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The Wrong Dworkin, The Right Dionne

I try never to read The Wall Street Journal editorial page. Every now and then, I fall off the wagon, and I usually regret it. This morning I was tempted by the prospect of Ronald Dworkin's thoughts on health reform. One of the world's leading legal scholars and political philosophers, Dworkin has written brilliant books and articles about delicate constitutional and public policies in end-of-life care. His writings on social justice speak equally powerfully to our nation's health inequalities, which are so much greater than those found in other wealthy democracies.

Unfortunately, the Ronald Dworkin writing today is a different guy. This Dworkin is a conservative anesthesiologist ticked off by what he claims are deep reimbursement cuts to his profession included in the House health reform bill. In many ways, this is the standard conservative rap. This being the supply-side epistemic universe, a doctor's critique of health reform includes the passage "today's upper-middle-class professionals are very sensitive to marginal tax rates." I'm only surprised by the temporal qualifier. I thought that high wage elasticities of labor supply (and low income elasticities) were among the eternal verities that require no empirical verification.

Equally surprising is the pull-quote, which states: "Expect a two-tier medical system and needless ER deaths if Congress and the White House have their way."

Dr. Dworkin should get out more. He has picked two issues that precisely underscore why we need health reform. We already are headed to a two-tier medical system. If you doubt that, call some major medical centers. Tell them you have breast cancer and that you would like to see an oncologist. Then tell them that you are uninsured. Ironically, the great (unstated) anxiety of health reform is that we will lose the two-tiered nature of our current system, that insured Americans will have to pay more to finance universal coverage, or that the currently-well-insured will have to share the indignities that their uninsured or Medicaid-covered fellow citizens already experience

As for those needless ER deaths, they are already happening. In one notorious case at Los Angeles's Martin Luther King Jr.-Harbor Hospital, relatives of one waiting patient became so desperate that they called 911. Paramedics refused to come, on the ostensibly reasonable argument that the patient was already at a hospital. She died in agony from a perforated bowel.

Rather than tell more horror stories, I will simply refer you to the June 2007 congressional testimony of Dr. Ramon Johnson of the American College of Emergency Physicians. Noting that between 1995 and 2005 hospital ER visits increased by 20 percent while the number of ERs decreased by 38 percent, Johnson goes on to say:

[I]n a system struggling with the closure of hundreds of emergency departments in the last 10 years because of huge amounts of uncompensated care, and in which ambulance diversions and the 'boarding' of patients in ER hallways for hours and sometimes days at a time have become commonplace, we simply can't always get to everyone. And if we can't get to you, we can't save your life.

I'm still hoping the right Ronald Dworkin will weigh in.

On a separate note: E.J. Dionne says what needs to be said about the people who are showing up with guns to health care town halls, even those attended by President Obama. (Hats off to Mark Kleiman, who has also raised this issue.) This needs to be repeated--not by liberals such as EJ, Mark, and I, but by responsible conservatives who understand how poisonous this is to American democracy.

It's sickening that someone would bring a gun to a public meeting, a protest, or a debate. I am especially disgusted that someone would do this knowing the specific concerns millions of Americans harbor for President Obama and his family. I certainly share those concerns. During the campaign, this was a constant worry for many people. Some of my own concerns stem from my specific regard for this president, but it's not only that. I remember feeling a chill when President Bush walked out to the pitcher's mound to throw out the first pitch at a ballgame in October 2001.

There's a lot of hysteria and hate out there right now. Sad to say, the hysteria and hate have more to do with President Obama's race and his middle name than they do with advanced care directives or the nuances of the public plan option. If it's not illegal to carry a gun within shooting range of the president, it should be. Even if it weren't, decent people across the political spectrum should draw a clear line. This is unacceptable.