Wednesday, June 17, 2009

Nevada senator apologizes for affair with former staffer


John Ensign, a rising GOP star and possible presidential candidate, says he won't resign.

Reporting from Las Vegas — Nevada Sen. John Ensign, an emerging Republican leader who has been mentioned as a possible 2012 presidential candidate, apologized Tuesday for an extramarital affair with a former staff member but indicated that he had no plans to resign.

"It's absolutely the worst thing I have ever done in my life," he said at a televised news conference. "If there was ever anything that I could take back in my life, this would be it."

A grim-faced Ensign, 51, did not identify the woman he was involved with from December 2007 to August 2008, although he described her and her husband as close friends who had worked for him.

"That closeness put me into situations during a very difficult time in my marriage, which led to my inappropriate behavior," he said. "We caused deep pain to both families, and for that I am sorry."

He and his wife, Darlene, sought counseling, he said, and their marriage is "stronger than ever." She was not at the news conference but issued a statement supporting him. They have three children.

It was unclear why Ensign made the disclosure so abruptly. He skipped a Senate vote related to tourism, his state's lifeblood, and flew to Las Vegas for the hastily arranged news conference.

The silver-haired, telegenic conservative has been a rising star in the Republican Party. He is a regular on the cable news circuit, often criticizing President Obama's economic stimulus package. Ensign recently visited Iowa, where he chatted up locals, ate ice cream and fueled speculation that he was gearing up for a presidential bid.

He headed the GOP's Senate campaign panel in 2008, when the party lost at least eight seats. Now he chairs the Republican Policy Committee, a Senate leadership position.

Political experts speculated that Ensign's admission would do him little harm here. "He's the leading voice in Nevada and in the country for fiscal restraint," said Robert Uithoven, a Republican consultant based in the state.

But the revelations could derail his national ambitions, at least in the short term, by turning off values voters in the South and the Corn Belt, experts said.

"It's hard enough for someone in Nevada to run on the national stage because Nevada has such a libertarian streak that others don't understand," said Joseph M. Valenzano III, who teaches political communication at the University of Nevada, Las Vegas. "He didn't need this."

The senator also could be vulnerable to charges of hypocrisy. He belongs to Promise Keepers, a Christian group whose members pledge, among other things, to abide by biblical principles to build strong marriages.

As a candidate for the Senate, Ensign demanded that President Clinton resign after having an affair with a White House intern. He also voted to impeach Clinton.

Years later, Ensign strongly suggested that Sen. Larry Craig resign in the wake of his arrest in a 2007 airport bathroom sex sting in Minneapolis. The Idaho Republican pleaded guilty to a misdemeanor.

Ensign is a social conservative who opposes abortion and backs gun rights, but he won office by touting small-government principles, said Eric Herzik, who chairs the University of Nevada, Reno, political science department.

A veterinarian, Ensign spent four years in the House and was elected to the Senate in 2000. Two years earlier, he had lost a contentious race by a few hundred votes to Sen. Harry Reid, now the Senate majority leader.

The pair has a well-known nonaggression pact: They refuse to criticize each other in public.

"I don't know the details. I talked with him today," Reid told reporters, according to "Of course, he's my friend. This is a private family matter. I just hope that Darlene and he work things out."

Ensign, among Nevada's most popular politicians, has vowed to help the state party rebuild after the devastating 2008 election.

The GOP has been hobbled by an unpopular governor, Jim Gibbons, whose estranged wife has accused him of having affairs with at least two women.

Gun Rulings Open Way to Supreme Court Review


A year ago, the United States Supreme Court issued a landmark decision establishing the constitutional right of Americans to own guns. But the justices did not explain what the practical effect of that ruling would be on city and state gun laws.

Could a city still ban handguns? The justices said the District of Columbia could not, but only because it is a special federal district. The question of the constitutionality of existing city and state gun laws was left unanswered.

That left a large vacuum for the lower courts to fill. Supporters of gun rights filed a flurry of lawsuits to strike down local gun restrictions, and now federal appeals courts have begun weighing in on this divisive issue, using very different reasoning.

One court this month upheld Chicago’s ban on automatic weapons and concealed handguns, while in April a California court disagreed on the constitutional issue.

The differing opinions mean that the whole issue of city and state gun laws will probably head back to the Supreme Court for clarification, leading many legal experts to predict a further expansion of gun rights.

The new cases are fallout from last year’s Supreme Court case, District of Columbia v. Heller, which struck down parts of Washington’s gun control ordinance, the strictest in the country, and stated for the first time that the Second Amendment gives individuals a right to keep and bear arms for personal use. But the court declined to say whether the Second Amendment in general applies to state and local governments.

In January, the United States Court of Appeals for the Second Circuit, in New York, in a ruling joined by Judge Sonia Sotomayor, declined to apply the Second Amendment to a New York law that banned the martial arts device known as chukka sticks. The ban was allowed to stay in place.

Then in April, a three-judge panel of the Ninth Circuit, in San Francisco, ruled that the Second Amendment did apply to the states, even though it allowed a California county to ban guns on government property like state fairgrounds. That case, Nordyke v. King, is being considered for a rehearing by the full Ninth Circuit.

Those two conflicting cases set the stage for two other cases that were heard as one in the Seventh Circuit in Chicago, testing that city’s handgun ban. On June 2, a three-judge panel of the court, led by Chief Judge Frank H. Easterbrook, a well-known conservative, ruled that there was no basis for the court to apply the Second Amendment to the states. Such a decision, Judge Easterbrook wrote, should be made only by the Supreme Court, not at the appellate level.

The right of states to make their own decisions on such matters, Judge Easterbrook wrote, “is an older and more deeply rooted tradition than is a right to carry any particular kind of weapon.”

The lawyers for the plaintiffs, including the National Rifle Association, have asked the Supreme Court to take up the Chicago cases.

A split among the federal appeals circuits, especially on constitutional issues, invites Supreme Court action, said Adam Winkler, a law professor at the University of California, Los Angeles.

“Californians, Hawaiians and Oregonians have a Second Amendment right to bear arms, but New Yorkers, Illinoisans, and Wisconsinites don’t,” Professor Winkler said. “The Supreme Court will want to correct this sooner rather than later.”

The process of applying amendments of the Bill of Rights to the states, known as incorporation, began after the Civil War but had its heyday in the activist Supreme Court of the Earl Warren era. Much of the Bill of Rights, including the First Amendment’s freedom of speech and some rights of criminal defendants, have been applied to the states, but other elements have not, including the Seventh Amendment right to a civil jury trial and the Second Amendment.

Incorporation fell out of favor after the 1960s, but a new generation of largely liberal scholars of law and history have brought it back into the intellectual mainstream, said Akhil Reed Amar, a law professor at Yale University, who supports the process.

“The precedents are now supportive of incorporation of nearly every provision of the Bill of Rights,” Professor Amar said. “Now what’s odd is that the Second Amendment doesn’t apply to the states.”

Sanford Levinson, a law professor at the University of Texas, said he would be surprised if the Supreme Court accepted these gun cases, because some of the conservative justices on the court had scoffed at incorporation arguments in the past and might not want to set a precedent.

Professor Amar, however, argued that the justices would not only take up the case but would also ultimately vote for incorporation of the Second Amendment.

Even if the Second Amendment becomes the controlling law of every state and town, constitutional scholars say it is still unlikely that gun laws would be overturned wholesale. The Supreme Court’s Heller decision last year, notes Nelson Lund, a law professor at George Mason University, “clearly indicates that governments will still have wide latitude to regulate firearms.”

Even the Ninth Circuit in California, while applying the Second Amendment to the states, still upheld the gun ordinance that gave rise to the lawsuit.

Eugene Volokh, a law professor at the University of California, Los Angeles, said the view of the Ninth Circuit reflected what polls have said was, by and large, the view of the American people.

“There is a right to bear arms,” Professor Volokh said, “but it’s not absolute.”

Health Care Rationing Rhetoric Overlooks Reality



More to the point: Rationing!

As in: Wait, are you talking about rationing medical care? Access to medical care is a fundamental right. And rationing sounds like something out of the Soviet Union. Or at least Canada.

The r-word has become a rejoinder to anyone who says that this country must reduce its runaway health spending, especially anyone who favors cutting back on treatments that don’t have scientific evidence behind them. You can expect to hear a lot more about rationing as health care becomes the dominant issue in Washington this summer.

Today, I want to try to explain why the case against rationing isn’t really a substantive argument. It’s a clever set of buzzwords that tries to hide the fact that societies must make choices.

In truth, rationing is an inescapable part of economic life. It is the process of allocating scarce resources. Even in the United States, the richest society in human history, we are constantly rationing. We ration spots in good public high schools. We ration lakefront homes. We ration the best cuts of steak and wild-caught salmon.

Health care, I realize, seems as if it should be different. But it isn’t. Already, we cannot afford every form of medical care that we might like. So we ration.

We spend billions of dollars on operations, tests and drugs that haven’t been proved to make people healthier. Yet we have not spent the money to install computerized medical records — and we suffer more medical errors than many other countries.

We underpay primary care doctors, relative to specialists, and they keep us stewing in waiting rooms while they try to see as many patients as possible. We don’t reimburse different specialists for time spent collaborating with one another, and many hard-to-diagnose conditions go untreated. We don’t pay nurses to counsel people on how to improve their diets or remember to take their pills, and manageable cases of diabetes and heart disease become fatal.

“Just because there isn’t some government agency specifically telling you which treatments you can have based on cost-effectiveness,” as Dr. Mark McClellan, head of Medicare in the Bush administration, says, “that doesn’t mean you aren’t getting some treatments.”

Milton Friedman’s beloved line is a good way to frame the issue: There is no such thing as a free lunch. The choice isn’t between rationing and not rationing. It’s between rationing well and rationing badly. Given that the United States devotes far more of its economy to health care than other rich countries, and gets worse results by many measures, it’s hard to argue that we are now rationing very rationally.

On Wednesday, a bipartisan panel led by four former Senate majority leaders — Howard Baker, Tom Daschle, Bob Dole and George Mitchell — will release a solid proposal for health care reform. Among other things, it would call on the federal government to do more research on which treatments actually work. An “independent health care council” would also be established, charged with helping the government avoid unnecessary health costs. The Obama administration supports a similar approach.

And connecting the dots is easy enough. Armed with better information, Medicare could pay more for effective treatments — and no longer pay quite so much for health care that doesn’t make people healthier.

Mr. Baker, Mr. Daschle, Mr. Dole and Mr. Mitchell: I accuse you of rationing.

There are three main ways that the health care system already imposes rationing on us. The first is the most counterintuitive, because it doesn’t involve denying medical care. It involves denying just about everything else.

The rapid rise in medical costs has put many employers in a tough spot. They have had to pay much higher insurance premiums, which have increased their labor costs. To make up for these increases, many have given meager pay raises.

This tradeoff is often explicit during contract negotiations between a company and a labor union. For nonunionized workers, the tradeoff tends to be invisible. It happens behind closed doors in the human resources department. But it still happens.

Research by Katherine Baicker and Amitabh Chandra of Harvard has found that, on average, a 10 percent increase in health premiums leads to a 2.3 percent decline in inflation-adjusted pay. Victor Fuchs, a Stanford economist, and Ezekiel Emanuel, an oncologist now in the Obama administration, published an article in The Journal of the American Medical Association last year that nicely captured the tradeoff. When health costs have grown fastest over the last two decades, they wrote, wages have grown slowest, and vice versa.

So when middle-class families complain about being stretched thin, they’re really complaining about rationing. Our expensive, inefficient health care system is eating up money that could otherwise pay for a mortgage, a car, a vacation or college tuition.

The second kind of rationing involves the uninsured. The high cost of care means that some employers can’t afford to offer health insurance and still pay a competitive wage. Those high costs mean that individuals can’t buy insurance on their own.

The uninsured still receive some health care, obviously. But they get less care, and worse care, than they need. The Institute of Medicine has estimated that 18,000 people died in 2000 because they lacked insurance. By 2006, the number had risen to 22,000, according to the Urban Institute.

The final form of rationing is the one I described near the beginning of this column: the failure to provide certain types of care, even to people with health insurance. Doctors are generally not paid to do the blocking and tackling of medicine: collaboration, probing conversations with patients, small steps that avoid medical errors. Many doctors still do such things, out of professional pride. But the full medical system doesn’t do nearly enough.

That’s rationing — and it has real consequences.

In Australia, 81 percent of primary care doctors have set up a way for their patients to get after-hours care, according to the Commonwealth Fund. In the United States, only 40 percent have. Over all, the survival rates for many diseases in this country are no better than they are in countries that spend far less on health care. People here are less likely to have long-term survival after colorectal cancer, childhood leukemia or a kidney transplant than they are in Canada — that bastion of rationing.

None of this means that reducing health costs will be easy. The comparative-effectiveness research favored by the former Senate majority leaders and the White House has inspired opposition from some doctors, members of Congress and patient groups. Certainly, the critics are right to demand that the research be done carefully. It should examine different forms of a disease and, ideally, various subpopulations who have the disease. Just as important, scientists — not political appointees or Congress — should be in charge of the research.

But flat-out opposition to comparative effectiveness is, in the end, opposition to making good choices. And all the noise about rationing is not really a courageous stand against less medical care. It’s a utopian stand against better medical care.