Mississippi Airlines

I had seen Suzie before. And before and before and before and before. Emergency room staff call people like Suzie frequent fliers, and they do not apply the word kindly. Frequent fliers are the bane of emergency room physicians, and of impatient – excuse me, inpatient – medicine. They come in to the ER complaining of this or that weekly, sometimes daily. Always the same complaint, and usually the standard ER workup shows nothing. The obvious thing to do in such situations, to send the patient home with an appointment to see a clinic doctor in a few days, almost never works. The patient comes back to the ER in a few days with the same complaint. When asked about the doctor’s appointment, the patient says variably, “I forgot,” or “the doctor was out of town,” or “what appointment?”

These patients are unbelievably common. So common that I feel completely confident that if I slapped a $100 bill on a desk and preceded to call every ER doctor in the nation on a bet that every ER has a Suzie, 6 months and 10,000 calls later that bill would still be sitting there. There are no exceptions. Every ER has a Suzie. If there is an ER without a Suzie, there is a Suzie in the vicinity trying to find that ER.

I found Suzie on the hospital floor a few months back, admitted to my care. The ER doc put her in with the diagnosis of dehydration and abdominal pain. The nursing staff said as soon as she arrived on the floor she asked for IV pain medication. Then a friend slipped her a box of fried chicken and she ate that, despite orders that she stay on a liquid diet.

Suzie is an ER doctor’s nightmare because she really has something wrong with her. She has a chronic disease that leads to chronic abdominal pain as well as recurrent infections. It is not possible to dismiss Suzie out of hand. And yet, Suzie is in the emergency room so often that it is also not possible to attribute every complaint to the disease. She comes in complaining of a fever and has no measurable fever. She says she has been vomiting for a week and does not vomit as long as she is observed.

The morning I got Suzie as an admission I talked to the ER doctor, and he confessed that the real reason he admitted her is because she had been to the ER five times in four days. Even though he could find nothing wrong with her, he felt he couldn’t keep sending her away. I can understand that.  Although insurance companies give us hell for it, not knowing for certain what is going on is an appropriate reason for hospital admission. You can only write off a patient complaint so many times.

Though I had seen Suzie many times when I was on call for other doctors, this was the first time she had been admitted to me. When I pulled her file up on the computer, I saw that in the previous 8 weeks she had been to the emergency room 32 times, and admitted twice. In that same time, she had been to only one clinic visit.

When I examined Suzie on the floor I found a young woman who did not appear to be in any distress. I asked her why she had been to the emergency room so many times. Her calm response was: “I was hurting.” Why not see your regular doctor? “I was in too much pain and thought I needed to be in the hospital.”

As I said, Suzie has a real medical problem. It is not my job to blow her off. On the other hand, her choices are driving her medical care in a direction she has no right to take them in. Suzie is choosing hospital care over every other type of medical care, and doing this over the objections of all of her doctors. I would never advise a patient of mine to go to the ER 32 times in two months. If a patient came to see me that often, I might admit her once to rule out serious problems, then refer her to specialists who can better manage her. In fact, Suzie had a appointment with a specialist in Jackson, someone who has specific knowledge and experience with her illness. I discharged her two weeks before that appointment date, and I don’t know if she ever kept the appointment. I hope so, but her track record for keeping outpatient appointments is too poor for me to be hopeful that this will be a long term solution.

A solution, though, is what we need. Suzie, and patients like her, cost hospitals millions of dollars a year. Insurance companies will not pay for 32 ER visits in two months. Suzie has Medicaid, which does not pay well even on a good day; but Medicaid usually has caps on the number of ER visits it will cover in a year. When a patient exceeds that, the bill goes to the patient. Suzie is disabled, meaning she has no money. If we are to assume that each ER visit generated $1000 in charges (a pretty sure bet), and that Medicaid paid none of it because Suzie had used up her ER benefit a long time ago (also a pretty sure bet), the hospital has a bill of over $30,000 it cannot collect. $30,000 is close to a full-time employee’s annual salary. It would not take too many Suzies to put a hospital in serious financial trouble.

Unfortunately, the law is on Suzie’s side. The ER cannot turn her away. Nor can it order her to pay up front. The law says emergency rooms must treat all patients in need. Once the ER verifies that the patient does not have a life-threatening condition, it can discharge the patient at will, but it has to evaluate her. Suzie can come to the ER three times in a day and the ER must at least examine her each time.

There is a solution to this problem, though admittedly it is a long shot. The hospital should contact Suzie and make a deal with her. The deal is this: Every January 1 the hospital will create a bank account in Suzie’s name with $500 in it. Each time Suzie goes to the ER, $25 is deducted. At the end of the year, Suzie gets whatever is left.

This stands the whole situation on its head. Suddenly, Suzie has a financial incentive to see her doctor instead of going to the ER. Like every patient on private insurance, it now costs Suzie to go to the ER. The hospital has to pay $500 each year, but this is a small price to pay to eliminate $30,000 in unpaid bills.

I intend to run this idea by the CEO of the hospital, but I am almost certain he will shoot it down. His reasons will be: (1) If we do this for her we will have to do this for many others; (2) Technically, we are paying her to stay away, and this will look very bad if the hospital should ever be sued; (3) She could start going to other ERs and then come here to get her money; (4) She could make the same deals with multiple ERs and get rich doing it; (5) The hospital will be suddenly deluged with offers from other patients to get the same deal; (6) Aren’t we rewarding bad behavior here?

None of these objections hold much water. We can take the easy ones first. Just because the hospital enters into a deal like this with one patient, this does not mean it has to offer the same deal to anyone else. This is the hospital’s money, and this amounts to a business decision. I treat all my patients individually. I will give a medication to one patient that I might not even think of writing for another. It all depends on the patient’s needs, and the patient’s reliability.

The problem of the patient simply going to another ER is also without merit. Have the patient sign an agreement promising not to use another ER without notifying the hospital. If the patient breaks that promise, the deal is void. Tracking her activities is possible in the digital age. Medicaid knows where she has been.

Are we rewarding bad behavior? No, what we are really doing is paying for better behavior. It is in Suzie’s interest that she behaves better. She is not benefiting from 4 ER visits a week. Furthermore, in taking up ER resources it can be plausibly argued that Suzie puts other lives at risk. A person can go to jail for repeatedly making bogus 911 calls. The fire department can be late for a real fire if it is busy investigating a false report. This is also true in the emergency room.

This leaves us with the real question, liability. Unfortunately, the practice of providing cash incentives to modify patient behavior has not been tested in court. If a patient were to sit at home with abdominal pain rather than go into the ER for the sake of $25, and then die of a ruptured appendix, an attorney could argue that the hospital is to blame for encouraging the patient to stay at home. And he might win.

But he shouldn’t win. Insurance companies offer incentives to avoid ERs. In a typical plan (the one I had 2 years ago), the copay for an ER visit was $100, for an “urgent care” clinic $50, and for a regular office visit $25. When I am at home on a Sunday with abdominal pain, I have to decide if I hurt badly enough to run to the ER for an extra $75. This is how medicine works in our country: Patients decide what level of care they need based on the degree of pain and the size of the copay. Since insurance companies in effect pay patients not to go to the ER by discounting clinic visits, they are already doing legally what I am proposing we do with Suzie. There is no difference, except that with private insurance the insurer is doing the paying, and in this case, the hospital is. But there’s the rub – laws protect insurers from patient lawsuits. Hospitals and doctors, on the other hand, can be sued for absolutely any reason, justified or not.

Since it costs Suzie $3 to see a doctor in clinic through the Medicare program and nothing to see one in the ER, her choices so far have been rational. The only way to change her behavior is to give her a reason to keep a clinic appointment. Consumers cannot be expected to choose the more expensive of two options on a regular basis. Our roads will never be crowded with hybrid cars until hybrids cost less than internal combustion vehicles. And ERs will never be free of frequent fliers until it costs the patients less money to go somewhere else. Period. That means giving them money to make decisions with.

I stole this idea from a man named Charles Murray. Murray, the reader may recall, first made a name for himself a decade ago with the controversial book The Bell Curve. The Bell Curve was widely abused for arguing that intelligence is genetic and that public policy should be structured with this fact in mind. I do not support the arguments in that book. However, Murray’s more recent book, In Our Hands: A Plan to Replace the Welfare State, has an attractive premise: The government should give every citizen a stipend of $10,000 a year. Financial problems aside, Murray makes a compelling point in arguing that one of the great problems of welfare is that poor people have virtually no incentive to behave responsibly. Poor people, he argues, would make economically responsible decisions if they had a little money to work with.

Our society is built on the principle of supply and demand. But supply and demand only works if the people involved have money. For example, a person who is broke has no incentive to buy car insurance. If he gets into an accident and gets sued, he has no money! In the same way, a poor person has no incentive to invest in good health. If a poor person has diabetes and no health insurance, he can work day and night to pay for his medications and doctor’s visits. This is an investment in health – pay for quality care now and avoid the catastrophic consequences later. But financially, a poor person might be better off doing nothing. Eventually the diabetes would produce a stroke, heart attack, or kidney failure. At that point he qualifies for disability, and health insurance. So, in a distorted way of thinking, he is better off neglecting his health than fighting to keep it.

This is where Murray’s idea makes sense. If you give a person money, suddenly he has a reason to do better. If he gets sick and has to go to the ER for treatment, the hospital can take a piece of that $10,000 stipend. Now the patient has a reason to take care of himself. If he doesn’t, ER visits will take all his spending money.

I most certainly am not poor, and don’t pretend to be. But many of my patients are, and as their doctor I sometimes have to contend with my patients’ problems. From my perspective, limited though it may be, poor people often do not think like people with money. In a capitalist system people are taught to respond to economic stimuli. They price shop for products; they leave jobs or situations that are not profitable to them; they weigh short term expenses like vacations and plasma TVs against long term issues like saving for a new home or for their kids’ college. This difference isn’t simply a matter of education. Poor people, because they have no money, never learn about long term planning. For them, life is about living from moment to moment. A dollar earned is a dollar spent. It is not possible to learn to make economic decisions when you live like that.

I offer two examples from my patient files. A few years ago I cared for a middle-aged women with multiple medical problems, most of them related to anxiety. One day during an office visit she told me that she was stressed out because she had to sell her house. She couldn’t afford the payments. She had inherited the house, with the mortgage, when her mother died a few years earlier. The mortgage was at least 20 years old, meaning she had less than 10 years left and the house would be completely paid off. The monthly mortgage note was $250. I tried to explain to her that she was crazy to sell the house. She would never find a rental for $250. Yes she would have the money from the house once she sold it, but in the long run rent would eat up that money and she would be in worse shape than before. She couldn’t hear that. All she knew was that she couldn’t afford the payments now. Nothing else mattered.

A more recent case: I had a patient tell me that he was going to cancel his Medicare insurance. It cost him over $100 a month, and he couldn’t afford it. I tried to explain to him that he was seeing me in my office 6 times a year, and that plus routine bloodwork could easily cost him that much. A single hospitalization would ruin him financially. But he could not understand that. All he knew was that he got X dollars a month from disability, and Medicare plus his rent left him short each month.

I am not blaming either patient for the decisions they made. Both did what they felt they could afford. But both, because they had no money to work with, were unable to make economically sound decisions. In fact, in poverty, they had no choices to make. So they ate the goose that laid the golden eggs. This is the way poor people behave every day, and in light of this, it is no surprise to me that the poor stay poor most of the time.

If you want people to do better, teach them. Give them decisions to make. Perhaps a patient like Suzie will find it in her interest to be something better than a frequent flier. She might even surprise us and make the right choice, every once in a while.

Requiescat in pace

Two more of my favorite medical blogs have disappeared, Dr. Flea and Fat Doctor. I wish their erstwhile authors well in their future endeavors.

Fat Doctor explains in what is left of her blog that she deleted all of her entries to the beginning because she was identified by one of her colleagues. She has been blogging anonymously, and apparently felt that, once identified, she could no longer continue.

Dr. Flea offers no explanation. Unfortunately, Flea also blogged anonymously, so it is impossible to speculate on the sudden death of his blog.

I have always felt blogging is something of a fad. Either bloggers will be institutionalized -- that is, absorbed -- by large online publishers, or they will fade away. Writing takes sustained commitment and it is hard to hold down a full time job and continue to write well on a daily basis. Anonymous  bloggers have an additional problem. It is impossible to keep an identity secret forever, especially in the health care profession, where, if you are writing about your work, you are bound sooner or later to leak identifying information.

Some bloggers come back, and I hope this is the case with these two. If not, we can still thank them for what they gave us while they could. 

Dr. Z

Doctor Zomanian, who was known to everyone as Dr. Z, waited impatiently at the nursing station. His face was bulging and pink, the color only slightly subsiding after half a dozen minutes of continuous growling. He didn't like to yell at the nurses, but sometimes it was necessary. Nothing personal, but his time was not to be wasted. He rounded at one, and all of his patient charts were supposed to be pulled and on a rolling cart so he could stride up to the nurses' station, grab the cart, roll it down the hall and start on his patients without a pause.  

That wasn't happening today. There was a new nurse, Emily, in charge of the unit. She must have been new. Dr. Z would have noticed such a beauty before. Red hair in chaotic waves. His daughter had hair like that, or at least he thought so, but his daughter changed her hair sometimes and he hadn't seen her in awhile. Come to think of it, the last time he saw his daughter she was probably blonde. No telling what her original color was.

Emily looked about twenty-five.  Obviously unused to dealing with authoritative doctors such as himself. She moved fast enough when he shouted that he figured he could eventually break her in. Ten minutes and all the charts were on the rack. Not too bad.

By habit, he started with room 401, working down the hall in order from left to right. He always worked from left to right. After he started working at the hospital six years ago, the floor nurses quickly figured that out and always (at least until today)  had the charts arranged accordingly.

First up, Mrs. Duncan. Fifty-two years old, gasping for breath. Dr. Z had ordered home oxygen for her the last time she was in, but it was not reducing the frequency of her hospital admissions. And she was a liar. Dr. Z told her the first time he saw her in his office that she needed to quit smoking. She had told  him on a clinic visit a month ago that she had quit the cigarettes. Then she tells him the same thing in the emergency room. He could smell the smoke on her, and accused her of lying right there, on the gurney, in ER 4.

"That looks like a pack of cigarettes in your purse there," he had said gruffly. "I told you a dozen times that if you light up with the oxygen around you will be barbecue. Barbecue! And even that is an understatement because pure oxygen burns hotter than wood." She had looked at him like a whipped dog, about to cry.

He studied her chart before going in. As long as all the reports were where they were supposed to be, he could assemble the needed data in his head in a few seconds. Chest x-ray this morning was okay. White cell count up. Creatinine stable. He went in.

"Hello, Mrs. Duncan," he said, in his cheery voice. "How are you feeling?"

"Better, Dr. Z," she said.

"Good. Your white cell count is higher today, but with a negative chest x-ray I am chalking that up to the steroids. I am going to keep you on ceftriaxone for another day at least just in case. I'm also ordering PFTs."

Mrs. Duncan nodded as if she understood it all. Except for one thing. "PFTs?"

"Yes. Pulmonary function tests. You'll breathe into a machine and I'll get the report. Don't worry about it. I'll take care of everything. See you tomorrow!"

He returned to his cart full of charts and turned to a blank page. "Chronic Obstructive Pulmonary Disease," he wrote. "Tobacco abuse. Patient counseled to quit smoking but has repeatedly refused," he concluded.

Moving down the hall, he paused at room 413 and pulled a chart labeled "T Shears." Mr. Shears was admitted for chest pain. Dr. Z quickly turned to the cardiology section of the chart. He checked the morning EKG, and looked for the echo and stress test he had ordered yesterday. Not back yet.

He went into the room. Mr. Shears was sitting in a chair at the bedside, monitor wires running all over his chest, an IV in his left arm. T Shears was an enormous man, 400 pounds at least, so large his hips barely fit between the arms of the chair. His calves, visible below the hem of his gown, were deep red and purple, discolored from years of venous stasis. Dr. Z saw that the IV was running normal saline at 70 cc an hour. "I probably should stop that before he develops edema," he thought to himself.

"How are you doing today?"

"I'm doing OK," Mr. Shears said.

"Any more chest pain?"

"Well, yes, I still have a little tightness here." He pointed to his sternum.

Dr. Z put the stethoscope to the patient's chest. "Good, good," he said. "Any shortness of breath?"

"I have some, and a bad cough."

"Fine, fine," Dr. Z said. "It will be some time before I get the echo and the stress test results.  They may not be ready until tomorrow. But if they check out, I will send you home then."

"But doctor, what is causing my chest pain?" Mr. Shears asked. He asked it to the air, because Dr. Z had already left.

Out in the hall, the doctor opened the chart. He figured the echo had already been read, and possibly the stress test, too. He considered yelling to the nurse to get the reports on the chart, but he decided that would take too long. By tomorrow it would all be there.

He wrote: "Acute Coronary Syndrome. Morbid obesity. Chest pain likely brought on by failure to take medication. Needs to lose a lot of weight." He closed the chart. Another patient who refuses to help himself.

Sometime later he reached his final patient, Mrs. Arnaz, who was admitted for intestinal bleeding. In contrast with the enormous Mr. Shears, Mrs. Arnaz was a wraith of a woman, hardly more than a hundred pounds. It is easy to keep one's weight down, Dr. Z had observed to a nurse the other day, when ninety percent of your calories come from a whiskey bottle. Mrs. Arnaz had drunk herself into three bleeding ulcers. This time she had almost bled to death, which, if Dr. Z were completely honest about it, as he often was when not talking about himself, would not have been an entirely bad thing.

The nurse told Dr. Z in the hallway that Mrs. Arnaz had been confused all night. No surprise. She had been in the hospital for three days, and delirium tremens would certainly have set in by now. Z was not always aggressive about treating DTs -- in a way, he thought any patient that drank that much deserved to suffer a little -- but from what the nurse was telling him it sounded pretty bad. He might have to boost her sedation.

He went into the room. Mrs. Arnaz was much sicker than he expected. Overnight she had gone from mildly yellow sclerae to completely yellow. The color was completely unnatural, almost orange, as if an iodine tincture had been painted everywhere on her skin. Dr. Z walked around the bed and shook his head.

"You've had one too many, my dear," he said. "You've probably had your last."

Mrs. Arnaz moaned in reply. With her liver failing she was barely conscious. After looking her over, Dr. Z concluded she only had a couple of days. The room was still except for the television, which muttered from the corner of the room. It always amused Dr. Z to see what comatose patients watch on television. Most of the time someone on the staff would turn the TV on to a good background channel -- news, sports, or weather -- the kind of channel that staff, coming in for a few minutes at a time, can glance up at. A news channel was on. Dr. Z saw that there was a shooting at a university, and 31 people had been killed. He was stirred when he saw that the shooting had taken place at Virginia Tech; he had gone to college at Wake Forest, just down the road.

The nurse walked in. She checked the patient's IV, then flushed it with heparin. Dr. Z turned and looked at her. She was one of the new nurses, one of the ones he had yelled at. She was short, black hair cut to the shoulder, dark eyes, in her twenties. She was attractive, he realized. "Sad about the college kids, isn't it?" she said.

For the second time in a few minutes, he shook his head. "Innocent kids shouldn't be cut down like that. They didn't deserve it." He looked up at the TV again, then at the nurse, who was now leaning over the patient in the bed. As she leaned forward, he saw the faint outline of her panties through her white trousers. He walked out.

In the hall, he wrote a note in Mrs. Arnaz's chart, something to the effect of "she's going to die soon," except that he phrased it as "prognosis grim" and "poor prognosis" and "needs DNR status." He resolved to talk to a family member, if he could find one, to emphasize that she will die soon and should not receive CPR. He rolled his chart full of charts down the hall and pushed it mindlessly towards the clerk at the unit desk.

Dr. Z went to the end of the hall and down the steps and out the back door of the hospital. His car was parked at his personal spot, only fifty steps from the door. As he stepped out of the door he felt a breath of hot air pouring between the decks of the parking garage. April and finally it was summer in Louisiana. He was looking forward to it this year.

As he walked to his car he remembered something. "Damn. I forgot to stop the IV fluids on that patient." He paused, and briefly considered going back. "Oh, I'll do it tomorrow."

He slid into his car and turned on the conservative radio show. Dr. Z was not very political, but the guy on that show always made him angry with his stories about the evil things liberals were doing. He liked getting angry. He got angry a lot at work, but somehow his raging never seemed to do any good. Every year the nurses got worse, the clerks in his office got younger and more incompetent. Only Nina, his clinic nurse for thirty years, was any good. And even she got on his nerves from time to time. But on his drive home, he could get angry about things that didn't matter like work did, and it felt good. He had trouble remembering the name of the Angry Man on the radio, but little did his patients and the staff at the hospital and clinic know what a monster he would have been if he couldn't be angry along with the Angry Man on the radio.

He was home in the usual twenty-six minutes. As he entered the front door, Dr. Z stumbled over a box and had to reach out to the wall to steady himself. "That bitch!" he said aloud. "When is she going to come to pick up this worthless crap!"

The box was filled with his soon-to-be ex-wife's personal effects -- makeup, family pictures, a pair of $600 boots, a half-used dispenser of contraceptives, a Bible, and a bottle of champagne they had bought in Europe and planned to open on their tenth anniversary. Mandy was supposed to pick the box up while he was at work and leave the house key, but the box had remained there for three weeks. Dr. Z was sick of looking at it, but he couldn't justify throwing out such expensive boots or a champagne bottle worth at least $300. So it sat.

The house had been all his for over a month. It was spotless, partly because he continued to pay the housekeeper to clean it twice a week, and partly because he had so little free time to live in it. It was well nigh time, he thought, to bring a girl over for the night. Well nigh time. The nurse in Mrs. Arnaz's room seemed a fair candidate.

He had poached nurses from the hospital before. Mandy was a hospital nurse, before she became his second wife. He guessed that with alimony she wouldn't be going back to nursing again. Dr. Z had started sleeping with Mandy before he left his first wife. That was why he could not understand her wanting to leave him. After all, she had stolen him from someone else. How could she complain if he sometimes strayed? All his hours at work paid for the boots, the champagne, the antiques. This was the cost of living with a doctor.

If she doesn't pick up that damned box before I get that nurse in here, I am going to use the champagne to get her drunk, he said to himself.

Lost in his bitterness, Dr. Z suddenly remembered he needed to deactivate the house alarm. He moved quickly and almost didn't make it in time. Then he went through the kitchen and opened the door to the back porch. His golden retriever, Percy, bounded in and started jumping on him repeatedly.

He filled Percy's bowl with dog food and watched contentedly as he devoured it. Then he walked over to the kitchen table and sat down to look at the mail. The housekeeper had left it there for him. After Percy finished his meal, he came over and pushed his nose into Dr. Z's lap.

Dr. Z scratched Percy under the chin. "You're lucky someone competent is taking care of you," he said.

The Veto

This week, President Bush vetoed a bill that would provide funding for the Iraqi war, but tied the funding to a timetable for troop withdrawal. In rejecting the bill, Bush said that “setting a deadline for withdrawal is setting a date for failure, and that would be irresponsible.” He sent the bill back to Congress, with the threat that he would veto any war funding bill that includes a timetable. So here we go again; as soldiers get shot at in Iraq, His Majesty George W enters another game of chicken with the Democrats.

The newspapers today are saying that Congress is regrouping to rewrite the bill. I wish they wouldn’t. There is no need to compromise with this man.

I don’t think Congress owes it to the President to give him a spending bill of his liking. It is Bush who owes the American people a full explanation for why he does not think he can wrap things up in Iraq between now and next October (the withdrawal deadline specified in the bill). Eighteen months is a long time for a military action, and Bush in his recalcitrance is indicating that he cannot get the job done in that length of time. He put a lot of time and effort into explaining to everyone why we needed to invade Iraq in the first place. The least he can do now is explain — honestly, this time — why he can’t get out.

I say leave him on the hook. Congress should tell the president that he has gotten his spending bill already and rejected it. If he wants a different one he had better explain why. Otherwise, he can forget it.

He has been playing this my-way-or-no-way game since Inauguration 2001. It doesn’t fly any more. For a president who talks all the time about accountability, he doesn’t seem to care for it much when he is the one held to account. But no one else is exempt from performance standards. If I have to live with performance standards, if the cook at McDonalds’s has to live with them, the Commander and Chief of the United States can live with them too.

The Bush apologist argument that refusing to compromise means cutting the troops off from proper funding is a blatant lie. Congress gave Bush the money. He wouldn’t take it because he is too proud to submit to oversight.

The second objection, that setting a timetable is the same as giving the enemy a blueprint of our battle plan, holds no water either. In the first place, the “enemy” is not one but several, and the “enemies” in Iraq are not fighting us nearly as much as they are fighting each other. The only thing a timetable does is increase the pressure on the Iraqi government to stand on its own two feet and stop depending on U.S. forces to maintain order. Besides, the timetable is not necessarily set in stone. If the president would agree to one in principle, and then events prevented him from meeting the milestones, I think Congress would agree to extensions. Congressional leadership is not trying to undermine military activity in Iraq; it is trying to make military action more efficient by establishing firm goals. This beats the listless “we’re making progress” nonsense we have gotten out of the White House for the last four years. What Congress and the American people want is good faith. They want to hear their president say he will do his best to get out by the end of his term.

But he won’t do that. He won’t even admit informally that setting goals is a good idea. If he is so terribly concerned that a published timetable would compromise the Iraq mission, he could meet with Congress privately and come up with a secret plan for withdrawal. If Congressional leaders and the president publicly announced that they had agreed to a timetable but would keep it secret for security reasons, I would accept that. But even this is not on the table. His current plan is to stay in Iraq however long it takes. In other words, he has no plan.

My political attitudes lean towards moderation. Even when I do not have a moderate view, I sympathize with people willing to search for middle ground. Compromise is a very difficult thing to do, and no one ever gives compromisers credit. The very word compromise implies failure or weakness. Yet compromise is absolutely necessary in society— everyone cannot have his way.

Until very recently, I agreed with the middle ground people who felt that the war is going badly, but we cannot get out. I felt that, as bad as things have gone so far, we produced the instability in Iraq and have a responsibility to get things under control before we leave. Last week, though, I changed my mind when I read that the U.S. is now building walls in Baghdad to separate warring communities. The wall-building story was barely noted in the media, but to me it represents a watershed moment in our Iraqi occupation. You build walls between communities when you have given up hope that the communities will ever get along. You build walls when diplomacy and peaceful efforts have totally failed. You build walls when you have run out of ideas. To me, the walls are a clear indication that the Bush White House has no idea when the suicide bombs will stop, or when the shooting will end.

What kind of a strategy for establishing peace is permanently dividing communities? It would be like Southern leaders saying, “Well, blacks and whites just can’t seem to get along. So let’s separate black and white communities and wall them off from one another. It worked before!”

Walls are the beginning of apartheid. That is the Bush administration’s best thinking on Iraq — apartheid. Separate one faction from the other. One group will prosper faster than the other. The richer group, threatened by its poorer neighbors, will then manipulate the political system to keep the poor people from getting stronger. That is what apartheid is — a rich group insuring its success by keeping its competition down. That is what walls give you, every time.

Since the current plan to establish peace in Iraq is to build walls, I feel comfortable in saying that we will never do any good there. Since we cannot make things better, the best approach is a steady and organized withdrawal. This now seems to me perfectly straightforward. Even the most ardent Bush backer has to admit that there is a chance that we will not be able to establish stability in Iraq. Some things simply cannot be done. I don’t care how smart or how strong you are, you can’t put a broken egg back in the shell. At the very least, we need to entertain the possibility that the damage done in Iraq is irreparable. George W. Bush seems to be thinking along these lines. After all, he is building walls in Baghdad instead of getting communities to work together.

This is why the presidential veto this week makes no sense. If the war is going so badly that it is time to partition cities into war zones, it makes sense to explore solutions with Congress. Instead, the White House has rejected every opportunity to compromise. In February, Congress passed a non-binding resolution asking for a withdrawal timetable. That was ignored. In fact, Bush supporters derided the resolution, arguing that Congress showed a lack of courage in making the resolution non-binding. The current bill, coming three months later, is a follow-up to the resolution. It turned a non-binding suggestion into a requirement. In between the two events, the president had three months to find common ground. For three months he did nothing but posture. Congress should not reward such irresponsibility with a friendlier bill.

Democratic leaders need to be careful; Bush has a history of luring the opposition into compromise and then beating them to death for waffling. It is likely that if Congress compromises now, Bush will sign the bill and then issue a signing statement declaring that the new legislation allows him to do whatever he wants. He has interpreted over 750 other bills he has signed into law as the right to expand executive power. Of course he will do it again.

George W. Bush started this war. Since he started the war, finding the money for it is his problem. If he is so concerned about getting funding with no strings attached, he devote a lot more time to explaining why he, when given unlimited funds with no questions asked for four years, has turned in such unacceptable results.

If a plan is not working, you change it. If four years without an exit plan gets us where we are, you get an exit plan. If Bush can’t explain how he plans to get out of Iraq, he shouldn’t get the money. Does this mean we are putting the troops at risk? Only if you think giving unlimited funds to a leader with no plan and no accountability makes the troops safer. Under no circumstances will I submit to the idiotic argument that, in opposing a war that was fought for non-existent WMDs and that was incompetently and corruptly managed from the start, I am setting us up for defeat. We are assured of defeat as long as the Man in Charge thinks he can fight a war without accountability.

Mr. Bush, when you submit to accountability, you get your money. Not before.*

* This, by the way, is precisely what the Bush administration has been telling Katrina survivors.

Thought I'd Seen It All

With all the things that have come out about the government and its handling of Hurricane Katrina, I thought I had reached the limits for being appalled. I guess I don't know George W. Bush as well as I thought.

The Washington Post reported yesterday that in the weeks after Hurricane Katrina hit, foreign countries offered $854 million in assistance. Of that, the White House accepted and spent about $40 million. Most of the rest was uncollected. Some countries, frustrated at the President's lack of response, withdrew their offers and redirected the money to private charities such as the Red Cross.

I vividly remember the whining that came out of Washington about how much the hurricane recovery was going to cost. It is unconscionable that government officials would complain about recovery costs and then leave $800 million in free money on the table. $800 million is more than has been spent on levee reconstruction costs so far. It is more than has been paid out to citizens in New Orleans for home reconstruction under the Road Home program.

If the federal government is going to ignore that kind of money someone needs to give a damn good reason why. It is outrageous that 100,000 people on the Gulf Coast still live in temporary trailers almost 2 years after Katrina, and the White House thinks it is too good to scoop up $800 million lying around in the street.

It is simply astonishing. I don't know what else to say.