Single Payer Health Care in Vermont

                                                                         

The two articles below illuminate a broad swath of American healthcare initiative.

The first article, from Kaiser Health News, is entitled "Vermont Edges Toward Single Payer Healthcare." (October 2, 2011)

The second article, published hours ago, is entitled "Massachusetts Tries to Rein in Its Health Cost" and details Governor Deval Patrick's effort to bring cost containment to the state's "universal healthcare system" devised by Republican presidential candidate, Mitt Romney, in 2006 - http://en.wikipedia.org/wiki/Mitt_Romney

Excerpt (from "Vermont Edges"): Starting now, Vermont begins building a single-payer health system that will move many state residents into a publicly financed insurance program and pay hospitals, doctors and other providers a set fee to care for patients. Proposed by the governor and passed by the Democratic-controlled legislature, the new program will replace the traditional insurance plans currently used in the state and the traditional fee-for-service reimbursements, giving the state a system different from its 49 counterparts and more like its neighbor to the north, Canada... "Under the plan, single payer coverage will be a right and not a privilege, and will not be connected to employment," he wrote in a recent blog post.

Excerpt (from "Massachusetts Health Cost"): On the Republican campaign trail, the health care debate has focused on the mandatory coverage that Mitt Romney signed into law as governor in 2006. But back in Massachusetts the conversation has moved on, and lawmakers are now confronting the problem that Mr. Romney left unaddressed: the state’s spiraling health care costs. After three years of study, the state’s legislative leaders appear close to producing bills that would make Massachusetts the first state — again — to radically revamp the way doctors, hospitals and other health providers are paid. Although important details remain to be negotiated, the legislative leaders and Gov. Deval Patrick, all Democrats, are working toward a plan that would encourage flat “global payments” to networks of providers for keeping patients well, replacing the fee-for-service system that creates incentives for excessive care by paying for each visit and procedure. “We have shown the nation how to extend care to everybody,” Mr. Patrick said in an interview, “and we’ll be the place to crack the code on costs.”

Elsewhere... 

In the summer of 2011, friend David Stoltze M.D. - named "Family Practitioner of the Year" by the New Mexico Academy of Family Physicians - moved to Canada to establish his medical practice in British Columbia. I hope David will blog about his experience. I will keep you posted.

Immediately following the two articles below, I have pasted David's acceptance speech on the occasion of his New Mexico award.

David is the second American physician I know who has moved to Canada to practice medicine.

David's "F Word" speech upon receiving his "Family Physician of the Year" award is web-posted at 
http://paxonbothhouses.blogspot.com/2011/10/american-physician-re-establishes.html

                                                                                           ***

http://www.kaiserhealthnews.org/Stories/2011/October/02/Vermont-single-payer-health-care.aspx

Vermont Edges Toward Single Payer Health Care

By Jessica Marcy

KHN Staff Writer

OCT 02, 2011

Starting now, Vermont begins building a single-payer health system that will move many state residents into a publicly financed insurance program and pay hospitals, doctors and other providers a set fee to care for patients.

Proposed by the governor and passed by the Democratic-controlled legislature, the new program will replace the traditional insurance plans currently used in the state and the traditional fee-for-service reimbursements, giving the state a system different from its 49 counterparts and more like its neighbor to the north, Canada.


Many of the details of the system, including the key issue of financing, still need to be worked out and more legislation will be required to complete the transformation. But Democratic Gov. Peter Shumlin has moved quickly since taking office last January to set the state on a path to create the single-payer system, called Green Mountain Care.


"Under the plan, single payer coverage will be a right and not a privilege, and will not be connected to employment," he wrote in a recent blog post. "This is groundbreaking. But our success in guaranteeing coverage depends on our ability to control health care costs, so our plan is focused squarely on that goal."


It will be a unique endeavor; no other state has tried such a dramatic restructuring of its health care system, and national lawmakers backed away from such an option in the health care overhaul debate after vehement opposition from conservatives.


But, Vermont has been a pioneer on other progressive initiatives. It was the first state to establish civil unions for gay couples; and nearly 20 years before the federal health overhaul, Vermont reformed its insurance regulations to bar plans from turning down applicants because of preexisting medical conditions and limit rate variation. It also has one of the nation’s most generous Medicaid programs, as well as a higher percentage of insured residents and health care spending than many other states.


Shumlin recently appointed the five-member Green Mountain Care board, which had an official start date of Oct. 1. That panel will set plans for revamping the state’s health care delivery and payment system including deciding on reimbursement rates.


"Every state in the nation faces a crisis in terms of health care costs rising faster than our ability to pay," said Anya Rader Wallack, who will chair the Green Mountain board. "What's unique about Vermont is that we have a governor who has said, 'I want to fix this problem,' and he's put us on a tight timeline for fixing it."

Here are some of the issues involved:


What would the Vermont law do?


Green Mountain Care would be a state-funded-and-managed insurance pool that would provide near-universal coverage to residents with the expectation that it would reduce health care spending. On May 26, Shumlin signed a bill that started the process. However, the process will take several years. Many key details – such as how to pay for the system – remain unresolved.


The law allows for either a completely public system or a public-private venture where the state could contract out some administrative functions to private insurers. Employers with self-insured plans (usually large companies) would be able to keep their current health coverage.


The law:


--Launches a health insurance exchange as required by the 2010 federal health care law.


--Creates pilot projects to revamp the way health care is delivered and paid for, including possible efforts to use bundled payments, where a provider or group of providers would receive a lump sum for managing specific conditions, or creating a system called an "advanced medical home" in which doctors and other health care providers work together to improve the cost and quality of primary care.


--Establishes the Green Mountain Care Board. The board will provide oversight of cost-control initiatives, review and set rates for medical procedures and design the health benefit package. It will also create a cost projection and recommend a funding plan to the legislature.


How does it fit – or not – with the federal health care law?


Vermont wants to use funds offered in the federal law to build a health insurance exchange that would provide the basis for Green Mountain Care. Under the federal law, all states will have an exchange, or insurance marketplace for individuals and small business, by 2014 – or the federal government will set one up for them. But the law also allows states to seek a waiver from the specific federal requirements for running that exchange if they show they are providing at least equal coverage and benefits another way. Vermont is seeking a waiver to pursue the single payer system and not have to run two duplicative programs.


What are the benefits?Supporters say that a single-payer system is friendly to consumers and providers and will help reduce the rate of health-care cost increases over time. A Commonwealth Fund report concluded that such a system could cut health care spending by 25 percent after it is fully implemented in about 10 years. After adding coverage for the uninsured and expanding other services, including dental care, the system would save Vermont households and employers nearly $200 million in the first year alone. Savings would come primarily from lower administrative expenses, reduced fraud and abuse, greater delivery system integration and malpractice reform. The report also found that the system would create about 3,800 new jobs and increase the state's total economic output by more than $100 million in 2015.


Dr. David Himmelstein, a professor at the City University of New York’s School of Public Health and a proponent of a national single payer system, said: "If they follow through like they say they would, it would be a fabulous thing, an enormous gift to the nation."


What are the criticisms?


Some business owners worry about losing control over how they provide employee insurance and about the potential for more taxes. Others are concerned about legal and fiscal challenges.


In addition is the key concern about the costs for the state. The legislature had to deal with a $150 million shortfall this year. No Republican in the House and only one Republican in the Senate supported the bill. Some House Republicans blasted the governor for not dealing with the hard part -- how to finance the plan -- until after he campaigns for a second two-year term in 2012.


Meanwhile, some single-payer advocates believe that the new system does not go far enough. Himmelstein said that the law should be more explicit about not having copayments and deductibles and make a greater commitment to global budgeting, in which providers pay for a patient’s healthcare with a set fee for the year.


He also warned that private insurance could undermine government coverage in the same way that the existence of Medicare Advantage plans has prevented the general Medicare program from upgrading its coverage. “The only reason to buy private coverage when there is public coverage is if the public is not good. So it gives the insurance lobby a very strong motive to make the public insurance inadequate since that gins up business for them," Himmelstein said.


How likely is it that the program will be implemented?The next few years will prove pivotal in laying the groundwork for implementation. During that time, opponents will be able to organize. They have worked effectively in the past to kill other efforts, including former Gov. Howard Dean’s push to create a single-payer system in 1994.


Implementation may also depend on overcoming certain legal challenges including whether the state gets waivers from the federal government for Medicaid and Medicare because the system would change how health providers are paid for services in those systems.


Vermont might also face challenges from self-insured employers, who are protected by federal law from state regulations.


How will the state pay for the system?


Vermont is just beginning to examine potential funding options, including sales, income and payroll taxes. In two years, the secretary of administration will need to recommend a financing plan and then the legislature will vote on it.


First though, the Green Mountain Care Board will have to reexamine the costs of a single payer system and then present its findings to the secretary. "The governor said he won’t ask anyone to support a public financing system until he knows that we can do a sufficient job of cost-containment," Rader Wallack said. "So, we really see it as we have to do our work immediately in order to show that the system is sustainable before we ask for endorsement of any particular financing plan."

This article has corrected to say Vermont was the first state to establish  civil unions for gay couples rather than the first state to recognize gay marriage.

We want to hear from you: Contact Kaiser Health News

                                                              ***

Bill Clinton on Single Payer Health Care and mixed system Universal Healthcare http://www.youtube.com/watch?v=Mp7WEdcarp0&feature=related

                                                               ***

http://www.blueridgenow.com/article/20111017/ZNYT02/110173036/1008/sports?Title=Massachusetts-Tries-to-Rein-in-Its-Health-Cost

Massachusetts Tries to Rein in Its Health Cost

ABBY GOODNOUGH and KEVIN SACK

Published: Monday, October 17, 2011 at 4:30 a.m.

Last Modified: Tuesday, October 18, 2011 at 4:07 a.m.

BOSTON — On the Republican campaign trail, the health care debate has focused on the mandatory coverage that Mitt Romney signed into law as governor in 2006. But back in Massachusetts the conversation has moved on, and lawmakers are now confronting the problem that Mr. Romney left unaddressed: the state’s spiraling health care costs.

Enlarge | Buy Photo

Gov. Deval Patrick vowed to “crack the code on costs” and lower the state’s health care spending.

J. Scott Applewhite/Associated Press

After three years of study, the state’s legislative leaders appear close to producing bills that would make Massachusetts the first state — again — to radically revamp the way doctors, hospitals and other health providers are paid.

Although important details remain to be negotiated, the legislative leaders and Gov. Deval Patrick, all Democrats, are working toward a plan that would encourage flat “global payments” to networks of providers for keeping patients well, replacing the fee-for-service system that creates incentives for excessive care by paying for each visit and procedure.

“We have shown the nation how to extend care to everybody,” Mr. Patrick said in an interview, “and we’ll be the place to crack the code on costs.”

Those who led the 2006 effort to expand coverage readily acknowledge that they deferred the more daunting task of cost control for another day. It was assumed then that the politics would pit doctors, hospitals, insurers, employers and consumers against one another, and obliterate the fragile coalition behind the groundbreaking coverage law.

Predictably, the plan did little to slow the growth of health costs that already were among the highest in the nation. A state report last year found that per capita health spending in Massachusetts was 15 percent above the national average. And from 2007 to 2009, private health insurance premiums rose between 5 and 10 percent annually, according to another state study.

Yet the plan, which generated fresh attacks on Mr. Romney in a recent New Hampshire debate and a blistering Internet ad by Gov. Rick Perry of Texas, has largely succeeded in providing nearly universal coverage. Only 2 percent of residents and a fraction of 1 percent of children in Massachusetts are uninsured. The law’s popularity has given state leaders added incentive to make it financially sustainable.

But the process has been painstakingly slow. It started in 2008, when the Legislature appointed a commission to study changes in the medical payment system. A year later, the commission recommended the broad outlines of a global payment plan that essentially calls for teams of providers to be put on a budget for each patient’s care.

The networks would receive an annual fee for the care of each patient, with higher payments for patients deemed to be greater health risks and with bonuses for high-quality care. In theory, the healthier these so-called accountable care organizations can keep their patients, the more reimbursement they can pocket as profit. Insurers are already required to accept all applicants in Massachusetts, as will be the case nationally, in 2014, if the new federal health care law survives its legal and political challenges.

In February, three months after Mr. Patrick’s re-election, he submitted a bill that would impose a global payment system for most state employees, Medicaid recipients and others with state-subsidized health insurance — roughly one in four residents.

His plan would set parameters to help private insurers and providers follow suit, in the hope that they would gradually gravitate to global payments, without coercive legislation. And it would give the state’s insurance commissioner broader authority to reject premium increases deemed excessive, with an added goal of holding down hospital costs.

Lawmakers in each chamber have struggled to draft their own proposals, which they hope to bring to a vote by early next year. In the House, one idea is to move health care providers to a global payment system within three years, with a goal of keeping health care spending increases to about 3.9 percent a year after that — roughly the typical growth in the state’s gross domestic product.

But State Representative Steven Walsh, House chairman of the Joint Committee on Health Care Financing, said it would be crucial to move slowly, adding that it could take 15 years “to squeeze all the inequities out of the system.”

Because medical spending is driven not just by volume but also by pricing, a major question has been whether global payments alone will have much effect. It may be equally important, Mr. Patrick and others argue, to rein in the ability of the state’s most prestigious teaching hospitals and physicians’ groups to negotiate high rates of reimbursement.

A series of news media and government investigations have revealed that large, high-status providers, like Partners HealthCare System, which owns the Harvard-affiliated Massachusetts General and Brigham & Women’s hospitals, command substantially higher reimbursement from insurers than other entities.

In reports the last two years, Attorney General Martha Coakley, a Democrat, has concluded that differences in payments to hospitals cannot be explained by variations in their quality, the mix of their patients or the costs of academic medicine. Last month, the House majority leader, Representative Ronald Mariano, introduced a bill that would force insurers to narrow the inequities in payments.

Mr. Patrick said the state needed to help struggling hospitals by raising Medicaid reimbursement rates. But he also cited his insurance commissioner’s recent denials of premium increases as the kind of pressure needed to keep prices down. “I think having the authority that we have in respect to the insurers has been a very, very important tool,” Mr. Patrick said, “and we need similar authority with the hospitals.”

Massachusetts has had a model for global payments since 2009, when Blue Cross Blue Shield of Massachusetts, the state’s biggest health insurer, began experimenting with an “alternative quality contract” that pays groups of doctors and hospitals a set fee to work as a team in caring for patients. The plans cover about 613,000 people, or roughly two-thirds of Blue Cross members in health maintenance organizations, but none of those in preferred provider organizations.

This month, in an important advance, Partners HealthCare joined the program, with incentives to keep cost growth below the Blue Cross average.

“It’s a big deal,” said Stuart Altman, a health economist at Brandeis, “because they’re the biggest player in town and it sort of solidifies that this will be one of the major changes in the system and that it’s likely to be around for a while.”

Under market and political pressure, Partners also agreed to renegotiate its contract with Blue Cross Blue Shield and accept lower reimbursements, which is expected to save $240 million over three years. Andrew Dreyfus, president of Blue Cross Blue Shield of Massachusetts, said payments to Partners would increase at about 2 percent a year rather than the previously anticipated 5 percent to 6 percent.

The politically powerful hospitals clearly hope to persuade lawmakers that price controls are not needed. “This contract is evidence that at Partners, we think the market is working to address affordability,” said a company spokesman, Rich Copp.

Mr. Patrick said such experiments were important, but did not go far enough. “We still need a bill because we’ve got to have scale,” he said. “It can’t be one-offs.”

Initial resistance is also expected from doctors. The most recent annual work force study by the Massachusetts Medical Society found that nearly 60 percent of physicians — and higher rates of specialists — said they were not likely to join a voluntary global payment system.

But Mr. Walsh said that doctors and other stakeholders were becoming more comfortable with the idea. “It’s not seen as a foreign approach anymore,” he said.

                                                                                       ***

Until his recent move to Canada, David Stoltze M.D. was professor of Family Medicine at University of New Mexico's Medical School. David also served as guiding light for the public health clinic in Las Vegas, New Mexico, which David describes as "America's only socialist clinic". David co-founded the health clinic on the floor of Mexico's Cañón del Cobre (Copper Canyon), and, for 23 years, has been a dedicated builder of Nicaragua's health care system.

After decades of disenchantment with medical culture in the United States, David moved to British Columbia in the summer of 2011 to establish his practice there.

Currently, David is employed by Royal Inland Hospital in Kamloops, British Columbia’s second largest city - http://www.interiorhealth.ca/health-services.aspx?id=284

             

Acceptance Speech

by

David A. Stoltze, MD, MPH

Upon Receiving "Family Physician of the Year" Award

New Mexico Academy of Family Physicians

Annual Statewide Family Medicine Conference

Taos, New Mexico, August 7, 2004

First of all, I would like to thank the Board of the Academy for this award. I am surprised and grateful at having received it.

Although I am not usually in the habit of offering unsolicited advice on the personal level, I am going to make the leap of faith that being chosen for this award gives me a few minutes of "poetic license". I have been in practice in Las Vegas for 22 years now. I am reasonably happy most of the time, perhaps more so than many other practicing physicians my age, and I would like to share some of the things that I do to maintain my own personal happiness, as well as how I think personal happiness relates to the functioning of the health care system as a whole.

On the most personalized level, I have some daily activities that I believe contribute substantially to my day-to-day happiness. How many of you have read The House of God by Samuel Shem? (About half the audience responds). It’s one of those novels where you probably laughed a lot, but might not have been particularly proud of yourself for doing so. The cardiology attending in the novel is a rather stuffy but nonetheless somewhat insightful character who puts forward to the interns the idea of hobbies: "Do you have a hobby? Everyone needs a hobby. I have two myself: running for exercise, fishing for relaxation".

I actually have two hobbies myself, both of which are rolled into my activities-of-daily-living: bicycling for exercise, meditation for relaxation. Starting with the  2^nd of those, I wanted to acknowledge Dr. Bien’s presentation earlier today (Ed. Note: Dr. Tom Bien, a clinical psychologist from Santa Fe, gave a presentation at the scientific assembly of the conference entitled "Mindful Medicine: Finding Peace and Well-Being in Your Life and Practice" which was very well received). I have started most of my days with 20 minutes of meditation for many years now and have been very well served by it. In addition to being very relaxing and centering, it alters my perception of time in such a way that it is much easier to not be "in a hurry" throughout the day. I recommend it highly.

My other "hobby" is bicycling. I live in a small town (Las Vegas, NM, pop. about 20,000) and can get anywhere in town on a bicycle within 5 minutes of how long it would take to drive there. By bicycling instead of driving, I get my daily exercise without committing other "down time" to it, and I avoid over-reliance on the automobile, which, in my opinion, is the source of a great number of problems on a societal level.

On a personal level, I have had one other insight over the years which has been of great value to me: I have a fairly clear "take" on the relative importance of time and money. Many people, including physicians, when asked how much money they think they need, will reply, in effect, "a little bit more." I submit that all of us, as physicians, have "plenty", especially when viewed from the perspective of the world as a whole. Even the "poorest" among us is quite affluent on a world scale. What we are really in need of , I think, is more time. I have been very well served by this outlook. For several years now, I have only been working 8 months per year, primarily as a family practice hospitalist. When I am working, I am WORKING, just like most of us. During the other 4 months, I have been free to work on a variety of teaching and international health projects, be a husband and father, and, frankly, to just be a "slacker" from time to time (applause). There will be a wide range of individual differences among us at to where the "cut point" between time and money is, but I submit that we all have such a "cut point" somewhere.

As I mentioned a moment ago, the practice of meditation has been very helpful to me in terms of my perception of time. In addition, a few years ago, I made a New Year’s resolution to not be in a hurry. It’s often a difficult trade-off between working a little bit longer hours without being in a hurry versus having slightly more time at home.

The upshot of the life-style choices I have made is that, on the whole I think, I have been relatively happy on a scale of physicians. I can honestly say that I enjoy myself most of the time at work. That is not to say, though, that I am immune to the hyper-endemic hassles of day-to-day American medical reality. When we think of what we find irritating in medicine, it’s usually stuff that distracts our attention or promotes anxiety and is not directly related to medical practice per se.

One of these is certainly the medico-legal element of our work. While I do my best, frankly, to avoid having lawyers on the brain on a day-to-day basis, a certain amount of non-constructive fear-mongering is more or less inevitable. I’m afraid that until meaningful tort reform occurs, we are still going to be making, (and with some justification) poor-taste lawyer jokes (laughter, applause).

The other of these irritants is the endless stream of bureaucratic paperwork and other gratuitous harassment that we have to put up with. Our national health system has by far the largest administrative overhead of any industrialized nation—30% of the total health care budget the last time I checked. A great deal of very poor quality professional time is spent on all of these "prior authorizations", "formulary exemptions", "certificates of medical necessity", and various other arguments with insurance guys about whether a patient’s expenses are going to be covered. To me, these kinds of issues are the most irritating and time-consuming of our day-to-day distractions. And when one stops to consider it, the bottom-line purpose of most of these obstacles is to try to figure out ways to deny care to people! I suspect that most of these denials of care are not ultimately reflected as savings to the system, but as an increased bottom-line to the various profiteers involved in the administration of it.

Which brings us to the Canadian portion of our program…(laughter). First of all, I would like to introduce my wife Rosemarie, a proud Canadian. Rosemarie and I have often visited friends and family in Canada over the years, and we have been acquainted with several Canadian physicians. It would be very unusual for a Canadian physician to have a full-time employee whose only job description was to argue with the insurance industry all day. In our office (Editorial Note: Health Centers of Northern New Mexico, Las Vegas, NM, part of a large group of Community Health Centers), we have 2 people whose time is almost completely occupied with arguing with the VA all day long, and I-don’t- know-how-many others who spend almost all of their time battling the insurance and pharmaceutical industries. Is this how we want to spend our time? I don’t think so. And do we really think that Cimarron Salud or some such agency or combination of agencies can fix this situation? (Editorial Note: Cimarron Salud is one of 3 private HMO’s that administer the New Mexico Medicaid program) How many of you actually think that Cimarron Salud can fix the current situation? (No hands go up). Right! I didn’t think so.

Although my boss is out there in the audience, and I don’t want to irritate him too much, I can’t resist adding here that there is another benefit to making somewhat less money than one might theoretically "deserve". When I am handed some kind of a large form or other administrative document, I have a pretty short fuse for handing it back with a smile and saying, in effect, "Don’t go away mad, but go away." I don’t feel that I am being paid to do these things. Although I must admit that it makes me feel good for a while when I say things like that, it’s not really the solution to a systemic crisis of the sort we are facing.

I believe that nothing short of a system overhaul will fix our potentially excellent but highly dysfunctional health-care system. I agree with the Physicians for a National Health Plan -- Alan here... http://www.pnhp.org/  ///  http://www.pnhp.org/facts/single-payer-faq  -- and its local affiliate, which put forward the idea of a Canadian-style single-payer health care system. Do I think that this will solve all of our problems? No. The Canadian system is definitely not perfect. There is a more or less continuous and acrimonious conflict between the provincial governments and the medical societies which negotiate a standardized fee-scale province-wide. This causes the medical societies to function somewhat like trade unions. But, it gets a lot of the really annoying and time-consuming stuff I’ve just been talking about out of our faces on a day-to-day basis. At the end of the day, your average Canadian doctor takes all of his billing statements, puts them in an envelope, sends them to the provincial government and goes home. Wouldn’t that be easier? (Applause)

I’m sometimes surprised at the extent to which we physicians are unable to recognize our own interests. The issue of a single-payer system is commonly phrased as a struggle against government intervention. This implies that in the absence of intervention, we could still somehow be engaged in a kind of cottage industry, in which individual patients would pay fee-for-service in cash or with an "in-kind" service. Such an idealized system has not existed for a long time. I submit that the real decision to be made is not "government intervention versus no intervention" but "government intervention vs control of the health-care system by powerful for-profit corporate interests".

One of the side effects of a single-payer health-care system is that it places the debate about the health care budget into the realm of a more general political debate about national priorities. It is a variant of the age-old economic question: do we want more guns or more butter? We probably can’t have health care for all, a burgeoning military budget, and a big tax cut at the same time. Although the level of political discourse in this country often does not lend itself well to this type of complex discussion, I still believe it would be a good idea if we, as a nation, were more concretely presented with this decision-making process.

The various permutations of a single-payer system that have been proposed over the last few years have not fared well. This is, I think, partly due to skillful manipulation of public opinion by the insurance industry, partly due to our own misunderstanding of our interests, and partly due to the American political climate as a whole. That climate, unfortunately, has been deteriorating in recent years. It is presently characterized by militarism, extreme nationalism, and repression of domestic dissent. That combination of national priorities is, to me as an American, and more particularly as a German- American, very ominous. We already have a term in the dictionary for that set of priorities, and I'm afraid that I have to use "the f-word" here: fascism (silence). Do we want to go there for a tax-cut? I surely hope not.

In my "15 minutes of fame" I have tried to link the personal and the political, in terms of optimal strategies to maximize my (our) personal and professional happiness. I hope I have succeeded in at least provoking some on-going discussion of these issues. A good one-line summary might be Pete Seeger’s old slogan from the labor and folk-music movements: "Take it easy… but take it."

Thank you very much. (Applause)

                                                                             ***

22 Oct. 2004

To the editor:

I would like to make a point in relation to the upcoming election, and I believe that I can make it without mentioning any present-day American politician or political party…

Our family is German-American. Although we are not old enough to have lived through it ourselves, the absolutely darkest time in history was the Third Reich (1933-1945). Nazi Germany, as a nation, was responsible for World War II and the Holocaust.

The political stance of Nazi Germany was characterized by fascism. The term "fascism" arose somewhat before the rise of the Nazis in Germany, in Mussolini’s Italy.

What are the defining characteristics of the politics of fascism? Most dictionaries cite a combination of militarism, extreme nationalism (and, by extension, racism) and vicious repression of domestic dissent.

Fascism, however, is more than that. Otherwise, the term could be applied to any government with an extremely aggressive and warlike stance in relation to other nations and to its own domestic opposition.

The other aspect of fascism, which is key to understanding its political meaning and its relevance to contemporary politics was well articulated during World War II by US Vice President Henry Wallace. Vice-President Wallace pointed out that the political-economic configuration that brought about all of the more obviously negative manifestations of fascism was a complete merging of the state (government) apparatus with the most powerful and aggressive corporate interests in the national economy. In Italy in 1938, after a few years under Mussolini, the Italian parliament was dissolved and decision-making was vested in the "Camara di Fascisti e delle Corporazioni", a council of Mussolini’s inner circle and leaders of Italian corporations, whose main concern was the protection and expansion of their profits by the means mentioned above.

Events took a similar, but even more drastic course in Germany.

Of additional note, after the fascists (Nazis) took power in 1933, there were still many viable opposition forces there.

Unfortunately, they were unable to form a United Front, and were eventually relatively easily crushed.

I am reminded of well-known phrase "Those who fail to learn the lessons of history are doomed to repeat them".

Do we want militarism, extreme nationalism and repression of domestic dissent in the interest of maintaining and expanding corporate power to be the guiding principles of the US government?

David Stoltze, MD

1005 2^nd St.

Las Vegas, New Mexico