This series of commentaries now enters its fourth year in a continuing effort to achieve two goals.

Health care is a big-deal issue for all of us. It goes to the core of our personal well being, literally. It’s existential. Through the health care system we are assisted into the world; it is where we seek professional refuge in times of illness. For many it is the final reality before life’s end. Coming into contact with the health care system reaches deeply into, and often beyond, our financial resources. It offers the elation of successful treatment and the tragic news of failure. And it is accompanied by a mind-numbing administrative complexity. Birth, life and death (and maintaining health throughout) would elicit existential considerations even if we were still hunting and gathering our way across the Great Plains. But we aren’t hunters and gatherers, and determining how to address those existential issues has, regardless of the rhetoric of individual, market-based initiatives, become a national political question. And it has become so just as the systems of national governance seem to be fundamentally breaking down.

Our earlier commentaries have told the story of the unlikely journey through Congress of the Affordable Care Act, labeled immediately by the President’s opponents as ObamaCare, an appellation now seemingly accepted if not embraced by a White House looking to enumerate the administration’s accomplishments. Over these four years, we’ve also analyzed the emerging political realities that shape the evolving future of the health care reform debate. Today we would like to do both.

The political New Year begins with a narrowing skirmish for the Republican Presidential nomination. Mitt Romney, the man with the money but not “true conservative” street credibility, is fighting off challenges from a passel of non-Romney alternatives that would be more acceptable to the party’s true believers. Apparently, however, the true believers are experiencing the singular problem of not being able to agree upon their true beliefs. Social conservatives seem, for now, to be coalescing around former Senator Rick Santorum of Pennsylvania, though former Speaker of the House Newt Gingrich and current Governor of Texas Rick Perry are still in the race. Meanwhile, the libertarian wing of the base has, thus far, stood with Ron “The Energizer Bunny” Paul in the battle for delegates.

In the race for the nomination, “Repeal ObamaCare” has emerged as standard Republican boilerplate. Santorum, Gingrich, Perry and Paul all believe it, while Romney has managed to accommodate “that was then, this is now” to explain his current rejection of financing expanded insurance coverage pools by mandating that individuals purchase insurance. That he once described the individual mandate as wholly consistent with the conservative tenet of personal responsibility may or may not cost him the nomination this time around. Time will tell, but our role here is not to further add to the clutter of commentary and prognostication as we move towards the Republican National Convention in August of 2012.

How will a potential running mate enhance or balance the nominee’s ticket? Will a mystery candidate emerge? Might there be an extended round of jockeying for a third party candidacy? All that is in the wind, yet somehow we’ll get to the summer and the main event.

One insight from the early rounds, however, is that you’ll never be far off the pace by betting on MONEY as the driving force to a win. Money has long held the high-ground advantage, and in a post-Citizens United world of SuperPac tsunamis pouring unlimited and untraceable millions onto the airwaves and other electronic portals, we’ll likely see a televised-in-30-seconds-sound-bite campaign like never before. Hence, if for no other reason, the nomination is still Romney’s to lose even though surprise has been a constant companion this time around.

Politically, much has happened since our last entry in November.

As the inside bet had predicted, the congressional attempt to delegate its deliberative budgeting role to a bicameral, bipartisan twelve-member Super Committee (more formally known as the Joint Committee on Deficit Reduction) turned into a Thanksgiving turkey for which few gave thanks — save for those nostalgic about representative democracy. Republicans won’t, or with current representation can’t, produce an agreement which brings in net new revenue. Read: taxes. On the other hand, Democrats (putting their base on pins and needles) appeared more flexible in reducing spending and altering the parameters of current entitlement spending — though, politically speaking, party leadership in Washington may have felt it worth the bluff, as they were unlikely to have their hand called in this environment for any genuine compromise. Having faltered politically from December 2010 through the August debt ceiling debacle, the politics were risky. The Obama White House was already in danger of a serious loss of support by the Democratic base. Yet, the failure of the Super Committee left the President free for the next round of confrontation.

Health care interests were pleased by the Super Committee’s failure. Already at risk for an across-the-board two percent cut in Medicare reimbursement rates, service providers would surely have faced even deeper cuts, including reductions in Medicaid spending, had there actually been a long-term compromise. Yet, the decision by Congress last summer, when the Super Committee was established, to sequester money from the 2013 budget (of which, importantly, half will come from defense spending) if the Super Committee failed to reach a long-term compromise, has allowed “advantage Democrats” to slip back into the political equation for the first time in at least two years.

The political sands shifted further toward the President as Tea Party House conservatives ended the year with what Speaker John Boehner called, in understatement, “not the smartest political move.” With the White House framing the debate as “Democrats want to protect middle-class families by giving them a deeper payroll tax exemption” and “Republicans are out of touch with middle-class families,” the President finally brought a street version of Chicago politics back into his playbook. Without reliving the inane details too deeply, the bargaining devolved into a mess. Senate Republicans, being less beholden to Tea Party extremism in their ranks, but properly reading the political tea leaves, agreed to a two month extension of the payroll tax reduction and lived to fight another day. The House Republican leadership thought it could sell the plan, but ran headlong into the Tea Party Express who wanted no compromise with this White House under, apparently, any circumstance. Speaker John Boehner, trying to ride two elephants at once, finally said enough is enough and got his caucus out of town just in time for Christmas, leaving a huge political present underneath the President’s tree.

All of these machinations affirmed a long-time political rule: When you are most in trouble, count on your opponents to overplay their hand. From December 2010 to a year later, Obama has been strengthened by the very Congressmen who had achieved his mid-term defeat. He now has Congress (with a nine percent overall approval rating) as an institutional target for a reprise of Harry Truman’s, “give ‘em Hell, do-nothing Congress” 1948 campaign. A campaign, which Governor Tom Dewey and overly confident Republicans learned just a few hours too late, that Mr. Truman ultimately won.

In the November / December 2011 issue of La Cuadra, we published an  analysis of the Guatemalan presidential election by Kevin Casas-Zamora. In this edition, one of our regular readers and contributors, Paul Goepfert, takes issue with some of Casas-Zamora’s arguments. We value the contributions of both authors, and hope that La Cuadra can continue to serve as a vehicle for thoughtful political debate on conditions in this nation.

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Shall I part my hair behind? Do I dare to eat a peach? –T.S. Eliot

On, in my case, do I dare take on the Honorable Kevin Casas-Zamora, the former Vice-President of Costa Rica and Director of the Latin American Initiative at the Brookings Institution, whose article, Guatemala: Between a Rock and  Hard Place, was reprinted in the November / December 2011 edition of La Cuadra?

There is much with which to agree in that article, originally published by The Brookings Institution in September of 2011. In that piece he spoke of the near moribund political system and the vast, complex social issues that any government elected in November of 2011 in Guatemala would have to face. Yet, I can’t resist declaiming a vociferous “NO” to his suggestion that it didn’t much matter who would eventually win that election. Casas-Zamora opined in the piece that the dual national and international crises faced by Central American nations — corruption and narcotics transportation — would require an intense imposition of international governance on Guatemala if this nation were to stand a chance of maintaining its fragile democratic institutions. Whereas that would certainly have been the case had the eventual loser in that electoral contest, Manuel Baldizón, in fact, pulled out a win, I feel that one needs to give the current president, Otto Perez Molina, the benefit of the doubt.

As readers of either La Cuadra (March / April 2011) or The Harvard Review’s LaRevista (Fall 2010 / Winter 2011) may recall, I may have made the short list of most excoriating profilers of Guatemala in recent years. My negative prognostication for the future of this country was, perhaps, a photo-finish win for its own plethora of sordid details about Guatemala with Cassa-Zamora’s own.

Said succinctly, I have respect for Kevin Casas-Zamora, but I think he made some missteps in his analysis.

So what’s the problem?

I agree with much of what Casas-Zamora had to say, and I most especially agree with his description of Manuel Baldizón as “a populist buffoon of the worst kind.” Casas-Zamora is correct that Baldizón is a farrago whose one-fourth of the popular vote was “a reminder that unjust and violent democracies are doomed to walking on the edge of a cliff.” He got that right. Baldizón’s meteoric rise on the political scene has been a case-study in amoral, populist political opportunism filling a hole in the soul of a desperate nation: a hole left gaping by the failed hubris of Sandra Torres, the former first lady, and current divorced wife of Álvaro Colom, in her effort to buy the rural vote in an enormous, unaudited give-away from the meager state treasury. The positive take from that story is that both the Electoral Tribunal and the Constitutional Court rejected Torres’ bid for a presidential candidacy on constitutional grounds. That has been a huge step forward in a nation yearning for a rule of law.

But Casas-Zamora also cast a critical eye on the other candidate who made it to the second round of voting, retired general and current Guatemalan President, Otto Perez Molina. As has been the customary attack on Perez Molina (in two presidential campaigns),  Casas-Zamora brought Perez Molina’s official command position (as a local Commandante in Nebaj, Quiche) during a time in which the Guatemalan army has been accused by national and international human rights organizations of  massacres and even genocide. However, Otto Perez Molina’s name has never appeared in any of the extensive documentation about these horrific events.

I don’t mean to argue that Perez-Molina was an angel in camouflage fatigues. It was a long and brutal war that didn’t make for angels on either side. There have been claims by individuals in the Ixil Triangle area that guerrilla suspects were captured and interrogated by members of Perez Molina’s army command unit and died. While this may indeed be true, it deserves to be noted that there are, so far, no official denunciations. Moreover, in Guatemala: Nunca Mas, the Catholic Church’s four-volume documentation of massacres, extra-legal murders, and human rights abuses in general, the name of Otto Perez Molina, known locally in Nebaj as Comandante Tito, was never mentioned.

In the heated debate about military officers returning to executive positions in this new government, there is a great deal of historical amnesia. Some people think of the Guatemalan army as just a monolithic killing machine. This, in my opinion, doesn’t take into consideration the various factions and divisions within the army itself over these many, bloody years.

In this ongoing analysis of health care reform, we took a brief diversion (La Cuadra, Volume V, Issue 4, July / August 2011) to look at the political context in which the debate takes place.

That message would, of course, be embedded in the larger conservative dogma of: deregulate, drill and don’t ever tax people, especially the job-creators.

Meanwhile, Obama soldiers on: his drone-aircraft delivered message to Al Qaeda more effectively finding its mark than his domestic agenda to the American public. Despite success as community organizer cum Commander-in-Chief, the Great Recession has so far prevailed. Job plan follows job plan, ignored by Congressional opponents and suspicious supporters alike. Voters dislike the economic titans but government scores even lower in the polls. Movements to “Occupy Wall Street” highlight income inequality and have served, at least for now, to challenge deficit reduction in the headlines. Meanwhile, we await the Thanksgiving gift of the Supercommittee, hardly noticing our tacit admission that representative government is on the ropes.

We’ve come a long way from Joe Biden’s “big….deal” whisper into the President’s ear in what seemed a moment of genuine triumph, the passage of the Affordable Care Act (ACA).

Election Day is twelve months away, and while it’s never easy to predict the dynamics of a Presidential campaign, it seems likely that “ObamaCare’s” lightning-rod status on the Right has receded from its post-passage intensity. Unemployment has taken center stage. Deficit reduction, including Paul Ryan’s budget plans to dramatically alter Medicare, showed the potential to create big problems politically for the Republicans. And in any case, the likely Republican candidate Mitt Romney will hardly want to highlight “ObamaCare” as it is the issue on which his record most agrees with the President (before Romney’s epiphany with the Right).

While polls show a slightly negative tilt toward the health care law, fueled by partisan identification, there’s no consensus for an alternative. Many of the early improvements in existing insurance practices (staying on the parents’ policies, reduced pre-existing condition bans) even draw strong support. Still, the White House is wary. Given the signature passage of a law which had eluded Presidents for a century, health care may simply be too complicated for Sound-bite Nation. Further, the law’s real change (bringing coverage to thirty-two million more Americans in 2014) may not appeal to a fearful and divided land.

As such, while health care reform may not be the center of the Presidential campaign, the results of that election will go far to determine the future of health care reform in the United States.

Before any votes are counted, however, the Supreme Court may well have their say. A critical issue they may consider is whether or not the Commerce Clause of the Constitution permits the Federal government, as it does in the ACA, to mandate that persons purchase health insurance. A second issue, whether the Congress can order states to maintain nationwide standards for the Medicaid program, seems less likely to engage the Court. Beyond the specific issue of the purchase mandate will also be the question of whether the Court’s striking down that part of the law would invalidate the ACA as a whole.

A fascinating sidebar to this speculation is whether the Court will even take up the substance of the conflicting lower court decisions. Some argue that the Court will sidestep the immediate controversy by deciding that provisions of law which take effect in 2014 are hardly ripe for an immediate Constitutional test. That’s the substantive argument. A more nuanced issue is whether the Court, with its 5-4 Conservative majority, would want to directly challenge the Executive Branch with what might be perceived as a second “Bush v. Gore” type intrusion into electoral politics.

Whatever the action by the Supreme Court, the shape of the 2012 election frames much of health reform’s future. Most commentators believe the House will likely stay Republican. Absent an unforeseen realignment of the current political landscape, it seems unlikely, even with an ascendant grass roots movement on the left, for Democrats to overcome the 2010 Republican surge in the House.

With just about twice as many Democratic incumbents as Republicans up in the Senate (George W. Bush’s faltering 2006 popularity the proximate cause of a class of Senate Democrats facing their first reelection) and several vacant seats previously in the Democratic column up for grabs, improved Republican numbers, perhaps a majority, seems a likely Senate outcome.

Democrats would, under all but the most extraordinary of circumstances, at least hold a filibuster-empowered Senate minority.

The health care implications of the election would play differently depending on the scenario. Let’s consider some of the more probable post-election possibilities.

If President Obama wins re-election, he would most likely face an immediate ACA repeal effort from the House, perhaps with Republican majority support in the Senate. If that turns out to be the case and Senate Democrats in the minority then threaten filibuster, Republicans would likely counter with a turn to the budget reconciliation process to decimate both the subsidies and administrative supports necessary to implement the law. In this scenario, the most likely result would be the White House, urgently needing to find a governing consensus, open to at least some changes in the ACA.

With the same Congressional results, a President Romney would be faced with a remarkable set of choices. This really was his law before it became Obama’s law. In Massachusetts in 2006, he combined expanded public insurance, subsidized purchase of private coverage through an insurance exchange, and a mandate to purchase coverage (or pay a penalty) into a universal insurance plan. An individual mandate, argued Gov. Romney, was simply enforcing the conservative value of personal responsibility. There were to be no free riders in Mitt Romney’s Massachusetts plan.

When considering the unexpected consequences in development work around the world,

The year is 1947. The place is the Barren Lands of North-Central Canada, a half-day’s flight from the end of any railroad track. Two children, five and ten years old, are found in an igloo next to the frozen body of their mother. Their village is deserted — no other survivors are found. All other members of their remote community died from exposure, starvation or suicide. This tragedy began innocuously, benignly, even beneficially. It began as what some call “development,” but along the way it mutated, spread and destroyed what it aimed to foster.

For centuries the Inuit had inhabited the Barren Lands between Hudson Bay and Great Slave Lake. To say that they thrived may be an overstatement, but in their frozen wilderness they had survived as a people longer than most countries or kingdoms. They lived the nomadic life of hunters, heavily dependent on their wits and the herds of caribou. The Inuit had learned to make oil lamps that burned deer fat, bows from antlers and clothes from deerskin. They took sustenance from caribou meat. They were a model of sustainability, stability and subsistence in one of the most unforgiving corners of the Earth. They had lived much in the same way as had their ancestors who crossed Bering land bridge from Asia some 10,000 years ago.

Then came “development.”

In the late 1800’s, a fur trading company reached the area. A single outpost, a thousand miles from any road, extended its influence further north. The trading outpost offered bullets and seashells in exchange for the pelts of the Arctic Fox. With those traded goods, the Inuit could buy meat, candles, bowstrings and such. And while trapping Arctic Fox is no walk in the park, it is far less taxing than hunting Caribou. “Progress” dictated a change from hunting with bow and arrow to hunting and trapping with guns and steel. “Progress” brought a new variety to the Inuit diet. “Progress” dictated a change from an economy of subsistence to one of the market.

And then that market took a downward turn due to events several thousand miles removed from the Barren Lands. The fur trading company closed up shop. The proprietor of the outpost went into business for himself — a single man now controlling the entire fur market for over a thousand square miles. He did well for himself, as capitalists with monopolies tend to. Unburdened by competition, he exploited the Inuit and gave little in return for their furs. The Inuit response was to spend more time trapping, and less time hunting and preparing for survival. After several lean years, the trader moved on, leaving his sons to run the outpost. They ran the business more fairly than their father, but “development” and “progress” had taken their toll. The Inuit now made their living almost exclusively by trapping fox, and much of the generational knowledge had been lost. The dependency to a larger world that development had fostered led to the displacement of subsistence skills in favor of market skills.

True, the Inuit tribe knew how to survive day-by-day. However, the resilience of a society, a people, or even a species is shown not in day-to-day life, but in extremis. Those extreme circumstances came in the winter of 1947. The caribou left the region early that winter and the Inuit, preoccupied with their trap lines, had failed to set up adequate stores of food or oil. Then the winter came early and fierce. In an early generation, this band of Inuit (like Inuit all over Northern Canada) would have hunkered down and lived off their stores of caribou. Instead, they had piles of useless fox pelts.

Hunger came, then starvation. Blankets and clothing made of animal hide were boiled for whatever weak porridge they could produce until no fuel remained. Some fled the community for a precarious fate in the frozen tundra. Others remained to face almost certain starvation. Those left behind butchered their dogs and ate them raw — an act of utter desperation in a community dependent upon sled dogs for mobility. The old ones chose their time to go, walking naked into the frozen night, leaving the meager scraps for the younger generation. The ancient custom that the hunter must be fed first was broken so that the children might survive.

News of their plight eventually reached Canadian officials by relayed Morse code. The official reaction was well-intentioned, but misguided. Sacks of dried white beans were shipped (and cached) some 200 miles from those in need. Two hundred miles, or two million miles wouldn’t have mattered. The starving had neither the strength nor the dogs to pull their sleds to the food.

Records from the debt log of the fur trading company indicated that there were fifty families who perished. An outpost of a civilization that had survived for millennia was erased in fifty years.

Mowat featured this story in his book, The People of the Deer. Like all his books, it comes highly recommended, and should serve as a warning to those of us who work in the world of “Economic Development.” The story is a warning to consider the unintended consequences of our actions, and a warning to ask the question at every turn: What is the cost now and what will it be down the road? 

I am the director of As Green As It Gets, a development project in Guatemala, and I’m constantly engaged trying to answer the difficult questions surrounding the law of unintended consequences. For example: every year we are offered a donation of 90-day corn seeds that promise to increase food yield. Every year we say “No, thank you.” The donor is aghast. These corn seeds are an improvement — they represent newer technology and more food for the people. Why would anyone say no?

The story of the traders and the Inuit may seem far removed from Guatemala today, but we need to consider, “what might be the unintended consequences?”

Will this “improved” corn blow down when there is a hurricane on the coast? Can the stalks be used to build houses like our unimproved, local variety? Are they strong enough to support the pole beans that will be planted at their base — the beans that provide protein for families and nitrogen for next-year’s corn? Are the proving grounds of Illinois an accurate representation of Guatemala? Does our local corn have a resistance to tropical diseases that weren’t studied by Monsanto? Perhaps the question is better phrased: “How many diseases does our local corn resist that were NOT studied by Monsanto?” Are the seeds fertile or sterile hybrids? If they are sterile, how do we plant next year without depending on another handout? If the seeds are fertile, will Monsanto sue us for collecting and planting them? Most difficult of all: “Am I intelligent and informed enough to even ask the right questions?”

Or perhaps that’s the easiest question, as it’s the only one I can assuredly answer: I’m not.

But that’s only the first level. The problems become more complex and theoretical. What is the value of a corn field compared to a forest? What discount factor do I apply to the future value of the forest when I choose to cut it down and plant corn? Is our goal to maximize food production, to maximize quantity of life, or to maximize quality of life? Do we have the right to decide this question? Which is a greater sin: to allow a child to starve, or to cause future starvation by short-term development under the banner of feeding the children? If I am fully cognizant of population dynamics, and understand that increased food production leads to population growth, which implicitly means a de facto decrease in quality of life for the next generation, can I in good conscience increase food yield? The answers to those questions will yield Masters’ theses in Agronomy, Economics, Philosophy, Ethics, and Mathematics. The danger isn’t in the difficulty of these questions, but in how seldom they are asked.

As Green As It Gets helps Guatemalan farmers plant and sell coffee. As coffee is a cash crop, I’ve seen corn fields turn to coffee fields. Production of food gives way to the production of cash with which to buy food, thus maybe I can answer my theoretical questions. The future value of the corn field is low, and the future value of the coffee field is high. We are minimizing (local) food production to maximize (local) quality of life by putting more food on kitchen tables, though it wasn’t grown here. No one starves. We have secured the moral and economic high ground. If the current market economy will be the future means of distributing wealth, then the farmer will be in an increasingly strengthened position to provide for his family. But do I make the mistake of measuring that strength today, a relatively average point in time? As the Inuit and countless others have learned along the trajectory of their “development,” crisis happens in extremis.

Maybe the better question is this: What happens when coffee production has completely supplanted corn, the local coffee harvest has failed and the world market is glutted?

Are those conditions really so unimaginable?

Only if the following conversation is also beyond imagination: One Inuit hunter turns to another and says: “Why not give up on the caribou? The future’s in fox pelts.”

In the world of “development,” we tend to measure success in seashells and fox pelts, coffee beans and dollar bills. Yet, I can’t shake this nagging feeling that we’re using the wrong units. I don’t know the right answer, because I’m not even sure which of the countless possibilities will grow from the question I didn’t even think to ask.

A number of attacks in Antigua on the night of August 18 sparked a CNN iReport post entitled “Bloodbath in Antigua,” a stern warning from the US Embassy, and the spreading of alarming rumors on origins of the violence and its possible connection to narcotraffickers, gang violence, political corruption or a mixture of all three.

“On August 18, I met a friend for drinks at [a local bar]. We were ready to leave by midnight and called a taxi,” P. recalls. “The taxi never came, so we decided to walk.”

They were headed to a friend’s business to wait for a ride only three blocks away.

“We had walked one block when a black pickup truck with a camper flew past us and suddenly stopped. Two guys jumped out, and I instantly knew they were coming for us,” P. remembers. She was mugged last July, so she had a gut feeling. The first time she was attacked, she fought with the mugger who struck her forcefully on the head before fleeing with her bag.

“This time I took off my bag, flung it to the guy, and turned to run when I felt him stick a knife in the back of my leg.”

P.’s friend was also attacked. “She kept saying, ‘No tengo nada! No tengo nada!’ but the other man cut her arm twice,” P. said. “The guys looked as if they were crazed on drugs.”

The men returned to the pickup and fled. P. felt confused and disoriented. She could not find her way. Her leg was bleeding badly. “I was wearing a long skirt and it was completely drenched; I was dragging it on the ground while trying to walk when a cab stopped. The driver realized what happened and gave us a ride.” Once they arrived at her friend’s business, someone called the paramedics, and the Bomberos Municipales arrived shortly thereafter.

P. and her friend climbed into the ambulance only to find another stabbing victim already inside. His name is Jake Blanco, from Canada. He was stabbed after he stepped out of a bar to smoke a cigarette and was one of ten victims that P. met or heard about. Not all of them appeared in police reports.

The CNN iReport posted on August 21 listed eight victims (six Americans, one Australian, and one Guatemalan). The Bomberos Municipales only recorded four emergencies. The victims were taken to the public hospital, Hermano Pedro, in the early hours of August 19. At 6:00 a.m. the Bomberos Municipales also picked up a Guatemalan woman with a bad cut on her left ear. She was wearing corte and güipil, traditional dress, and had no ID. This information appears on records from the Bomberos Municipales Antigua station, according to paramedic José Juan García.

The Bomberos Voluntarios did not cover any emergencies in Antigua that evening, according to their spokesperson Hugo Galindo. However, the National Civilian Police (PNC) recorded four people attacked with a knife. The PNC’s spokesperson, Donald González, revealed that all four reported being attacked by men traveling in a brown pickup truck and a motorcycle.

The police reported one case in addition to the Bomberos Municipales: a Guatemalan, Francisco Monroy, who suffered minor knife wounds and was found on Alameda Santa Lucía around 1:30 a.m. on August 19, according to Officer Erick Tórtola, deputy chief of the PNC Sacatepéquez precinct.

The director of the state hospital Hermano Pedro, Dr. Miriam López, released records which show that three foreigners and one Guatemalan with stab wounds were admitted in the first hours of Friday, August 19. When considering these numbers, however, it should be noted that P’s friend was not listed on any official reports. Further, Blanco, Monroy and P. all reported that there were more victims.

“I met a couple from New Zealand at the hospital who had been mugged near La Merced by men on a yellow bike around 8:30 p.m.,” P. recalls. “They took their money and credit cards, and slashed the man’s face,” P. makes a cutting gesture, to show that the cut went from the right eyebrow to his jaw’s left side. “I also know of a gay couple who was attacked and went to a private hospital,” added P.

It is possible that the hospital records are incomplete due to some of the victims not being treated promptly, opting for a private clinic or not seeking medical help at all. Still, P. is certain that some who were at the state hospital do not appear in the official records.

Scarce Information, Heightened Alarm:

Local authorities and paramedics dub the attacks as “very unusual” for Antigua. Renato Melgar, from the Bomberos Voluntarios, says they cover — on average — one stabbing incident per month in Antigua. “Most of the cases are from the villages surrounding Antigua, or from other areas in Sacatepéquez,” says Melgar, who has worked at the Antigua station for ten years. Officer Tórtola agrees. He says that the only stabbing victims in Antigua between January and September 6, this year, are the five cases from August 18. The officer was assigned to Antigua last February.

Dr. López says the hospital treated only two other stabbing victims this year from Antigua. One on August 28, the other on September 5. These numbers strike a contrast with those for the entirety of Sacatepéquez. López revealed that the hospital treated 63 people with knife wounds, and 45 with gunshot wounds between January and August 2011.

The events of August 18 caused great alarm in the community, particularly as reports of an increase in criminal activity could drain an already compromised year for tourism, and a public meeting was called to address the issue. The meeting provided a forum for mutual accusations between the police, municipal and tourism authorities, and the local chamber of commerce. During the meeting a flurry of security measures was proposed, including an increase of police presence on the streets. It remains unclear what measures will be taken.

The fear of business owners who depend on tourism is real and fueled by crime elsewhere in the country. Some hotels in Antigua had large group cancellations after the May 14 massacre of 27 peasants several hundred miles away in Petén.

Misinformation and Solutions:

The PNC still knows little about the assailants who acted on August 18. P. only remembers that they were short and dark-skinned. But there is also no explanation as to how the “Plan Cuadrante” did not prevent the attacks. This plan involves two police officers assigned to patrol each cuadrante (a square with sides of two blocks each) by foot or car.

P. says the attack was quick, and Tórtola explains that “the assault could have happened when the police were two blocks away” However, this explanation would have to fit the other cases, as well. And the attacks took place over a four hour period, between 8:30 p.m. to 12:30 a.m. How this could have happened was not addressed.

Yet, Tórtola complains that the police alone cannot provide security. “It would help to have surveillance cameras and a joint command center with the traffic and tourism police,” he says. “There are smaller towns like Pachalum, Quiché, where the mayor installed cameras, or Mixco, [close to the capital, and much larger], where the municipality works together with the PNC.” In Antigua there are cameras, but they are not functioning, the blame being placed on insufficient funding from the municipality or business owners — some of whom scramble to make ends meet. Still, cooperation between the PNC and the municipality is showing some signs of progress.

“This month we began a combined patrolling program involving the PNC, the Municipal Police [PMT] and the Army,” says Tórtola, as a result of the August attacks. Yet, the PNC doesn’t have an answer for the reluctance some individuals feel towards reporting crime.

This reluctance had some effect on the night of the eighteenth. P. admits that she didn’t feel comfortable talking to the PNC. “I am not sure what my rights are as a US citizen in Guatemala,” she says.

Tórtola wishes more foreigners would trust the police. “The police is not what it used to be; we are different now,” he offers, perhaps alluding to a history of corruption which, while it still exists, does not involve all officers. “I have even given tourists a ride,” he says, genuinely surprised that there is a lack of trust. “Sometimes we get the information two or three hours later by a third party, when it’s too late to catch anyone,” the officer says.

Speaking of ways that the public could be more mindful of its own security, Tórtola mentioned the consumption of alcohol. “If [people are] drinking, and it’s late at night, they become a target,” he said. Further, he noted again the lack of technological sophistication in Antigua. “If we had cameras in key locations, we could monitor most of the town and act faster on suspicious vehicles and situations.” When asked whether the police would stop a pickup truck if spotted speeding at midnight, Tórtola says “yes” without hesitation.

Due to the attacks, which the authorities took pains to point out were highly unusual for Antigua, some foreigners have chosen to leave town. Others, however, have decided to stay. Even after being mugged twice in the last three months, P. is philosophical.  “I learned a lot, but this raises the question of what will happen next time.” As she speaks she is stroking a small bump on the side of her forehead, a scar she bears from the first attack. “This whole thing has made me think of ways to better protect myself. I feel that if I leave [the criminals] win. I don’t want to die, but I don’t want to leave either. I like it here.”

P. is still coming to terms with the attack and its aftermath. In many ways, Antigua is trying to do the same.

Presidential candidate Herman Cain, at the Family Leader Presidential Lecture Series in Pella, Iowa, promised that in his Administration no congressional bill longer than three pages would be signed into law

The comment led to a recent campaign kerfuffle between Jon Stewart and Fox News. Stewart, mocking Cain’s lack of interest in reading with a mildly black inflection in his delivery, opened the door for a twenty-four hour Fox assault against the “racism” inherent in Comedy Central’s treatment of Cain, an African-American, Republican Presidential candidate, talk show host, and former CEO of Godfather’s Pizza chain.

In one sense, this was just another blip in the seemingly endless, twenty-four hour news cycles which will guide America to the 2012 Presidential election. Lost in the haze of commentary, the Cain / Stewart / Fox imbroglio disappeared just days later when MSNBC commentator Mark Halperin referred to Barack Obama as a “dick.”

And thus passed another week in America.

But wait a minute. Stop the torrent of emptiness. Herman Cain said that bills, indeed laws, should be only three pages long. Cain may be trapped in the Tim Pawlenty range of public opinion polling among Republican candidates, but he’s there on the debate stage. If the presidential campaign were like the NCAA Basketball Tournament, then in political bracketology, Cain is past the sweet sixteen, heading for the elite eight; he’s a businessman with a flair for language; he once famously challenged Bill Clinton on health care during a 1994 town hall meeting; and he represents a legitimate constituency within the orbit of his party.

And he said that bills should only be three pages long.

Consider this: What if, at this stage in our democratic experiment, this really is the debate that matters?

One of Majority Leader Eric Cantor’s attacks on health care reform (the Affordable Care Act or ACA) was its length. To express this he carried around the 2700-page bill to various televised committee meetings and press conferences and repeatedly referred to it as “this behemoth 2700-page bill.” So, is Cain exercising extreme hyperbole, or is he merely extending the “wisdom is inversely related to volume” logic of policy debate? At what point do clips from the campaign trail begin to actually shape the substance of policy discussion? Are we at risk of ever more examples of “death panel digressions” defining real decisions?

That should be a sobering thought.

Our enormous challenges today are to escape the depths of the sinkhole into which the American economy has fallen — to create real jobs, to teach the kids the skills for a new century, and, as has been my professional focus, to assure affordable health care for our people. All of this proceeds within the context of an intensely competitive world economy and physical threats to safety and security. You can build your own list of the big issues. But we can agree: there’s heavy lifting ahead.

This series of commentaries in La Cuadra has provided a contemporaneous account of, now, almost three years of health care reform debate — an important but discrete corner of the big picture. In this summer of 2011, a number of states are taking the initial steps to prepare for the coverage expansions scheduled for 2014 under the ACA, and an even larger group of states have joined in judicial challenges to the law, which will likely be resolved by the Supreme Court during the 2012 election season. Further, health care policy plays prominently in the continuing struggle between the President and the Congress to reach agreement on raising the national debt ceiling.

As described in our most recent commentary (La Cuadra, Vol. V, Issue 3, May / June, 2011), House Budget Committee Chairman Paul Ryan (R-WI) recently proposed a repeal of the Affordable Care Act and a series of reforms which would include the creation of block grants to pay for a reduced Medicaid program, and, in 2022, a full redesign of Medicare into a voucher support system. His proposal gave vitality to both parties. Ryan earned accolades for his courage from the right, and he enabled Democrats to unify in opposition, especially to the long term restructuring of Medicare.

Now in the heat of summer, the Republicans argue for no new taxes, no way, never again. The White House focuses on eliminating tax breaks for corporate jets, tax preferences for the oil and gas companies, the rich in general, and, borrowing a theme from Harry Truman 1948, Congressional indolence. President Obama’s centrist instincts offer up a hundred billion, here or there, in health care cuts obscured in a maze of formula changes.

Meanwhile, the nation lurches forward toward an early August deadline to increase the debt ceiling or, if the politicians are unsuccessful, an end to the world economy as we know it. Just another day in Politics, USA.

Which brings us back to Herman Cain.

At what point does the caricature of debate take control of the nation’s destiny?

The Spring 2011 version of the health care debate has taken on the look of Russian matryoshka dolls, although one measures the risk of conspiracy theory in even mentioning the term.

Recently the debate has been dominated by changes proposed for the future of Medicare. House of Representatives Budget Committee Chairman Paul Ryan, a Republican from Wisconsin, advanced a proposal to shift Medicare from the current program which pays doctors and hospitals directly for services provided to the nation’s seniors to an approach called “premium support” by analysts, vouchers to the layman, where the federal government provides financial subsidies to seniors who would then buy insurance coverage in the private market.

The change would take effect in 2022, more than a decade hence. It would have no effect on current beneficiaries or those who reach 65 years of age between now and 2022. The value of the vouchers would grow at the rate of the Consumer Price Index (CPI), estimated at 2.5 percent annually. Per capita health spending is projected at 5.4 per cent annual growth. Under this plan, therefore, the beneficiary would be exposed to dramatically higher out-of-pocket costs over time. Ryan argued that a drastic cut in future Medicare spending was an essential step if the nation was to reduce dramatically its long-term debt.

Medicare beneficiaries, according to Ryan, could limit their own out-of-pocket costs by shopping for value in an open health care market. Skeptics, however, see the proposal as a massive cost shift to future seniors.

For Democrats, Ryan looked like a political Easter Bunny. He had broken the Government’s promise that future retirees could depend on access to necessary health care. Democrats knew that the same block of senior voters who had abandoned them in 2010 over the fear generated by largely false charges against the Affordable Care Act could be encouraged to suspect the Ryan agenda, even if protected from its provisions. Seniors are back in play for the Democrats in 2012.

House Republicans adopted the Ryan proposal, along with other deep reductions in spending, as part of their budget resolution for 2012. They have recently signaled caution, however, in pushing the dramatic Medicare proposal further before the 2012 elections.

As attention retreats from this skirmish about Ryan’s long-term vision for Medicare, now more than a year after passage of the law, the Obama Administration is carrying out the early provisions of the ACA.

Programs to allow high-cost, high-risk previously-uninsured persons to buy coverage, with federal financial support, now exist in every state. In half, the states took the lead. Elsewhere, in those states opposed to the ACA, the program is under federal control.

New provisions halting the ability of insurance carriers to deny coverage for pre-existing conditions for children or to terminate the coverage of high-cost patients have taken effect. While some temporary waivers have been granted, provisions capping the ratio of administrative to medical care costs in determining health insurance benefits have been applied.

Along with billions of dollars in federal aid to support the adoption of electronic health records by doctors and hospitals (a provision of the 2009 Stimulus Law) federal authorities are providing grants and developing regulations to encourage the creation of better coordinated and more cost-effective arrangements for providing care. The idea is simple: Don’t pay separately for every doctor’s visit, every test, every procedure; instead, require that doctors, hospitals, pharmacists and other providers work together. Pay them to maintain quality standards, but also with incentives to reduce costs.

Administration leaders also have provided grants to selected states to improve enrollment practices in public insurance programs for the poor. Further, they have begun planning for the exchanges which will be the “insurance stores” through which individuals and businesses will purchase insurance, thereby avoiding a mandated tax penalty for remaining without coverage. Both individuals and businesses will also access subsidies through these exchanges.

As Barack Obama stepped to the microphone, Joe Biden, with a stage whisper said, “This is a big deal.”

At least six twentieth-century Presidents had advanced comprehensive health care reform. All had failed.

President Lyndon Johnson’s enactment of Medicare and Medicaid in 1965 and President Clinton’s second-term insurance expansion for children were partial steps which, in their targeting (of the elderly, the disabled, kids, a fraction of the poor) served to emphasize the gaps in America’s patchwork “system,” unique among industrial countries. And still, by far, the most costly.

The Affordable Care Act, ACA to its friends, “ObamaCare” in the attack commentary, had found its way to the President’s pen in the form of two interdependent bills. In three earlier commentaries, we offered La Cuadra readers a more-or-less contemporaneous analysis on the substance and politics of the legislative journey.

Now, nine months (and one electoral shellacking) after the President’s “victory” lap, the law is indeed a big deal. But the political debate it ignited may be inching, even more so, toward a defining moment for the American Republic.

The ACA, as we have written, was a big step, but confined to a familiar path. It filled the gaps in insurance, imperfectly, by expanding Medicaid coverage to an estimated sixteen million people and by creating insurance exchanges (organizations which provide online or in-person comparisons of coverage and price information) to offer subsidized private coverage to sixteen million more. It continued to rely on voluntary employer-provided coverage, with modestly increased incentives, for the bulk of the population. After implementation in 2014 and beyond, around twenty million people will still be left without coverage. Of that number, roughly seven million will be undocumented immigrants who, due to opposition demands during the drafting of the bill, are ineligible to participate in the exchanges, even with their own resources.

Congress built a major part of the expansion on the Medicaid program, the nation’s state-operated, federal-and-state-financed, “safety net” benefits program for the poor, the disabled and the low-income elderly. Under Congressional Budget Office (CBO) “scoring,” Medicaid was the least costly expansion alternative since it traditionally pays doctors and hospitals less than Medicare and private insurance for comparable services. The ACA requires that Medicaid income eligibility be set uniformly at 133 percent  of the poverty level, or just under thirty thousand dollars for an average family. While the Federal Government would pay well over ninety percent of the additional costs, the uniform standard would double, even triple, Medicaid eligibility in more than a dozen states that have historically resisted government obligations for the poor. The divide is cultural, to some extent racial, and now emerges at the core of the Red State opposition to this most recent perceived federal intrusion into states’ rights.

Similarly, an inside-the-process quirk gave states the major role in creating insurance exchanges. When Scott Brown’s election in Massachusetts reduced the Democratic Senate count below the sixty-vote supermajority required now for routine business, the ACA could proceed only by using the Senate’s focus on state implementation of insurance exchanges rather than the House version built on a national strategy.

While the law still contains the authority for residual national action, the immediate state focus gave impetus to what are now more than twenty state legal challenges, alleging that the ACA’s requirement that individuals ultimately face a tax penalty should they not purchase coverage oversteps the bounds of the Commerce Clause of the Constitution. The argument is that if you don’t buy insurance, you are not participating in commerce and therefore can’t be regulated. The law’s supporters say that this is all about how we pay for health care rather than narrow individual action, clearly interstate commerce, and that insurance purchased voluntarily as sickness occurs defeats the entire scheme of shared risk. A Supreme Court decision will likely clarify the legal dispute. Should the plaintiff states prevail, an amendment to the ACA increasing premiums for those who delay enrollment would be required. The political importance is this: even a Supreme Court ruling against the mandate will not repeal the law. It would require that other, perhaps less effective, methods be implemented to achieve broad participation in the exchanges.

These insurance expansions, through Medicaid and subsidized exchange-based purchase, are the “big deal” changes in the law. Additional provisions will guide and support reorganization among doctors and hospitals to assume more responsibility for better coordinating patient care and will provide grants and eventually revised Medicare payment protocols to support the improvements. The watchwords are “value not volume,” replacing fee-for-individual-service payments with new approaches that reward overall quality of care. Anticipated is that private insurance and Medicaid will follow Medicare’s payment-reform lead. To most observers, the cost-control provisions of the law move in a positive direction but fall far short of the targets set later in the year by several proposals aimed at reducing the long-term national debt.

Finally, part reform and part political tactic, the ACA has imposed, almost immediately, a series of changes in the practices of the health-insurance industry. Lifetime caps on coverage are lifted, pre-existing conditions for children, later for adults, can no longer be used to deny coverage, young adults nineteen to twenty-six can stay on their parents’ policies, sickness no longer means cancellation of a policy. High-risk arrangements are now available in every state, some under national administration, to insure those previously deemed uninsurable.

In addition, seniors were given a bonus payment toward their doughnut-hole gap in Medicare drug coverage, moving toward its eventual elimination. Doctors can even discuss real care choices with dying patients as part of a routine visit. Myriad specific and immediate “improvements” were seen by the White House as concrete steps toward building public support for the law prior to its 2014 implementation.

The cable chatter about Scott Brown’s surprise

But wait a minute. Inside the polling data was a more subtle message. No doubt, opinion was mixed to negative, in some polls even strongly negative, on the results of Congressional action. But inside the specifics, significant majorities – not only of Democrats, but Independents and even Republicans – favored reforming the practices of health insurance companies that allow them to avoid coverage of sick people, favored creating health insurance exchanges, were in support of closing the Medicare prescription drug “doughnut hole,” providing tax credits to small business, and increasing insurance pools for high risk individuals.

And on a deeper political level, Massachusetts voters offered the nation some genuine irony. In some ways, referring to their own 2006 comprehensive insurance law – a law crafted with significant federal financial support and bipartisan political leadership which is a virtual framework for the current federal proposals, they said, “We have a plan and we like it. Why get Washington involved and pay for everyone else? Let’s vote for Scott Brown.”

What’s going on here?  In a world of focused messages and instant expectation, it is important to remember that Congress represents, however imperfectly, the complexity, the diversity, and even simply the size of America. The House, based on population, faces voters every two years. The Senate, two votes per state, big and small alike, faces voters less frequently. And the Senate now requires a sixty vote super majority for virtually all business. And yet, facing multiple committee jurisdictions and never far removed from special interest influences, both Houses of Congress, amazingly and indeed historically, did pass significant reform bills.

But the price of process was high. Time and momentum had been wasted. Indefensible personal deals had been struck. Moreover, the leaders of the Congress, both Democrats and Republicans, elevated to their roles because of their skill inside their institutions, had become the public faces of the issue. And large segments of the electorate, fearful in a faltering economy and reminded daily of the uneven distribution of opportunity, wealth and power in the nation, were driven in their frustrations to the negative side of the polls on Congressional Health Reform. But maybe it’s the “Congressional” more than the “Health Reform” that they really didn’t like.

Inside the Obama White House the answer couldn’t have been more important.

While never putting his name on a specific bill, the President had identified Health Reform as central to his vision of future economic security. They were almost there. Throughout late December of 2009 and early January 2010, Congressional leaders convened at the White House, with the President at the table to work out an agreed-upon version of a House and Senate bill. Chances are this would have succeeded. And then, Scott Brown.

Some Democrats, taking the simplest reading of the Brown victory were ready to bolt, but others said, “Wait, there’s a different way to get this done. We don’t need sixty Senate votes if the House passes the already approved Senate bill.” Both Houses could also pass agreed-upon amendments under budget reconciliation rules which require only a simple majority vote. Senate rules stipulate that only financial issues, increased or decreased spending, can be passed under reconciliation, but that may be enough to get an agreement. This appears to be the direction in which the President is leading his party and the nation.

The December 2009 edition

Early in the Fall, I accepted LaCuadra’s invitation to put into plain language the major criteria to judge what at least for now will be called ObamaCare (Oct. / Nov. 2009) There were five:

● Could uninsured people buy a decent insurance package at a price, even with a stretch, that they could afford?

● Could the country transition Medicaid from its last-option welfare roots to a streamlined health care program for the poor?

● Could Congress agree how to raise about $50 billion per year in new revenue to add to a similar amount in projected savings?

● Could our national health care cost growth, an outlier against all other industrial economies, be slowed over time?

● Finally, can the deal survive the next two political cycles to imbed itself in the national economy?

At this point, with qualifications, it’s four “yes, we cans” on the policy issues and a “maybe” on the political question as Congress tries to nail down the final deal.

The details follow, but remarkably little substance has changed in the months since Labor Day. As is clear to any observer, the debate has become all politics all the time.  In August the myriad forces of the Right seized control of Congressional town meetings. The “plot” to create death panels emerged as among the milder charges as the shouting crowds denounced Obama’s Fourth Reich, quite a goal for someone allegedly not even born in the US of A.  A constant in earlier debates, the fear of change in our health care arrangements, was exploited into the demonization of anything governmental.  If there were potential moderate Republican supporters, the combination of frenzied constituents and threatened primaries locked Republican incumbents into total opposition.

Schooled in Chicago politics, The White House saw the scope of the potential threat. It absolutely had to regain post Labor Day control of the debate, at least among Democrats. If the Right could demonize government, the President’s team could raise the Insurance demon. When under assault, attack! And soon, the focus of health reform was to control the perceived enemies: the insurance limits on pre-existing conditions; caps on benefits; cancellation of coverage; and wasteful administrative costs. My demon checks your demon. Let’s get to counting votes.

There are real differences between the parties. During the November House debate, Congressman Joe Barton, Republican of Texas and ranking member of the House Energy and Commerce Committee said simply and honestly, “we have a difference in philosophy.”  For Democrats, the bottom line according to Barton was insurance coverage.

Republicans, he argued, want to control costs.  They assert that if you make people pay more out of pocket at the point of service, they will limit their own use of care. The premise is that consumer choice ultimately drives the health care cost equation.  Like other services in the economy, the purchase of health insurance should be a voluntary decision.

The serious Democrats say that this health care “market” doesn’t work. If you’re sick you’re quickly priced out (or closed out) of health insurance. If you face a large out of pocket cost, you may avoid or delay a service that you really need. At some point in the course of illness, you’ll then be likely to enter the health care system with greater need and in a more expensive way. More broadly, buying services piecemeal plays into the market incentives, as they exist, for providers of care (hospitals, doctors, drug and device makers) to increase the volume of the services they provide.  Broad coverage in a structured and regulated insurance market less reliant on fee for service payment, the counter argument goes, is the more effective way to control costs.  Agreeing at least in part with Congressman Barton’s label, these Democrats assert that, yes, insurance coverage is the bottom line in crafting an alternative approach to cost control.

Perhaps the best political observation is that whatever the philosophical differences, the broad health reform issue didn’t dent the Bush 43 agenda, which, following the cyclical pattern of American politics, helped bring a Democrat back to the White House.