to Pierre Gustave Toutant-Beauregard, the man who fired the first shots of the Civil War. He wasn’t just a Confederate General, he was also a prominent advocate for the civil rights of freedmen after his side was “defeated.” He was the most prominent advocate of the New Orleans Unification movement, which saw local Democratic lawmakers and business leaders unite with local wealthy pre-war free people of color to propose equal representation in government for both races and integration of the schools, among other things. It represents New Orleans’s unique pre-war racial dynamics, and an attempt by one of the most prominent Confederates to accept defeat and move on. Beauregard’s change of heart demonstrates that individual opinions varied, and the City of New Orleans has a history at odds with the glorification of Liberty Place. It is certainly an injustice that we have failed for so long to acknowledge the true legacy of the Confederacy. However, it would be foolish and dangerous to overcompensate by pretending that everyone in the Confederacy or in the history of the South should be dismissed as wholly malevolent for participation in white supremacy. Among other things, painting the entire history of every white southerner as purely evil will simply provoke resistance to the message, even in sympathetic people. Coming to terms with history means coming to terms with the whole of history, not creating a new anti-Southern mythology to replace the old pro-Southern mythology. Fortunately, other states and countries have had creative solutions to this problem.

Education, Truth, and Reconciliation

I think possibly the best way to use the Confederate statues removed this month is to create something like Memento Park in Budapest.  The Hungarian government understandably removed a great many public statues after the fall of Communism. They represented Russian ideological control of the country and all of the wrongs done by the Hungarian regime against its people. So the government created a curated presentation of those statues designed to educate future generations about their oppressive past. Can you imagine a similar exhibit in City Park in New Orleans? I can. I think it would be a powerful start to the reconciliation this country sorely needs right now, which can only come from processing the whole truth of our history.

That sort of reconciliation through truth has been going on in Maryland, and I think they have the right idea. In front of the Maryland State House stands a statue of Chief Justice Roger B. Taney, a Marylander who wrote the infamous Dred Scott decision, and who opposed Abraham Lincoln’s emancipationist policies until his death in 1864.  This year, the descendants of Taney and Scott met at the statue and Taney’s descendant apologized to the Scott family. The Scott family asked that the State “Add to [the statue], don’t take from it,” suggesting it would be educational to add a statue of Scott and explanation of the court case to the statue of Taney. There is also a movement for the addition of a statue of Frederick Douglass, another Marylander with a profound impact on the Civil War. These ideas will use and value history, rather than attempting to erase an ugly past or hide it away on a plantation. If there is one thing the New Orleans battle over Confederate monuments has taught us, it is this: failing to come to terms with the history of American apartheid and the people who participated in it – the good, the bad, and the ugly – will only create two polarized mythologies and contribute to the schism in our national life.

Why The Special Counsel Ain’t Special Enough To Stop Trump

This week the US and the world received a well-deserved bit of relief from the scandal-plagued disaster that is the Trump Presidency: Deputy Attorney General Rod Rosenstein has appointed former FBI Director Robert Mueller as the Justice Department’s Special Counsel for the investigation into the Trump Campaign’s ties to Russia. This is undeniably welcome news; the furor ensuing from Donald Trump’s decision to fire FBI Director James Comey has revealed that Attorney General Jeff Sessions has no intention of respecting his promised recusal from matters relating to the Russia investigation. Appointing a Special Counsel to investigate the Trump-Russia connection effectively prevents Sessions from polluting or controlling the information and decisionmaking within the investigation. However, the Special Counsel is an internal position governing a specific investigation within the Justice Department. He is still controlled by the Executive Branch, which can fire him and control his access to resources.

Right now, the Republican Party, whose leaders have stood behind Trump’s every provably false tweet, have no claim to objectivity or, frankly, integrity. They also control two of the three branches of government. Any effective investigation must be taken out of their hands.  That leaves us with two types of independent investigators that have been used before: independent counsels and independent commissions. In order to figure out which solution fits the problem, we have to ask ourselves: what is the most critical outcome of this investigation? Is it criminal prosecution, proven beyond a reasonable doubt, or is it a full and fair assessment of all the evidence from all sources, in a form presentable to the American People (and usable by Congress for impeachment)? I think it is the latter, and the only way to properly hold Trump accountable and restore the integrity of our Republic is for Congress to get a veto-proof majority together and form an independent commission to investigate Trump’s connections to Russia.

Independent Prosecutions have been nasty, brutish and very, very, long

After Richard Nixon stepped down as a result of the Watergate scandal, Congress passed the Ethics in Government Act, which authorized either Congress or the Attorney General to create a special prosecutor (later an Independent Counsel) to investigate the misdeeds of elected officials. The results of that law were mixed – Congress allowed it to expire in 1999 for a reason. The Independent Counsel was overseen by a three-judge panel of the United States Court of Appeals for the DC Circuit, but in reality, he had expansive power, and that power was frequently abused. As David Frum ably explained in The Atlantic, a prosecutor is exclusively tasked with finding crimes to prosecute. As with most prosecutors, Independent Counsels tended to go after any crime they could find, even if it was only tangentially related to the matter they were appointed to investigate. Possibly the best example is Kenneth Starr, the Independent Counsel under Bill Clinton, who managed to turn the investigation of an inept real estate deal into an impeachment over a semen-stained dress. The Counsels who investigated Presidents, Starr and Lawrence Walsh, who investigated Reagan’s involvement in the Iran-Contra affair, each took seven years to conclude, and neither found prosecutable Presidential misconduct. The difference between crime-finding and truth-seeking is significant, and it is unlikely that an Independent Counsel would give Congress, the American public, and the world the assurance we need that the American President, the most powerful man on earth, is not wholly compromised. While the FBI Investigation into Trump’s Russia connections is critical, a prosecutor is not the right person to gather the whole picture and present it to the American people.

Everyone can trust an Independent Commission of politically disinterested experts

An Independent Commission created by Congress is a group of appointees from outside government who engage in fact-finding about a clearly defined subject. No branch of government oversees the content of the investigation (although Congress, as always, has the power of the purse). At the end of the investigation, the Commission produces a report laying out all of their findings. A good example of this is the 9/11 Commission. Because Independent Commissions are tasked only with fact-finding, they would be able to draw inferences and report intelligence and other information on Russian activities that might never be usable in a court of law. A 9/11 Commission for Trump-Russia could provide ample evidence for Congress to start the political process of impeachment, which is distinct from the criminal process of indictment and prosecution. No prosecutor can do that. Moreover, an Independent Commission includes individuals from different ideological viewpoints who do not have skin in the political game. The 9/11 Commission was credible because it was bipartisan and because no one on the Commission was seeking reelection. We need that kind of credibility right now, and there really are no downsides, unless you are Donald Trump or his associates, and you have something to hide.

Congress has to stand up to Donald’s Trump card

The only problem with an Independent Commission (or, for that matter, a new Independent Counsel authorization act) is that Donald Trump has to sign the authorizing legislation into law. I don’t think anyone doubts that Trump, if given the chance, is going to veto any legislation authorizing anyone to investigate him. We know he does not care about optics; the man fired his FBI Director and then told the international news media that he did so because he didn’t like being investigated. However, the Constitution gives the first branch of government the right to override a petulant President’s veto. It is time for the Republican Party to rediscover its moral fiber. Trump, as odious as he is, is not the best evidence that our Republic is in danger. The cowardice of Congress is our real problem. Each branch of government is given rights and duties under the Constitution. Congress does not just have the right to act as a check on the President, it has the duty to do so. The Republican Congress is trying to avoid the truth about what it has inflicted on this country, and that abrogation of duty has the power to unbalance our government permanently. Congress needs to grow up and appoint some truth-seekers. As Justice Louis Brandeis once wrote about the value of publicity,  “Sunlight is said to be the best of disinfectants.”


Red Tape And Regulations: Is There A Benefit To Bureaucracy?

Who needs a bunch of interfering bureaucrats? We do. From unwieldy Medicare administration to environmental regulations, both states and individuals have their reasons to bemoan the cumbersome federal bureaucracy. A lot of this criticism comes from the right wing of the political spectrum. Republicans usually complain about federal interference with states’ rights and individual autonomy, but a new reason for the Republican Party to fear the federal bureaucracy has begun to emerge over the first 120 days of this train wreck of a Presidency. The career civil service does not like to have its work disrespected and impeded, and Donald Trump is doing his best to withhold the personnel and resources federal agencies need to carry out their respective missions. He has already infuriated the National Park Service and the EPA, and now, by firing James Comey, he has alienated the second most powerful element of the domestic bureaucracy (the first being the IRS): the men and women of the FBI. This raises an interesting question when the leadership of two of our three branches of government appear determined to dismantle it: could the monolithic, unchanging, much maligned nature of the career federal bureaucracy be the institution that saves us from authoritarianism?

Trump can starve executive agencies, but bureaucrats will still execute their missions

It is no secret that Trump has done his best to impede federal agencies by depriving them of politically appointed staff.  For the 530 positions that require political appointments, he has only put forth 37 nominees. However, in using this tactic, he is really compromising his own agenda, not the daily functions of the Executive. Critical agency positions do not simply go unfilled in the absence of a nominee – they are filled by career bureaucrats unassociated with political parties (for instance, the current Acting Director of the FBI is married to a Democratic operative). Consequently, career civil servants have been preventing Trump’s Cabinet nominees from destroying their respective Departments. Fortunately for us, those bureaucrats have the law on their side.

Unless and until Congress rescinds the laws each department is designed to execute – the National Environmental Protection Act and Clean Water Act, for instance – career civil servants will continue to carry out the daily functions of the Executive Branch. Even after Trump has installed his saboteurs, their ability to destroy their agencies will be limited in the long term; many of the authorizing statutes, especially environmental laws, authorize citizens to sue to force executive agencies to carry out their missions and enforce Congress’s mandate.  So if, for instance, the new EPA destroyer-in-chief rescinds anti-pollution regulations, and pollution grows demonstrably worse, any affected citizen can sue to reverse that decision. It seems unlikely, given the profusion of leaks in Trump’s first 100 days, that career bureaucrats responsible for the day to day running of the Executive Branch will obey any instruction to disregard court decisions or betray their agencies’ missions. Just look at Sally Yates. Why would they destroy the agencies to which they have devoted their careers if they have the law on their side?

The FBI is the worst agency to alienate because it is semi-independent and has the authority to destroy Trump

It also seems that Trump has infuriated many career FBI agents and administrators by firing James Comey disrespectfully and on a transparently pretextual basis. No reasonable person believes Trump fired Comey because his mistreatment of Hillary Clinton proved incompetence. Acting FBI Director Andrew McCabe contradicted Trump’s assertion that Comey was incompetent under oath before the Senate. Subsequently, Trump revealed that he was going to fire Comey no matter what, because of Comey’s insistence on investigating Trump’s Russia connections. Suddenly, a profusion of leaks flowed out of the FBI. Trump clearly has not considered the potential consequences of his actions; knowledge is power, so any individual FBI agent working on the Russia investigation has power over Trump, if that agent is willing to talk to the Press. The benefit of a large bureaucracy like the FBI is that even if Trump goes after big names, the relatively anonymous cogs will continue pursuing the task at hand – in this case, the unmasking of Donald Trump. I’m not saying the FBI or any other bureaucratic organization is a permanent bulwark against Trumpism. However, the highly regulated, protocol-driven, red tape riddled nature of a complex bureaucracy can slow the progress of Trump’s agenda until, hopefully, we can elect functional leaders to the Legislative Branch.

Trump has taken on a behemoth he cannot control

Until this week, Trump has been focused on undermining agencies like the EPA, the National Park Service, and the Department of Education, and the employees of those agencies have ensured the Press is well informed of the changes he wants to impose. Now he has taken on a bureaucracy that can truly harm him. As much as Trump and Jeff Sessions appear inclined to co-opt the federal law enforcement apparatus for political retaliation and drug prosecutions, the FBI’s investigation into Trump’s Russia connections is relatively protected from their interference because of Sessions’s recusal. Deputy Attorney General Rod Rosenstein oversees that investigation, and for all that Trump tried to pin the Comey firing on him, he is a well respected and ethical former US Attorney under both the Bush and Obama Administrations. It seems unlikely he will deliberately sabotage this particular investigation. The FBI investigation, infuriatingly slow and full of bureaucratic rules though it is, will labor on. Bureaucrats in the FBI and elsewhere are a force for continuity; simply by following byzantine agency protocols and imposing the red tape we all despise, they slow the rate of change. They can, if they are willing, curb the excesses of a President determined to undermine America’s institutions.

It’s The Sun Wot Won It… the topsy-turvy world of American media – and why it’s dangerous

By Mince Pie

In this week of dramatic developments on both sides of the Atlantic, I write from 35,000 feet above the Indian Ocean, having made a last minute trip home to London. A week surrounded by tea, queueing and the British media offered up much food for thought.

The UK is in the grips of election fever (or rather election malaise). After 3 major votes (Scottish Independence, General Election, Brexit) in two years, the British people will head to the polls again on June 8th after Prime Minster Theresa May called a surprise “snap” election.

In that context, in a supposed world of 24 hour news, fake news and social media hysteria one would expect wall-to-wall election coverage with vehement opinions flying all over the place. And yet, the British seem oddly calm and level headed about all this and the invective of American politics seems strangely absent. So I started to wonder why that might be.

One could chalk this up to natural British diffidence and refusal to get too excited about anything in case it “starts to rain later.” I don’t think that’s it though. I have been a resident of Australia for the last three years and have seen the same thing there.

I think the comparative equanimity of British and Australian voters comes not from the absence of political invective in media but from who is supplying that invective. In the USA, the TV channels are fundamentally biased towards either left or right. The TV companies that soak up the majority of news viewing were founded with agendas in mind: MSNBC, Fox etc. Sure if you want unbiased news coverage on TV you can find it (on CBS for example) but the big audiences are with the commercial behemoths. In general, my experience of the US is that if you want a level headed approach to news reporting and news commentary you have to pick up a newspaper.

In Europe and in Australasia, this situation is completely reversed. Small countries (in either geography or population) that have national broadcasters (the BBC, the ABC, TF1, ZDF etc) have embedded the concept of the neutral TV news report. In the UK, the BBC is duty bound by its governance to report both sides of an argument (in fact it often gets in trouble with conservatives for “sympathizing with the bad guys” because of it). Even the majority of the commercial channels get their news coverage from one source – Independent Television News (ITN) – which has a long history of outstanding independent news reporting and investigation. Monopoly rules prohibit agenda setting moguls like Rupert Murdoch from owning 100% of the news coverage of their own channels. Sky News (part owned by Murdoch’s right wing News International) has a rightward, populist tilt but he can’t push it too far. Certainly not as far as he’s pushed Fox in the USA.

The print media on the other hand is entirely different. From the holier-than-thou lefty liberalism of the Guardian to the right wing invective of the Daily Mail, the British press is a whole smorgasbord of vibrant political opinions of all stripes. The press are famous for claiming responsibility for shifting elections, particularly close ones. The support of the key tabloids is still, even in the declining age of print, seen as crucial to any would-be-leader’s chance of success.

So, why does having an even handed TV news underpinned by biased newsprint produce a more stable political culture than the other way around? Why do the Brits and Aussies manage to keep a lid on the invective when Americans do not?

The obvious answer is that print is much smaller. 5m people will watch the BBC TV news in an evening. Another 2m will be watching an ITN production on another channel. At the height of its powers the Daily Mail will sell only a third as many copies as that. The quality press (the right wing Telegraph, the centrist but establishment Times and the lefty Guardian) will come up with around a million readers a day between them. This creates a natural foundation of people who get either all or at least part of their news coverage from more even handed sources. That doesn’t happen in the US. The only people getting unskewed news coverage are the readers of certain print publications (The New York Times for example) or viewers of venerable TV channels like CBS.

Print also encourages thought through its format. Long form content that uses only one of the senses (sight) is a relative rarity in the digital age. Whilst sensationalist headlines sell newspapers, they don’t get far without the content underneath them. TV news isn’t like that. A big headline, a few talking points and on to the next story with no pause for thought provocation or analysis is the staple of lots of commercial TV news operations.

A vibrant mix of news is good – it showcases new thinking, new ideas and ensures minority opinion is heard. Bias is good as long as it is balanced by a healthy source of objectivity. The British, French and Australians have a news culture where TV is even handed and print is politically skewed. The USA is the other way around – and its news culture is all the more divisive and dangerous for it.

Trump Fires Comey: It’s About The Subpoenas, Stupid

May 9 started as an ordinarily confusing and disorganized day at the Trump White House. When asked whether the White House has confidence in Comey, Sean Spicer hedged and said he needed to ask the President. A few hours later, James Comey learned that he had been fired as FBI Director when the news media reported it. At some point in the day, he received a certifiably bizarre letter from Donald Trump, sayingI greatly appreciate you informing me, on three separate occasions, that I am not under investigation” and then firing him.  Earlier this hour, CNN reported that grand jury subpoenas had been issued to associates of former National Security Adviser Michael Flynn, saying it had learned of the subpoenas hours before Comey was fired. I think the chaotic, characteristically ill-executed firing of James Comey was a consequence of the progress of the Flynn prosecution, and the media’s awareness of it.

This is NOT about Hillary’s e-mails

I’m not one for excessive conjecture, but it doesn’t take an avid conspiracy theorist to conclude that Trump’s excuse for firing Comey is a pretext. Trump’s ostensible reason, as outlined in a very competent analysis by Deputy Attorney General Rod Rosenstein, is that Comey deserved to be fired because he mishandled the conduct of his investigation into Hillary Clinton’s e-mails, largely by discussing the investigation publicly and opining on whether she was prosecutable, which is not the FBI’s job (all true). However, given that the President and the Attorney General were fully supportive of this action until this morning reveals this justification as only the thinnest of pretexts.

Some say this termination has something to do with Comey’s mischaracterization of Huma Abedin’s use of e-mail on her home computer, and his subsequent “correction” of his misstatement. That explanation makes little to no sense. Comey’s initial statement supported Trump’s narrative. His need to walk it back, or at least to soften it, has been a constant theme in the Trump Administration. I think the explanation is a whole lot simpler than that.

It’s a pathetically transparent attempt to CYA

Donald Trump and his associates have been acting as if they are hiding something since the day they took office. Michael Flynn, Jeff Sessions, and Jared Kushner have all been caught in significant lies about ties to foreign powers, particularly Russia. It cannot be a coincidence that, on the day we discover a grand jury has been convened to consider the alleged criminal activities of Michael Flynn, Trump uses a very public termination letter to the man investigating Flynn to assert that Trump himself has never been under investigation. I don’t think we’ll know the full story anytime soon, but I don’t think we need to look far to figure out why an impulsive, reactionary, ignorant President decided to fire the nation’s Top Cop the day the country found out one of the architects of his campaign is in the early stages of a criminal prosecution.