Robert C. Bowman, M.D.


"I cannot help fearing that men may reach a point where they look on every new theory as a danger, every innovation as a toilsome trouble, every social advance as a first step toward revolution, and that they may
absolutely refuse to move at all for fear of being carried off their feet. The prospect really does frighten me that they may finally become so engrossed in a cowardly love of immediate pleasures that their interest in
their own future and in that of their descendents may vanish and that they will prefer tamely to follow their course of their destiny rather than make a sudden energetic effort necessary to set things right." Alexis De
Tocqueville 1805 - 1859 Democracy in America 1840 Vol 2 part 3 Chapter 21

Every society honors its live conformists and its dead troublemakers. Migno McLaughlin 1963


Not making the "sudden energetic efforts" is a problem. Enacting legislation to make it nearly impossible to change is a step not even anticipated by visionary historians and the founding fathers.


The nation has been bombarded with a variety of Propositions that have to do with limiting government. This was written to address a similar proposal in Nebraska. For Nebraska, the Proposition did not make sense. This may not be true in some states.


I am passing this on as the efforts are centrally orchestrated and you should be aware that your state is tracked and tallied and targeted, much like the efforts to reverse affirmative action. I see no national conspiracy across these various efforts other than there are many who have discovered that government can be used to further personal gain. There are a variety of reasons to support or reject Propositions. Not all have to do with personal gain. However national trends are important. Jumping on a Band Wagon is a calculated political strategy that can lead to good things, or bad:


The first thing neglected by proponents and opponents alike is what is actually involved. Proposition 423 limits the state spending to the greater increase of inflation rate plus population growth or last year’s state spending limit. This limit may only be exceeded by a 2/3rds legislature vote plus a majority of the state voters at a statewide election. The language makes it very, very difficult to exceed spending limits.


The various Proposition 423s across the nation certainly make sense for states where leadership is out of touch with budget realities where damage can be limited. There are other solutions for lack of integrity and trust, and these involve voting for representatives worthy of trust. If Nebraskans feel that their elected representatives are not worthy of trust to decide basic revenue and appropriation issues, then they should vote for Proposition 423, change their legislators, then remove in a few years when the legislature can be trusted.


If Nebraskans trust their government to make important and basic legislative decisions about revenues and expenditures for the short and long term, then they should vote against Proposition 423. Nebraska has a Unicameral and legislators that are much closer to a fair representation of the people. The state is very different than other states or the nation where two legislative house systems and professional politicians can be increasing problems.  


What other states have done has little relevance. The various commercials are entertaining but prey upon ignorance to make their point. The commercials and writings about Colorado are an example. Colorado is an entirely different state in a different region with a different rate of growth, different economics, and a different relationship with government. The “musical chairs” commercial which depicts a child, a policeman, an elderly lady, and other representatives of government components, although entertaining, is not accurate with regard to 423. Government will still apportion the various divisions of spending. Musical chairs does happen, but the effects have been far more subtle over the long term. Health care and costs of neglect such as prison, unemployment, and welfare are displacing education. The ending of the commercial is accurate with regard to minority children losing out, but not the cute elderly woman. Those younger and less visible in rural and underserved areas of our nation are increasingly excluded from consideration. Those older, more urban, and richer have increasing attention – a result of voting, political influence, and accumulated wealth and health.


It is the patterns of neglect with the sudden realization of the need for change that necessitate a vote against 423. Proposition 423 creates a firewall for spending. It makes it nearly impossible to increase funding for any area without major cuts in other areas. The opposition of one or more major groups would make it very difficult to get a spending limit increase. Any established special interest group could fight the 2/3rds vote in the legislature. It could fight the majority vote at the state level. It could even tie the entire matter up in a debate over the specific amount of increase needed.


Major reforms in government may well be the target of 423. Major reforms in this nation have involved sudden changes to address specific and significant needs. Constitutional limitations would have made it very difficult to respond to Sputnik to reform schools, boost education degrees to the greatest level in our history, and raise higher education investments to peak levels. Forget about Medicare, Medicaid, new medical or professional schools and other programs that involved massive increases. The dilemma of our elderly in the 1960s and the efforts of the War on Poverty were just a few major increases. Medicaid doubled from 1990 – 1995. Medicaid and Medicare increases targeted those outside of major medical centers in rural and in underserved areas. The nation distributed physicians at the highest levels in our history. The nation also reigned in health care costs for a time, leading to the end of a recession and the beginning of the longest period of economic progress in recent history and the first time that we have made progress on deficit reduction.


Government is not always about saving taxes. Government is about societal efficiency and competitions with other nations regarding efficiency. There are many areas where government improves efficiency. Education, communication, and transportation are just a few. Education and early childhood investments are linked to future cost savings in education, health care, prisons, social costs, housing, welfare, and unemployment. In a nation that has painted itself into a corner in finances, we must pay much more attention to creative, innovative, and long term solutions. Somehow we must reduce the cost of government, repay deficits, and restore an impaired economic engine. Early education and child development to develop the full potential of our youth and to reduce the great costs of neglect of our youth is the best bet for a better future.


Why be creative and visionary in a state or a nation with restrictions on new and needed investments? Those who think that government flexibility is important and those that think that the nation should attract the best to government to provide the best solutions should vote against 423.


There are important reforms that are needed. All involve basic infrastructure changes in child development, education, public safety, and public health. The infrastructure of the nation includes teachers, nurses, therapists, counselors, policemen, and other serving young professionals. Hope for the future goes to those with a good start. The most critical needs involve age 0 – 8 years. Child development still lags behind other nations such as Denmark. The United States spends 0.5% of GDP on age 0 – 6 child development compared to Denmark at 2% GDP (Starting Strong II, OECD). Child development and education reforms all point to the most efficient and effective interventions involving age 0 – 8. Children by age 8 segment out by income levels that translate into standardized test scores and classroom placements that stick children in certain categories, in many cases for life. Young children cannot vote and those with the most children and the children in most need are the least likely to vote. Unfortunately all of us are impacted by the inefficiencies, traumas, and tragedies that impact our families, our cities, the state, and the nation when we fail to invest enough early enough.


Public safety is another huge issue. We actually spend more than enough, but we restrict our spending to the highest income areas and corporate locations. Even before 9/11 the nation was spending well over 10 times as much for private security as compared to police. Instead of moving criminals, crime, abuse, and violence away from higher income neighborhoods, we should do more to deal with crime at its source.


I have practiced family medicine in inner city Nebraska for 14 years. For 13 years I felt that I could go into the room and see a patient with the realistic hope that I could help improve their life in some way. This year I lost that hope. The situations that I see have become much more complex and challenging. The medical problems are no different and the people are no different. However their health is a function of their education, social conditions, housing, and public safety. The counselors, teachers, and public servants that I see as patients and through contacts regarding patients are also frustrated.


Divisions in the Nation and People and States Who Are Less Divided


Abraham Lincoln and most of our great leaders have long ago defined us all too well. They figured out that the nation would never be taken over from outside. They were more concerned about the neglected inside components. Those framing the constitution were very concerned about the use and abuse of the government to line the pockets of the wealthy. The leaders of our nation have done a great job in delaying this, but recent decades have revealed a different pattern. We are becoming richer and poorer. The rich also appear to be less and less aware of the poor and the poor are all too aware of how poor they are, and how hopeless their situation is.


Basically the US is only average in social mobility. Those in the poorest quartile remained so for 45% while 9% advanced to the top quartile and 9% to the richest. Those in the top quartile maintained the top for 33% and were in the richest at 25%. Those in the richest group had 25% in the top quartile and 55% stayed in the richest. This was the stickiest group of all. The second stickiest was the 45% from the poorest remaining the poorest quartile. The point of the article was that education is the key to progress. (Education Week October 25, 2006 Page 8  Rags to Riches in the US Largely a Myth, Scholars Write, from Brookings Institution)


Education is clearly the important aspect of higher education and professional education, the only way out of lower income brackets for many children. It is important to remember that the highest income groups can build their children a pipeline to private school, top higher education, and professional school. The rest of the 70% of the nation depend upon infrastructure built, reformed, updated, and maintained by government. No New Taxes, status quo, and propositions favor those of higher income, the most urban origins, and professionals. For the most privileged to forget the need for infrastructure is the most dangerous of situations.


Physicians are a prime example of what is happening. Over 70% of physicians come from the top 30% in income. Only 30% of physicians come from the bottom 70%. In studies of our top 146 colleges, 74% of the students are top income quartile in origin and only 3% come from the bottom 25% in income. (Carnevale and Rose in Kahlenberg, Left Behind, New Century Foundation, page 9) The United States admitted 16000 medical students each year from 1997 – 2004. Over that time period the nation admitted 1500 fewer from the bottom quartile and 1500 fewer from the middle quartiles. They were replaced by 3000 highest quartile medical students, those from parents making over $100,000 (Association of American Medical Colleges data). This has to do with neglect of rural and inner city areas of the nation, poor understanding of the limits of standardized testing known since the 1920s, and legal actions supported by groups of privilege in the nation. It does not help that colleges and medical schools appear to compete for top US News and World Report rankings. We have serious and growing problems in the distributions of education, income, health, and economics.


The people of Nebraska have invested in a different pattern. We are less likely to neglect education, higher education, or medical education. The top income quintile makes just over $100,000 but the bottom quartile also makes over $10,000. We do not tolerate the 30 to 1 ratio of a Washington DC where children are surrounded by the symbols of freedom and equality and basically have no opportunity at all. Nebraska shares the 7 – 9 to 1 ratio of the upper Midwest and Utah, arguably the most equitable states in the nation and major exporters of serving professionals to other states. We only manage to keep 35% of our new teachers. Many might change their minds if they found out that a $40,000 salary in Omaha requires a $64,000 salary in California. Over and over in my patients in eastern Omaha, I have found that it takes a near genius IQ to be poor and survive. One can only imagine what people have to do to survive on $7000 in Los Angeles, New Orleans, or Washington DC.


Medical school admissions across the state and across the nation reflect state and local investments. Nebraska born medical students are admitted at twice the national average to United States medical schools. We have a top rural high school graduation rate and rural born medical students are admitted at the same rate as the national average. We obviously have a problem with a developing inner city and this also shows in the lowest admission rate, but this rate is better than inner city rates across the nation. These rates are still poor by Nebraska standards, however.


Nebraska costs are low for prison and social programs and health and unemployment. Those who start high school or college tend to finish at the highest rates in the nation. The politicians would love to claim credit, but the real factor is a great start in life. Children in Nebraska as in the Upper Midwest and Utah and some western states have a good start.  However Nebraska has clearly moved into the ranks of those with inner city/neglected infrastructures as evidenced by lower medical school admissions for inner city children. The controversies in the school system and the challenges in schools, health care, and more in South Omaha and North Omaha are problems with solutions that will require decades of sustained efforts in education, housing, social programs, public safety, and other areas. In the mean time those most connected to people, the infrastructure professionals, will face the most challenges.


It could even be one of the reasons why physician morale is so low (ACPE Physician Morale Survey), why primary care choice is rock bottom, and why physicians place more and more layers between themselves and people, especially those from the highest income backgrounds


Robert C. Bowman, M.D.


About the Site and Author


Physician Workforce Studies


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