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Posted by steveneidman on February 4, 2010

It’s the Phenome and Not the Genome: Put Your Money on Mortal Flesh

by Abraham Verghese

doctor-David McNew-big.jpg

Strong is your hold O mortal flesh . . .

From The Last Invocation, Walt Whitman

Is it just me, or are you also getting a bit tired of all the hype about the genome? Don’t get me wrong– it’s pretty incredible that in my lifetime we have mapped out the 25,000 plus genes in our DNA. What’s even more amazing is that the price for that chart of the human genome has gone from millions to less than $50,000 and now it takes only a few weeks. I bet by next year it might be a few hundred dollars and take a day! Companies like 23andMe (an innovative venture with a great marketing plan) offer to check you for genetic markers that predict your risk for certain diseases for just a few hundred dollars.

But the fact remains that for most of us, the genotype is much less relevant than the phenotype. What is phenotype? It is the things we can see, the outward or observable physical or biochemical characteristics and they are determined by both your genetic makeup and environmental influences. Your blond hair, your weight, your strange nose, green eyes and that funky shaped little toe of yours –all examples of phenotype.

So what do I mean when I say phenotype is more relevant than genotype? Well, let’s say a new patient, a male, walks into my office and he is in his fifties. Let’s say he happens to have the outline of a pack of cigarettes showing in his front pocket. As a male he already has one risk factor for coronary artery disease–just being male, alas. The cigarettes tell me that he is four times more likely to have a heart attack than his peers who don’t smoke. His risk of sudden death is at least doubled. Let’s say I notice he happens to be carrying more than 30 pounds of extra poundage above the belt line: that allows me to predict he has a higher chance of being at risk for diabetes, if he is not already frankly diabetic. Let’s say that I notice too the pale outline of a recently-removed wedding ring (I can’t help it, my eyes are always looking at the body as text–even when I am out of the hospital), then I know that his risk of death as a  recently divorced man can be double that of his married peers.

At this point, before he has even said a word or before I have examined him, I already know so much about his risk of death and disease. Once we talk and I learn more about his job, his stress, his heredity, his habits, his past illnesses, then my predictions get more accurate. Once he disrobes and I examine him, I might find other phenotypic markers that predict risk (such as yellow plaques related to high cholesterol on his eyelids or elbows; high blood pressure; skin tags and velvety darkened areas of skin that predict diabetes; narrowed blood vessels when I look into the back of his eye . . . the list could go on for pages). In short, I’ll have an excellent sense of my patient’s risk for death or disease. At that point, mapping his whole genome, sexy as it might seem, won’t tell me much more than I know and will probably matter much less than getting him to quit smoking, exercise and lose weight.

The famous Whitehall Study of British Civil Servants ranging in ages from 20 to 64 found that the lower grades of civil service had higher mortality rates from heart disease and from all causes than did people in higher grades, even after accounting for risk factors like obesity and smoking. (Yes, it was counterintuitive and that is why we do studies).  Stress was thought to be the factor responsible for this disparity.

The Whitehall studies are ongoing and one of the latest reports from that study made me think of Walt Whitman and reminded me that the phenotype is so relevant. In their report (titled, “Utility of genetic and non-genetic risk factors in prediction of type 2 diabetes: Whitehall II prospective cohort study” and appearing in the British Medical Journal, 2010 Jan 14;340:b4838), the scientists compared a panel of genetic tests for diabetes (common single nucleotide polymorphisms) with non-genetic or phenotypic findings like age, sex, drug treatment, family history of type 2 diabetes, body mass index, smoking status, HDL, triglycerides, fasting glucose.

What they found was that the phenotypic tests did better. Indeed the gene tests added little to the risk already determined by phenotypes. In their own words, “the addition of genotypes to phenotype based risk models produced only minimal improvement in accuracy of risk estimation  . . .”  Translation: use your eyes, take a good history, weight the patient and get a few simple blood tests, and you can predict risk far better than a panel of genetic tests. 

I am not a Luddite (I find I say that a lot) and indeed, I do think the genome studies will help us eventually understand more about causes of disease, and perhaps even point to particular treatments. But utill then the message for us in the trenches is: Strong is your hold O mortal flesh and that’s where the money (speaking diagnostically) is.

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Posted by steveneidman on January 26, 2010

The Supreme Court’s Ruling: What Would Milton Friedman Say?

Justin Fox

 

The “one and only social responsibility of business,” economist Milton Friedman wrote back in 1970 in a New York Times Magazine essay that launched a thousand arguments, is “to use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game …” Friedman contrasted this with the multiple responsibilities that an individual — such as a corporate executive — might have “to his family, his conscience, his feelings of charity, his church, his clubs, his city, his country.”

His point was that CEOs shouldn’t go around imposing their own notions of social responsibility on corporations that were owned by others. Since the only interest that could possibly unite the disparate shareholders of a large corporation was making money, that was what executives should focus on during their working hours.

Now think about this argument in the context of the Supreme Court’s decision (pdf) last week to strike down all restrictions on political spending by corporations. During the oral arguments, Solicitor General Elena Kagan hinted at the Friedmanite line that corporate executives who spent shareholders’ money on political causes might not really be looking out for shareholders’ interests. To which Chief Justice John Roberts retorted:

Isn’t it extraordinarily paternalistic for the government to take the position that shareholders are too stupid to keep track of what their corporations are doing and can’t sell their shares or object in the corporate context if they don’t like it?

Both James Fallows and Felix Salmon (in a blog post with the best headline ever) have made the case that Roberts doesn’t seem to understand how the relationship between corporations and their shareholders really works in these modern times, and that his obliviousness fatally undermines the Court majority’s reasoning. But let’s say Roberts is right, and America’s corporations are all faithfully abiding by Uncle Miltie’s exhortation to focus single-mindedly on looking out for their owners’ interests by making lots of money. Then the argument for imposing restrictions on corporate political activities grows even stronger.

The individuals who make up the electorate in the United States are, as Friedman described, beings of many facets — their actions and their views shaped by pecuniary self interest but also by values, beliefs, and loyalties that might conflict with that self interest. The ideal for-profit corporation, on the other hand, is out to do nothing but make as much money as it can “within the rules of the game.” It is supposed to behave in a fashion that for an individual would probably be described as psychopathic. And if corporations are allowed to play a decisive role in shaping the “rules of the game,” we have effectively put the inmates in control of the asylum.

This feels like a pretty compelling justification for treating corporations differently from individuals in the political process. And there is of course a long tradition of treating them differently. We don’t give corporations the vote, and for generations states and the federal government have tried to restrict campaign spending by corporations. Because corporations are made up of individuals, it can of course be awfully hard to draw the dividing line between corporate and individual activity. Justice Anthony Kennedy dwells on this in his majority opinion in Citizens United v. Federal Election Commission. He dwells even more on the inconsistency involved in banning some political speech (campaign spending) by corporations when we would never consider banning corporate-owned newspapers from endorsing candidates, Keith Olbermann from calling some Republican the “Worst Person in the World,” or Fox News talking head after Fox News talking head from referring incessantly to “the far-left policies of Barack Obama.”

Consistency is of course the hobgoblin of little minds (adored by little statesmen and philosophers and divines). We probably want our judges to be little statesman — not brilliantly imaginative rulebreakers. Legal opinions are supposed to be consistent with precedent and the law. In this case, though, the Supreme Court was dealing with three different and conflicting strands of law and precedent: (1) the many laws and past court rulings restricting corporate political involvement, (2) the precedent that political spending is equivalent to First-Amendment-protected speech, (3) laws and precedent that establish corporations as persons.

The Court majority chose to jettison (1) and stick with (2) and (3). I’m in no position to say the justices were wrong as matter of law. But as a matter of policy and common sense, it’s clearly (3) that’s most problematic. If corporations are persons, they are — if they behave as Milton Friedman wanted them to — persons with mental and emotional impairments so severe that any decent judge would feel entirely justified in declaring them incompetent.

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Supreme Court Decision Warps Corps’ Electoral Muscle

Posted by steveneidman on January 26, 2010

The “Devastating” Decision

Ronald Dworkin

David Bosse, president of Citizens United, posing with the group’s advocacy videos (Lucian Perkins/Washington Post/Getty Images)

Against the opposition of their four colleagues, five right-wing Supreme Court justices have now guaranteed that big corporations can spend unlimited funds on political advertising in any political election. In an opinion written by Justice Anthony Kennedy and joined by Chief Justice John Roberts and Justices Samuel Alito, Antonin Scalia, and Clarence Thomas, the Court overruled established precedents and declared dozens of national and state statutes unconstitutional, including the McCain-Feingold Act which forbade corporate or union television advertising that endorses or opposes a particular candidate.

This appalling decision, in Citizens United v. Federal Election Commission, was quickly denounced by President Obama as “devastating”; he said that it “strikes at our democracy itself.” He is right: the decision will further weaken the quality and fairness of our politics.

The Court has given lobbyists, already much too powerful, a nuclear weapon. Some lawyers have predicted that corporations will not take full advantage of it: they will want to keep their money for their business. But that would still permit carefully targeted threats. What legislator tempted to vote for health care reform or Obama’s banking reorganization would be indifferent to the prospect that his reelection campaign could be swamped in a tsunami of expensive negative advertising? How many corporations fearful of environmental or product liability litigation would pass up the chance to tip the balance in a state judicial election?

On the most generous understanding the decision displays the five justices’ instinctive favoritism of corporate interests. But some commentators, including The New York Times, have suggested a darker interpretation. The five justices may have assumed that allowing corporations to spend freely against candidates would favor Republicans; perhaps they overruled long-established laws and precedents out of partisan zeal. If so, their decision would stand beside the Court’s 2000 decision in Bush v. Gore as an unprincipled political act with terrible consequences for the nation.

We should notice not just the bad consequences of the decision, however, but the poor quality of the arguments Justice Kennedy offered to defend it. The conservative justices savaged canons of judicial restraint they themselves have long praised. Chief Justice Roberts takes every opportunity to repeat what he said, under oath, in his Senate nomination hearings: that the Supreme Court should avoid declaring any statute unconstitutional unless it cannot decide the case before it in any other way. Now consider how shamelessly he and the other Justices who voted with the majority ignored that constraint in their haste to declare the Act unconstitutional in time for the coming mid-term elections.

Citizens United, a small nonprofit corporation almost entirely financed by individual contributions, had made a very negative film about Hillary Clinton. It asked the Court only to rule that its method of distributing that film, on a video-on-demand service, was not outlawed by the Act. It offered several arguments, some of them plausible, for interpreting the Act that way. So the Court did not have to decide whether to overrule the Act: it could have agreed with Citizens United while reserving that larger question. But after they first heard arguments in the case, the five justices declared that they wanted, on their own initiative, to consider declaring the Act unconstitutional. They introduced that unnecessary issue themselves and then scheduled an emergency special hearing during the summer so that they could strike down the statute as quickly as possible.

Justice Kennedy, in his opinion for the 5-4 majority, tried to explain why that was necessary. It would have been possible, he conceded, to interpret the McCain-Feingold Act’s prohibition of corporate “broadcast, cable, or satellite” electioneering that is “publicly distributed” as not applying to video-on-demand TV. But he declined this strategy because transmission technology could be expected to change so that the Court would be required to revisit the issue time and time again. He did not explain why the Court could not have drafted a general principle interpreting the statute to guide future decisions as technology develops, as it has in so many other cases. For example, the court’s doctrine of “reasonable expectation of privacy” is designed to adapt to evolving technology of surveillance and spying.

The conservative justices also had to overrule two of the Court’s prior decisions—its 1990 Austin and 2003 McConnell decisions. In his Senate hearings, Roberts declared his great respect for judicial precedent: he said that just because he thought that an earlier Court decision had been wrongly decided or poorly argued would be no reason to overrule it. It would have to have proved unworkable or its basis in principle would have to have been eroded by other intervening decisions. Kennedy offered no evidence that restrictions on corporate electioneering had proved unworkable, which is not surprising because such restrictions had been in place since 1907.

Instead he argued that the two decisions were themselves inconsistent with other precedent. But as Justice John Paul Stevens pointed out in his long and impressive dissenting opinion, Kennedy was able to cite only one past decision actually to that point: the Court’s 1978 Bellotti decision, in which it in fact denied what Kennedy takes it to have held. “Our consideration of a corporation’s right to speak on issues of general public interest,” the Court stated in that case, “implies no comparable right in the quite different context of participation in a political campaign for election to public office.” Kennedy disregarded that clear statement because, he said, it occurred in “a single footnote.” But that is a natural place for a clarification; and Kennedy’s suggested distinction between text and note is entirely novel. Some of the Court’s footnotes have proved much more important than the decisions to which they were attached.

The main theoretical flaw in Kennedy’s opinion is different, however. The opinion announces and perpetuates a shallow, simplistic understanding of the First Amendment, one that actually undermines one of the most basic purposes of free speech, which is to protect democracy. The nerve of his argument—that corporations must be treated like real people under the First Amendment—is in my view preposterous. Corporations are legal fictions. They have no opinions of their own to contribute and no rights to participate with equal voice or vote in politics.

Kennedy’s opinion left Americans very little room to protect themselves against this further degradation of their democracy. But it did leave some. He acknowledged that the ruling does not prevent Congress from requiring reasonable disclosures and disclaimers in corporate advertising. I believe Congress should require a prominent statement in every such ad disclosing any corporate sponsors and declaring that their support represents the opinion of the corporation’s officers, who have a duty to promote the corporation’s own interests, and not necessarily the opinion of any of their shareholders who are actually paying for the ad.

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Cost Control and the Healthcare Reform Bill- It’s In There

Posted by steveneidman on November 25, 2009

A Milestone in the Health Care Journey

by Ronald Brownstein

When I reached Jonathan Gruber on Thursday, he was working his way, page by laborious page, through the mammoth health care bill Senate Majority Leader Harry Reid had unveiled just a few hours earlier. Gruber is a leading health economist at the Massachusetts Institute of Technology who is consulted by politicians in both parties. He was one of almost two dozen top economists who sent President Obama a letter earlier this month insisting that reform won’t succeed unless it “bends the curve” in the long-term growth of health care costs. And, on that front, Gruber likes what he sees in the Reid proposal. Actually he likes it a lot.

“I’m sort of a known skeptic on this stuff,” Gruber told me. “My summary is it’s really hard to figure out how to bend the cost curve, but I can’t think of a thing to try that they didn’t try. They really make the best effort anyone has ever made. Everything is in here….I can’t think of anything I’d do that they are not doing in the bill. You couldn’t have done better than they are doing.”

Gruber may be especially effusive. But the Senate blueprint, which faces its first votes tonight, also is winning praise from other leading health reformers like Mark McClellan, the former director of the Center for Medicare and Medicaid Services under George W. Bush and Len Nichols, health policy director at the centrist New America Foundation. “The bottom line,” Nichols says, “is the legislation is sending a signal that business as usual [in the medical system] is going to end.”

Both the Senate bill’s priority on controlling long-term health care costs, and its strategy for doing so, represents a validation for Senate Finance Committee chairman Max Baucus (D-MT). When Baucus released his health reform proposal last September, after finally terminating months of fruitless negotiations with committee Republicans, Democratic liberals excoriated his plan as a dead end. And on several important fronts–such as subsidies for the uninsured, the role of a public competitor to private insurance companies, and the contribution required from employers who don’t insure their workers–Reid moved his product away from Baucus toward approaches preferred by liberals.

But the Reid bill’s fiscal strategy, and its vision of how to “bend the curve,” almost completely follows Baucus’ path from September. Baucus’ bill was the first to establish the principle that Congress could expand coverage while reducing the federal deficit; now that’s the standard not only for the Senate but also the House reform legislation. And, perhaps even more importantly, the Reid bill maintains virtually all of Baucus ideas’ for shifting the medical payment system away from today’s fee-for-service model toward an approach that more closely links compensation for providers to results for patients. In the Reid bill, there is some backtracking from Baucus’ most aggressive reform proposals, but not much.

Almost everything Baucus proposed to control long-term costs have survived into the final bill. And, with only a few exceptions, that’s just about all the systemic reforms analysts from the center to the left have identified as the most promising strategies for changing the economic incentives in the medical system. (The public competitor to private insurance companies championed by the Left would affect who writes the checks in the medical system, but not what the checks are written to pay for.) Most of the other big ideas for controlling costs (such as medical malpractice reform) tend to draw support primarily among Republicans. And since virtually, if not literally, none of them plan to support the final health care bill under any circumstances, the package isn’t likely to reflect much of their thinking.

In their November 17 letter to Obama, the group of economists led by Dr. Alan Garber of Stanford University, identified four pillars of fiscally-responsible health care reform. They maintained that the bill needed to include a tax on high-end “Cadillac” insurance plans; to pursue “aggressive” tests of payment reforms that will “provide incentives for physicians and hospitals to focus on quality” and provide “care that is better coordinated”; and establish an independent Medicare commission that can continuously develop and implement “new efforts to improve quality and contain costs.” Finally, they said the Congressional Budget Office “must project the bill to be at least deficit neutral over the 10-year budget window and deficit reducing thereafter.”

As OMB Director Peter Orszag noted in an interview, the Reid bill met all those tests. The CBO projected that the bill would reduce the federal deficit by $130 billion over its first decade and by as much as $650 billion in its second. (Conservatives, of course, consider those projections unrealistic, but CBO is the only umpire in the game, and Republicans have been happy to trumpet its analyses critical of the Democratic plans.)  “Let’s use the metric of that letter,” said Orszag, who helped shape the health reform debate for years from his earlier posts at CBO and the Brookings Institution. “Deficit neutral; got that. Deficit-reducing second decade, got that. Excise tax: That was retained. Third is the Medicare commission: has that. Fourth is delivery system reforms, bundling payments, hospital acquired infections, readmission rates. It has that. If you go down the checklist of what they said was necessary for a fiscally responsible bill that will move us towards the health care system of the future, this passes the bar.”

McClellan, the former Bush official and current director of the Engleberg Center for Health Care Reform at the Brookings Institution, was one of the economists who signed the November letter. McClellan has some very practical ideas for improving the Reid bill (more on those below), but generally he echoes Orszag’s assessment of it. “It has got all four of those elements in it,” McClellan said in an interview. “They kept a lot of the key elements of the Finance bill that I like. It would be good if more could be done, but this is the right direction to go.”

Reid gave ground on one Baucus proposal that the economists identified as a priority-taxing high-end insurance plans. Like many health reformers, the economists who wrote Obama argue that such a tax “will help curtail the growth of private health insurance premiums by creating incentives to limit the costs of plans to a tax-free amount.” Amid intense opposition from unions, Reid raised the thresholds at which family plans would face that excise tax from $21,000 to $23,000. But given all the pressure from labor, the more striking thing may have been that Reid didn’t increase the thresholds even more; the CBO calculated the proposal, which the House excluded from its bill, would still raise $35 billion annually by 2019. “They held pretty strong,” said one administration health care expert. “It’s not like unions haven’t been making the case that it shouldn’t have been a much higher number.”

On delivery reform, Reid stayed even closer to the Baucus blueprint. The Finance bill laid out a series of measures to change the way providers are paid for delivering care to Medicare recipients; the hope was that once Medicare instituted these reforms, private insurers would also adopt many of them. “The goal here is that the things we do in Medicare will translate over into the private sector, and there is quite a bit of historical precedence for that,” said one Democratic aide involved in drafting the package.

The Baucus delivery reform ideas revolved around two central aims. One was to reward Medicare providers who deliver care more efficiently and penalize those that don’t. The Reid bill upholds the major proposals Baucus offered to advance that goal. For instance, hospitals under current law must report on their performance in treating patients for common conditions like heart problems and pneumonia; under the bill, their Medicare payments, for the first time, would be affected by their ranking on those reports. Hospitals would also be penalized if they readmit too many patients after surgery or allow too many to acquire infections while in the hospital itself. Another provision would begin the process of applying such “value-based purchasing” toward other providers like hospice providers and inpatient rehabilitation facilities.

With physicians, the Reid plan takes a step back from the Finance Committee bill but still a long step beyond current law. The Finance Bill proposed automatic reimbursement reductions for doctors who order up the most care for Medicare recipients with similar medical and demographic characteristics. That was meant to respond to the research showing big disparities in spending on medical services for similarly-situated patients in different communities. But, Democratic sources say, that proposal ran into charges that it would promote rationing-and even function as “a death panel by proxy”-by compelling doctors to arbitrarily reduce care. So the final bill takes a less direct route toward a similar end. It requires Medicare to begin studying the utilization patterns of doctors participating in the program. And then it establishes a “values based payment modifier” that would, in a budget-neutral manner, increase reimbursements for physicians found to deliver high-quality care at lower cost, and reduce them for physicians at the other end of that spectrum. “It will, we believe, have the same net effect [as the original proposal],” said the Democratic aide. “It should change behavior around that threshold.”

The other set of Baucus proposals were intended to promote more coordination among providers. These have survived almost verbatim into the final bill. The bill encourages groups of providers to establish doctor-led “accountable care organizations” to more comprehensively manage patients’ care by allowing them to share in any savings for Medicare they produce. It also establishes a voluntary national pilot of “bundled” payments that would encourage hospitals, doctors and other providers to work more closely together. Another pilot program would test coordinated home-based care for chronically ill seniors.

Finally, the Reid bill maintains the two powerful institutions the Finance legislation proposed to promote these reforms and develop new ones. The one that’s attracted the most attention is an independent “Medicare Advisory Board.” Under the Senate bill, that board would be required to offer cost-saving proposals when Medicare spending rises too fast; Congress could not reject its proposals without substituting equivalent savings. Since the board would be prohibited from offering changes that raise taxes or “ration care,” and since the legislation initially exempts hospitals from its recommendations, it could choose to promote the sort of payment reforms the bill establishes. (More prosaically it might also clear away some of the expensive coverage mandates that Congress imposes on Medicare under pressure from different elements of the medical industry). Given the limitations imposed on the commission, an equally important means to expand these reforms might be a second institution the legislation creates: a Center for Medicare and Medicaid Innovation in the Health and Human Services Department. Though this center has received much less attention than the Medicare Commission, it could have a comparable effect. It would receive $1 billion annually to test payment reforms; in a little known provision, the bill authorizes the HHS Secretary to implement nationwide, without any congressional action, any reform that department actuaries certify will reduce long-term spending. While the House bill omitted the Medicare Commission (a top priority for Obama) it included the innovation center.

No one can say for certain that these initiatives will improve efficiency enough to slow the growth in health care spending. Some are only pilots; others would affect only a small portion of providers’ revenue from Medicare. CBO typically evaluates them skeptically: it generally scores little or no savings from most of them. Former CBO director Robert Reischauer, who signed the November 17 letter, says that’s not surprising. “CBO is there to score savings for which we have a high degree of confidence that they will materialize,” says Reischauer, now president of the Urban Institute. “There are many promising approaches [in these reform ideas] but you…can’t deposit them in the bank.” In the long run, Reischauer says, it’s likely “that maybe half of them, or a third of them, will prove to be successful. But that would be very important.”

While generally supportive of Reid’s approach, McClellan, the former Medicare administrator under Bush, offered several specific ideas for strengthening it. He says the Senate should improve the capacity of HHS to more quickly evaluate whether the payment reforms are working, and also to provide data and technical assistance to new physician groups like the accountable care organizations that will be attempting to better coordinate care. “Ideally you’d both be able to tell the organizations involved and Congress what is working or not, and give the organizations the feedback and data they need to know whether they are doing a good job,” he says. McClellan also believes that the plan needs sharper sticks-tougher penalties on providers who don’t provide efficient and effective care. “There are a lot of carrots and not so many sticks,” he maintains. Of course, tougher penalties might provoke more opposition from provider groups like hospitals and physicians now tenuously supporting the legislation.
[[McClellan stands at the forefront of centrist Republican thinking on health. Even the more ideologically conservative health care thinkers to his right generally don’t oppose long-term reform ideas like bundling payments (John McCain promoted that during his presidential campaign). But they tend to view them as insufficient or tangential to the real problem. Their view highlights a fundamental difference between the parties’ on health care. To save costs, Democrats mostly want to change the incentives for providers. Republicans mostly want to change the incentives for patients by shifting toward a model where insurance covers only catastrophic expenses and people pay for more routine care from tax-favored health savings accounts. In essence, the Republican view is that the best way to hold down long-term costs is to directly expose patients to more of them. Few Democrats accept that logic though and it has little influence on either chamber’s legislation.

Another Republican cost-containment priority missing from the bill is meaningful medical malpractice reform. (The bill only encourages states to think about it.) Nichols, of the centrist New America Foundation, would like to see that included as well. Its omission is one reason he says he gives the plan a “b” rather than an “a”; the other is he’d like to see mechanisms to more quickly diffuse into the private insurance system reforms that show promise in Medicare. Democratic sources say a group of centrist Democrats led by Virginia Senator Mark Warner is trying to devise a package designed to do just that, perhaps by expanding the role of the independent Medicare advisory commission.

The attempt in all these ideas to nudge the medical system away from fee-for-service medicine toward an approach that ties compensation more closely to results captures how much the health care debate has shifted toward cost-control. So far, the rise in health care spending has proven almost invulnerable to every previous attempt to tame it, like the managed care revolution in the 1990s. Even if Obama signs into law a final bill embodying all these reform proposals, many skeptics wonder if they can bend, much less break, the seemingly inexorable increase in health care spending. Reischauer understands that skepticism, but isn’t able to entirely suppress a kernel of optimism that this latest reform agenda may prove more effective than its predecessors. “One never knows whether we’re turning the corner or if this is just playing the same old game for another inning,” he says. “But I sense there’s something different out there. I think the medical profession and its leaders have read the handwriting on the wall and are trying to evolve.” If so, the ideas the Senate will begin voting on tonight could mark a milestone in that journey.

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Neglecting the Most Obvious Model in the Health Care Expansion Debate

Posted by steveneidman on October 8, 2009

Medicaid: Uniquely Prepared To Deliver On Health Care Reform

by Stephen Somers and Michael Sparer

For those of us who have made Medicaid the focus of our work, it never ceases to amaze us as we watch the great health care debate unfold how frequently we find ourselves saying, “Medicaid can do that.” Or, even more often, “Medicaid is doing that.”

These are heady times for big concepts for transforming health care delivery, but there is not always an obvious, real-world mechanism for implementing these innovations at scale. Just look more closely at many of the most-favored concepts of the day: covering the uninsured; accountable care entities; patient-centered medical homes; public reporting and performance measurement; pay-for-performance; health information technology for meaningful uses; reducing racial and ethnic disparities; and integrated preventive care for patients with multiple chronic conditions.

For each of these innovations, somewhere across the country — and in some cases, in many places — Medicaid is in fact already doing it.

National experts and policymakers, especially those inside the Beltway, tend to focus on Medicaid’s older sibling — Medicare — for obvious reasons. But, lest they forget, we should remind them: Medicaid is already serving more than 60 million Americans and, depending upon the trajectories of unemployment and health care reform, could hit 100 million in the next decade. The cost of their care is topping $360 billion, and last year while he was still at the Congressional Budget Office, Peter Orszag was predicting roughly 8 percent annual Medicaid spending growth through the next decade. Thus, by 2018, program spending would reach an estimated $700 billion. No matter how low the Medicaid payment rates are, that is a lot of purchasing power.

Indeed, in many states and communities, Medicaid is by far the largest purchaser, is well-positioned to lead the market, and is taking a leadership role in doing so. For example, in Rhode Island, the state has built a multipayer collaborative to test accountable patient-centered medical homes, and North Carolina state leaders created community-based accountable care networks that will potentially extend beyond Medicaid to improve care management for the entire Medicare population.

Choosing Medicaid Expansion Over Subsidies For Private Insurance: Building On What Works

But, first things first; let’s start with the debate over access to care and see why a Medicaid expansion is better policy than the most plausible alternative, which is providing subsidies to purchase private coverage through a newly-created health insurance exchange. In his June 23 contribution to this blog, Leighton Ku provides part of the answer, as he demonstrates that a Medicaid expansion is less expensive (both to government and to the beneficiaries) than subsidized private coverage, and also generally better for the beneficiaries (who get access to more preventive services and prescription drugs). More generally, Medicaid provides a relatively rich set of benefits to many of the nation’s most chronically ill and needy and it does so at a relatively low per capita cost.

Put simply, health reformers should build on what works (Medicaid) before enacting complicated new administrative infrastructures that may or may not work (insurance exchanges for low-wage families).

It is far from clear, for example, whether there would be a single national insurance exchange, or several regional ones, or 50 state-based organizations. It also is unclear whether current Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries would need to participate in the newly created exchange(s). Whatever administrative structure were to be developed, however, is less likely to have the experience and the institutional history of the nation’s long-standing and generally quite effective state Medicaid agencies. Health reform is too important to overlook the federalism and implementation variables, and both of these considerations point in favor of a Medicaid expansion.

The politics of this issue are also more complicated than they might seem at first blush.  To be sure, the nation’s governors (or at least those in states that now have relatively low Medicaid eligibility levels) are skeptical, and federal officials likely would need to promise full federal funding for most or all of the expansion beneficiaries. There also is for many a “welfare-based” stigma attached to Medicaid, which while fading in potency should still be addressed. Finally, health care providers justifiably complain about low Medicaid reimbursement rates, and Medicaid agencies will need to pay higher rates (and rely more heavily on nurse practitioners and physician assistants), though even the promise of higher rates is unlikely to overcome physician resistance to the program.

The Evolution Of Medicaid: From A “Poor Program For Poor People” To The Most Successful Way To Help The Uninsured

Nevertheless, one of the most extraordinary stories of the American health care system is the evolution of Medicaid from a poor program for poor people (prior to the mid-1980s) to the most successful program in our history for aiding the uninsured. How did this happen, and how is that history relevant today?

Ironically, the very same factors that have previously dashed more comprehensive reform initiatives themselves encouraged Medicaid expansions. Business and insurance groups, for example, that have traditionally opposed employer mandates have often supported Medicaid expansions, both to relieve pressure to cover low-wage workers and also to leave intact the core of the existing private insurance system. Similarly, the nation’s complicated system of checks and balances might make it hard to enact comprehensive reform (as we’re re-learning in 2009), but Medicaid’s intergovernmental structure and shared financing actually has encouraged program expansion. Finally, the flexible, state-based variation inherent, by design, in Medicaid programs may minimize the anti-big government argument of some reform opponents. These factors explain why Medicaid enrollment has grown far faster than Medicare’s, even though it is Medicare that has been long touted as the presumed path to universal coverage.

For all of these reasons, regardless of whether Congress enacts universal coverage in 2009, it is reasonable to assume there will be some additional Medicaid expansions forthcoming.

Two other points on the politics of this issue. First, reports out of Washington suggest that Congress is looking to cut the cost of reform by (in part) cutting the level of premium subsidies.  This is not surprising: it is easier to cut premium subsidies than to cut Medicaid enrollment.  Second, a Medicaid expansion (especially if combined with a Medicaid buy-in program) could lessen the need to push for a brand-new public insurance program. The employer-sponsored system works pretty well for most Americans, and Medicaid is best viewed as a complement to that system, covering those (such as low-wage workers, small businessmen, and the sole proprietor) for whom the larger system does not work.

Medicaid Programs Have Been Leaders In Mining Data To Improve Quality

Finally, politics aside, state Medicaid programs offer important lessons and future directions for those focused on improving the quality of care, especially for high-need patients. Medicaid also offers lessons that can help to constrain costs (i.e., bending the trend) and thus make resources available for coverage expansion. Again, state Medicaid agencies are perfectly positioned for leadership in this area. For example, a number of states — Michigan, Oklahoma, and Pennsylvania – have figured out how to mine their data on the size and performance of primary care practices, beneficiaries’ race and ethnicity, and chronic disease burden to: (a) stratify their high-volume Medicaid practices in which there are significant disparities in care; and (b) design and support interventions to improve quality and reduce avoidable emergency room and hospital readmissions among these beneficiaries. These state pilot projects are being independently evaluated to determine whether they can generate savings that can potentially be reinvested elsewhere in the health care system.

Efforts to create integrated systems of care for the highest-need, highest-cost beneficiaries with multiple serious chronic illnesses are, perhaps, even more promising in terms of the potential for dramatic improvements. The top 5 percent of these patients account for 50 percent of Medicaid’s costs. While Medicaid is the primary insurer for this population with disabling and extremely costly chronic conditions, the same basic expenditure pattern exists in Medicare and even in employer-based insurance.

This fact has impelled leading-edge health plans like Kaiser Permanente and Aetna/Schaller Anderson to invest in Medicaid-based demonstrations to, for instance, integrate physical and behavioral health care for those with serious mental illnesses. These plans are also supporting pilot efforts to integrate care for those with numerous chronic conditions who have multiple physicians and complex health care needs, yet no accountable care management entity. That should sound familiar, in fact, very similar to fee-for-service Medicare.

Another dramatic area of opportunity is the alignment of care for those who are dually eligible for Medicaid and Medicare. Currently, these programs tend to operate at cross-purposes, with plans and providers for the respective programs often acting on incentives to shift costs to the other. The more than 7.5 million older Americans and people with disabilities who are fully eligible for both programs are among the highest-need, highest-cost patients in America, accounting for 46 percent of all Medicaid expenditures — mostly for long-term care — and 24 percent of all Medicare expenditures. According to a recent Lewin report, that translates into more than $239 billion per year for a group that constitutes less than 3 percent of the American population.

A number of those on the front lines suggest that it would be entirely reasonable to aim for a combined 20 percent reduction in expenditures from avoidable hospitalizations and long-stay institutionalizations for this population. Arizona, Massachusetts, Minnesota, and Wisconsin have long been leaders in this arena and have been joined more recently by states like North Carolina, New Mexico, New York, and Vermont. These states all see the opportunity to provide higher-quality care that will help their residents live independently in the community and benefit their state budgets at the same time.

We could continue in this vein, because there are so many ways in which Medicaid can inform the transformation of the U.S. health care delivery system, starting with its role as an essential coverage vehicle with ready-made infrastructure. We urge the national experts and policymakers to remember that “Medicaid for More” is both good policy and good politics.

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What the Screaming is REALLY About

Posted by steveneidman on August 17, 2009

‘Mad Men’ Crashes Woodstock’s Birthday

By FRANK RICH

IN our 24/7 mediasphere, this weekend’s misty Woodstock commemorations must share the screen with Americans screaming bloody murder at town hall meetings. It’s a vivid reminder that what most endures from America, 1969, is not the peace-and-love flower-power bacchanal of Woodstock legend but a certain style of political rage. The angry white folk shouting down their congressmen might be — literally in some cases — those angry white students whose protests disrupted campuses before and after the Woodstock interlude of summer vacation ’69.

The most historically resonant television event this weekend, however, may be none of the above. Sunday night is the premiere of the third season of “Mad Men,” the AMC series about a fictional Madison Avenue ad agency in the early 1960s. The first episode is to be simulcast in Times Square after a costume party where fans can parade their retro wardrobes. This promotional event is Woodstock, corporate style, with martinis instead of marijuana, Sinatra instead of Shankar and narrow ties supplanting the tie-dyed.

Woodstock’s 40th anniversary is being celebrated as well — with new books, a new documentary, a new Ang Lee movie and the inevitable remastered DVDs and CDs. But it’s “Mad Men” that has the pulse of our moment. Though the show unfolds in an earlier America than Woodstock, it seems of far more recent vintage, for better and for worse.

As many boomers have noted, Woodstock’s nirvana was a one-of-a-kind, one-weekend wonder anyway, not the utopia of subsequent myth. It wasn’t even meant to be free; in the chaos, the crowds overwhelmed and overran the ticket sellers. That concept of “free” — known to some adults as “theft” — persists today in the downloading of “free” music, which has decimated the recording industry far more effectively than brown acid ever did.

Even in Woodstock’s immediate aftermath, there was no consensus on its meaning. A Times editorial titled “Nightmare in the Catskills” saw “a nightmare of mud and stagnation” and asked rhetorically, “What kind of culture is it that can produce so colossal a mess?” Time magazine, surprisingly, was more sympathetic. “It is an open question,” the writer intoned, “whether some as yet unknown politician could exploit the deep emotions of today’s youth to build a politics of ecstasy.” Actually, both proved wrong. Woodstock was no apocalypse, but neither was it a political turning point. Nixon would be re-elected in 1972, and the only politician with a touch of ecstasy, Robert Kennedy, had already been murdered.

Ten years later, a New Yorker cartoon depicted a Woodstock reunion as a buttoned-down yuppie cocktail party, not a hippie love-in. By then, the ’60s counterculture had been completely commodified. Today a Woodstock couldn’t exist without corporate sponsorship; in fact this weekend’s planned 40th-anniversary concert was canceled for lack of one. Any large-scale youth “community” would be virtual, on Facebook and Twitter, and so might some of the sex. Only pot remains eternal.

That the early ’60s of “Mad Men” seems more contemporary than the late ’60s of Woodstock has little to do with the earlier period’s style or culture in any case (however superior the clothes). The rock giants of Woodstock remain exponentially more popular than Vic Damone and Perry Como, the forgotten crooners heard in “Mad Men.” The repressive racial and sexual order of Sterling Cooper, the show’s fictional ad agency, is also a relic, in part because of the revolutions that accelerated in the Woodstock era. The misogyny, racism and homophobia practiced in the executive suites of “Mad Men” are hardly extinct — and neither are the cigarettes that most of the characters chain-smoke — but they are in various stages of remission.

What makes the show powerful is not nostalgia for an America that few want to bring back — where women were most valued as sex objects or subservient housewives, where blacks were, at best, second-class citizens, and where the hedonistic guzzling of gas and gin went unquestioned. Rather, it’s our identification with an America that, for all its serious differences with our own, shares our growing anxiety about the prospect of cataclysmic change. “Mad Men” is about the dawn of a new era, and we, too, are at such a dawn. And we are uncertain and worried about what comes next.

In his new book “1959: The Year Everything Changed,” Fred Kaplan writes about the forces that were roiling America in the year before “Mad Men” begins. It was in 1959 that Berry Gordy founded Motown, that G. D. Searle applied to the F.D.A. for approval of the birth-control pill, and that Texas Instruments announced the advent of the microchip. The year began with a Soviet technological triumph, the launching of the spacecraft Lunik I, and ended with an embarrassing capitalist fiasco, Ford Motor’s yanking of the ignominious Edsel. Along the way the first two American soldiers were killed in South Vietnam. “By the end of 1959,” Kaplan writes, “all the elements were in place for the upheavals of the subsequent decades.”

The first season of “Mad Men” was set in 1960. This season — and there will be no spoilers here — opens in 1963. That’s the year of Beatlemania’s first sightings, of the Rev. Dr. Martin Luther King Jr.’s march on Washington and, of course, of gunfire in Dallas. Bruce Handy sums it up in the current Vanity Fair: “As in Hitchcock, the characters are unaware of shocks that the audience knows all too well lie ahead, whether they be the Kennedy assassination and women’s lib or long sideburns and the lasting influence of Doyle Dane Bernbach’s witty, self-deprecating ‘lemon’ ad for Volkswagen.”

What we don’t know is how the characters will be rocked by these changes. But we’re reasonably certain it won’t be pretty. That’s where the drama is, and it’s tense.

In the world of television, “Mad Men” is notorious for drawing great press and modest audiences. This could be the season when the viewers catch up, in part because the show is catching up to the level of anxiety we feel in 2009. In the first two seasons, the series was promoted with the slogan “Where the Truth Lies.” This year, it’s “The World’s Gone Mad.” The ad hyping the season premiere depicts the impeccably dressed Don Draper, the agency executive played by Jon Hamm, sitting in his office calmly smoking a Lucky Strike as floodwater rises to his waist.

To be underwater — well, many Americans know what that’s like right now. But we are also at that 1963-like pivot point of our history, with a new young president unlike any we’ve seen before, and with the promise of a new frontier whose boundaries are a mystery. Something is happening here, as Bob Dylan framed this mood the last time around, but you don’t know what it is. We feel Don Draper’s disorientation as his once rock-solid ’50s America starts to be swept away. We recognize his fear that the world could go mad.

It’s through this prism we might re-examine the raucous town hall eruptions this month. Even if they are inflated by activist organizations and cable-TV overexposure, they still cannot be dismissed entirely as made-for-media phenomena made-to-measure to fill the August news vacuum. Nor are they necessarily about health care. The twisted distortions about “death panels” and federal conspiracies “to pull the plug on grandma” are just too unhinged from the reality of any actual legislation. These bogus fears are psychological proxies for bigger traumas.

“It’s the economy, the facts that millions of people have lost their jobs and millions of others are afraid of losing theirs,” theorizes one heckled senator, Arlen Specter. That’s surely part of it. So is fear of more home foreclosures and credit card bankruptcies. So is fear of China, whose economic ascension stands in stark contrast to the collapse of traditional American industries from automobiles to newspapers. So is fear of Barack Obama, whose political ascension dramatizes the coming demographic order that will relegate whites to the American minority. In our uncharted new frontier, even the most reliable fixture for a half-century of American public life, the Kennedy family, is crumbling.

These anxieties coalesce in various permutations right, left and center. In most cases they don’t surface in the explosions we’re seeing at these town hall meetings but in the kind of quiet desperation that afflicts Don Draper and his cohort in “Mad Men.” But this summer’s explosions are also in keeping with 1963.

The political rage at the young, liberal Kennedy administration in some quarters that year was rabid and ominous. When Adlai Stevenson, then ambassador to the United Nations, spoke in Dallas that October, jeering zealots spat on him and struck him with a picketer’s placard. Stevenson advised Kennedy against traveling there. Dallas rushed to draft a new city ordinance restricting protesters’ movements at lawful assemblies and passed it on Nov. 18. We need not watch “Mad Men” to learn how that turned out.

Oh, to be back in the idyllic summer of 1969, when the biggest sin committed by the rebellious mobs at Woodstock was getting stoned. Something else is happening here in our anxious summer of 2009, when instead of flower-power and free love there are reports of death threats and fanatics packing guns.

Posted in Computers, Democrats, Healthcare, Law, Medicaid, National Security, Obama, Politics, Supreme Court, Wall Street, abortion, business, culture, economics, economy, gender, history, psychology, terrorism, women | Tagged: , , , , , , , , , , , , , , , , , , , , , | Leave a Comment »

Palin’s Bombshell: The Right Move?

Posted by steveneidman on July 8, 2009

Palin’s Brilliant 2012 Play

by Joe Mathews

The worst thing about Sarah Palin’s decision to resign the governorship of Alaska is the conclusion she appears to have reached about the political calendar: Even three years before the 2012 elections, the job of potential presidential candidate doesn’t leave any time for governing, even a lightly populated state.

As strange as her announcement sounded, Palin’s view of the electoral world is clear-eyed. These days, politics trumps governing all the time.

This reality is why Minnesota Gov. Tim Pawlenty has already announced he would not run for re-election next year; he’s too busy working as a presidential contender. And it’s why Mississippi Gov. Haley Barbour, in the middle of a serious budget crisis, left the state for a campaign swing through Iowa and New Hampshire, where votes won’t be counted until January 2012.

Woe to those who don’t fully understand that the 2012 presidential campaign is already in full swing. South Carolina Gov. Mark Sanford’s Argentine-flavored implosion drew intense scrutiny not merely because of the narcotic of sex-related news or the mystery of his whereabouts but also because Sanford was running for president.

Gov. Bobby Jindal’s response to President Obama’s January address got terrible reviews in part because he was being evaluated not as the nation’s youngest governor but as a presidential candidate. By comparison, the Republicans who look strongest are those who are already running free and clear—2008 campaign veterans and very former governors Mitt Romney and Mike Huckabee.

The notion of the permanent campaign is a generation old. But with the addition of Internet fundraising and the constant communication of Twitter and Facebook, we’ve entered a new era: the Age of Hyper Politics. This age is a glorious one for campaigning and for those who follow the horse race, but there is precious little room left for governing.

The winners in hyper politics are pollsters and pundits and consultants and just about anyone without a real job. The losers are everyone else. Constant campaigning isn’t good for anybody—not the candidates who are drawn away from their families and distracted from their day jobs, not the constituents they are abandoning, and certainly not a country that needs sustained, thoughtful governance in a time of crisis.

America’s elected officials desperately need a holiday from politics, especially after the end of the too-long 2008 presidential campaign. Instead, the 2012 campaign is already under way. The mindless logic of this too-early contest—all campaigning all the time, even when no one should be paying attention—seems to be spreading to state races. One reason why South Carolina’s leaders have struggled to respond to Sanford’s troubles is that they are consumed by next year’s gubernatorial race, a fierce contest that is already being fought.

But the madness of hyper politics is most apparent in California. One might think that a state that faces so many immediate troubles—economic collapse, record foreclosures, a huge budget deficit, a cash shortage that has forced the government to pay some of its bills with IOUs—would have no time for other political topics. But you’d think wrong.

Although California won’t pick a new governor until November 2010, the race has been well under way for more than a year. On the Democratic side, San Francisco Mayor Gavin Newsom is running full-time, blasting supporters nearly daily with policy statements and fundraising appeals. Attorney General Jerry Brown hasn’t formally announced his candidacy, but he’s been behaving like a candidate since he assumed his current office in early 2007. In fact, Brown, who served as governor from 1975 to 1983 (a period during which he ran twice for president and once for the U.S. Senate), was an early innovator in hyper politics.

But it is the three leading contenders for the Republican gubernatorial nomination who have set new records for early starts. The campaign of Insurance Commissioner Steve Poizner, who took office only in January 2007, is issuing nearly daily blasts at former eBay CEO Meg Whitman, a relative latecomer to the race. (She started only this February, though that came after what she says was more than a year of reading up on the state, meeting people, and planning.)

Poizner has been particularly critical of Whitman’s unwillingness to debate him or detail her views on some policy issues. Since she has until the June 2010 primary to do both, Whitman’s reluctance would appear perfectly sensible. But the attacks continue.

The two Republicans also are engaged in an endorsement battle that verges on the bizarre. Poizner, who must never be accused of procrastination, began announcing endorsements of his 2010 gubernatorial candidacy last fall. But in the last few weeks, Whitman has begun announcing her own high-profile endorsements, including some from former Poizner backers.

Yes, you heard that right—California Republican politicians have issued endorsements, rescinded endorsements, and issued new endorsements, all a year before anyone votes. One of these serial endorsers, Rep. John Campbell, had declared his support for Poizner last December with a statement that said: “Steve is the right man at the right time for California.” By the time Campbell switched to Whitman last month, a year before the primary, Steve’s “right time” had apparently passed.

The third GOP candidate, former Rep. Tom Campbell (no relation to John), has distinguished himself by releasing the sort of detailed budget and policy plans that one sees from politicians only after they have entered office. In fact, his proposal to address the current fiscal crisis is arguably more detailed—and courageous—than that offered by Gov. Arnold Schwarzenegger. Campbell’s commitment to detail is admirable, but it’s not all that useful for voters, since he can’t become governor until January 2011.

By then, Campbell’s current policies may feel stale, a serious peril of endless campaigns. President Obama’s candidacy, when viewed with through the prism of his presidency, is Exhibit A of this problem. The country’s economy and budget looked very different in early 2009 than when he began laying out his program in early 2007. As a candidate, he had no well-developed policy on bank bailouts, fiscal stimulus, or trillion-dollar-plus deficits. Voters had little idea what he would do on these most important issues.

Is there anything that can be done to shorten campaigns? Given the competitive pressures of running for office, candidates are unlikely to dial back without outside pressure. Campaign-finance regulations, which need revamping anyway, might be re-examined with an eye not only to limiting the influence of money but also to limiting the length of campaigns.

Instead of tying public financing of elections to limits on campaign spending, why not tie them to a requirement that campaigns not form committees until some appropriate time period before the election date? Or why not raise contribution limits for campaigns that start late, making it easier for latecomers to raise money and thus penalizing those who start too early?

Some will say such restrictions infringe on expression or are anti-competitive. Nonsense. Politics must have its season, but politics is not for all seasons. A campaign should be a means to an end—good governance—and not an end in itself.


Posted in Democrats, National Security, Obama, Politics, Polls, abortion, business, celebrity, culture, economy, gender, history, prayer, women | Tagged: , , , , , , , , , , , , , , , , , , , , , | Leave a Comment »

The Vanity Fair Article on Sarah Palin

Posted by steveneidman on July 1, 2009

It Came from Wasilla

By TODD S. PURDUM

The crowds begin streaming into the Evansville Auditorium and Convention Centre a couple of hours before the arrival of the “special guest speaker” at the Vanderburgh County Right to Life dinner on a soft Indiana spring evening—nearly 2,200 people in the banquet hall, 800 more in an adjacent auditorium watching the proceedings on a live video feed. The menu is thick slices of roast pork and red velvet cake, washed down with pitchers of iced tea, and when Sarah Palin finally enters, escorted by a phalanx of sheriff’s deputies and local police, she is mobbed. The organizers of the dinner, billed as “the largest pro-life banquet in the world,” have courted Palin for weeks with care packages of locally made chocolates, doughnuts, barbecue, and pastries, and she has requited by choosing Evansville, a conservative stronghold in southern Indiana, as the site of her first public speech outside Alaska in 2009. Like Richard M. Nixon, who chose the coalfield town of Hyden, Kentucky, for his first post-resignation public appearance, Palin has come to a place where she is guaranteed a hero’s reception. She is not only a staunch foe of abortion but also the mother of a boy, Trig, who was born with Down syndrome just a few months before John McCain chose Palin as his running mate. The souvenir program for this evening’s dinner is full of displays for local politicians and businesses, attesting to their pro-life bona fides. An ad for Hahn Realty Corporation reads, “If you need commercial real estate, call Joe Kiefer! Joe is pro-life and a proud supporter of the Vanderburgh County Right to Life.”

As Palin makes her way slowly across the crowded ballroom—dressed all in black; no red Naughty Monkey Double Dare pumps tonight—she is stopped every few inches by adoring fans. She passes the press pen, where at least eight television cameras and a passel of reporters and photographers are corralled, and spots a reporter for a local community newspaper getting ready to take a happy snap with his pocket camera. For a split second she stops, pauses, turns her head and shoulders just so, and smiles. She holds the pose until she’s sure the man has his shot and then moves on. A few minutes later, the evening’s nominal keynote speaker, the Republican Party’s national chairman, Michael Steele, who has been reduced to a footnote in the proceedings, introduces the special guest speaker as “the storm that is the honorable governor of the great state of Alaska, Sarah Palin!”

Just where that storm may be heading is one of the most intriguing issues in American politics today. Palin is at once the sexiest and the riskiest brand in the Republican Party. Her appeal to people in the party (and in the country) who share her convictions and resentments is profound. The fascination is viral, and global. Bill McAllister, until recently Palin’s statehouse spokesman, says that he has fielded (and declined) interview requests from France, England, Italy, Switzerland, Israel, Germany, Bulgaria, “and probably other countries I’ve forgotten about.” (Palin, keeping her distance from most domestic media as well, also declined to talk to V.F.). Whatever her political future, the emergence of Sarah Palin raises questions that will not soon go away. What does it say about the nature of modern American politics that a public official who often seems proud of what she does not know is not only accepted but applauded? What does her prominence say about the importance of having (or lacking) a record of achievement in public life? Why did so many skilled veterans of the Republican Party—long regarded as the more adroit team in presidential politics—keep loyally working for her election even after they privately realized she was casual about the truth and totally unfit for the vice-presidency? Perhaps most painful, how could John McCain, one of the cagiest survivors in contemporary politics—with a fine appreciation of life’s injustices and absurdities, a love for the sweep of history, and an overdeveloped sense of his own integrity and honor—ever have picked a person whose utter shortage of qualification for her proposed job all but disqualified him for his?

In the aftermath of the November election, the conventional wisdom among Palin’s supporters in the Republican establishment was that she should go home, keep her head down, show that she could govern effectively, and quietly educate herself about foreign and domestic policy with the help of a cadre of experienced advisers. She has done none of this. Rather, she has pursued an erratic course that, for her, may actually represent the closest thing there is to True North. Her first trip to Washington since the election was to attend the dinner of the Alfalfa Club, an elite group of politicians and businesspeople whose sole function is an annual evening in honor of a plant that would “do anything for a drink.” Some of her handlers first said she had accepted—though she then went on to decline—an invitation to speak at the annual June fund-raiser for the congressional Republicans. She created a political-action committee—Sarahpac—with the help of John Coale, a prominent Democratic trial lawyer. But just months into its existence the pac’s chief fund-raiser, Becki Donatelli, a veteran of Republican campaigns, suddenly quit. One person familiar with the situation told me that Donatelli could not stand dealing with Palin’s political spokeswoman in Alaska, Meghan Stapleton, who has drawn withering fire from Palin friends and critics alike for being an ineffective adviser. Also with Coale’s help, Palin formed the grandiosely named Alaska Fund Trust, to defray a reported half million dollars in legal expenses arising from a slew of formal ethics complaints against her in her home state—prompting yet another formal complaint, that the fund itself constitutes an ethical breach. Onetime supporters have become harsh critics. Walter Hickel, 89, a former two-term governor and interior secretary, and the grand old man of Alaska politics, who was co-chair of Palin’s winning gubernatorial campaign, in 2006, now washes his hands of her. He told me simply, “I don’t give a damn what she does.”

Palin is unlike any other national figure in modern American life—neither Anna Nicole Smith nor Margaret Chase Smith but a phenomenon all her own. The clouds of tabloid conflict and controversy that swirl around her and her extended clan—the surprise pregnancies, the two-bit blood feuds, the tawdry in-laws and common-law kin caught selling drugs or poaching game—give her family a singular status in the rogues’ gallery of political relatives. By comparison, Billy Carter, Donald Nixon, and Roger Clinton seem like avatars of circumspection. Palin’s life has sometimes played out like an unholy amalgam of Desperate Housewives and Northern Exposure.

Another aspect of the Palin phenomenon bears examination, even if the mere act of raising it invites intimations of sexism: she is by far the best-looking woman ever to rise to such heights in national politics, the first indisputably fertile female to dare to dance with the big dogs. This pheromonal reality has been a blessing and a curse. It has captivated people who would never have given someone with Palin’s record a second glance if Palin had looked like Susan Boyle. And it has made others reluctant to give her a second chance because she looks like a beauty queen.

Soon Palin will take a crack at her own story: she has signed a book contract for an undisclosed but presumably substantial sum, and has chosen Lynn Vincent, a senior writer at the Christian-conservativeWorld magazine, as co-author of the memoir, which is to be published next year not only by HarperCollins but also in a special edition by Zondervan, the Bible-publishing house, that may include supplemental material on faith. During the presidential campaign, Palin’s deep ignorance about most aspects of foreign and domestic policy provided her with a powerful political reason not to submit to interviews. The forthcoming book adds a powerful commercial reason.

Palin is a cipher by choice. When she chooses to reveal herself, what she reveals is not always the same thing as the truth. Her singular refusal to have in-depth conversations with the national media—even Richard Nixon and Dick Cheney, among the most saturnine political figures in modern American history, each submitted to countless detailed interviews over the years—has compounded the challenge of understanding who she really is. There has been Hollywood talk that Palin could star in a reality-TV show about running Alaska, but nothing has come of it yet. Recently, Palin did star in a week-long seriocomic feud with David Letterman over some of his borderline jokes. Meanwhile, she has begun sharing insights several times a day on Twitter, with chipper reports on her own doings and those of her husband, Todd, and the rest of what she calls the “first family.” “Look forward to today’s staff discussion re: my 3rd justice appt to highest court in 3 yrs. Supreme Court truly effects AK’s future,” reads one. And another: “Picking up my handsome little man to rtrn to Juneau, Trig got 1st haircut so my little hippie baby’s ready for AK sunshine on his shoulders.”

Sarah Palin winking

Palin turns her debate with Joe Biden into a winkathon.

Little Shop of Horrors

The caricature of Sarah Palin that emerged in the presidential campaign, for good and ill, is now ineradicable. The swift journey from her knockout convention speech to Tina Fey’s dead-eyed incarnation of her as Dan Quayle with an updo played out in real time, no less for the bewildered McCain campaign than for the public at large. It is an ironclad axiom of politics that if a campaign looks troubled from the outside the inside reality is far worse, and the McCain-Palin fiasco was no exception. As in any sudden marriage of convenience in which neither partner really knows the other, there were bound to be bumps. Palin had been on the national Republican radar for barely a year, after a cruise ship of conservative columnists, including The Weekly Standard’s William Kristol, had stopped in Juneau in 2007 and had succumbed to her charms when she invited them to the governor’s house for a luncheon of halibut cheeks. McCain had spent only a couple of hours in Palin’s presence before choosing her, and she had pointedly failed to endorse him after he clinched the nomination in March. The difficulties began immediately, with the McCain team’s delivery of the bad news that the pregnancy of Palin’s daughter Bristol, which was already common knowledge in Alaska and had been revealed to the McCain team at the last minute, could not be kept secret until after the Republican convention.

By the time Election Day rolled around, the staff had been serially pummeled by unflattering press reports about the gaps in Palin’s knowledge, her stubborn resistance to direction, and the post-selection spending spree in which she ran up bills of $150,000 on clothes for herself and her family at high-end stores. The top McCain aides who had tried hard to work with Palin—Steve Schmidt, the chief strategist; Nicolle Wallace, the communications ace; and Tucker Eskew, her traveling counselor—were barely on speaking terms with her, and news organizations were reporting that anonymous McCain aides saw Palin as a “diva” and a “whack job.” Many of the details that led to such assessments have remained obscure. But in a recent series of conversations, a range of people from the McCain-Palin campaign, including members of the high command, agreed to elaborate on how a match they thought so right ended up going so wrong.

The consensus is that Palin’s rollout, and even her first television interview, with ABC’s Charles Gibson, conducted after an awkward two-week press blackout to allow for intensive cramming at her home in Wasilla, went more or less fine, though it had its embarrassing moments (“You can’t blink,” Palin said, when Gibson asked if she’d hesitated to accept McCain’s offer) and was much parodied. At least one savvy politician—Barack Obama—believed Palin would never have time to get up to speed. He told his aides that it had taken him four months to learn how to be a national candidate, and added, “I don’t care how talented she is, this is really a leap.” The paramount strategic goal in picking Palin was that the choice of a running mate had to ensure a successful convention and a competitive race right after; in that limited sense, the choice worked. But no serious vetting had been done before the selection (by either the McCainor the Obama team), and there was trouble in nailing down basic facts about Palin’s life. After she was picked, the campaign belatedly sent a dozen lawyers and researchers, led by a veteran Bush aide, Taylor Griffin, to Alaska, in a desperate race against the national reporters descending on the state. At one point, trying out a debating point that she believed showed she could empathize with uninsured Americans, Palin told McCain aides that she and Todd in the early years of their marriage had been unable to afford health insurance of any kind, and had gone without it until he got his union card and went to work for British Petroleum on the North Slope of Alaska. Checking with Todd Palin himself revealed that, no, they had had catastrophic coverage all along. She insisted that catastrophic insurance didn’t really count and need not be revealed. This sort of slipperiness—about both what the truth was and whether the truth even mattered—persisted on questions great and small. By late September, when the time came to coach Palin for her second major interview, this time with Katie Couric, there were severe tensions between Palin and the campaign.

By all accounts, Palin was either unwilling, or simply unable, to prepare. In the run-up to the Couric interview, Palin had become preoccupied with a far more parochial concern: answering a humdrum written questionnaire from her hometown newspaper, the Frontiersman. McCain aides saw it as easy stuff, the usual boilerplate, the work of 20 minutes or so, but Palin worried intently. At the same time, she grew concerned that her approval ratings back home in Alaska were sagging as she embraced the role of McCain’s bad cop. To keep her happy, the chief McCain strategist, Steve Schmidt, agreed to conduct a onetime poll of 300 Alaska voters. It would prove to Palin, Schmidt thought, that everything was all right.

Then came the near-total meltdown of the financial system and McCain’s much-derided decision to briefly “suspend” his campaign. Under the circumstances, and with severely limited resources, Schmidt and the McCain-campaign chairman, Rick Davis, scrapped the Alaska poll and urgently set out to survey voters’ views of the economy (and of McCain’s response to it) in competitive states. Palin was furious. She was convinced that Schmidt had lied to her, a belief she conveyed to anyone who would listen.

The next big milestone for Palin was the debate with Joe Biden, on October 2. An early rehearsal effort in Philadelphia found 20 people sitting in a stifling room with hundreds of sample questions on note cards. Palin just stared down, disengaged, non-participatory. A disaster loomed, so Schmidt made the difficult decision to leave campaign headquarters, in Virginia, and fly to McCain’s vacation retreat in Sedona, Arizona, where it was thought that Palin might be able to relax and recharge, and accept the assistance of a voice coach and a television coach. For three full days—at the height of the campaign—Schmidt dropped virtually all other business to help Palin prepare.

He also enlisted some extra help. By this point, Palin’s relations with Nicolle Wallace—a veteran of the Bush White House and a former CBS News analyst who had tried to help Palin get ready for the Couric interview, and whom Palin blamed for the result—were so strained that campaign aides cast about for someone who could serve as a calming presence: Palin’s horse whisperer. They settled on Mark McKinnon, a smart, funny, soft-spoken former Democrat from Texas. McKinnon had long admired McCain, and had begun the Republican primary season helping him out—though warning that he would never work against Obama in the general election. But now McKinnon, whose role in helping prepare Palin has not been previously reported, and who declined to elaborate on it to V.F., changed his mind and quietly signed on. Mark Salter, McCain’s longtime aide, says that McKinnon was picked because “he’s got a lovely manner You sort of want a guy who’s very easygoing, gives good advice, and doesn’t add to the natural nervousness.”

Palin worked hard, and the results were adequate. Palin’s winking “Can I call you Joe?” performance against Biden was nothing like a disaster. In fact, it seems to have emboldened her enough that the next day she openly voiced disagreement with the McCain team’s decision to pull out of active competition in Michigan. When orders or advice from McCain headquarters began to conflict with her own impulses, aides told me, she simply did what she wanted to do. “The problem was she came down from Alaska with basically Todd as a sort of trusted bellwether adviser,” one McCain friend says. “She was given this staff of 20. It was probably too big a staff. To be real honest with you, I don’t think she could figure out who to trust.” All the while, Palin was coping not only with the crazed life of any national candidate on the road but also with the young children traveling with her. Some top aides worried about her mental state: was it possible that she was experiencing postpartum depression? (Palin’s youngest son was less than six months old.) Palin maintained only the barest level of civil discourse with Tucker Eskew, the veteran G.O.P. operative who had been made her chief minder. A third party had to shuttle between them to convey even the most rudimentary messages. “She started to hedge her bets,” the same McCain friend says. “Frequently, she would be concerned about how something would play in Alaska. What? You’re worried about your backside in Alaska when there are hundreds of millions of dollars being spent?” One longtime McCain friend and frequent companion on the trail was heard to refer to Palin as “Little Shop of Horrors.”

Election Night brought what McCain aides saw as the final indignity. Palin decided she would make her own speech at the ticket’s farewell to the faithful, at the Arizona Biltmore, in Phoenix. When aides went to load McCain’s concession speech into the teleprompter, they found a concession speech for Palin—written by Bush speechwriter Matthew Scully, who had also been the principal drafter of her convention speech—already on the system. Schmidt and Salter told Palin that there was no tradition of Election Night speeches by running mates, and that she wouldn’t be giving one. Palin was insistent. “Are those John’s wishes?” she asked. They were, she was told. But Palin took the issue to McCain himself, raising it on the walk from his suite to the outdoor rally. Again the answer was no.

Polar Disorder

There is virtually nothing about Palin’s performance in the fall campaign that should have come as a surprise to John McCain. Had he really attempted to learn something about her before the fateful day of August 29, 2008, when he announced that she was his choice for running mate, he would easily have discerned all the traits that he belatedly came to know.

The narrative that the McCain campaign employed to explain Palin’s selection and to promote her qualifications—that she was a fresh-faced reformer who had taken on Alaska’s big oil companies and the corrupt Republican establishment, governing with bipartisan support—was never more than superficially true. In dozens of conversations during a recent visit to Alaska, it was easy to learn that there has always been a counter-narrative about Palin, and indeed it has become the dominant one. It is the story of a political novice with an intuitive feel for the temper of her times, a woman who saw her opportunities and coolly seized them. In every job, she surrounded herself with an insular coterie of trusted friends, took disagreements personally, discarded people who were no longer useful, and swiftly dealt vengeance on enemies, real or perceived. “Remember,” says Lyda Green, a former Republican state senator who once represented Palin’s home district, and who over the years went from being a supporter of Palin’s to a bitter foe, “her nickname in high school was ‘Barracuda.’ I was never called Barracuda. Were you? There’s a certain instinct there that you go for the jugular.”

The first thing McCain could have learned about Palin is what it means that she is from Alaska. More than 30 years ago, John McPhee wrote, “Alaska is a foreign country significantly populated with Americans. Its languages extend to English. Its nature is its own. Nothing seems so unexpected as the boxes marked ‘U.S. Mail.’” That description still fits. The state capital, Juneau, is 600 miles from the principal city, Anchorage, and is reachable only by air or sea. Alaskan politicians list the length of their residency in the state (if they were not born there) at the top of their biographies, and are careful to specify whether they like hunting, fishing, or both. There is little sense of government as an enduring institution: when the annual 90-day legislative session is over, the legislators pack up their offices, files, and computers, and take everything home. Alaska’s largest newspaper, the Anchorage Daily News, maintains no full-time bureau in Juneau to cover the statehouse. As in any resource-rich developing country with weak institutions and woeful oversight, corruption and official misconduct go easily unchecked. Scrutiny is not welcome, and Alaskans of every age and station, of every race and political stripe, unself-consciously refer to every other place on earth with a single word: Outside.

So, of all the puzzling things that Sarah Palin told the American public last fall, perhaps the most puzzling was this: “Believe me, Alaska is like a microcosm of America.”

Believe me, it is not.

But Sarah Palin herself is a microcosm of Alaska, or at least of the fastest-growing and politically crucial part of it, which stretches up the broad Matanuska-Susitna Valley, north of Anchorage, where she came of age and cut her political teeth in her now famous hometown, Wasilla. In the same way that Lyndon Johnson could only have come from Texas, or Bill Clinton from Arkansas, Palin and all that she is could only have come from Wasilla. It is a place of breathtaking scenery and virtually no zoning. The view along Wasilla’s main drag is of Chili’s, ihop, Home Depot, Target, and Arby’s, and yet the view from the Palins’ front yard, on Lake Lucille, recalls the Alpine splendor visible from Captain Von Trapp’s terrace in The Sound of Music. It is culturally conservative: the local newspaper recently published an article that asked, “Will the Antichrist be a Homosexual?” It is in this Alaska—where it is possible to be both a conservative Republican and a pothead, or a foursquare Democrat and a gun nut—that Sarah Palin learned everything she knows about politics, and about life. It was in this environment that her ambition first found an outlet in public office, and where she first tasted the 151-proof Everclear that is power.

The second thing McCain could have discovered about Palin is that no political principle or personal relationship is more sacred than her own ambition. To be sure, Palin is “conservative,” whatever that means, but she can be all over the lot in the articulation of her platform. In a June interview with Sean Hannity, she sounded like a New Dealer when she proudly proclaimed that “a share of our oil-resource revenue goes back to the people who own the resources—imagine that.” In the next breath, sounding like a “starve the beast” conservative, she said she hoped the price of oil, the principal variable of state revenue, would not rise too much. “The fewer dollars that the state of Alaska government has, the fewer dollars we spend, and that’s good for our families and the private sector.” Palin has always been a party of one. She gained the mayoralty of Wasilla in 1996 by turning against the incumbent, John Stein, who had been one of her mentors when she was on the city council, and injecting sharply partisan issues such as gun rights and abortion into what had previously been a low-key local contest. She fired the police chief, eased out the museum director and the city planner, and fired and then rehired the librarian (who had opposed book censorship). Palin was entitled to make the dismissals, and she variously justified them on the grounds of budget difficulties or the need for a team that she could be sure would support her efforts. But the Frontiersman accused Palin of confusing her election with a “coronation.”

Even in broad outline the story of how a small-town mayor became the youngest governor in Alaska history seems improbable. There was her long-shot campaign for lieutenant governor, in 2002, in which she came in second against a veteran state senator in a five-way race; her appointment as chair (and ethics supervisor) of the state’s Oil and Gas Conservation Commission, which oversees drilling and production; and her resignation from that post, charging that a fellow commissioner, Randy Ruedrich, the chair of the Alaska Republican Party, was conducting political business on state time. In a climate where the sitting Republican governor, Frank Murkowski, had become the most unpopular figure in the state, and where the F.B.I. was swarming over Alaska, pursuing the corruption probe that later ensnared the state’s senior U.S. senator, Ted Stevens, Palin seemed like a breath of fresh air.

Yet Palin herself cut corners. Ruedrich, Palin’s target on the Conservation Commission, was forced to resign, but in 2006, as Palin was beginning her campaign for governor, a conservative columnist dug up e-mail messages showing that she too had conducted campaign business from her mayoral office. Confronted by the columnist, Palin acknowledged that she had erred. Then she turned around and issued a press release, demanding to know why the columnist was publishing smears.

Palin won the crucial support of Walter Hickel in her campaign for governor in part by supporting one of his longtime hobbyhorses, an “all-Alaska” natural-gas pipeline that would pump gas to the port of Valdez for export worldwide. As the campaign wore on, Palin backed away from that idea. “I helped her out, she got elected,” Hickel says now. “She never called me once in her life after that.”

Palin’s 2006 campaign for governor relied at first almost wholly on a ragtag band of true believers. “She had this little grassroots group that was going around the state on a wing and a prayer, talking up her platitudes,” says John Bitney, an old friend of Palin’s from junior-high band in Wasilla, where he played the trombone and she played the flute. Bitney at the time was a lobbyist and veteran legislative aide in Juneau, and he began passing political intelligence and advice to Palin. When Palin routed Murkowski in the Republican primary, she still had no real professional campaign staff. Bitney signed on, forming a triumvirate with Curtis Smith, a veteran Anchorage media consultant, and Kris Perry, another old friend of Palin’s from Wasilla, who functioned as her personal assistant and also held the title of campaign manager. Palin began preparing for a general-election campaign against Tony Knowles, the former two-term Democratic governor, and Andrew Halcro, a former Republican legislator who was running as an independent.

She apparently didn’t like preparing for debates back then either. “In the campaign for governor, they’re prepping her for debate,” Curtis Smith’s former business partner, Jim Lottsfeldt, told me recently in Anchorage, “and Curtis says, ‘The debate prep’s going horribly. Every time we try to help her with an answer, she just gets mad.’” (Smith himself says, “Unfortunately, I don’t recall having that exact conversation with Mr. Lottsfeldt, nor do I recall my experience, including debate prep, with Governor Palin in the light he portrayed.”) But Palin’s lack of knowledge turned out not to hurt her. Andrew Halcro later remembered that he and Palin once compared notes about their many encounters, and she said, “Andrew, I watch you at these debates with no notes, no papers, and yet when asked questions, you spout off facts, figures, and policies, and I’m amazed. But then I look out into the audience and I ask myself, Does any of this really matter?”

Palin’s victory that November was one of the flukiest successes in modern American politics. Rebecca Braun, the publisher of the Alaska Budget Report, a respected nonpartisan newsletter, describes the result as something “far beyond anything you could explain in terms of intellect or training.” But Palin had promised three big things, and with the help of Bitney, who became her liaison with the legislature, and Mike Tibbles, her chief of staff, she achieved them. She increased oil taxes; she won the legislative framework for a gas pipeline, though not the one Hickel wanted; and she signed significant ethics reforms. In all three efforts she won strong cooperation from Democrats. “She had an easy go of it,” says Larry Persily, a former editorial-page editor of the Anchorage Daily News, who went to work in Palin’s Washington office but is now a critic of the governor’s. “The Democrats were in love with her. She slew the oil-company Gorgon, and came in on the magic carpet of oil-tax reform and ethics. The Democrats were intoxicated because she wasn’t Frank Murkowski.” Rising oil prices provided an added lift. Palin was able to increase the annual distribution from the state’s Permanent Fund to about $3,000 per resident, almost double the amount received the previous year. She could be a fiscal conservative and a big spender all at the same time.

Sarah Palin and Cindy McCain

Palin and Cindy McCain, never soulmates.

But there were ominous signs—indications of an erratic nature. This is the third thing McCain could have discovered about Palin—a woman, after all, who kept a pregnancy secret for seven months, flew all the way home from Texas to Alaska with a near-full-term baby while leaking amniotic fluid, and then finally drove the 45 minutes from Anchorage to a hospital in Wasilla, all so that the child could be born in the 49th state. Palin was for the infamous Gravina Island “bridge to nowhere” before she was against it, and reversed herself only when such pork-barrel projects prompted a nationwide backlash. As governor, she hired several old high-school, hometown, or political friends with minimal qualifications for important state jobs. One friend, a former mid-level manager for Alaska Airlines, headed the department that reviewed candidates for state boards and commissions; another became director of the state Division of Agriculture, citing a childhood love of cows as one qualification. Palin communicated with legislators and her staff mainly by BlackBerry, sometimes using a personal e-mail account to avoid having to disclose documents under the state public-records laws. (The one time Meg Stapleton, who handles Palin’s personal and political public relations, ever answered multiple e-mails was when I wrote her and Palin’s gubernatorial office at the same time, and she replied: “Thank you for emailing. I will email you separately so as to remove us from the state account.”) Palin’s anti-politician stance had worked so well in her campaign that she carried it over into her dealings with actual politicians in Juneau, who didn’t take kindly to the practice. After one meeting between the governor and legislators in 2007, Lyda Green, then the president of the state senate, returned to her office to catch up on some paperwork. She caught Palin on the news. “And she comes on TV and says, ‘I want to once again confirm that neither I nor my staff ever holds closed-door meetings.’ Well, we had just been in a closed-door meeting for an hour and a half!” Representative Les Gara, an Anchorage Democrat who often worked with Palin, told me that he had at first thought that some of Green’s sharp criticism of Palin amounted to Republican infighting, or maybe just sour grapes that Wasilla had produced a new political figure whose star far outshone Green’s. But he came to realize, he said, that Green had a better handle on Palin than he did. “She didn’t work very hard. You would speak to her on particular issues, and it was like she didn’t know anything about them and she never seemed very engaged.” That said, “if your priorities happened to be her priorities, you could build a coalition.”

On the other hand, if your priorities happened to differ from hers, you could pay a terrible price. Only weeks after Palin praised John Bitney for doing so much to make her first legislative session a success, she summarily fired him—because, he says, he had had the bad luck to fall in love with the wife of one of the Palins’ best friends (a woman he has since married). At the time, Palin’s office cited what it called “personal” reasons for an “amicable” departure. But when The Wall Street Journal called Palin’s office during last fall’s presidential campaign to ask about the case, a spokeswoman for Palin said that Bitney had been “dismissed because of his poor job performance,” and refused to elaborate.

Not quite a year after Bitney’s departure, Mike Tibbles abruptly resigned as chief of staff, for reasons that neither he nor Palin has ever explained. Jim Lottsfeldt, a friend of Tibbles’s, says that the chief of staff was worn down “by the steady drumbeat of her not consulting with him.” She replaced Tibbles with Mike Nizich, a part-time taxidermist, who over 30 years had served seven governors of both parties, most of that time as director of the state Division of Administration—a man who made the trains run on time in the governor’s office but had nothing to do with policy issues. Palin’s effectiveness was never again the same. The brutal reality is that many people who have worked closely with Palin have found themselves disillusioned.

More than once in my travels in Alaska, people brought up, without prompting, the question of Palin’s extravagant self-regard. Several told me, independently of one another, that they had consulted the definition of “narcissistic personality disorder” in the Diagnostic and Statistical Manual of Mental Disorders—“a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy”—and thought it fit her perfectly. When Trig was born, Palin wrote an e-mail letter to friends and relatives, describing the belated news of her pregnancy and detailing Trig’s condition; she wrote the e-mail not in her own name but in God’s, and signed it “Trig’s Creator, Your Heavenly Father.”

Perhaps no episode of Palin’s governorship has drawn more attention than the one that came to be known as Troopergate. For more than a year of her tenure as governor, Palin and her husband and aides repeatedly and aggressively complained to Walt Monegan, the former Anchorage police chief whom Palin had named to head the state’s Department of Public Safety, about Mike Wooten, a state trooper who had been involved in a messy divorce from Palin’s sister Molly. Wooten was no angel. Before Palin ever took office, he had been disciplined after drinking beer in his patrol car, Tasering his stepson, illegally shooting a moose, and making threatening remarks about Palin’s father. But Wooten had already been disciplined, and Monegan believed that further action was unjustified if not impossible. The final straw may have been Monegan’s June 30, 2008, e-mail warning to Palin that an unnamed state legislator had complained that she’d been seen driving with her newborn son, and that the infant had not been strapped into an approved car seat. “I have never driven Trig anywhere without a new, approved car seat,” Palin fired back. “I want to know who said otherwise—pls. provide me that info now.” Twelve days later, Nizich fired Monegan on Palin’s orders. Forty-nine days after that, John McCain announced that Palin would join him on the ticket.

Arrows in the Back

In Alaska, there has never been a gubernatorial tradition of pardoning a turkey at Thanksgiving, but Palin decided to stage such a ceremony last November all the same, at the Triple D Farm & Hatchery, outside Wasilla. After granting the lucky bird its reprieve, she stopped to talk to a local television reporter about what she had learned in the campaign just concluded. “I don’t think it’s changed me at all,” she insisted, clutching a cup of coffee as her breath steamed into the frosty air. “You know, it’s pretty brutal, the time consumption there, and the energy that has to be spent in order to get out and about with the message on a national level, a great appreciation for other candidates who have gone through this, but also just a great appreciation for this great country. There are so many good Americans who are just desiring of their government to kind of get out of the way and allow them to grow and progress, and allow our businesses to grow and progress. So, great appreciation for those who share that value.”

As Palin spoke, a grisly scene unfolded behind her. A worker hefted one squirming white turkey after another into a metal funnel, slit its throat, and bled it out in full view of the camera. The clip was replayed tens of thousands of times on YouTube and seemed an all too apt metaphor for how Palin’s political fortunes had changed in the wake of her great national adventure, even if her personality had not. A career that thrived for years on extraordinarily good luck seems to have known nothing but trouble since November 4. In December, Bristol Palin gave birth to Tripp Easton Mitchell Johnston, her son with her boyfriend, Levi Johnston, and for a time there was talk of a wedding. But by early spring the couple had split up, and their families fell to trading charges on talk shows and in the tabloids. After Levi told Tyra Banks that he had often spent the night in the Palin home, in the same room as Bristol, and assumed that the governor knew they were having sex, Palin, through her spokeswoman, released a blistering statement expressing disappointment “that Levi and his family, in a quest for fame, attention, and fortune, are engaging in flat-out lies, gross exaggeration, and even distortion of their relationship.” On the CBS Early Show, days later, Johnston seemed resigned. “They said I didn’t live there. I ‘stayed there,”’ he said. “I was like, O.K., well, whatever you want to call it. I had my stuff there.” Although Bristol initially told Greta Van Susteren that teen abstinence is “not realistic at all,” by springtime she had signed up as an ambassador for the Candie’s Foundation to promote abstinence as the way to avoid teen pregnancy.

Meantime, Levi’s mother, Sherry, agreed to plead guilty to a felony count of possessing OxyContin with intent to sell it, in exchange for the state’s agreement to drop five other drug-related charges against her. Her lawyer has conceded that she will draw an automatic jail sentence, but hopes to minimize the time she spends behind bars, because she suffers from chronic pain. In April, Todd Palin’s half-sister Diana was arrested on charges of twice breaking into a house in Wasilla to steal money from a bedroom cabinet, under circumstances that remain unexplained.

Because Palin had taken particular umbrage in the fall campaign at any effort to criticize her children or invade their privacy, her willingness to mix it up in public with an 18-year-old, who is after all the father of her only grandchild, struck many in Alaska as odd. So did Palin’s suggestion, at a time when declining oil prices have thrown the state budget into the red, that she did not want to accept about a third of the $930 million in federal stimulus money available to Alaska, because it would come with too many big-government strings attached. The move seemed calculated to burnish her national conservative credentials. In the face of bipartisan outcry, Palin’s aides insisted she had never meant to say she wouldn’t take the money, only that she wanted to review the matter carefully. That was news to former aide Larry Persily. After the first meeting on the stimulus money, Persily told me, “Everyone in the room left thinking she’d said no. Then her staff said, ‘She didn’t say no. She just didn’t say yes.”’ Palin wound up taking all but about 3 percent of the $900 million available to Alaska. The consensus even among the Republicans I spoke to was that she rejected the last $28 million—for energy assistance—mostly to save face.

The ever shifting sands of Palin’s sensibility were also on display after former senator Ted Stevens’s conviction on corruption charges was set aside, in April. Palin’s old nemesis, the Alaska Republican Party chair Randy Ruedrich, called on Stevens’s Democratic successor, Mark Begich, who had defeated Stevens just days after the original conviction last fall, to step down and allow a new election. Palin told theFairbanks Daily News-Miner in an e-mail, “I absolutely agree.” Days later, at a news conference, Palin insisted she had never called on Begich to step down.

Perhaps nothing has caused a bigger stir than Palin’s nomination of Wayne Anthony Ross to be Alaska’s attorney general. Ross is a two-time gubernatorial candidate and a board member of the National Rifle Association. He had sown controversy over the years by referring to gays and lesbians as “degenerates” (he later sought to downplay the remark, saying his aversion to homosexuals was no different from his aversion to lima beans) and for staunchly opposing subsistence-hunting preferences for native Alaskans. A flamboyant divorce lawyer who drives a big red Hummer with the vanity license plate war, Ross is a good old boy of pithy expression and considerable charm. (“In Alaska,” Ross told me, “a liberal is someone who carries a .357 or smaller.”) The final vote against Ross—with the Republican leaders of both chambers joining to defeat him—came just as Palin was speaking in Evansville. It was the first time in Alaska history that a cabinet nominee was rejected. “If I wince a little, it’s from the arrows in my back,” Ross told me a few weeks later. “I think there were a number of people who were trying to show her who the boss was.”

A year ago, 80 percent of Alaskans viewed Palin very favorably or somewhat favorably; by this spring, just 55 percent had a positive opinion. All this has given rise to speculation in Alaska that Palin may not run for re-election next year. She does not have to declare her candidacy until June 2010. Most politicians of both parties in Alaska with whom I spoke assume she could win, though not as persuasively as she did in 2006, which would hardly help her standing in a 2012 presidential campaign. Though Palin’s spokeswoman has said she does not intend to challenge Senator Lisa Murkowski, the former governor’s daughter, who is also up for re-election next year, Palin has changed her mind without warning in the past, and becoming a senator would keep her in the national spotlight. Surveying the landscape of political and policy troubles in Alaska, Gregg Erickson, an independent economic consultant in Juneau, concludes, “Everything she’s doing seems to be saying that there’ll be a problem in the future owing to her inattention, but she won’t be here to deal with it.”

“Just Make It All Go Away”

As Palin has piled misstep on top of misstep, the senior members of McCain’s campaign team have undergone a painful odyssey of their own. In recent rounds of long conversations, most made it clear that they suffer a kind of survivor’s guilt: they can’t quite believe that for two frantic months last fall, caught in a Bermuda Triangle of a campaign, they worked their tails off to try to elect as vice president of the United States someone who, by mid-October, they believed for certain was nowhere near ready for the job, and might never be. They quietly ponder the nightmare they lived through. Do they ever ask, What were we thinking? “Oh, yeah, oh, yeah,” one longtime McCain friend told me with a rueful chuckle. “You nailed it.” Another key McCain aide summed up his attitude this way: “I guess it’s sort of shifted,” he said. “I always wanted to tell myself the best-case story about her.” Even now, he said, “I don’t want to get too negative.” Then he added, “I think, as I’ve evaluated it, I think some of my worst fears … the after-election events have confirmed that her more negative aspects may have been there … ” His voice trailed off. “I saw her as a raw talent. Raw, but a talent. I hoped she could become better.”

None of McCain’s still-loyal soldiers will say negative things about Palin on the record. Even thinking such thoughts privately is painful for them, because there is ultimately no way to read McCain’s selection of Palin as reflecting anything other than an appalling egotism, heedlessness, and lack of judgment in a man whose courage, tenacity, and character they have extravagantly admired—and as reflecting, too, an unsettling willingness on their own part to aid and abet him. They all know that if their candidate—a 72-year-old cancer survivor—had won the presidency, the vice-presidency would be in the hands of a woman who lacked the knowledge, the preparation, the aptitude, and the temperament for the job. To ask why none of them dared to just walk away is to ask why Colin Powell did not resign in protest over the Bush administration’s foreign policy, or why none of Bill Clinton’s disillusioned aides resigned after he lied to them about Monica Lewinsky. The question cannot comprehend the intense bonds that the blood sport of modern politics produces. To leave a campaign—especially a struggling, losing campaign—is akin to desertion in wartime, and even as they began to understand her limitations, plenty of McCain aides still saw Palin as the campaign’s best hope. Some still believe that, simply in terms of the electoral math, she helped at least as much as she hurt, and maybe helped more.

McCain has delivered his own postmortem on Palin with the patented brand of winking-and-nodding ironic detachment that he usually reserves for painful political questions, an approach that simultaneously seeks to confess his sin and presume absolution for it. In November, he told Jay Leno he was proud of Palin and did not blame her for his defeat, but by April, when Leno asked him about who was running the Republican Party, McCain declined to mention Palin: “We have, I’m happy to say, a lot of choices out there: Bobby Jindal, Tim Pawlenty, Huntsman, Romney, Charlie Crist—there’s a lot of governors out there who are young and dynamic.” McCain went on, “There’s a lot of good people out there, and I’ve left out somebody’s name and I’m going to hear about it.” When I ask Mark Salter, McCain’s longtime speechwriter and co-author, about that comment, he says simply, “McCain always talks unscripted,” and adds that he has heard “not one word of regret” about Palin ever pass McCain’s lips. McCain’s daughter Meghan, who has continued the blog she began on the campaign last year, has said that Palin is the one topic on which she will have no public comment.

Palin herself has alternately shied away from the spotlight and injected herself into public debate on questions dear to conservatives, as she did when she issued a statement defending the former Miss California, Carrie Prejean, for opposing gay marriage despite “the liberal onslaught of malicious attacks.” Palin’s speech in Evansville was her first major post-election foray into the national media, and she followed it up in June with a trip to New York State, to commemorate the 50th anniversary of Alaska’s entry into the union, visiting Auburn, the hometown of William H. Seward, who bought the Alaska territory from Russia, and making appearances at events supporting families with autism and developmental disabilities. But the biggest headlines the trip produced were those about Palin’s feud with David Letterman, who joked that Palin had gone to Bloomingdale’s to update her “slutty flight-attendant look” and made a tasteless sexual jibe about one of the Palin daughters. Letterman eventually apologized, though Palin fanned the flames in ways that were not necessarily to her advantage.

In Evansville, though, Palin concentrated on the task at hand: an emphatic defense of the anti-abortion cause. But in doing so she made a startling confession about what she thought when she learned she was pregnant at 43 with her youngest child, Trig, who arrived in April 2008, as the world now knows, with Down syndrome. “I had found out that I was pregnant while out of state first,” Palin told the crowd. “While out of state, there just for a fleeting moment, I thought, Nobody knows me here. Nobody would ever know. I thought, Wow, it is easy to think maybe of trying to change the circumstances and no one would know—no one would ever know. Then when my amniocentesis results came back, showing what they called abnormalities—oh, dear God—I knew, I had instantly an understanding, for that fleeting moment, why someone would believe it could seem possible to change those circumstances, just make it all go away, get some normalcy back in life.” It is almost impossible not to be touched by the rawness of her confession, even if it is precisely this choice that Palin believes no other woman should ever have, not even in the case of rape or incest.

Sarah Palin is a star in Evansville and all the many Evansvilles of America, but there is a big part of the Republican Party—the Wall Street wing, the national-security wing—in which she cuts no ice. At the 2009 Conservative Political Action Conference, Palin essentially came in tied for second with Governor Bobby Jindal, of Louisiana, and Representative Ron Paul, of Texas, with 13 percent support in a straw poll of potential 2012 presidential candidates; former governor Mitt Romney, of Massachusetts, got 20 percent. A more recent survey has Palin in a three-way tie with Romney and former Arkansas governor Mike Huckabee. She could do well in the Iowa caucuses or South Carolina primary, but it is much harder to imagine her making headway in New Hampshire, where independent voters were turned off by her last fall. It is also difficult to see just how she would expand her appeal beyond the base that already loves her.

In Alaska, almost everyone I met wondered who was advising her in Washington—and in Washington, everyone wonders the same thing. There are one or two clues. On the eve of the Alfalfa dinner, in January, Palin was a guest in the home of Fred Malek, a veteran Republican fund-raiser and government official dating back to the days of the Nixon administration. Malek raised money for McCain’s campaign last year, and also agreed to play host to a fund-raising dinner for Republican governors in early May. (Palin was to have been an honored guest, but canceled owing to spring flooding in Alaska.) As noted, Palin has established a political-action committee with the legal advice of John Coale, who met Palin when his wife, Greta Van Susteren, the Fox News host, went to interview her during the campaign. Coale, a former Hillary Clinton supporter, told me he felt Palin had gotten a bum rap from liberals and conservatives alike, and he advised her that a pac was a logical and legal way to pay for out-of-state political travel. “We raised a good bit of money without even asking,” Coale says. “Just set up a Web site and, I think in the first month, $400,000 came in.” Coale says he still exchanges e-mails with Palin from time to time, but doesn’t consider himself a political adviser; he also says that Van Susteren has “put up a Chinese wall about all of this,” and has obtained her interviews with the Palins independently. Since the campaign ended, Van Susteren has interviewed Palin twice more, but she says she has never had a conversation with Palin off-camera, except for when Palin called to rescind her acceptance of Van Susteren’s invitation to the White House Correspondents’ Dinner in May, because of the Alaska flooding. Todd Palin came solo as Van Susteren’s guest, and when a reporter for Politico sought to interview him at a pre-dinner brunch attended by hundreds of journalists, Van Susteren interposed herself, as in the manner of a staffer, to say it was a social event. Van Susteren told me she was just trying to exercise good manners.

Palin’s closest adviser remains her husband—the “first gentleman” or “first dude,” as she calls him. Testimony in the Troopergate investigation suggested that Todd was physically in the governor’s office for about 50 percent of the time, often sitting in on meetings or phone calls in which he had no obvious official function. By the end of last fall’s campaign, McCain’s friends had picked up word that Todd was calling around to Republicans in South Carolina, urging them to keep his wife in mind for 2012—the implication being that the Palins believed McCain was about to lose. This spring, he stood in for Palin at an event in Manhattan—at Alaska House in SoHo, the cultural antipode of Wasilla—promoting the Alaska commercial-fishing industry’s contributions to world food aid. In a brief prepared speech, he extolled Alaska salmon as “some of the world’s healthiest protein, rich in vitamins and minerals, and a source of omega-3 fats.”

“She doesn’t at all have anyone who’s willing to give it to her straight,” one person who occasionally advises Palin told me. Todd may be the one exception. “I saw nobody else like that, nobody who would sit her down and say, ‘Hey, wait a minute.’” He added, of the poor communications operation run by Stapleton, “I don’t know what part Sarah Palin plays in the lack of communications, but I don’t think she’s aware of how big a problem it is.”

And her national ambitions? “What it looks like to me she’s trying to do is try the same formula that got her the governorship,” John Bitney says. “You sort of start off with a conservative base. The right-wing base is obviously out on the far end of the spectrum, but it’s a very motivated base. They show up, they’re committed. It gets you that political beachhead. She did not get started with the blessing of the Republican Party. She started with a dedicated corps of sort of right-wing true believers who killed themselves for her, and got her going. And then she began to build on that, and after she crossed the primary hurdle, she moderated her message on some points.”

When I ask Bitney what he makes of the whole Palin phenomenon, he sighs. “What do I take away from this?” he asks. “Oh, I don’t know. I don’t know. It’s just a lot of emotions and stuff. I find it’s frustrating dealing with Sarah, because it seems we’re always dealing with emotional crap and we never seem to be able to focus on the business at hand that needs to be done. I don’t know whether to blame her or pity her for all this emotional upheaval that we’re always going through with her. Now we all get to listen to Levi and Bristol. Check my feet for horseshoes if I have to sit there and listen to another talk show. I got involved in helping her become governor because we needed to change some policy directions. Teen abstinence is not why I waved signs for her.”

Palin herself often sounds tired and resentful these days, as if wondering whether she should have blinked and just said no to John McCain. In a rambling, 17-minute speech introducing Michael Reagan, the former president’s son and a conservative radio host at an event in Alaska in June—a speech that borrowed heavily, without clear attribution, from a four-year-old article by Newt Gingrich and the Republican strategist Craig Shirley—Palin seemed resigned to the fact that her reputation would never again be as fresh and glowing as it once was. She complained about “national figures and some in the press who, who want to put not just me, but anybody who dares speak up, it seems nowadays, right back down in their place.” She bemoaned her changing fortunes in Alaska. “I think things here that have so drastically changed these past months … Some want to forbid others from speaking up, and it’s been through lawsuits, been ethics-violation charges, media distortions And those are the folks who want to tell me, they want to tell you to sit down and shut up. We will not do so. I just can’t because I love my state, I love my country, and I need you, we need Michael Reagan to keep on fighting for our freedoms, for our country, and what we’re being fed today, it seems, is a steady diet of selected misrepresented news So I join you in speaking up and asking the questions and taking action, and here at home in my beloved Alaska, I just say, politically speaking, if I die, I die.”

Palin has disappointed many of those who once had the highest hopes for her. She has stumbled over innumerable details. But as she said to Andrew Halcro years ago, “Does any of this really matter?” Palin has shown herself to have remarkable gut instincts about raw politics, and she has seen openings where others did not. And she has the good fortune to have traction within a political party that is bereft of strong leadership, and whose rank and file often demands qualities other than knowledge, experience, and an understanding that facts are, as John Adams said, stubborn things. It is, at the moment, a party in which the loudest and most singular voices, not burdened by responsibility, wield disproportionate power. She may decide that she does not need office in order to have great influence—any more than Rush Limbaugh does.

On a rare fine day in Juneau, not long ago, Palin was seen sitting in the sunshine in the broad plaza near the state capitol, alone with her thoughts and some reading material for more than an hour and a half. Down the hillside below her, the big cruise liners that ply Alaska’s Inside Passage in the summer months were beginning to call in the port. Only two years have elapsed since William Kristol and his colleagues disembarked from one of them and hearkened to her siren call. Sarah Palin might well have been wondering whether her own ship is going out, or just coming in.

Posted in Democrats, Healthcare, National Security, Obama, Politics, Polls, abortion, culture, economics, economy, gender, history, prayer, women | Tagged: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , | 2 Comments »

What Died With George Tiller

Posted by steveneidman on June 3, 2009

 

The Compassion of Dr. Tiller
 
George Tiller is frequently described as “controversial.” But in the tight-knit world of abortion providers and pro-choice activists, he was often called a saint.
 
 
MICHELLE GOLDBERG | June 2, 2009 | web only
 
 

The Web site A Heartbreaking Choice is a place where women share their stories of late-term abortion. Though clearly pro-choice, the point of the site is not political; it is a support group for grieving parents. These are women who desperately wanted their babies but whose pregnancies turned disastrous. A section of the site is devoted to “Kansas Stories,” because when women learn very late in their pregnancies that their fetuses have abnormalities that are likely to be fatal, Dr. George Tiller’s Wichita clinic, Women’s Health Care Services, was one of the only places in the country that could help them.

One woman described her elation at being pregnant and how the possibility of motherhood offered a glimmer of hope through several family deaths. Then she found out her fetus had severe spinal and cerebral deformities. “I laid on the table crying and knowing in my heart at that point my son was not going to make it,” she wrote. At almost 23 weeks pregnant, she was too far along for an abortion in her own state, and so, like many women in her situation, she made the anguished pilgrimage to Wichita.

Writing five weeks after her abortion, she said, “I hate that my son is gone. I hate that I had to make the decision to end his life. I hate that my womb and my arms are empty. But I am strengthened in the fact that I made my decision by focusing on him and what was best for him. I am eternally grateful to the wonderful people that guided me through this horrible experience with compassion, love, and understanding.”

Her gratitude toward Tiller and his staff is not unique. Ayliea Holl, the administrator of the site, saw a different doctor for her own abortion, but she’s met many of Tiller’s patients. “Every single one of them received the kindest, most caring and compassionate, the best health care that they could get,” she says. “Dr. Tiller was extremely compassionate. He was so helpful to so many women.”

After his murder, it’s not clear who will take his place. In the mainstream media, Tiller is frequently described as “controversial.” But in the tight-knit world of abortion providers and pro-choice activists, he was often called a saint, because he took on the hardest cases, whether they could pay or not, and was incredibly tender with his patients. “His clinic was known for really treating women with extraordinary decency and respect,” says Carol Joffe, a professor of sociology at the University of California, Davis, and one of the country’s foremost experts on abortion. They sent him volumes worth of letters of effusive and urgent thanks.

Tiller’s death is an incalculable loss to women’s health care. There are two other clinics that do late-term abortions, but neither are known for taking patients regardless of their ability to pay or for ministering so comprehensively to their emotional needs. Tiller’s murder leaves a void that could imperil women across the country.

Late-term abortion is often spoken of as the most morally dubious aspect of the abortion debate. Many people who are nominally pro-choice, particularly politicians, are quick to condemn it, to treat the work that Tiller did as repugnant even if it’s legal.

Ironically, though, many of the procedures Tiller did were as far away from the much-reviled concept of “abortion on demand” as one could get. Unwanted pregnancy can, to some extent, be prevented. A pregnancy that goes horribly wrong cannot. Almost anyone of child-bearing age could end up needing Tiller’s services. And now some of them will be forced to carry pregnancies to term against their will even when their fetuses can’t survive outside the womb.

Bill Harrison, an abortion provider in Arkansas, referred hundreds of patients to Tiller over the years. “To do what George does is like doing major cancer surgery,” he says. “It’s a subspecialty all its own. It took a real organization to do it safely and effectively and cheaply like he did it.” Over the years, Harrison had 20 or 30 patients who were so poor that he had to give them money for gasoline to get to Wichita. “I would call him and tell him about the patients, and he would say, ‘Send them up,’” he says. “Obviously if they couldn’t pay for gasoline, they couldn’t pay for anything, and he did the abortions anyway.”

Of course, not all of Tiller’s cases were as morally clear-cut as those recounted on A Heartbreaking Choice. Tiller performed abortions at 26 or 27 weeks for developmentally disabled abuse victims or girls who’d hidden their pregnancies and then become suicidal. Harrison himself is uncomfortable with such late abortions. When patients of his sought them, “unless they were a real threat to the mother’s life, and I consider suicide a threat to her life, we would talk about having a baby and putting it up for adoption,” he says. But it was precisely because such abortions are so grueling for everyone involved that Harrison admires Tiller’s willingness to do them. As everyone who knew Tiller points out, Tiller’s motto was “trust women.” He had the phrase printed up on buttons.

Tiller never set out to become an abortion provider, or even an ob/gyn. The son of a doctor, Tiller was working as a Navy surgeon when his father, mother, sister, and brother-in-law were killed in a plane crash. He took over his father’s family practice, and soon women started asking him if he was going to do what his father did. That’s how he found out his father had provided abortions in the years before Roe v. Wade. He committed himself to providing the same service.

“He came to this because it was what his patients needed in the middle of Kansas,” says Susan Yanow, the founder of the Abortion Access Project and a longtime friend and colleague of Tiller’s who referred many women to him. Whenever Tiller was asked why he endured the endless threats and harassment that came with providing late-term abortions, he would simply say he was doing what his patients needed. “George was able to be with the woman who was his patient in a truly unique way,” says Yanow.

Randi Berry saw what that meant six years ago, when her 14-year-old cousin got pregnant. Her cousin hid the pregnancy from her parents until it was too late to get an abortion in New York. At the time, her cousin’s mother, Berry’s aunt, was herself six months pregnant with twins. Her cousin was “having thoughts of suicide,” says Berry. “She was extremely depressed and isolated.” She and her family wanted an abortion but her mother couldn’t travel, so Berry accompanied her to Witchita.

It was a harrowing time, but at Women’s Health Care Services, “everyone was so gentle and understanding,” Berry says. “They gave us as much advice as we felt like we needed.” There was extensive counseling, individually and in groups. “One of the families that really struck me while I was there, their daughter was developmentally challenged and had a really difficult time communicating,” says Berry. “Her parents had no idea what had happened to her, whether she was raped or became sexually active.” Without Tiller, she says, “I don’t know what they would have done.”

The same is true, she says, of her cousin. “I have no idea what would have happened to my cousin if we had to go back to her and say, ‘Your only option is to have this baby and put this baby up for adoption.’ I don’t know if she would have made it.” Today, she says, her cousin is doing well. She finished school and has a committed partner and a young child. Berry isn’t sure how to break the news to her about Tiller. “I’m sure she looks to him as somebody who saved her life,” she says.

Whatever his own qualms about very late-term abortions, Harrison says that if he were younger, he’d take up Tiller’s practice. At 73, though, he’s already largely given up performing major surgery. “As I say, this is a complex, tough procedure, and I’m much too old to learn this new trick,” he says. Women will surely still come to him, sick or desperate or both and too far along for him to end their pregnancies. “I don’t know what happens to them now,” he says.

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