That's the word from the architect of John McCain's health care proposals, John Goodman. No one in the United States is uninsured, Goodman, pronounced, because Americans have access to emergency room care. As the Dallas Morning News reported:

Mr. Goodman, who helped craft Sen. John McCain's health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American - even illegal aliens - as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care. So, there you have it. Voila! Problem solved."

For a candidate who diagnosed the economic downturn as "psychological", the semantic solution to the crisis in medical coverage is unsurprising. And to be sure, with its GOP "Emergency Room" health care plan, the McCain campaign is just following in the footsteps of Republicans deniers George W. Bush and Tom Delay.

During a July 2007 visit to Cleveland, President Bush unveiled his emergency room cure for the ills of the U.S. health care system. Rejecting the expansion of the successful - and even more popular - State Children's Health Insurance Program (S-CHIP), Bush assured Americans that there was no crisis in medical coverage:

"I mean, people have access to health care in America. After all, you just go to an emergency room."

In November, indicted former House majority leader Tom Delay took Bush's health care clown show overseas. Speaking in the UK, Delay announced:

"By the way, there's no one denied health care in America. There are 47 million people who don't have health insurance, but no American is denied health care in America."

But while his comments were greeted in England (as the AP reported) with "derisive laughter," no one was chuckling back home.

As it turns out, of course, millions more Americans are denied - or are forced to deny themselves - health care each year. Just days after Delay spoke, a new report from the Economic Policy Institute showed a dramatic decline in employer-provided health care. That drop-off from 64.2% of Americans covered through workplace insurance in 2000 to just 59.7% in 2007 added 2.3 million more people to those without coverage. And in June, a devastating new assessment from the Commonwealth Fund showed fully 25 million Americans are now "underinsured," a staggering 60 percent jump since 2003. All in all, 42% of the people in the United States under age 65 have insufficient insurance - or simply none at all.

(As it turns out, the recent dip in the number of uninsured to 45.7 million is due almost exclusively to expanded state and federal government insurance programs, including Medicare, Medicaid and SCHIP. Of course, John McCain joined President Bush in opposing the expansion of the popular program providing coverage for children.)

And to be sure, America's overflowing emergency rooms do not have the capacity, staffing or funding to be the health care solution of last resort. A 2006 report by the Institute of Medicine revealed that U.S. emergency rooms can barely cope with the volume of patients in the best of circumstances:

The study cited three contributing problems to the rise in emergency room visits: the aging of the baby boomers, the growing number of uninsured and underinsured patients, and the lack of access to primary care physicians.

The report found that 114 million people, including 30 million children, visited emergency rooms in 2003, compared with 90 million visits a decade ago. In that same period, the number of U.S. hospitals decreased by 703, the number of emergency rooms decreased by 425, and the total number of hospital beds dropped by 198,000, mainly because of the trend toward cheaper outpatient care, according to the report.

And that's in the best of times; the forecast for the worst of times is grimmer still. A March 2008 study from the House Oversight and Government Reform showed an American ER system woefully unprepared to handle a "predictable surprise" of a terrorist attack on the scale of the 2004 Madrid bombing:

The results of the survey show that none of the hospitals surveyed in the seven cities had sufficient emergency care capacity to respond to an attack generating the number of casualties that occurred in Madrid. The Level I trauma centers surveyed had no room in their emergency rooms to treat a sudden influx of victims. They had virtually no free intensive care unit beds within their hospital complex. And they did not have enough regular inpatient beds to handle the less severely injured victims. The shortage of capacity was particularly acute in Los Angeles and Washington, D.C.

Particularly acute in Los Angeles, indeed. As CBS reported, security cameras captured the death last year of Edith Isabel Rodriguez in a Los Angeles emergency room lobby, a woman who lay without help on the floor for 45 minutes as hospital personnel passed by.

And the scene was repeated on June 19 in New York, where 49 year old Esmin Green collapsed and died while waiting almost 24 hours in the emergency room of a psychiatric hospital. (The video of the CBS segment is available here.)

Later this summer, John McCain will address the Republican National Convention in Minneapolis. There, he will talk in glowing terms about the McCain health care plan, one virtually identical in its outlines - and dismal shortcomings - as that of President Bush. As Minnesota Public Radio recently detailed, the emergency rooms of Minneapolis and St. Paul are prepared to handle the GOP faithful should they become sick before, during or after McCain's speech.

Then again, in the America of George Bush, John McCain and the Republican Party, no one is denied health care, not even the "whiners." They can always go to the emergency room.

In 2007, Americans learned that they had relinquished their 200-year hold on the title of world's tallest people. Now a devastating new report shows that across a growing range of indicators of health, wealth and education, Americans simply aren't measuring up.

The "Measure of America" study by the American Human Development Project (funded by Oxfam America, the Rockefeller Foundation and the Conrad Hilton Foundation) documents a laggard United States trailing other leading advanced economies. Reflecting growing income inequality and the exploding population of Americans without health insurance, the U.S. has dropped from its lofty second place ranking in 1990 to #12 on the study's index of human development now.

The grim numbers portray an American people living lives that are less healthy and less secure than those in countries where per capita income - and health care expenditures - are dramatically lower than in the U.S. Among the grim harvest of numbers from the report:

• The U.S. ranks 24th in life expectancy out of the 30 most affluent nations and 42nd globally despite spending $5.2 billion a day for health care. The racial disparities are even more glaring, with African-American living 4.6 years less than the national average of 77.9.
• America is only 34th in infant mortality, putting it on a par with is on a par with that of Croatia, Cuba, Estonia and Poland.
• 40 million Americans (14%) lack the literacy skills to perform simple, everyday tasks such as understanding newspaper articles and instruction manuals.
• Income inequality in the U.S. also surpasses virtually every other industrialized nation. The richest fifth of Americans earn on average $168,170 a year, almost 15 times the average of the lowest fifth, who must get by on $11,352.
• The US has a higher percentage of children (15% or 10.7 million kids) living in poverty than any of the world's richest countries.
• Sadly, the United States ranks first among the 30 OECD member states in terms of its prison population, measured both in absolute numbers and as a percentage of its population. A nation with 5% of the world's population has 24% of its prisoners.

Of course, residents of the United States are not returning to a Hobbesian state of nature where life is nasty, brutish and short. No doubt, the American standard of living remains high and the envy of much (if not as much) of the world.

But the Measure of America analysis reveals a nation where life is harsher than many people - and probably most in the United States - would have expected. As the authors suggest, the disintegrating health care system with its 47 million uninsured, the skyrocketing indebtedness of Americans, the spiraling cost of education, nonexistent childcare and a vanishing safety net are putting "the American Dream in peril."

President Bush this week played a game of chicken on Medicare - and lost. Congress easily overrode Bush's veto of legislation designed to prevent an 11% cut in physicians' compensation under the health care program for elderly Americans. And speaking of chicken, John McCain was nowhere to be found.

On June 26, Congressional Republicans led by Senate minority leader Mitch McConnell blocked action by Democrats to avert the looming July cut in fees to doctors serving Medicare patients. While Barack Obama cast his vote in favor, John McCain was AWOL, as the June measure failed by a single vote. For his part, McConnell gloated:

"The path the majority leader just recommended we go down leads to a presidential veto and an expiration of this law at the end of the week. In other ways, the doctors' cut is going to go into effect at the end of this month because of this recalcitrant view, this excessively partisan approach."

As it turned out, McConnell's celebration was premature -and ill-advised. The American Medical Association (AMA) and the AARP mobilized immediately, targeting Republicans including McConnell who opposed the bill. As the Hill noted:

Four of the top 20 recipients of campaign cash from physicians and other health professionals are Republicans who voted against the Medicare bill, according to data from the Center for Responsive Politics.

Other than three senators with presidential campaigns, Sen. John Cornyn (R-Texas) got the most, $308,033, including $2,500 from the AMA. The Texas Medical Association rescinded its support of Cornyn on June 28 after he voted against the measure.

The impact was quick and dramatic. On July 9, the bill passed both houses of Congress overwhelmingly, as terrified Republicans turned tail in the face of their public relations fiasco. (Among those who voted "no" on cloture in June only to switch sides two weeks later was John Cornyn of Texas.) In the Senate, the measure reached the veto-proof threshold of 69-30, thanks to Massachusetts Senator Ted Kennedy. Kennedy, though battling cancer, journeyed to Washington to cast his veto-busting ballot.

Barack Obama joined Kennedy in putting the Medicare package over the top (though he was absent for the subsequent override). Again, John McCain was a no-show, choosing the cover of the campaign trail over taking a stand on a critical issue.

Which brings us to Tuesday's veto override. The House easily rejected President Bush's rejection by a 383-41 margin. In the Senate, the vote was 70-26. As for John McCain, who has missed a staggering 63% of votes during this session of Congress, he apparently had more pressing business elsewhere. As for what he might have done, The Hill noted:

Although McCain missed all four votes on the Medicare legislation, he has said he opposes it.

Opposed it perhaps, just not on the record.

During a July 2007 visit to Cleveland, President Bush unveiled his emergency room cure for the ills of the U.S. health care system. Rejecting the expansion of the successful - and even more popular - State Children's Health Insurance Program (S-CHIP), Bush assured Americans that there was no crisis in medical coverage:

"I mean, people have access to health care in America. After all, you just go to an emergency room."

In November, indicted former House majority leader Tom Delay took Bush's health care clown show overseas. Speaking in the UK, Delay announced:

"By the way, there's no one denied health care in America. There are 47 million people who don't have health insurance, but no American is denied health care in America."

But while his comments were greeted in England (as the AP reported) with "derisive laughter," no one was chuckling back home.

As it turns out, of course, millions more Americans are denied - or are forced to deny themselves - health care each year. Just days after Delay spoke, a new report from the Economic Policy Institute showed a dramatic decline in employer-provided health care. That drop-off from 64.2% of Americans covered through workplace insurance in 2000 to just 59.7% in 2007 added 2.3 million more people to those without coverage. And just three weeks ago, a devastating new assessment from the Commonwealth Fund showed fully 25 million Americans are now "underinsured," a staggering 60 percent jump since 2003. All in all, 42% of the people in the United States under age 65 have insufficient insurance - or simply none at all.

And to be sure, America's overflowing emergency rooms do not have the capacity, staffing or funding to be the health care solution of last resort. A 2006 report by the Institute of Medicine revealed that U.S. emergency rooms can barely cope with the volume of patients in the best of circumstances:

The study cited three contributing problems to the rise in emergency room visits: the aging of the baby boomers, the growing number of uninsured and underinsured patients, and the lack of access to primary care physicians.

The report found that 114 million people, including 30 million children, visited emergency rooms in 2003, compared with 90 million visits a decade ago. In that same period, the number of U.S. hospitals decreased by 703, the number of emergency rooms decreased by 425, and the total number of hospital beds dropped by 198,000, mainly because of the trend toward cheaper outpatient care, according to the report.

And that's in the best of times; the forecast for the worst of times is grimmer still. A March 2008 study from the House Oversight and Government Reform showed an American ER system woefully unprepared to handle a "predictable surprise" of a terrorist attack on the scale of the 2004 Madrid bombing:

The results of the survey show that none of the hospitals surveyed in the seven cities had sufficient emergency care capacity to respond to an attack generating the number of casualties that occurred in Madrid. The Level I trauma centers surveyed had no room in their emergency rooms to treat a sudden influx of victims. They had virtually no free intensive care unit beds within their hospital complex. And they did not have enough regular inpatient beds to handle the less severely injured victims. The shortage of capacity was particularly acute in Los Angeles and Washington, D.C.

Particularly acute in Los Angeles, indeed. As CBS reported, security cameras captured the death last year of Edith Isabel Rodriguez in a Los Angeles emergency room lobby, a woman who lay without help on the floor for 45 minutes as hospital personnel passed by.

And the scene was repeated on June 19 in New York, where 49 year old Esmin Green collapsed and died while waiting almost 24 hours in the emergency room of a psychiatric hospital. (The video of the CBS segment is available here.)

Later this summer, John McCain will address the Republican National Convention in Minneapolis. There, he will talk in glowing terms about the McCain health care plan, one virtually identical in its outlines - and dismal shortcomings - as that of President Bush. As Minnesota Public Radio recently detailed, the emergency rooms of Minneapolis and St. Paul are prepared to handle the GOP faithful should they become sick before, during or after McCain's speech.

Then again, in the America of George Bush, John McCain and the Republican Party, no one is denied health care. They can always go to the emergency room.

A year after he admitted "you've stumped me" when asked whether contraceptives help stop the spread of HIV, John McCain once again finds himself in the AIDS spotlight. On Wednesday, Americans learned that arch-conservative Tom Coburn (R-OK) is blocking Senate action on a proposed tripling of President Bush's global AIDS program. That would be the same Tom Coburn John McCain extolled in March 2007 as "the guy I really respect" when it comes to policy for AIDS and contraceptives.

As Politico detailed, Coburn and a group of six other socially conservative GOP Senators have placed a hold on the reauthorization of one of President Bush's few popular initiatives, the Emergency Plan for AIDS Relief (PEPFAR). Enjoying broad bipartisan in Congress, the Senate has proposed boosting funding to $50 billion over five years. But the Senate bill would do away with the previous requirements "that 55 percent of the HIV/AIDS appropriation be spent on treatment and drugs and that about 30 percent of prevention funds be allocated to abstinence education."

Which is what raised the ire of John McCain's AIDS mentor Tom Coburn. Rather than see American aid dollars flowing to the "C" in the U.S. "ABC" strategy against AIDS ("abstinence, be faithful, condoms"), the physician Senator and his group of 7 socially conservative colleagues are demanding that treatment receive the lion's share of the expanded PEPFAR funding. Otherwise, Coburn insists:

"The vast majority of the money is going to get consumed by those wanting to help people with HIV, rather than [by] people with HIV."

The overwhelming consensus in both the Senate and the public health community, of course, holds just the reverse:

"Most experts agree that treatment is only one small part of the prevention agenda," said Denis Nash, director of monitoring, evaluation and research at the International Center for AIDS Care and Treatment Programs at Columbia University.

"The prevention effect of treatment is not likely to be anywhere near the magnitude of prevention through prevention," including safe-sex education and condom distribution, said Mead Over, senior fellow at the Center for Global Development.

Which is why John McCain found himself in hot water at a town hall meeting in Pennsylvania on Wednesday. The first question came from health care activist Kaytee Riek, who asked whether McCain would work to advance the bill in the Senate now being blocked by Coburn. Despite his grand December 1, 2007 proclamation recognizing World AIDS Day ("Today is a call to action to roll-back the scourge of HIV and save lives"), McCain on Wednesday was caught off guard and in the dark:

"I'll be glad to assist. I'm sorry to tell you I'm not that familiar with the process of this legislation."

That McCain was asked to "look into talking to his Senate buddy Tom Coburn" about the PEPFAR reauthorization should have come as no surprise to the supposed maverick. After all, during an even more uncomfortable March 2007 ride with reporters on his campaign bus in Iowa, McCain identified Dr. Coburn as the man with the plan when it came to HIV/AIDS and abstinence.

That infamous exchange, so bizarre and so unsettling, requires to be seen in its entirety to fully appreciate John McCain's ignorance and confusion when it comes to HIV/AIDS:

Reporter: "Should U.S. taxpayer money go to places like Africa to fund contraception to prevent AIDS?"

Mr. McCain: "Well I think it's a combination. The guy I really respect on this is Dr. Coburn. He believes - and I was just reading the thing he wrote - that you should do what you can to encourage abstinence where there is going to be sexual activity. Where that doesn't succeed, than he thinks that we should employ contraceptives as well. But I agree with him that the first priority is on abstinence. I look to people like Dr. Coburn. I'm not very wise on it."

(Mr. McCain turns to take a question on Iraq, but a moment later looks back to the reporter who asked him about AIDS.)

Mr. McCain: "I haven't thought about it. Before I give you an answer, let me think about. Let me think about it a little bit because I never got a question about it before. I don't know if I would use taxpayers' money for it."

Q: "What about grants for sex education in the United States? Should they include instructions about using contraceptives? Or should it be Bush's policy, which is just abstinence?"

Mr. McCain: (Long pause) "Ahhh. I think I support the president's policy."

Q: "So no contraception, no counseling on contraception. Just abstinence. Do you think contraceptives help stop the spread of HIV?"

Mr. McCain: (Long pause) "You've stumped me."

Q: "I mean, I think you'd probably agree it probably does help stop it?"

Mr. McCain: (Laughs) "Are we on the Straight Talk express? I'm not informed enough on it. Let me find out. You know, I'm sure I've taken a position on it on the past. I have to find out what my position was. Brian, would you find out what my position is on contraception - I'm sure I'm opposed to government spending on it, I'm sure I support the president's policies on it."

Q: "But you would agree that condoms do stop the spread of sexually transmitted diseases. Would you say: 'No, we're not going to distribute them,' knowing that?"

Mr. McCain: (Twelve-second pause) "Get me Coburn's thing, ask Weaver to get me Coburn's paper that he just gave me in the last couple of days. I've never gotten into these issues before."

Just as disturbing as McCain's incomprehensible response to a simple question on American global AIDS policy is his reliance on Tom Coburn as the authority on the topic. The anti-earmark crusader blocked funding for breast cancer and ALS (Lou Gehrig's Disease) research. Coburn, an obstetrician, has said he favors the death penalty for abortion providers and called his home state legislators "a bunch of crapheads." The good doctor, who called his 2004 race against Brad Carson a choice between "good and evil", also has been accused of Medicaid fraud and sterilizing a woman without her permission. And during his 2004 Senate campaign, the Oklahoman famously alerted his fellow Sooners to the threat of lesbians run amok in the their high schools:

"Lesbianism is so rampant in some of the schools in southeast Oklahoma that they'll only let one girl go to the bathroom. Now think about it. Think about that issue. How is it that that's happened to us?"

For the American people, the pressing question is, how did Tom Coburn come to have any influence at all on public health policy in general and on AIDS in particular? And how can Americans take a presidential candidate like John McCain seriously when he cites Tom Coburn as the source of his own knowledge on HIV/AIDS?

Over the past several days, a flurry of stories has raised red flags about the prospects for state-based health care mandates. On Saturday, the AP reported that soaring costs are buffeting the pioneering insurance mandate program in Massachusetts. Just days earlier, the New York Times described a Massachusetts primary care system now swamped with new enrollees seeking treatment. And complicating matters further, the deepening recession is hitting state budgets hard, producing a financial crisis almost certain to halt the expansion of state-based universal health care coverage.

First, a little background. Under a law signed in 2006 by then Governor Mitt Romney, Massachusetts residents beginning this year are required to obtain health insurance either through work or the private marketplace. While coverage for lower income residents is subsidized (or exempted) by the state, those not acquiring insurance face fines and tax penalties. Businesses with 10 employees or more must also provide health care coverage or similarly face penalties from the state. By December 2007, Massachusetts announced that 300,000 people had enrolled in new insurance programs. Still, between 100,000 and 300,000 (according to the federal government) remain without coverage.

Despite the early success in reducing the pool of the uninsured, Massachusetts is already experiencing spiraling costs for the program. The $1 billion experiment as initially designed was supposed to be paid for largely from the state's existing fund for emergency medical care for the uninsured. With the program's costs now expected to hit $1.4 billion, Governor Deval Patrick signed a $400 million expansion for 2009. To fund it, the state is looking to pass a new dollar-a-pack cigarette tax designed to generate over $150 million in revenue annually. Meanwhile, penalties for non-compliance are also being raised, up to $912 for individuals and $1,824 for families on top of the $219 personal tax exemption.

The good news coming out of the Commonwealth - over 300,000 more residents now possessing medical insurance - is also creating growing challenges for Massachusetts' primary care physicians now overwhelmed by the newly covered. As the New York Times detailed, the program's very success is producing waiting lists and long delays for patients:

Here in western Massachusetts, Dr. Atkinson's bustling 3,000-patient practice, which was closed to new patients for several years, has taken on 50 newcomers since she hired a part-time nurse practitioner in November. About a third were newly insured, Dr. Atkinson said. Just north of here in Athol, the doctors at North Quabbin Family Physicians are now seeing four to six new patients a day, up from one or two a year ago...

...The share who accept new patients has dropped, to barely half in the case of internists, and the average wait by a new patient for an appointment with an internist rose to 52 days in 2007 from 33 days in 2006. In westernmost Berkshire County, newly insured patients are being referred 25 miles away, said Charles E. Joffe-Halpern, director of an agency that enrolls the uninsured.

As the Times details, skewed market forces and an overemphasis on specialized treatment has left the primary care system in Massachusetts - and nationwide - simply unable to provide routine, preventive care when Americans' access is dramatically increased. Dr. Patricia A. Sereno, state president of the American Academy of Family Physicians, put it:

"It's a recipe for disaster. Its great that people have access to health care, but now we've got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care."

For other states contemplating the Massachusetts model, the American economic slowdown is quickly rendering such debates moot. Facing a massive $16 billion deficit, California has been forced to backburner Governor Schwarzenegger's ambitious $14.7 billion universal health care proposal. Across America, the news is grim for the country's governors. As the Washington Post recently reported:

State budgets have been hit hard by a worsening national economy, including rising costs for energy and health care. In addition, fallout from the subprime mortgage crisis -- declining home sales, deflated property values and mounting foreclosures -- has caused a slide in states' anticipated tax receipts. Revenue from property taxes, sales taxes and real estate transfer taxes is affected.

At least half of the nation's states are facing budget shortfalls, some of them severe, and policymakers in most of the states affected are proposing and passing often-painful measures to trim costs and close the gaps. Spending on schools is being slashed, after-school programs are being curtailed and teachers are being notified of potential layoffs. Health-care assistance is being cut for the elderly, the disabled and the poor. Some government offices, such as motor vehicle department locations, will start closing on weekends, and some state workers are receiving pink slips.

The impact of these budget shortfalls on the future of state-based health care coverage is clear. As Ezra Klein argued in his prescient Washington Monthly piece last summer ("Over Stated"), state "laboratories of democracy" cannot achieve universal health care:

Over the years, states have tried programs of many different ideological and economic persuasions. All of them failed, and not because the programs were insufficiently inventive, but because states are structurally incapable of sustaining them.

Analyzing the histories of health care initiatives in Hawaii, Washington and Tennessee, Klein showed the impact that economic downturns have had in undermining the viability of even initially successful programs. At the time he wrote his piece, Klein predicted that Massachusetts "may be the exception that proves the rule," given its high median family income and comparatively low numbers of uninsured residents.

This triple whammy of an inadequate primary care system, rising costs and recession suggests that the solution to the American health care crisis must come from the nation's capital and not the state capitals. (Governor Deval Patrick's lukewarm response to Hillary Clinton's call for a national health insurance mandate may have less to do with being an Obama supporter and more to do with his experience in Massachusetts.) The emergency of 47 million uninsured Americans needs to be treated not in Boston, Sacramento or Santa Fe, but in Washington DC.

John McCain is facing a major health care crisis. Not so much his own, though questions abound about the Republican presidential nominee's bouts with skin cancer. No, as the Boston Globe details, it is the feeble McCain health care plan itself which is terminally flawed.

Which isn't to say McCain's age and medical history aren't a concern of his campaign. While the McCain camp has repeatedly delayed releasing his medical records, the New York Daily News is reporting that McCain will host a public meeting with his doctors some time next month. For man who has described himself as "older than dirt" and emphasized the importance of his vice presidential selection by noting "I'm aware of enhanced importance of this issue because of my age," reassuring American voters about his longevity can't come too soon.

But as Elizabeth Edwards highlighted last week, John McCain's personal medical situation is the least of his problems on the road to the White House. Noting that due to their respective pre-existing conditions, "neither one of us would be covered by his health policy," Edwards suggested that it is McCain's gap-filled health care medical policy prescription itself which fails test after test for the American people.

Those failures were further detailed by the Boston Globe Sunday in its devastating assessment, "McCain Camp Working Out Healthcare Details." Even as polls consistently show health care to be Americans' greatest concern after the economy and the war in Iraq, John McCain's doctrinaire laissez-faire approach raises more questions than it answers.

Last fall, for example, McCain flatly rejected mandating that insurance companies provide coverage to Americans with pre-existing conditions, proclaiming "that would be mandating what the free enterprise system does." As the Globe noted:

McCain's response highlights the challenge he faces as he prepares to try to sell his healthcare plan in the fall campaign. He says the country must provide access to healthcare for all our citizens, and that "we need to help people who need it." But McCain also wants to shrink government's role in healthcare and doesn't want to impose regulations on insurance companies.

As a result, McCain's aides have been scrambling to come up with ways to satisfy those who want more coverage without violating what they call McCain's conservative principles on the issue...

..."These are real questions, and I think there will be answers, and there better be, but they are not there yet," said McCain adviser Thomas P. Miller, a resident fellow at the American Enterprise Institute. "A lot more remains to be hammered out"...

..."We are working on it," said Douglas Holtz-Eakin, McCain's top policy adviser. "We'll put out more details. As we do, it will be clearer to people."

What McCain has offered to date is a mixture of platitudes and half-baked rehashed proposals rehashed from President Bush's playbook. At the core of McCain Care is the end of the employer-health care tax break, which is replaced by a $5,000 tax credit for families to purchase insurance in the private market. That those credits are woefully inadequate when the average family policy tops $12,000 a year (and useless when insurers can still cherry pick among healthier Americans) is apparently beside the point. As the McCain web site proclaims, good outcomes will magically occur because "John McCain believes in personal responsibility:"

"We must do more to take care of ourselves to prevent chronic diseases when possible, and do more to adhere to treatment after we are diagnosed with an illness."

In his public statements, McCain is seemingly unconcerned by 47 million Americans without health care, a dramatic drop in the percentage of employers providing medical insurance and spiraling costs:

McCain compared health insurance to buying a home, saying it was desirable but not required. "I think that one of our goals should be that every American own their own home," he said. "But I'm not going to mandate that every American own their home. If it's affordable and available, then it seems to be that it's a matter of choice amongst Americans."

If that "let them eat cake" attitude from John McCain sounds familiar, it should. After all, in what was billed as a major economic address 10 days ago, John McCain announced that he adamantly opposes federal government action in addressing the housing market crisis:

"Some Americans bought homes they couldn't afford, betting that rising prices would make it easier to refinance later at more affordable rates," he said. Later he added that "any assistance must be temporary and must not reward people who were irresponsible at the expense of those who weren't."

It's no surprise that in poll after poll, Americans overwhelmingly prefer Democratic approaches to health care to the "you're on your own" abdication of the GOP. As for John McCain and his 19th century laissez-faire philosophy, Bill Clinton's 1996 description of Bob Dole sums it up:

"I can only tell you that I don't think Senator Dole is too old to be president. It's the age of his ideas that I question."

A new study released last week revealed a Republican Party ever more out of touch with the mushrooming crisis of the American health care system. Predictably, 68% of Republicans believe the U.S. has the best health system in the world, compared to only three in 10 Democrats. Ironically, those findings come just as new studies show a growing "income gap" in Americans' life expectancy and the painful impact of rising health care costs on Americans' stagnant wages. Most ironic, the failure of the health care system is at its worst in precisely those states that voted for George W. Bush.

The survey from the Harvard School of Public Health showed sharp partisan cleavages in perceptions of the U.S. health care system. While 45% of Americans claim the U.S. has the best health care in the world, only 32% of Democrats and 40% of independents compared to 7 in 10 Republicans believe that is the case. (39% of all respondents believe other nations provide superior health care, 15% didn't know or didn't answer.)

Unsurprisingly, Americans of all political persuasions made these claims despite knowing little to nothing about the systems in other nations. Large percentages answered that they didn't know how the United States compared to France (53%), the UK (40%) or even Canada (26%).

The division between Democrats and Republicans is just as pronounced when it comes to both what is ailing the American health care system and what to do about it. Followers of the GOP seemed to believe that access to medical care is not a problem for Americans. "Four-in-ten (40%) Republicans believe the U.S health care system is better than other countries when it comes to making sure everyone can get affordable health care, compared to just one-in-five Democrats (19%) and Independents (22%) who share that belief." Predictably, 56% of Democrats and 37% of independents say they would support a presidential candidate wanting to make the U.S. system more like those in Canada, France and Great Britain.

Which is a tragedy for Red State America. While the GOP's country club class no doubt suffers little from or knows even less about the chronic failure of the American health care system (George W. Bush dominated the 2004 vote among every income group earning over $100,000 annually), the Republican base has it the worst.

That health care is just another major red state failure is the inescapable conclusion of a 2007 analysis by the Commonwealth Fund. As it turns out, Americans' health care varies dramatically from state to state. It should come as no surprise that in general Southern states ranked at the bottom in almost every category.

The Commonwealth Fund report, "Aiming Higher: Results from a State Scorecard on Health System Performance," examined states' performance across 32 indicators of health care access, quality, outcomes and hospital use. Topping the list were Hawaii, Iowa, New Hampshire, Vermont and Maine. Bringing up the rear were the Bush bastions of Kentucky, Louisiana, Nevada, Arkansas, Texas, with Mississippi and Oklahoma. The 10 worst performing states were all solidly Republican in 2004.

The extremes in health care performance are startling. For example, 30% of adults and 20% of children in Texas lacked health insurance, compared to 11% in Minnesota and 5% in Vermont, respectively. Premature death rates from preventable conditions were almost double (141.7 per 100,000 people) in Tennessee, Arkansas, Louisiana and Mississippi compared to the top performing states (74.1 per 100,000). Adults over 50 receiving preventative care topped 50% in Minnesota compared to only 33% in Idaho. Childhood immunizations reached 94% in Massachusetts, compared to just 75% in the bottom five states. As the report details, federal and state policies, such as insurance requirements and Medicaid incentives, clearly impact health care outcomes.

Sadly, conditions have only deteriorated further since the Commonwealth Fund study was published. In November 2007, research from the Economic Policy Institute showed that employer-provided health care in the United States has dropped sharply, with workplace insurance covering only 59.7% of Americans now, compared to 64.2% in 2000. As the New York Times reported this morning, premiums for family health insurance have surged 78% since 2001 to over $12,000 a year. That cost explosion comes even as Americans' salaries and wages have barely moved: "inflation-adjusted median family income has dipped 2.6 percent -- or nearly $1,000 annually since 2000." It should come as no surprise that the wealthiest Americans now live 4.5 years longer than the least-well off, a startling jump from just a 2.8 year gap reported in 1982.

Despite their own worsening circumstances, followers of the GOP seem blissfully unaware - or unconcerned - about an American health care system on the brink of breakdown. Perhaps, as Jonathan Chait and Thomas Frank among others suggest, social and national security issues real or imagined trump economic self-interest for working Republicans. In 2008, they risk once again enabling the agenda of their country club cousins. After all, it's impossible to cure the disease that is weakening the American health care system without first acknowledging there is have a problem.

(For more background, see "Health Care the Latest Red State Failure.")

Greeted in Africa by banners proclaiming "Thank you for helping fight malaria and HIV," President Bush championed his commitment to doubling to $30 billion the President's Emergency Plan for AIDS Relief (PEPFAR). But as ever, those funds come with strings attached, courtesy of Bush's base.

One-third of all prevention spending under Bush' program must go to abstinence-until-marriage programs. Senate Democrats want to remove that provision, which has been criticized by both the U.S. Institute of Medicine and the Government Accountability Office. Of course, despite the miserable track record of abstinence programs worldwide, President Bush is undeterred and demanded Congress support "what works" in Africa. As the Los Angeles Times reported:

"It is a balanced program. It is an ABC program: abstinence, be faithful, and condoms. It's a program that's been proven effective," he said, speaking at a news conference with Tanzanian President Jakaya Kikwete, an enthusiastic supporter of the effort.

"I understand there's voices on both ends of the political spectrum trying to alter the program," Bush said.

"I would ask Congress to listen to leaders on the continent of Africa...analyze what works, stop the squabbling and get the program reauthorized," he said.

While that battle continues at home, President Bush's AIDS diplomacy provides an excellent distraction from American challenges abroad. As Bush revels in the warm welcome he is receiving in Africa, tensions with Russia are rising in the wake of Kosovo's declaration of independence. Meanwhile, Bush ally Pervez Musharraf awaits election results in Pakistan, a vote delayed by the assassination of Benazir Bhutto.

The pattern by now is familiar one. Last May, Bush tried to deflect criticism of American global warming policy in advance of an imminent G8 summit. Just days before, Bush announced his new proposal for $30 billion in U.S. funding for AIDS programs around the world. In 2003, of course, his problem was the looming Iraq war.

It was U2 frontman Bono who offered President Bush the prospect of a global American public relations triumph in the run-up to the invasion of Iraq by announcing a massive commitment to fighting AIDS:

"Maybe it's smart to just help people with these crushing problems. These drugs are great advertisements for us in the West, for our ingenuity, our technology, our innovation, particularly in the United States. I said that to President Bush. I said, 'Paint them red, white and blue if you want, but these drugs are the best advertisement you are going to get right now, and that might be important right now.'"

Shortly thereafter, President Bush shocked the world by announcing a five-year, $15 billion dollar AIDS program for Africa and the Caribbean in his 2003 State of the Union Address. Later, he would tap First Lady Laura Bush as his global AIDS ambassador.

That aid, of course, came with strings attached. Only $1 billion would go to the UN's Global AIDS Fund. Over $1 billion would be distributed through faith-based organizations, such as Graham's Samaritan's Purse. Worse still, the Bush administration and allies such as Kansas Senator Sam Brownback followed the lead these religious groups in balking at the use of condoms (the "C" in the Ugandan ABC formula of "Abstinence, Be Faithful, Condoms"). As a result, Brazil declined to accept Americans AIDS funding which barred programs involving condoms. Pioneering Ugandan AIDS activist Noerine Kaleeba could only ponder in amazement:

"I have met President Bush twice. He strikes me as a very brilliant, very passionate and very caring person. But when I contrast the President Bush that I have met with the policies and practices that are coming out of the United States, I can't reconcile it."

By now, of course, it is very easy to reconcile the timing and content of Bush's generous AIDS crusade. As the history shows, President Bush opens the purse strings as politics foreign and domestic require. And as ever, Bush's faith-based followers control those purse strings. So even as he tries in his final days in office to cement his legacy as the friend of Africa, George W. Bush is always thinking about his friends - and enemies - back home.

On Saturday, President Bush scored a triple victory when he quietly signed a bill extending the State Children's Health Insurance Program (S-CHIP) through March 2009. First, the President teed up "socialized medicine" as the definitive 2008 GOP talking point in response to any new health care initiatives coming from the Democratic Party. Second, he added another win for the GOP campaign of obstructionism, blocking Democratic successes at any cost in the hope of painting Harry Reid and Nancy Pelosi as leaders of a "do-nothing" Congress. And last, George W. Bush kept intact his consistent record of fierce opposition to the popular children's health insurance program dating back to his days as Governor of Texas. And as in Texas, he went on to claim credit for it.

Unable to override the two Bush vetoes of their $35 billion proposal expanding S-CHIP coverage from 6.6 million to 10 million beneficiaries, the Democratic leadership gave up the fight for now. While Rahm Emanuel (D-IL) vowed to press on ("What we couldn't resolve, the American people will resolve in November") White House spokesman Tony Fratto proclaimed victory:

"We're pleased that the program will be extended and that states can be certain of their funding."

The Bush administration's ultimately successful campaign to block the expansion of the very successful - and wildly popular - S-CHIP program began in earnest this summer. In August, the White House fired the first salvoes in Bush's second war against the insurance program for children. Just two weeks after the House and Senate each approved major expansions of S-CHIP, the Bush administration announced draconian new eligibility rules that would trim thousands of low income children from the rolls. But unlike his Texas two-step when he claimed credit for a program he fought tooth and nail, this time George W. Bush isn't running for anything.

As the New York Times described, the White House quietly dispatched a letter at 7:30 PM on a Friday evening outlining its new curbs on S-CHIP eligibility. With Congress out of session, Dennis Smith of the federal Center for Medicaid and State Operations notified states that they must reach 95% enrollment of families below 200% of the poverty level before they can expand their programs. Of course, no state currently approach the 95% figure today (nationally, almost 30% of eligible children remain unenrolled in S-CHIP). Worse still, several states previously received the federal government's OK to extend their coverage to even higher income levels and more are considering further expansion still:

In New York, which covers children up to 250 percent of the poverty level, the Legislature has passed a bill that would raise the limit to 400 percent - $82,600 for a family of four - but the change is subject to federal approval.

California wants to increase its income limit to 300 percent of the poverty level, from 250 percent. Pennsylvania recently raised its limit to 300 percent, from 200 percent. New Jersey has had a limit of 350 percent for more than five years.

It's no wonder incredulous state health care officials are horrified by the Bush administration's new regulations. Ann Clemency Kohler, deputy commissioner of human services in New Jersey, said "It will cause havoc with our program and could jeopardize coverage for thousands of children."

If this all sounds vaguely familiar, it should. As I wrote in July ("S-CHIP on Bush's Shoulder"), the unfolding saga over children's health insurance is a repeat of then-Governor George W. Bush's performance in Texas. There, Bush first opposed the S-CHIP program and then tried to limit its scope with restrictive income eligibility requirements. Facing certain defeat over the popular program, Governor Bush ultimately caved to public pressure. Of course, he then took credit for it.

As The New Republic noted, we've been here before. In the 1990's, then Texas Governor George W. Bush opposed a bi-partisan effort to expand S-CHIP in his state. Despite Texas' worst-in-the-nation status (then and now) in the percentage of residents without insurance, Bush (then as now) opposed the broadened program on both fiscal and philosophical grounds. As Salon reported in July 2000, Bush tried to limit eligibility to families with incomes at 133% of the poverty line, compared to the 200% standard adopted in most states (and over Bush's opposition, in Texas). Bush's hard line would have kept 200,000 kids off the program's rolls. As it was, the difficult and cumbersome application process limited sign-ups to only 28,000 of the 500,000 children eligible by mid-2000.

None of which stopped George W. Bush taking credit for the program during his 2000 presidential campaign. As Joshua Micah Marshall reported in Salon:

In Bush's press release it says: "When the CHIPs program was first implemented, Governor Bush embraced it as an opportunity to help deliver health coverage to thousands of uninsured children, and signed legislation providing health insurance for more than 423,000 children."

On July 20, 2000, Al Gore made a trip to San Antonio, Texas. Gore described Governor Bush's opposition to the program and the onerous eligibility process he set up to blunt participation by Texas families. "As a result," Gore said, "there are 600,000 children in Texas eligible for health insurance who don't have it." Sadly, Bush never paid a price for stonewalling on S-CHIP and his war against Texas' children.

Now, as Bush prepares to exit the stage, he again is claiming for an S-CHIP bill he furiously opposed. But with his S-CHIP "hat trick" today, George W. Bush may be setting up his Republican Party for a beating in 2008. As a hockey fan will tell you, the player scoring the hat trick of three goals in one game today is likely in for a fight the next time the teams play.

As the Washington Post reported Saturday, Senate hopeful Mike Huckabee in 1992 advocated the isolation of AIDS patients. Labeling homosexuality "an aberrant, unnatural, and sinful lifestyle" which could "pose a dangerous public health risk," Huckabee called for draconian - and discriminatory - action:

"If the federal government is truly serious about doing something with the AIDS virus, we need to take steps that would isolate the carriers of this plague.

It is difficult to understand the public policy towards AIDS. It is the first time in the history of civilization in which the carriers of a genuine plague have not been isolated from the general population, and in which this deadly disease for which there is no cure is being treated as a civil rights issue instead of the true health crisis it represents.

In light of the extraordinary funds already being given for AIDS research, it does not seem that additional federal spending can be justified. An alternative would be to request that multimillionaire celebrities, such as Elizabeth Taylor (,) Madonna and others who are pushing for more AIDS funding be encouraged to give out of their own personal treasuries increased amounts for AIDS research."

How ironic, then, that five years earlier in 1987 Ronald Reagan shared the stage with Elizabeth Taylor at a dinner honoring the American Foundation for AIDS Research (amfAR). There, Reagan refuted every point Huckabee would later make, even anticipating the kind of faith-based fear-mongering the former minister would later offer up:

"As dangerous and deadly as AIDS is, many of the fears surrounding it are unfounded. These fears are based on ignorance. I was told of a newspaper photo of a baby in a hospital crib with a sign that said, 'AIDS -- Do Not Touch.' Fortunately, that photo was taken several years ago, and we now know there's no basis for this kind of fear. But similar incidents are still happening elsewhere in this country. I read of one man with AIDS who returned to work to find anonymous notes on his desk with such messages as, 'Don't use our water fountain.' I was told of a situation in Florida where 3 young brothers -- ages 10, 9, and 7 -- were all hemophiliacs carrying the AIDS virus. The pastor asked the entire family not to come back to their church. Ladies and gentlemen, this is old-fashioned fear, and it has no place in the home of the brave.

The Public Health Service has stated that there's no medical reason for barring a person with the virus from any routine school or work activity. There's no reason for those who carry the AIDS virus to wear a scarlet A. AIDS is not a casually contagious disease...

...In addition to all the private and corporate research underway here at home and around the world, this fiscal year the federal government plans to spend $317 million on AIDS research and $766 million overall. Next year we intend to spend 30 percent more on research: $413 million out of $1 billion overall. Spending on AIDS has been one of the fastest growing parts of the budget, and, ladies and gentlemen, it deserves to be."

That address in May 1987 represented the culmination of a long journey for Ronald Reagan. As I wrote in "Reagan and Bush in the Age of AIDS," less than two years earlier, President Reagan in September 1985 only fueled the growing panic of American parents seeking to remove afflicted students such as Ryan White from their childrens' schools. Heeding the counsel of his adviser the future Supreme Court Chief Justice John Roberts (who argued "I would not like to see the President reassuring the public on this point"), a clearly uncomfortable Reagan told the audience at a press conference:

"I'm glad I'm not faced with that problem today and I can well understand the plight of the parents and how they feel about it...And yet medicine has not come forth unequivocally and said 'This we know for a fact, that it is safe.' And until they do I think we have to do the best we can with this problem. I can understand both sides of it."

Not wanting to anger his allies on the Christian right when it came to the "gay plague," Reagan remained silent on AIDS throughout most of his presidency. In what would be the first high-impact celebrity intervention among Republicans, it took that plea from Elizabeth Taylor to get Ronald Reagan to deliver the AMFAR speech in 1987. Only then did he finally begin to get the science - and the public policy - right.

Which is a lot more than can be said for Mike Huckabee. Facing a firestorm of criticism this weekend for his dangerously misguided and hate-filled comments in 1992, Huckabee turned to revisionist history for his defense:

"We now know that the virus that causes AIDS is spread differently, with a lower level of contact than with TB. But looking back almost 20 years, my concern was the uncertain risk to the general population -- if we got it wrong, many people would die needlessly. My concern was safety first, political correctness last.

The AIDS crisis was just that - a crisis. We didn't know exactly all the details of how extensive it was going to be. There was just a real panic in this country. If I were making those same comments today, I might make them a little differently."

Of course, the extremist Mike Huckabee could have gotten it right on AIDS in 1992. He just had to ask Ronald Reagan.

UPDATE: As ThinkProgress reported, Huckabee appeared on Fox News this morning and refused to "recant" or "run from" his words in 1992.

While the debate over the health care crisis in America remains focused on the expansion of S-CHIP and the competing proposals of the 2008 presidential candidates, a new study revealed the continuing and steady decline of employer-based health coverage in the United States. Once the lynchpin of the U.S. health care system, workplace health insurance now covers only 59.7% of Americans, down from 64.2% in 2000. And making matters worse, surging health care costs, insurance premiums and employees' own contributions continue to exceed inflation and the growth in wages.

The report from the Economic Policy Institute, "The Erosion of Employment-based Insurance," paints a bleak picture for working Americans. Overall, 47 million people (15.8%) in the U.S. had no health insurance in 2006, up 8 million from 2000 when 13.7% were without coverage. Helping to fuel that dramatic increase is the drop-off in employer-provided insurance, which dropped 4.5 percentage points over the same period resulting in 2.3 million more Americans without medical coverage.

Behind the national data is a startling disparity from state to state. Like most indicators of health care, employment-based coverage generally follows the 2004 electoral map. Blue states including New Hampshire (75.6%), Connecticut (72.3%) and New Jersey (71.2%) led the way in workplace health coverage for residents under age 65. (Those over 65 are generally covered by Medicare.) Unsurprisingly, the situation is worst in precisely those states that voted to re-elect George W. Bush. New Mexico (52.9%), Mississippi (54.5%), Texas (54.6%) and Louisiana (55.3%) were at the bottom of the rankings. The one notable exception is California. Its dismal performance (55.7%) is accounted for by the sheer size of its agricultural, service and tourism economies, sectors traditionally not providing workplace insurance.

The EPI findings also show alarming variations in employer-provided health coverage by race and income. In 2006, 76.4% of white workers received health insurance from their employers, compared to only 65.8% for African-Americans and just 48.4% for Hispanics. And while over 86% of the top quintile of wage earners had workplace health coverage, the figure for the bottom fifth was only 44.6%.

The picture for America's children is even worse. Between 2000 to 2006, 3.4 million fewer children had insurance through their parents' jobs, a decrease of 6.2%. The disparities by family income are shocking. Only 18% of children 17 and under for the bottom quintile of earners had insurance through their parents' work; kids in the top fifth of family incomes were almost five times (86.3%) more likely to be covered. As the report notes, "The group hurt the worst, however, was children in the second lowest quintile; their coverage rates declined by 10.6 percentage points, from 54.6% to 44.0%."

As the EPI points out, these grim numbers for working families not covered by Medicaid make a powerful argument for the expansion of the State Children's Health Insurance Program (S-CHIP), an initiative recently vetoed by President Bush:

Opponents of SCHIP expansion argue that the availability of a public insurance option leads parents to voluntarily drop private coverage and shift their children's coverage to the public sector. As shown in an EPI Economic Snapshot, research shows very little of such "crowding out" actually occurs. The large majority of SCHIP recipients - 86% - were either not covered six months before entering SCHIP or had lost private coverage within six months prior to enrolling.

The erosion of employer-based insurance detailed in the EPI report captures only part of the double-barreled health care squeeze facing American families. That is, even as workplace provided coverage declines, the increase in health care costs and the out-of-pocket expenses of Americans continues to rise at rates far outstripping wage growth.

That is the conclusion of the 2007 Employer Health Benefits Survey jointly produced by the Kaiser Family Foundation and the Health Research and Educational Trust. The average annual family premiums reached $12,106 in 2007, with workers contributing $3,281 of the total. Families' out-of-pocket expenses have surged $1,500 a year over the past six years. Despite a slowing in the rate of increase of health care costs, family incomes still aren't keeping pace:

Premiums for employer-sponsored health insurance rose an average of 6.1 percent in 2007, less than the 7.7 percent increase reported last year but still higher than the increase in workers' wages (3.7 percent) or the overall inflation rate (2.6 percent). The 6.1 percent average increase this year was the slowest rate of premium growth since 1999, when premiums rose 5.3 percent. Since 2001, premiums for family coverage have increased 78 percent, while wages have gone up 19 percent and inflation has gone up 17 percent.

According to the KFF/HRET survey of 3,078 firms, the future looks bleaker still. Employers are looking to shed their rapidly rising health care costs, shifting the burden onto American workers and their families:

Many employers indicate that they expect to make significant changes to their health plans and benefits in 2008. Overall, 21 percent of firms say they are "very likely" to raise workers' premium contribution next year. Some firms also say they are "very likely" to increase office visit cost-sharing (13 percent), increase deductibles (12 percent) and increase prescription drug cost-sharing (11 percent). Very few firms say they are "very likely" to restrict eligibility for coverage or drop health coverage altogether.

Back in Washington, President Bush and obstructionist Republicans in Congress continue to fiddle while the foundation of the American health care system burns. Even as Americans consistently cite health care as one of their most important issues (after the war in Iraq), it looks more and more like full employer-provided health insurance is becoming a thing of the past.

For more background and data on the state of American health care, see "SiCKO Required Reading: U.S. Health Care by the Numbers."

On Sunday, First Lady Laura Bush revealed a new side of her persona to the American people: policymaker. Describing herself "involved for a long time in policy," Mrs. Bush decried the Stepfordesque stereotype she claimed is applied to her. But given her past public statements and policy roles to date, Americans should be forgiven for chuckling in response.

The still popular First Lady made her comments during an attempt to defend the indefensible, her husband's veto of the expansion of the wildly successful and even more popular State Children's Health Insurance Program (S-CHIP). Mrs. Bush accused the Democrats of demagoguery, calling S-CHIP a "perfect issue" for bludgeoning the President:

"It's really easy to blame people for so-called voting against children."

Laura Bush then went on the make her surprising claim about her centrak role as policy maker in the White House:

"The fact is I've been involved for a long time in policy, and I think I just didn't get a lot of coverage on it. I was stereotyped as being a certain way because I was a librarian and a teacher...which are considered traditional women's careers."

As Stephen Colbert noted in 2006, "reality has a well known liberal bias." What Laura Bush sees as a stereotype is instead the appropriate reaction of the American people conditioned to the banality of what she says - and does.

For example, take the First Lady's penchant for diminishing the war in Iraq. As Perrspectives documented back in April, an out-of-touch Laura Bush was able to insult American troops and their families three times in under a year. Appearing on the Today Show, the First Lady in April offered the American people this shining nugget of detachment and tone-deafness:

"No one suffers more than their President and I do."

Laura Bush's shocking callousness today is hardly her first offense. In February, the First Lady cautioned Americans against being disheartened by the occasional blast in Baghdad:

"Many parts of Iraq are stable now. But, of course, what we see on television is the one bombing a day that discourages everybody."

That calming assessment was just the latest from the consistently upbeat - and seemingly medicated - First Lady. In May 2006, Mrs. Bush casually dismissed the consensus negative view of Iraq shared by the American people:

"I don't really believe those polls. I travel around the country, I see people, I see their response to my husband, I see their response to me...A lot of people come up to me and say, 'Stay the course.'"

But if Laura Bush can be forgiven for her casual disregard for the concerns of the American people (after all, it runs in the family), her role as self-proclaimed policy wonk rightly deserves the opprobrium it receives.

For the most part, the First Lady has been consigned to the backwater of Bush White House policy initiatives. Ironically, most of her symbolic roles reinforce her image as the mom/teacher. For example, President Bush during his 2006 State of the Union Address announced that his wife would head up something called the Helping America's Youth Initiative which encourages "caring adults to get involved in the life of a child." The year before, President Bush used the 2005 SOTU to proclaim that his wife would lead an anti-gang initiative. Using funds from the President's Faith-Based Initiative, the First Lady would help "bring hope to harsh places." As for brokering a peace deal between the Bloods and the Cripps, that apparently remains on her to do list. (As Jay Leno suggested, Laura Bush could rework Nancy Reagan's old tag line, "Just Say Yo.")

The one exception to Laura Bush's litany of symbolic tasks has been on HIV/AIDS. There, she has served as her husband's global ambassador on AIDS. While the United States has at least supported that effort with money, the results of her performance for AIDS victims and the health care professionals battling the disease haven't been pretty.

As I wrote in 2006, Laura Bush and the U.S. delegation to international AIDS conferences have been instrumental in blocking increased funding, removing language involving drug addicts, prostitutes and homosexuals and perhaps worst, perpetuating the dangerously counterproductive abstinence agenda demanded by the American religious right:

The typically smiling Mrs. Bush blithely ignored these and other controversies and contradictions central to the American policy of AIDS. The First Lady told the assembled delegates:

"In parts of sub-Saharan Africa, new data shows that Africa's ABC model of AIDS prevention has led to dramatic declines in HIV infection rates in young men and women...All people need to know how AIDS is transmitted, and every country has an obligation to educate its citizens. This is why every country must also improve literacy, especially for women and girls, so that they can make wise choices that will keep them healthy and safe."

But when it comes to the ABC's of AIDS (abstinence, be faithful, condoms), the United States seems to have forgotten the alphabet. Almost from its inception, Bush's $15 billion AIDS initiative PEPFAR (the President's Emergency Plan for AIDS Relief) has come with conditions attached. Bowing to the religious right, the White House has steered over $1 billion to religious groups stressing abstinence and undermining condom education and distribution programs. It's no wonder a defensive Laura Bush was forced to defend her husband's wildly unrealistic focus on abstinence during her last visit to Africa in January:

"I'm always a little bit irritated when I hear the criticism of abstinence, because abstinence is absolutely 100 per cent effective in eradicating a sexually transmitted disease."

Pioneering Ugandan AIDS activist Noerine Kaleeba could only ponder in amazement the effort led by the First Lady:

"I have met President Bush twice. He strikes me as a very brilliant, very passionate and very caring person. But when I contrast the President Bush that I have met with the policies and practices that are coming out of the United States, I can't reconcile it."

As it turns out, it is Laura Bush who can't seem to reconcile people's perceptions with her own self-image as a White House policy player. On this as in so many other areas, she is out of touch.

ThinkProgress speculates this morning that President Bush will give a recess appointment to James Holsinger, his bizarre and wildly homophobic nominee for Surgeon General. For the White House, Holsinger's quackery and desire to "cure gays" not only makes him a very attractive successor to the disagreeable Richard Carmona. More importantly, a recess appointment in the face of overwhelming opposition from the Senate Health Committee helps President Bush "ensure that I am relevant." It's just another part of George W. Bush's strategy of maximum confrontation guiding the remainder of his enfeebled presidency.

Maximum confrontation serves three purposes for President Bush. First, it is an essential ingredient in preventing Democrats from winning victories of any kind and claiming successes as they head into the 2008 elections. Second, perpetual conflict with the "Democrat" Party, whether over nominees, filibusters or vetoes, helps mobilize the President's hard right base. And last, as Robert Draper's new biography Dead Certain makes clear, the image of the battling, brawling President helps Bush cement his legacy as a man of resolve, unbending in the face of either opposition or reality.

With no reelection campaign to run, no vice president to protect and leading a party whose electoral strategy is to whip up the conservative base while suppressing Democratic and independent voter turnout, Bush will pay no price for his thirst for conflict. (His Republican allies in Congress, however, may be another matter.)

All of which suggests the disturbing logic behind the choice of an inflammatory, polarizing figure like Holsinger. For example, on the day of Attorney General Alberto Gonzales' resignation, conservative movement godfather Richard Viguerie counseled President Bush, "Confront the Democrats, don't 'reach out' to them as liberal commentators are urging." In his vitriolic statement lamenting Gonzales' departure, Bush appeared to heed Viguerie's advice, decrying the "unfair treatment" that led to Gonzales' being "dragged through the mud for political reasons." While Bush ultimately opted against the conservative darling Ted Olson, the mounting opposition even from some Republicans to Judge Michael Mukasey makes it clear that the President intends to sticks to his guns on domestic surveillance and detainee torture.

As the history shows, George W. Bush only too happy to resort to recess appointments to ensconce extremist appointees like Kerry Swift Boater turned Ambassador Sam Fox or former UN ambassador John Bolton. After all, President Bush has already filled 105 positions with recess appointments, compared to just 42 for Bill Clinton by the same point in his presidency.

Bush's craving for conflict and endless obstructionism hardly ends with his predilection for in-your-face nominees. As Robert Novak detailed in June, Bush's veto strategy will define the remainder of his term. While Bush withheld his veto pen during a first term featuring a compliant GOP Congress, the President is promising a tidal wave of vetoes from here on out. Blocking stem cell research, federal spending bills, Iraq war benchmarks, expansion of the State Children's Health Insurance Program (S-CHIP), and government negotiation of Medicare prescription drug prices are just a few on the threats Bush has issued. His dander (and testosterone) up, a feisty Bush crowed in June:

"If the Democrats want to test us, that's why they give the president the veto."

In the Senate, Bush's Republican allies are working overtime to make sure it doesn't come to that. The same GOP who demanded the "up or down vote" in 2005 is now making unprecedented use of the filibuster to block Democratic initiatives - and victories - at all costs. Republican obstructionism blocked every major Democratic effort to change the course in Iraq and even stalled the Alberto Gonzales no-confidence vote. The Republican commitment to portraying Harry Reid and Nancy Pelosi as leaders of a do-nothing Congress through the 208 elections ensures that the Democrats will need a filibuster-proof 60 votes to do anything. (President Bush's veto threats raise that bar to 67 votes.) As Senate Minority Whip Trent Lott (R-MS) publicly bragged:

"The strategy of being obstructionist can work or fail. So far it's working for us."

Even the Iraq debate reflects President Bush's endless appetite for political fireworks. During a 2004 debate with John Kerry, President Bush might as well have been discussing Democrats and not Islamic insurgents when he said, "best way to defeat them is to never waver, to be strong, to use every asset at our disposal, is to constantly stay on the offensive." His only concession to the reality of potential Republican devastation next November is the appearance of withdrawing U.S. troops beginning next summer.

No doubt, if President Bush gives James Holsinger a recess appointment, he will ignite a firestorm of angry confrontation with Democrats. Which is exactly what he wants.

While Republican politicians, conservative commentators and the right-wing blogosphere continued their jihad against the private school scholarship of 12 year old S-CHIP beneficiary Graeme Frost, the Supreme Court Wednesday quietly handed the son of multimillionaire former Viacom CEO Tom Freston private school tuition courtesy of New York taxpayers.

Frost, as you'll recall, is the Maryland child who delivered the Democratic response on September 29th to President Bush's veto of the bill expanding the State Children's Health Insurance Program (S-CHIP). Frost, whose working class parents' dual incomes do not top Maryland's $55,220 ceiling for eligibility, received S-CHIP benefits to pay for the treatment of severe brain injuries he suffered in a car crash.

Furious conservatives, including a top aide to Senate Minority Leader Mitch McConnell and Michelle M