Take a Deep Breath, and Do It Right

The New York Times has reported today that Medicare pays medical suppliers significantly more than the market price for goods and services. While the specific example is those who provide oxygen and oxygen equipment, the point is that there are a number of areas in which companies providing medical supplies are being paid for goods and services at rates well above market.

The article reports two reasons. First, many of the payment standards were set some years ago. Second, when the Centers for Medicare and Medicaid Services (CMS) wants to renegotiate, or Congress wants to establish new standards, the companies rally their customers to complain, and to demand that nothing change. Using the example of oxygen supplies highlights just how anxious patients might be. They see it as a matter of life and death, and they might well be right.

That said, I have some concerns about the reporting. It’s not that I don’t think there’s waste; I’m certain there is, based only on my knowledge of human nature. And nobody wants to pay for waste.

However, there were hints in the report of the difficulties actually deciding what’s appropriate. Case in point: the reporters looked only at numbers, and not at the human context of health care. At one point, the report says, “Even for a simple walking cane, which can be purchased online for about $11, the government pays $20, according to government data.” At another point it quotes Representative Pete Stark as saying, “All you have to do is pick up an equipment catalog or search for ‘oxygen device’ on eBay to figure out better prices than what we’re currently paying.”

That’s all well and good, but it ignores the people who need service, their perception of what they need, and their perception of the means at their disposal. Patients in need, whether for oxygen or other services, aren’t likely to do an Internet search for the best price. They want goods and services now, and not in “three to six business days, depending on the shipment option you choose.” Their perception is that their needs are immediate, if not critical; and so they’re much more likely to seek out those who can promise to provide within hours, if not within minutes. Moreover, having established are relationship that has worked, searching for an alternate supplier might seem to entail a risk the patient or caregiver is not interested in taking. Haven’t we all said at some time, about some expense, “I know it costs a little more, but I know it’s dependable.”

In advising patients, prescribing physicians are likely to choose in the same way. This isn’t a matter of collusion, although that does sometimes happen. Doctors, too, have a sense of which providers come through and provide better service to patients. They hear from patients when there are problems. So, they, too, are likely to refer to the same companies over and over, unless patients or experience demand a change. The old saying, “You get what you pay for,” includes the calculations of service and of experience, and not simply the product in this one instance.

But local, immediate providers cost more for reasons beyond profit margin. They have overhead costs, including warehouse and transportation costs, which may well be different from online providers. They argue, too, that they have different personnel expenses. Local services providing oxygen may well have on staff respiratory therapists to oversee patient care and provide patient education. We’ve all heard of the shortage of nurses, but there’s a shortage of respiratory therapists as well, and providing that additional service for patients adds to the costs of local providers.

This tendency to focus on price and not on larger context can sometimes cut the other way. A good example is Medicare reimbursement for procedures done at specialty surgery centers and “boutique” hospitals. They’re popping up everywhere: smaller institutions with a largely outpatient practice, and a few inpatient beds. They serve a particular specialty or patient pool, and they’re commonly owned by physician groups, often in partnership with developers who specialize in medical facilities. Patients are frequently very happy about them. They’re smaller and more focused institutions, and they often provide a high level of amenities – a real “customer care” focus.”

Within the limited services they provide, smaller institutions can often provide services at lower cost. They tend to have good outcomes, too, and good numbers on their patient satisfaction statistics. Those things make them attractive to patients, and to the insurers who pay for their care. Patients and insurers alike are quick to ask, “If these doctors can provide this care for this price, why can’t larger hospitals do it?

Of course, insurers know the answer, even if patients don’t. They can provide care at a lower price for a number of reasons. First, unlike a full-service hospital, there are a lot of services they don’t have to provide, and therefore a lot of staff they don’t have to keep. They don’t provide emergency services, for example, and only limited lab services. Because their practice is limited in scope, they don’t need to maintain as full a pharmacy or central supply. With few inpatient beds, they don’t have to maintain a large staff, or pay shift differential for as many folks at night. In many ways their overhead is lower.

They also get to choose patients. Unlike a full-service hospital, patients don’t just roll up to the doors of a specialty hospital. Instead, they are selected by the physicians who practice there. The selection is made, by and large, for good, medical reasons: since services are limited, only low-risk patients are served at the specialty hospital. High-risk patients are served by the same physicians in full service hospitals, because they may well need the additional services. On the other hand, that also means the patients more likely to need the additional services, the patients more likely to cost more money to care for than insurers (especially Medicare and Medicaid) are going to pay, are brought to the full-service hospitals. By the same token, the specialty hospitals can selectively serve those who have insurance. Since those who don’t usually make their entry into health care through the Emergency Room, the specialty hospitals don’t have to wrestle with unreimbursed care to anything like the extent full-service hospitals do.

There is no substitute for a full-service hospital. Every community needs its share; and every full-service hospital needs to be fully staffed and fully stocked, even when its beds aren’t fully utilized. The community needs that breadth and level of service to be available all the time, and for all in need; and that kind of security costs. So, prices for care at a full-service hospital may well be higher than those in a “boutique” hospital. But if your analysis looks only at dollar costs, and not at contexts, you can’t fully appreciate the economics of health care.

Again, my concern here is not, first and foremost, with defending the expenses charged (and some would say overcharged) to Medicare, or the expenses that Medicare does or doesn't cover. (Those concerned providers can do that for themselves; and here, too.) Instead, I’m concerned with how well all of us, patients and providers alike, understand the real costs of health care. Folks are smart enough to understand the problems. The researchers who study these issues, and the reporters who report on them, or investigate them, need to do better in giving us the context; because if you don’t know the context, you don’t really know the story.

The Forbidden Dance of Lambeth

(No, I guess that was the lambada.)

There is currently a lot of questioning that we might phrase, “to Lambeth, or not to Lambeth?” Diocesan conventions in Utah and Olympia (the western area of Washington state) have recommended that our bishops not attend. Bishop Steven Charleston has had the same thought. It’s been a topic of discussion over at Fr. Jake’s place.

That discussion brought about this response from me. Having first raised that thought in a “Brainstorming” post, I thought I would go ahead and bring my response over here, and perhaps expand on it a bit.

Once upon a time, a humble chaplain floated the possible thought that American bishops not attend Lambeth. They would still pay for it (somebody important once said something about "heaping coals of fire on their heads"), but would choose themselves to stay home. They would also then return to full participation in the Anglican Consultative Council, so as to affirm our place in the Anglican Communion. It was thought then that it might be an expression of humility, and a choice not to participate in the climate of invective.

The humble chaplain has not forgotten the climate of invective that resulted. He might still be cleaning up the stains. (Okay, so I'm not so humble; but otherwise the recent history is accurate.)

But, things have changed a lot. First, it seems ever more clear to me that the definition of "Anglican Communion" will be determined by who shows up at Lambeth - thus my occasional reference to "cowboy poker."

Second, we have more detailed information that the Global South Steering Committee primates have a whole lot more bark than bite regarding opinions across the Communion. Between the report of the majority of the Joint Standing Committee and the subsequent responses of most provinces to questions from Canterbury, across the Communion the pluralities of those who think the Episcopal Church has done enough and those who think we've done enough to keep talking significantly outweighs those who want to throw us out.

Finally, the Canterbury has said time and again that this Lambeth is to return to "reflection and mutual consultation," and not fall into attempting to legislate. Of those provinces who would agree that these are the appropriate activities for Lambeth, we have the largest bloc. We are best prepared - possibly essential - for inhibiting this Lambeth from being hijacked, whoever shows up (acknowledging, too, that those who would most want to hijack Lambeth are also those who would least want to show up if we do). Lambeth 1998 was hijacked, and we may be able to take a significant role in preventing that happening again.

With these things in mind, I'm coming to believe that, with these new circumstances, our bishops, or at least most of them, should go.

I could add to the matters that have changed since my initial thought. For example, while remaining publicly ambivalent about Lambeth, the Church of Nigeria – Anglican has been creating new dioceses and bishops wholesale. I’m referring to new dioceses in Nigeria, and not to their divisive insertions into the United States. If they did choose to attend, nonattendance by so large a group as our bishops would leave them with a plurality, perhaps a dominant plurality, at Lambeth.

On the basis of the CAPA statement, “The Road to Lambeth,” the Ugandans have expressed their intent to decline Lambeth, and others may follow them. But leadership in CAPA is changing. The new Chairman of CAPA, Bishop Ian Ernest of Mauritius appears so far to be a moderate – a conservative moderate, no doubt, but not a reactionary. Watching the Province of Central Africa come apart at the seams may well give him and other CAPA leaders a different perspective on fragmentation within the Communion.

Retired bishops from both the Episcopal Church and the Anglican Church in Canada have been signing on with the Church of the Southern Cone to assist in what seems to be a new “Oklahoma race” to divide up territory in North America. The report of the Joint Standing Committee, cited above, highlights boundary violations for the violations of the Windsor Process that they are. One thing that Canterbury has stated clearly in the past couple of years is his belief that there really is a Windsor Process, that it is the way to discover new ways in which provinces might relate to one another, and that hasty action undermines it. To support him by attending Lambeth is to affirm his support for continued, measured discussion instead of overly hasty “clarity.”

So, yes, I did have the thought that our bishops might decline Lambeth, not in a spirit of pique but in one of humility. However, enough has changed that I think it not the best idea. We need to confirm our support for the process orientation of the Archbishop of Canterbury, whether or not we’re always excited about his statements. To do that, we need to join in the dance.

If This Is a King: Reflections for the Feast of Christ the King, Year C

If this is a king, why would we follow him? If this is a kingdom, who would want to be a citizen?

Jesus hung on the cross, one of three so executed on that day on that hill. After all the excitement, after all the hope, not even a week since his triumphal entry into Jerusalem, it had come to this: execution on a cross, shared with two common thieves.

It’s no surprise that those who walked by laughed and jeered. Whatever Jesus had claimed for himself, the crowds had called him Messiah, the Son of David. The crowds had proclaimed him the one to save Israel – and now here he was. It’s no wonder they ridiculed him, even to one of the thieves hanging with him. Some kingdom! Some king!

We have always been uncomfortable with kings, we human beings. We cheer them when times are good, and things seem safely under control. We laugh at their failings, at least when we think it safe. We fear them when they get too close – all that power, and no way we can resist. For all the cheers for the leader who brings home the spoils, we fear lest he ask too much, take too much from us. Remember that most of our own founding fathers weren’t so concerned about democracy when King George was far away. It was when he came close, in the taxes that were enforced, and in the barracks of soldiers that enforced them, that they began to think perhaps they could do it better themselves. Remember in “Fiddler on the Roof” the rabbi’s prayer for the czar: “May God bless and keep the czar – far away from us!”

What kind of king was this, then? The sign above him said, “This is the king of the Jews.” The hooting spectators, and even the cynical thief, called on him to prove it, and most of them simply laughed when he did not. Some kingdom! Some king!

Oddly enough, in the history of the people of God the image of the king isn’t someone so powerful, so dangerous, so far away. Instead, the image was of the shepherd – from the call of David from the pasture ,to Jeremiah’s proclamation in the last days of the Judah. “Woe,” he says. “Woe to the shepherds who destroy and scatter the sheep of my pasture! says the LORD. You have not attended to my sheep; but now I will attend to you! Then I myself will gather my flock; and I will raise up shepherds over them who will shepherd them, and they shall not fear any longer, says the LORD.”

But, shepherds are so very unlike kings, aren’t they? Kings live in castles and palaces, surrounded by courtiers. Shepherds live in the fields, surrounded by sheep. Kings do battle with other kings, and calculate their results in victories and defeats and acceptable losses. Shepherds do battle with wolves and bears and jackals, and are concerned for every sheep. Indeed, shepherds often enough work for someone else, to whom they are accountable for every sheep. Kings are, as often as not, laws unto themselves – and so often that seems the very definition of what it means to be king.

And yet through the history of God’s people, the model for the king was the shepherd, and not the law unto himself. The model was of one who lived among his people, accountable for every single one – accountable to God.

That was not the model of those who jeered. Even among the leaders of the Jewish people, that was not the model they held. They had seen ruler after ruler come through – from Assyria to Babylon to Alexander to Rome. They had seen those men, powerful, dangerous, and far away. They did not see on the cross the Shepherd of Israel.

But someone did. One thief – one thief who hung with Jesus saw, not with the eyes of the world, but with the eyes of faith. He saw, and proclaimed, “We’re getting our just deserts. This man has done nothing wrong!” And then, he prayed: “Jesus, remember me when you come into your kingdom.” And it was he who heard this promise: “Today you will be with me in paradise.”

But, what did he see? Clearly, he saw beyond the man on a cross, beyond the mocking, ironic sign over his head. Perhaps he saw the shepherd: the one who lived, not far away, but in the midst of the flock. Perhaps he saw the one who had called on the flock to stand together and to gather the lost. Perhaps he saw the one who battled the wolves and bears and jackals of the soul, for whom there were no acceptable losses. Perhaps he saw the one accountable to God – indeed, the one making God present in the midst of the flock. And seeing God in Jesus, he could see the promise of God’s kingdom, of all things reordered the way they God meant them to be. He could seek his place in that kingdom; and he could trust Jesus when it was granted.

This is what we celebrate when we observe this feast of Christ the King. We celebrate the one who is God among us, even to this day: the one so committed to life among us that he shared in our death, and then overcame death and the grave, not only for himself, but for all of us. We celebrate the king who falls in the eyes of this world and yet rises as the Shepherd of Israel, and rising, lifts us with him. We celebrate the one who see us, even in the midst of our failings, and offers us citizenship in the Kingdom of God – the one who sees us in the midst of our just deserts, and promises us Paradise.

This is the King we proclaim! Some kingdom! Some king!

Canada Feels the Pinch

The latest news from our Canadian Anglican siblings is about a bishop retired from the Anglican Church of Canada, and immediately taken up by the Province of the Southern Cone, who is now preparing to preside at ordinations within the Diocese of New Westminster. What makes this especially egregious is that the congregations are still ostensibly congregations of the Diocese of New Westminster. Bishop Michael Ingham of New Westminster has, of course, expressed his distress and disapproval (news and reviews here at Thinking Anglicans).

What hasn’t been mentioned so far is that this is an explicit rejection of the Windsor Process and the leadership of the Archbishop of Canterbury. That is certainly been implicit in other, similar events – ordinations for CANA, or for AMiA. However, this is different. What makes this explicit is that these parishes sought the guidance of the Panel of Reference to the Archbishop, created as a tool of the Windsor Process and intended to advise on questions about maintaining communion with Canterbury.

To remind everyone, the Panel issued their first report in October of last year. The topic was the inquiry of certain parishes within the Diocese of New Westminster as to whether the actions of Diocesan Convention and the Bishop had impaired their communion with Canterbury and the rest of the Anglican Communion. The critical paragraph in the Panels response is as follows:

The argument that in order to remain “in full communion with the Church of England throughout the world” it is necessary for dissenting clergy and parishes to separate themselves from the diocese of New Westminster, adopting a title for their organisation which implies that they represent the Anglican Communion in New Westminster, in addition to or instead of the diocese and Bishop Ingham, can not be sustained. The Church of England itself remains in full communion with the Diocese of New Westminster and Bishop Ingham, pending resolution of the presenting issue, and therefore with all of its clergy, members, and parishes, including those who dissent from its diocesan synod decision but remain in full fellowship with the Bishop and the diocese, together with the dissenting parishes unless they formally withdraw themselves from the Anglican Church in Canada. Even if this were not the case there is no evidence that communion with dissenting parishes would in fact be broken since such provinces which have declared impaired communion have made it clear that they remain in communion with those whom they regard as faithful.

The report went on to affirm efforts to resolve differences within the Anglican Church of Canada and the Shared Episcopal Ministry (SEM) program approved by the Canadian bishops. They rejected the claim of the applying congregations that only change in jurisdiction would allow them to remain in communion with Canterbury. Thus, while the applying clergy and parishes might have found themselves at odds with Bishop and diocesan synod, they remained in communion with Canterbury through the diocese in the first instance, and through the Anglican Church in Canada, “unless they formally withdraw themselves.” As St. Matthew’s, Abbotsford, the congregation where the ordinations are to take place, continues to be listed as a parish of the diocese, there had, presumably, been no withdrawal.

That is, until now. To have Bishop Harvey come without consultation and consent with Bishop Ingham, to have him ordain persons not recognized by Bishop Ingham, is to functionally and practically reject the jurisdiction of New Westminster, and of the Anglican Church of Canada, and so the recommendations of the Panel of Reference.

Now, I will allow I’m not surprised by this. The General Synod and House of Bishops of the Anglican Church of Canada have not taken the conservative turn that might have made this easier. They have perhaps slowed change, but they haven’t reversed it. The applying congregations predicted this accurately.

On the other hand, neither has it changed that the Church of England remains in full communion with the Anglican Church of Canada and its Diocese of New Westminster. Nor has the tenor of counsel from Canterbury changed: reconciliation should be sought within existing provincial structures. In addition, the recent statement of the Joint Standing Committee of the Anglican Consultative Council and the Primates’ Meeting explicitly pointed out that violations of provincial boundaries are explicitly counter to the Windsor Report and damaging to the Windsor Process.

However, these churches have given up. They have rejected communion with Canterbury through the Anglican Church of Canada. They have lost hope that they might see the movement in the Church that they wish. They have lost interest in reconciliation, whether through the SEM or through the Windsor Process. Let’s hope those still invested in the Windsor Process take note.

A Simple Proposition - in the Swiftian Sense?

Not long ago, I observed that a core issue in many in current ethical issues is personhood - literally, what it means to be a person. Well, it appears that at least someone knows this. A group in Colorado is seeking to bring before voters an amendment to the state constitution to attribute personhood "from the moment of conception." They have recently won a decision of the Colorado Supreme Court allowing them to go forward in seeking signatures to put the amendment on the ballot. The specific language of the initiative is this:

Be it Enacted by the People of the State of Colorado:

SECTION 1. Article II of the constitution of the state of Colorado is amended BY THE ADDITION OF A NEW SECTION to read:

Section 31. Person defined. As used in sections 3, 6, and 25 of Article II of the state constitution, the terms "person" or "persons" shall include any human being from the moment of fertilization.

This is certainly an emotion-laden issue. Obviously, I've never been pregnant. On the other hand, I've been listening for years to many pregnant women, including the mother of my children, in good time and in bad. Almost all have spoken of or acknowledged the sense that the fetus is “a baby,” virtually from the moment the woman knows she is pregnant. Both of my sons were “real” to me, if not in the same sense, from the moment I knew about them. That’s when the planning, the dreams, begin, along with a lot of hope and fear.

That doesn’t mean there aren’t sometimes hard choices to be made. We make quite a number of distinctions of the different sets of rights for persons in different circumstances: children vs. adults, or felons vs. the innocent, or, lately, enemy combatants vs. prisoners of war. We make distinctions of rights that amount do differentiating degrees of personhood. The devil is in the details.

Supporters of the movement want to understate that. According to their site,

Many amendments are worded confusingly, and already there are people who would have you believe this is an overly complicated issue, but the simplicity of the text of this initiative speaks for itself. It is not complicated, it is not confusing, it simply states what should be obvious to everyone…

But, as any Biblical scholar can attest, simple language is no guarantee of a simple issue. Looking only at medical concerns, let’s consider some of the different circumstances this might affect.

• Up to 50% of fertilized ova fail to implant in the uterine wall. If these fertilized ova have rights, who is accountable for them?
• In the instance of ectopic pregnancy, to what extent do we go to protect any rights of the fertilized ovum? The natural outcome for ectopic pregnancy is death for the fertilized ovum, and commonly for the mother as well.
  
• To what extent is a pregnant mother responsible for her self-care in pregnancy as an expression of her accountability for the rights of the developing fetus? There have been efforts to prosecute women for use of illegal drugs for the potential damage done to the fetus. How far should we take such a thought? For example, is the woman responsible for a cigarette or a glass of wine? In law in many such instances each time a persons partakes is a separate violation. To what extent is a woman responsible for actions taken before she knew she was pregnant? And to what lengths are we prepared to go to seek such information? (We might recall here that the right to choose [including choosing to end the pregnancy] is based primarily on an implied right to privacy in medical decision making.)
  
• If a woman has a form of cancer sensitive to hormonal changes, such as ovarian, uterine, and some breast cancers, and is also pregnant, she may well be advised to terminate pregnancy, based on the risks to her of delaying treatment, and the risks to the fetus of accepting treatment. Would this constitutional change in Colorado change that discussion? Whose rights would be prioritized? Whose decision would be compelling? That such cases are uncommon is not to say they are unknown.
  
• How would this affect regulations regarding surrogate pregnancy, or the relative rights of genetic parents (father vs. mother), or their rights vs. adoptive parents? Who is accountable in protecting the rights attributed to this “person?”
  
• How would this affect regulations regarding infertility treatment, and especially storage and/or disposal of stored embryos? What are the rights of each of those embryos, and how do they weigh against the rights of the genetic parents? Indeed, we have had cases regarding the “parental” (ownership) rights of each genetic parent when one was prepared to dispose and the other wished to continue storing the embryos. And, if an embryo that has been stored is tried and fails to implant, who is accountable for “losses” attributable to that embryo?
  

Those are just a few of the circumstances that might be involved, even without addressing directly the right of a woman to make her own choices about her health care, including the right to terminate a pregnancy, in accord with her individual values.

Which is, of course, what the group supporting the initiative really wants. They want to end abortions in Colorado, and they believe that this amendment would provide a foundation for laws that would accomplish that objective. It’s not uncommon for the state to step in to protect the rights of persons when in the eyes of the state appropriate surrogates do not have at heart the best interests of the children. This is the basis of laws protecting both children and seniors from abuse. This group would simply push this principle to its logical extreme: if, as Dr. Seuss said, “a person’s a person, no matter how small,” designating personhood from fertilization can give the state a compelling interest (and “compelling” might be the operative word) in protecting rights attributed to a fertilized ovum.

It seems so simple indeed – until we have to figure out how to live with it. And then it’s not so simple at all.

Same Tune; Second Verse

A few months ago, I cobbled together this brief post (well, brief for me, anyway):

In light of the coming "deadline" in September, and all the rhetoric bouncing around the Anglican/Episcopal world, I was moved to recall the refrain of an old country song (Written by Don Rollins; made famous by George Jones, and covered by, among others, the Grateful Dead):

Now the race is on and here comes pride up the back stretch
Heartaches are going to the inside
My tears are holding back, trying not to fall
My heart's out of the running
True love's scratched for another's sake
The race is on and it looks like heartaches
And the winner loses all

In light of the recent offer from the Province of the Southern Cone to take in any Separatist diocesan bishop and party (remembering that a diocese per se can’t leave a province), the song came back to me again. It does seem, doesn’t it, that the race is on?

Southern Cone is angling for Separatist bishops, clergy, and parishioners. So far that’s been mostly in the West and Southwest (since Fort Worth is thinking about this even now). Nigeria through its CANA initiative is working, largely in the Midatlantic states, and perhaps in the Northeast. Kenya has consolidated a collection of congregations, most of them never Episcopal but filled with Separatist former Episcopalians, and largely in the Southeast and Midsouth. Rwanda, sponsoring AMiA, and Uganda have a wider distribution, less geographically defined. At the same time, there’s plenty to contest in the Midwest and Intermountain regions of the country. The Separatists in Kansas went with Uganda. The Separatists in Colorado Springs have gone with Nigeria. We wait to see what happens with Separatists in Illinois, and with the undecided centered in Pittsburgh.

And so, the race appears to be on. Somehow, it reminds me of Africa, and for that matter of North America, in the 19th Century. One of the things we don’t talk about as much in history of world missions is the competition, often bitter competition, that showed itself between different but arguably connected missionary societies. A blunt example, perhaps, is earlier: the displacement in Asia of Jesuit missionaries by Franciscans. It was a difference of internal culture that was visible in how each related to the surrounding culture. To paint broadly, Jesuits were looking for ways to express Christianity within the context of the local culture, while Franciscans were looking to introduce European culture, to their minds not only superior but necessary, to change the local culture. The Jesuits got to the Japanese and Chinese, and made some slow progress. The Franciscans got to the Pope, and got the Jesuits recalled; and China and Japan closed their borders to Christians without, and suppressed Christians within.

Similar competition between missionary bodies took place in the 19th Century in North America and in Africa, as well. And let’s remember that these conflicts were also sometimes bloody. There were a number of incidents in relations between Latter Day Saints and orthodox Christians, with blood on both sides. And even if the conflict was more visible in social conflict than in violence, it was certainly there. We tend to forget that two generations ago a marriage between a Roman Catholic and a Protestant was considered every bit as mixed, and was every bit as vulnerable to social stigma, as a marriage between an African American and a Caucasian American.

And so in this new “mission field,” trying to “rescue” Separatist Episcopalians from the dreaded forces of the Episcopal majority, we can expect there to be competition. Up to this point, it’s been congregation by congregation, with new “diocesan” structures being assembled as needed. However, the plucky folks from Southern Cone think big, for all their small numbers, and they’re looking to take in diocesan structures wholesale. It’s an ambitious step, but it’s one they’ve tried before (can you spell “Recife?” I knew you could!). Perhaps they hope it will work better this time.

I am convinced we will soon have on wider display something that’s really been happening in the United States for a generation. Since 1976 or thereabouts there have been numerous ecclesial bodies claiming the Anglican tradition, with one of them far and away bigger and firm in its historic connection to Canterbury. Soon, there will be fewer, but probably larger ecclesial bodies arguing both Anglican tradition and clearer connection to, if not necessarily communion with, Canterbury. The Episcopal Church will still be larger, and still in communion with Canterbury, although her communion to Canterbury and other Anglican provinces may be somewhat strained. We already have what Archbishop Williams prayed to avoid: divisions like those of the Eastern Orthodox churches, with so much in common and with some cultural and practical differences just important enough to maintain division. We’ve had it for some time, but now it will be harder to ignore.

And so the race is on, with every foreign province interested in supporting Separatists looking for their edge in the new “mission field.” They have so much in common, and yet enough little things and enough personal agendas that competition seems already in play. And all of us are wise to remember the last lines of the refrain:

The race is on and it looks like heartaches
And the winner loses all.

Grief and Adapting to Change

We all know that romantic notion: "I want to save this moment forever. I never want anything to change." We see it literature and in the movies all the time. Of course, in the movies, as soon as we hear someone say that, we know things are about to fall apart. The disaster happens, as it does in every drama. In real life, too, as much as we might want to, we know that we can't hold those moments. Things change,

Life is change. Most of the time we want that. Children grow into adults. We learn new skills, and want to use them. We choose to move from work to retirement.

Sometimes we face changes we don't want, or have mixed feelings about. Those same children grow up and move away. Unwanted job changes happen (including, for some, retirement). Illness comes – and especially chronic illness

Whatever the change, it involves stress. We know there is good stress and bad stress. Good stress is stimulating. Think about that good challenge – the good game when you knew you performed at your best; the time in school when you knew the answer, and you really wanted to be called on; the night before the wedding. Bad stress, on the other hand, is unfulfilling, and literally dis-stressing. I’m sure we all have enough examples in our lives: the time when the results weren’t so good, and after all our excitement we were left weak, sad, tired.

But in either case it affects us in a number of ways. We know many of the physical symptoms of stress (or, is it excitement?) –

• Dizziness or a general feeling of "being out of it" (or, is it ecstasy?)
• General aches and pains
• Grinding teeth, clenched jaw (or, is it determination?)
• Headaches
• Indigestion and upset stomach (or, is it butterflies?)
• Increase in or loss of appetite
• Muscle tension in neck, face or shoulders
• Problems sleeping
• Racing heart
• Cold and sweaty palms
• Tiredness, exhaustion
• Trembling/shaking
• Weight gain or
• loss

And we know emotional symptoms of stress –

• Anxiety
• Relationship problems
• Chronic sadness
• Even depression.
  

More important, change always involves grief. Again, not all change is unwanted or unhopeful. At the same time, all change, whether wanted or unwanted, involves some loss; and with any loss comes some grief.

I think this is one of the most important issues missed when folks adjust to changes. I think we miss it whether we are those making the changes, or those encouraging others to make changes. When we see the change as “positive,” we have those hopeful aspects that counterbalance or distract us from what we lose. When we don’t see the change as “positive, we tend to try to “push through,” to “get on with it.” Only when the change is significant do we actually acknowledge that we might have grief. We’re conscious of grief in proportion to our sense of the importance of the loss. But the truth is all changes involve some loss, and so some grieving is part of the process.

So, what to do? The answer: we have to address the grief, to recognize that this is a part of adapting to changes in our lives. According to psychologist William Worden, that involves four tasks.

First, accept the reality of the loss. In this case, accept the reality of the change. That might seem straightforward. At the same time, it’s so easy to accept the change intellectually, and resist the importance of the change. How easy is it to say, “Yes, I know things are different; but that’s no reason life can’t go on as before.” In fact things can’t go on as before, because the circumstances, the very facts of “before” are changed.

That brings us to the second task. The second task is to experience the pain of grief – or in our current discussion, to acknowledge the consequences of the change. Because the facts of “before” have changed, things simply can’t go on as before. Grieving families will sometimes say to me, “I just want things to be normal again.” My answer to them is, “You can’t get the old normal back, but you can get a new normal, and it can be joyful and blessed.”

And to get to a new normal we come to the third task. In grief, that task is to adjust to an environment in which the deceased is missing. In addressing change, we’d describe it better as making the adjustments necessary because the old “normal” is gone.

What’s important is that the adjustments, the adaptations we need to make are frequently the life changes that we’re encouraged to make to cope with stress, or to cope with chronic disease. In essence, it’s about making the decisions and taking the steps that improve life and health: the exercise, the healthy diet, the discipline of taking medication, and so on. And especially important is using the support of folks around you to help with the new way of living.

Granted, all this doesn’t come easily or immediately. We expect grief to take a while to live through – longer than most people want to expect. We don’t make these changes perfectly right from the start. But, we keep at it, knowing this is necessary in developing the new “normal.”

Which brings us to the final task. In grief that task is to withdraw emotional energy and reinvest it in another relationship. In adjusting to change. we can say that we need to let go of our wishes for the old “normal” and put our energy into the new “normal.” In that sense, the new “normal” is the new relationship in which we reinvest. We see ourselves as worth investing in, and so the new “normal,” the new relationship, is worth investing in.

We may even discover that some things were not so good in the old “normal,” things that in the new “normal” are better. We deal with chronic disease at our house, and one of the things we realized when it was finally diagnosed, is that it had been taking a toll for a long time. Once it was diagnosed and treatment begun, we were more secure, less afraid that unexpected flare-ups would happen, and less afraid when they did happen. While it took a while to adjust, and, yes, to grieve, we discovered that the new “normal had a lot of good in it, without some of the fears and shocks of the old “normal.”

That won’t always happen, I know; but I do know that the new “normal,” as I said, can be happy and joyful and blessed. We reinvest our energies in the new situation, the new “normal,” because it is how we reinvest in ourselves.

I think that’s why it’s important that we recognize that there will be some grief associated with every important change, and that we need to accept and address that grief as a part of adapting to the change. Changes, and especially important changes, aren’t easy; but I think if we recognize that part of making the changes is addressing the grief that comes with them, we will understand ourselves better in the process, be more forgiving of ourselves in the process, and will know and embrace the new “normal” we discover.

Presented 11/14/07 at our hospital's Munch and Meet Diabetes Support Group

At Grand Rounds

One of my recent posts has been accepted for Grand Rounds, a carnival of blogs interested in health care. You can see the latest Grand Rounds, and a host of interesting articles, at the blog of Doctor Anonymous. Take some time for these voices from health care.

Bishop Iker Rewrites History

Updated Wednesday

So, Bishop Iker has responded to the letter from Presiding Bishop Katherine Jefferts Schori asking him to “recede from this direction” – that is, to turn back from attempting to leave the Episcopal Church, taking with him the Diocese of Fort Worth intact. It is no surprise that he’s not inclined; that we expected.

Perhaps it’s also not a surprise that he should try to rewrite history to suit his purpose. I speak of this assertion:

I must remind you that 25 years ago this month, the newly formed Diocese of Fort Worth voluntarily voted to enter into union with the General Convention of the Episcopal Church. If circumstances warrant it, we can likewise, by voluntary vote, terminate that relationship.

Unfortunately, that’s not the way it works, nor was it the way it worked then. I was at the time part of the division of the Diocese of West Tennessee from the continuing Diocese of Tennessee, and can say from experience that the substance of Constitution and Canon have not changed in this.

Article V of the Constitution of the Episcopal Church specifies three ways of forming a new diocese:

Sec. 1. A new Diocese may be formed, with the consent of the General Convention and under such conditions as the General Convention shall prescribe by General Canon or Canons, (1) by the division of an existing Diocese; (2) by the junction of two or more Dioceses or of parts of two or more Dioceses; or (3) by the erection into a Diocese of an unorganized area evangelized as provided in Article VI. The proceedings shall originate… with the approval of the Bishop, in the Convention of the Diocese to be divided; … After consent of the General Convention, when a certified copy of the duly adopted Constitution of the new Diocese, including an unqualified accession to the Constitution and Canons of this Church, shall have been filed with the Secretary of the General Convention and approved by the Executive Council of this Church, such new Diocese shall thereupon be in union with the General Convention.

Note, then, that first and foremost a diocese is formed with the consent of General Convention. Moreover, Fort Worth was formed “by the division of an existing Diocese.” that being the continuing Diocese of Dallas, and not in an “unorganized area. It was, therefore, formed within, and not external to, the existing Constitution and Canons. So, in the current Canons, Title I, Canon 10:

Sec. 1. Whenever a new Diocese shall be formed within the limits of any Diocese, or by the junction of two or more Dioceses, or parts of Dioceses, and such action shall have been ratified by the General Convention, the Bishop of the Diocese within the limits of which a Diocese is formed, or in case of the junction of two or more Dioceses, or parts of Dioceses, the senior Bishop by consecration, shall thereupon call the Primary Convention of the new Diocese, for the purpose of enabling it to organize, and shall fix the time and place of holding the same, such place being within the territorial limits of the new Diocese....

Sec. 3. Whenever one Diocese is about to be divided into two Dioceses, the Convention of such Diocese shall declare which portion thereof is to be in the new Diocese, and shall make the same known to the General Convention before the ratification of such division.

Sec. 4. Whenever a new Diocese shall have organized in Primary Convention in accordance with the provisions of the Constitution and Canons in such case made and provided, and in the manner prescribed in the previous Sections of this Canon, and shall have chosen a name and acceded to the Constitution of the General Convention in accordance with Article V, Section 1 of the Constitution, and shall have laid before the Executive Council certified copies of the Constitution adopted at its Primary Convention, and the proceedings preparatory to the formation of the proposed new Diocese, such new Diocese shall thereupon be admitted into union with the General Convention.

Thus, the Diocese of Fort Worth did not have independent existence before consent. Rather, division was an action of the Diocese of Dallas, and under the Constitution and Canons of Dallas, and therefore under that diocese’s accession to the Constitution and Canons of General Convention. Indeed, Dallas was not divided until after receiving consent from General Convention.

Consent for that division was given in Resolution 1982-B018, titled, meaningfully, “Ratify the Division of the Diocese of Dallas Into Two Jurisdictions:”

Resolved, the House of Deputies concurring, That this 67th General Convention ratifies the division of the Diocese of Dallas to create a new Diocese which, until the new Diocese adopts a name, shall be referred to as the Western Diocese with the continuing Diocese to be known as the Diocese of Dallas. The boundaries of the two Dioceses shall be as follows:
a) The Diocese of Dallas shall include 25 counties: Grayson, Denton, Collin, Dallas (excluding the portion of the city of Grand Prairie that is in Dallas county), Rockwall, Ellis, Navarro, Henderson, Kaufman, Van Zandt, Hunt, Fannin, Lamar, Delta, Hopkins, Rains, Wood, Upshur, Camp, Franklin, Titus, Red River, Morris, Bowie, Cass.
b) The Western Diocese shall include 23 counties: Wichita, Archer, Young, Stephens, Eastland, Brown, Mills, Hamilton, Comanche, Erath, Somervell, Palo Pinto, Jack, Clay, Montague, Wise, Parker, Hood, Bosque, Hill, Johnson, Tarrant, Cooke, and the portion of the City of Grand Prairie located in Dallas County; and be it further

Resolved, That this 67th General Convention receive the following evidence supporting this resolution:
1. Certified copy of the resolution, duly approved by the Diocese of Dallas, committing the Diocese to its division and to the formation of a new Diocese;

2. The consent of the Bishop of Dallas;

3. Certificate of the Secretary of the Convention of the Diocese of Dallas concerning the number of Parishes, Missions, Institutions and Presbyters in the continuing Diocese and in the new Diocese;

4. Map of the existing and proposed continuing and new Diocese;

5. Certificate of the Treasurer of the Diocese of Dallas concerning the financial abilities of the continuing Diocese and of the new Diocese, together with supporting financial data;

6. Certificate of the Chancellor of the Diocese of Dallas that all aforesaid documents have been duly executed, are accurate, and are entitled to full faith and credit, and further that all of the appropriate and pertinent provisions of the Constitution and Canons of the General Convention of the Episcopal Church in the USA and the Constitution and Canons of the Diocese of Dallas have been fully complied with in respect of this submission.

Thus, the new diocese was consented by General Convention before it had even been named, under the existing Diocese of Dallas, and before the Primary Convention had been called.

I remember the excitement in the division of Tennessee into two, and subsequently three dioceses. I remember the excitement when in convention Tennessee called for the division. I remember the excitement in New Orleans in 1982 when consent was given for formation of the Diocese of West Tennessee. I remember the excitement when the Primary Convention of the Diocese of West Tennessee met – like the new Diocese of Fort Worth, in the fall after General Convention. I remember the process, and so do many others in the Church.

There have, of course, been changes in Constitution and Canons over the years. Much is made, for example, of the fact that the “Dennis Canon,” clarifying the accession of diocesan conventions, constitutions, and canons to national Constitution and Canons, was only clarified in the 20th century. (On the other hand, it was in force when Convention consented to the division of the Diocese of Dallas that resulted in the Diocese of Fort Worth.) However, the process and order of events in forming new dioceses hasn’t changed.

It makes you wonder why Bishop Iker would make an assertion so demonstrably false; or, maybe it doesn’t.

Update: Esteemed colleague Mark Harris of Preludium has provided additional details in reaching the same conclusion. It's worth the time to read.

One of Those Stories I Tell

It happened early in my career: specifically, in my first CPE residency.

I have long forgotten his name. We can call him Albert. Albert had been admitted to the hospital after being shot in the head. The bullet had somehow not been fatal, but had caused enough injury that Albert needed rehabilitation. This was in the good old days, when a patient entered rehab early in treatment, and would stay until he or she had made all the progress possible. Patients often stayed six to eight weeks, leaving when they could walk out of the hospital, perhaps with a cane.

Albert was an interesting young man. He had immigrated to the United States as a school child, and had grown to his young adulthood here. He was, of course, fluent in English and his native language. He was also something of a mystery: no one was quite sure how he had been shot. He was shot while sitting in his car with his girlfriend when it happened, but no one was certain whether he had shot himself, she had shot him, or there was a third party involved.

Albert, in fact, was something of problem. He was refusing to participate in the therapies of the rehab program. There was no longer a physical reason he couldn’t participate. He simply refused. Indeed, he was refusing to speak English. He spoke with his family in their native tongue, and they reported that he was fully alert and oriented; but his refusal to speak English and to cooperate with his therapies was hindering his work. In team meeting there was discussion of sending him to a nursing home, or to be cared for at home, since there was noting of consequence we could do with him in the hospital.

The day after that meeting, I went in to visit Albert. He had in previous visited noted my presence, and responded with a single word. He had then lapsed into silence, or turned to his family and returned to conversation in his native language. He was speaking with them as I entered, and I didn’t expect anything different about this visit.

Until, that is, I heard The Voice. I had heard that Voice before, perhaps three times. Each time it had addressed a specific call. Each time I had followed, and each time the results had been blessed.

This time The Voice said, “Ask him the question no one will ask him.” I paused, and a question occurred to me – certainly one I expected he hadn’t been asked. I said, “Albert, I have a question.” He looked at me. “I don’t know myself, and I don’t think I really want the experience; and yet I have to admit I’m terribly curious. What is it like to be shot in the head?”

He looked at me curiously. He answered, his English thoughtful and clear, “Well, first there’s a bright flash, and then you don’t feel anything. Then, there’s one hell of a headache.” After he spoke, he turned away from me and began speaking again to his family in the language of his childhood. I stayed another minute or two, and excused myself, almost without being noticed.

Albert never spoke to me again. In his room he hardly responded, and in therapies he simply ignored me. It was as if he wanted no more to do with me.

On the other hand, the next day he began to participate in therapy. He began to work for his own recovery with a commitment that was noted in the next team meeting. It was, therapists said, a remarkable turnaround. He worked hard, and at about six weeks he walked out of the hospital - walking with a cane, but walking nonetheless. Several months later he came back to visit the therapists and nurses, and he didn’t even need that.

I had heard The Voice before that, and I’ve heard it since, if still only a few times. Each time it has addressed a specific call – so specific, for example, that this one was just about Albert. I tried asking a similar question to another patient. I so offended her physician that, in the process of reaming me out on the phone, he committed himself to get all chaplains eliminated from the hospital. Each time the Voice has addressed a specific call; and as I’ve followed, each time the results have been blessed.

A Confusion of Bishops

Today’s Church Times reports on decisions in the Convention of the Diocese of Pittsburgh that a majority believe would prepare that Diocese to withdraw from the Episcopal Church. That is, of course, a much disputed position.

The story goes on to report a letter from four bishops of the Church of England in support of Bishop Robert Duncan of Pittsburgh (and thanks to Thinking Anglicans for pointing this out). Statements in the report show some clear and distinct misunderstandings about the choices being made by Bishop Duncan and by the Convention in Pittsburgh. Let me respond to some specific statements.

“We deeply regret the increase in the atmosphere of litigiousness revealed by the Presiding Bishop’s letter to Bishop Duncan.”

Unfortunately, the “atmosphere of litigiousness” is a result of the tool chosen by Bishop Duncan in this case. As Virginia took legal action only after the departing congregations sought court recognition of their independence, so action in Pittsburgh is only taking place after efforts of the Bishop and Convention of Pittsburgh to make changes to the Canons of the diocese. This was an action to change the laws; and so a response in terms of laws can only be expected.

“We hope the Archbishop’s response to Bishop John Howe of Central Florida will also apply to Bishop Bob Duncan of Pittsburgh.”

We need to note that Bishop Howe’s letter described a different, almost opposite position as the actions of Duncan and Pittsburgh. Bishop Howe took a stance that his Diocese was not an independent unit, and that he would continue to remain in the Episcopal Church. While Canterbury’s response was problematic in its emphasis on the importance of the diocese in apposition to the congregation and its de-emphasis of national structures, the clarification pointed out that this was a narrow response, not really intended to address the relationship between the diocese and the national church. That is entirely consistent with the Windsor Report and other statements Archbishop Williams has made, including in the interview after meeting with the House of Bishops of the Episcopal Church, that reconciliation should be sought within existing provincial and diocesan structures. (Indeed, this letter is evidence of just how problematic the poorly phrased letter to Bishop Howe, taken out of this context, might become.) Bishop Howe remains within the Episcopal Church and seeks to work within existing diocesan and provincial structures. Bishop Duncan manifestly does not.

The Bishop of Chester, Dr Peter Forster, said on Tuesday that the statement gave personal support to Bishop Duncan. He... emphasized that issuing the statement did not imply support for decisions taken at the Pittsburgh diocesan convention.

It seems very unclear what “personal support” might mean. The letter from the Presiding Bishop was focused primarily on the decisions taken at the diocesan convention. This seems to somehow separate Bishop Duncan’s status as a bishop from his leadership as a bishop. I’m as big a fan as anybody of the theology of an “indelible mark” in ordination. At the same time, we function as ordained persons only within the context of the community that has ordained us. I can’t simply walk into the local Methodist or Baptist church and expect that my ordination will have any significance. It has significance to the extent, and only to the extent, that it is accepted and respected by the different community. For all our intent that we ordain bishops “for the whole Church,” our bishops have no authority outside the province within which they are ordained. To function in a different province requires recognition and licensure. Bishop Duncan’s actions to violate the polity and integrity of the province within which he was ordained necessarily affect his status within that province in ways that should be resolved (preferably by resignation; necessarily by canonical measures if he doesn’t resign) before he should be accepted by any other Christian community. Want to offer personal support? Focus on Bishop Duncan’s emotions and beliefs, even as you state concerns about actions that are misguided. Otherwise, you do imply approval of the actions that Bishop Duncan has led.

“What’s needed is a pastoral, healing approach, which attempts to find a way forward.”

Well, that’s a hopeful thought. However, Bishop Duncan has rejected any pastoral care the Episcopal Church might offer. I don’t speak only of his rejection of the most recent opportunity for alternative oversight within the Episcopal Church. He rejected the first offer of alternative oversight when proposed in the fall of 2006 by Bishops Griswold and Jefferts Schori. He has largely rejected the community of the Episcopal House of Bishops for years, attending only those meetings that focus on his expression of discontent, refusing communion with sibling bishops, and even staying in different accommodations than the majority of the House. I’ve been in pastoral care for my entire career as a priest. You can’t provide pastoral care and support from someone who doesn’t want it from you, especially when he shows it by refusing your company.

Bishop Duncan is "holding out the prospect of those who wish to stay doing so, and promises to be fair and generous in his dealings with them. I think I'm asking for a similar fairness and generosity from the Episcopal Church towards those parishes who do want to leave," said Dr Forster.

I would leave response to this to the folks of Progressive Episcopalians of Pittsburgh. So far, they seem unimpressed with Bishop Duncan’s idea of what is “fair and generous.”

"Part of the Archbishop's comment is that these are matters for the bishop and the diocese. They are the primary unit.

"That doesn't give a diocese the right to do what it wants willy-nilly, but there has to be a fundamental respect, it seems to me, if a diocese says, 'We wish to align with a different province,'" Dr Forster said.

I’m sorry; what action seems more “willy-nilly” – more “I want my way or no way!” – than saying “We wish to align with a different province?” To say that it is an act of principle in no way mitigates that it is indeed an act of will in defiance of, and not in concurrence with, the Constitution and Canons of the Episcopal Church, or even with Anglican tradition. As noted, the clarification of Archbishop Williams’ letter and the clear intent of the Windsor Report is that, while the diocese might be the primary unit of the church, it functions only within the structures of the province. My heart pumps largely independent of my brain; but if they’re not connected in my body neither will survive. Nor can any “transplant” happen without someone being seriously injured.

I can hardly wait until some diocese of the Church of England is prepared to “align with a different province;” and I can hardly expect that this letter will hinder those in the Church of England who might want to do that. We will see how irrelevant that provincial structure is.

These four Bishops of the Church of England seem simply confused. They agree with Bishop Duncan in his opinions about GLBT persons in the life of the Church. That’s sad, but neither a surprise nor much worthy of note. On the other hand, by extending their expression of support beyond that simple fact they demonstrate their own misperceptions of the situation to which the Episcopal Church is responding. May God move in them and provide them greater clarity of vision.

A Cross-Cultural Experience

My recent sermon, "At Our Doorstep," was picked up and translated into German. You can read it here (well, perhaps you can; I can't). I think this is my first translated piece. I think it's really cool!

What the General Convention Has Done (and Might Do): Clergy Healthcare Coverage

There is a lot of attention these days on diocesan conventions, driven mostly by concerns about dissenting dioceses taking actions that further divisions in the Church. There are comments about other conventions, of course; and most of those are relatively quiet, and frequently pragmatic. Ours was; which is why I was able to draft my most recent posts while there.

One pragmatic topic that came up at our Diocesan Convention was the cost of health insurance for clergy and lay professionals. Costs have risen, just as for other professionals and staff. Churches have always struggled financially, and costs of clergy benefits have always been important expenses.

One factor in costs for coverage has been the fragmented way in which contracts have been negotiated. Basically, while negotiation is managed by the Episcopal Church Medical Trust of the Church Pension Group, it's managed on a diocese-by-diocese basis. As a result, each diocese is its own actuarial pool. That means that there are significant differences from one diocese to another. Large dioceses with many clergy are able to negotiate better deals, and so better costs, than smaller dioceses. More urban dioceses may have more and better options than largely rural dioceses. The result is an uneven patchwork of coverage and costs for clergy and lay professionals. Some years ago I listened as a colleague from another diocese told me his diocesan plan wouldn't cover him in my Episcopal hospital.

In response to these concerns, General Convention in 2006 passed Resolution A147, “Study the Costs and Issues of Healthcare Benefits for All Clergy:”

Resolved, That the 75th General Convention endorse the Church Pension Group’s proposal to conduct a church-wide study of the costs and issues surrounding the provision of healthcare benefits to all clergy and lay employees serving churches, dioceses and other church institutions and to report their findings to the 76th General Convention; and be it further

Resolved, That all dioceses, parishes and other church institutions are urged to cooperate with the conduct of this study by responding to requests for data regarding employee census and healthcare costs; and be it further

Resolved, That this study will include an analysis of the potential for a mandated denominational healthcare benefits program and other viable alternatives, culminating in a recommended solution and an actionable implementation plan.

There are two interesting aspects of this resolution. The first is in the first paragraph: the sheer breadth and scope of the study. This is not simply a statistical overview, but is instead a thorough review with which all institutions of the church are “urged to cooperate.” This should give shape and form to the patchwork we already know is there. Statistical review has its value, and anecdotal evidence is helpful; but this will give the most detailed picture of the current situation, including the current disparities, and perhaps some unexpected opportunities.

Which brings us to the second interesting aspect of the resolution: the requirement of a meaningful result. The study is to include analysis, recommendations, and a plan for “a mandated denominational healthcare benefits program [or] other viable alternatives.” The point is to include all clergy and lay employees. This would, of course, create in the Episcopal Church the largest possible actuarial pool. Conceivably this would provide the Episcopal Church Medical Trust with the best foundation on which to negotiate for coverage.

Now, such a plan certainly would not make everybody happy. In all likelihood, some people would end up paying more, although hopefully for more benefits. A mandated plan might well bring in some congregations and other institutions that have been trying to do it alone, or trying to do without; and some might certainly resent it. At the same time, a good analysis of the information should identify those concerns, and “viable alternatives” might provide choices.

Regular readers will know that I believe in a government-supported program for universal access to and coverage for healthcare. That said, I don’t expect it to happen in any meaningful sense before the 2009 General Convention. (I learned all too well from the misplaced optimism of the early Clinton years.) So, this might well provide better for so many of my colleagues in ministry in the Episcopal Church while we work for a system to provide better for everybody.

One thing that did happen at our Diocesan Convention is that I was elected a Deputy to the General Convention in 2009. I’ll have chance to vote on this, and perhaps to speak to it. I can hardly wait to see what the report will say.

Universal Health Care: Public/Private Partnerships

After this recent post, I continued to think about the idea of public/private partnerships as ways to meet social needs. Of course, I'm especially interested in such partnerships in pursuing universal access to health care. Perhaps this is a way to reframe the debate, and to imagine new options.

Watch the news, even for a few days, and you'll realize we enter into public/private partnerships all the time. Local and state governments offer tax incentives to bring new businesses, new jobs, to underserved areas. They do so believing that greater economic activity benefits not just the company per se, but also the residents employed by the company, and then other residents with whom they do business, and, ultimately, the community as a whole. Those governments provide some financial assistance, and perhaps some infrastructure assistance, and the rest is done by private interests - the company and those they employ or contract with. Those governments forego some immediate revenue to invest in long-term benefits for the whole community.

Consider the interstate highway system: it's a classic example on a grand scale. It was originally approved by Congress as a defense measure: to better move troops and materials for defense. However, the highways weren't built by federal employees. They were built, and continue to be maintained, by private businesses contracted by federal and state governments. Government bodies establish routes and engineering standards; they coordinate with private companies to plan implementation; and the private companies manage the construction.

Public participation is important to these activities. Granted, government bodies are the source of the funds. More important, government bodies have the widest accountability. Private companies are accountable first and foremost to their owners and/or shareholders. Believing as we do in a market economy, that's appropriate. They can be held accountable by individuals; but that can take a lot of time and money spent in legal pursuit.

Government bodies, on the other hand, are accountable to all of us - at least, to all of the citizens within the constituency. They can be held accountable with each election cycle; and between election cycles by constitutional processes for recall (not to mention an attentive press). Private companies, by and large, work to do well by those they serve; but only public servants are accountable to all of the public. And, by contracting out the work, public servants can hold private companies accountable more directly, under the terms of the contract.

And make no mistake: issues of those who don't get health care, or who get health care that doesn't get paid for, do affect all of us, citizens and non-citizens alike. Whooping cough has made a resurgence in this generation. Methicillin-resistant staph aureus (MRSA), a disease once known only in immune-suppressed patients in hospitals, is now showing up in the general population and in the news. We continue to prepare for the possibility of pandemic flu. These are public health issues that put all of us at risk; and the first line of defense for all of us is making primary care available to all, an especially to those least likely to get it through employment.

And make no mistake: we're already paying indirectly for health care for those who receive health care in extremis, and for care they can't pay for. It raises health care bills - how else is a provider to stay open when the provider cares for 100 patients but only gets paid for 95? The provider still has the expenses of all 100 patients. If the provider has to absorb too much, the provider has to stop; and then no one gets care. The differences get made up in higher premium payments for insurance and higher taxes for government-supported health services. We’re already paying; but there is little system or transparency in the process. We’re paying, but it’s hard to know how, where, or how much. Wouldn’t it be better to have a clearer, more systematic way of addressing these needs?

Why, then, involve government? More specifically, why use tax money? To spread the expenses as widely as possible. That’s what insurance companies do: to reduce premiums they encourage groups to contract, and the larger the group the lower the premiums. However, just government bodies are accountable to the greatest number of people, they also represent the greatest number of people, the largest actuarial pool. The group of “all taxpayers” is the largest possible group across which to spread the expenses – much larger than “all employed,” much less “all well-employed.” Spreading the expenses among the widest pool should be a significant step in controlling how quickly each individual’s contribution would increase.

So, why not seek such public/private partnerships in providing universal access to and coverage for health care? The experiments in coverage in Massachusetts and California do involve both public and private concerns; although some aspects of those plans don't really look like "partnerships." While there are concerns raised regularly about following the British model, there are programs in other nations that do involve public and private participation in providing coverage for all their citizens. We have shown great creativity in health care research and technology, and in business entrepreneurship; and often those have involved public/private partnerships. Why not bring that energy and that creativity to providing access to and reimbursement for health care for all? It makes good sense for public health (and so, among other things, homeland security) and for expenses (and so, among other things, for business). It just makes sense.

In the Midst of Things

So, I'm sitting in Diocesan Convention....

This year's Diocesan Gathering and Convention got off, for me, to a bad start. After a nice afternoon ride with a colleague, I learned that the hotel's computer had lost my reservation. I note that it was the computer primarily to state my belief that it was the machine, and not a person. It's also the fact that I made my reservation on line, using the hotel's own site; so, we'll see whether I do that again.

Then, and worse, I realized I had forgotten my needlepoint.

Yes, I do needlepoint- at least at diocesan convention. I began in seminary for stress relief. I quickly learned that I was, as we used to say, an auditory learner. With my needlepoint to occupy hands and eyes, I discovered that I heard what I needed to, and missed less information because I fidgeted less.

Now I do my needlepoint only at convention. It's not that I no longer have stress. Now and again I think that I should take it out and work on it. However, we have in our household multiple cats, some of whom have significant emotional needs. I'm not so much worried about claws. I'm more worried about trying to work with a cat sitting on my head.

So, I only bring out the canvas to work on at diocesan convention. Perhaps there are other meetings to which I could bring it; but I haven't done so. It has for me become a diocesan convention tradition.

Unfortunately, I forgot to bring it. When I left the house, it remained where I had set it out. So, what was I to do to occupy eyes and hands in the midst of everything going on around me?

Fortunately, I have a PDA; and I have a blog....

A Letter Has Gone Out

The Presiding Bishop has sent, and has publically released, a letter to the (so far, still) Episcopal Bishop of Pittsburgh and Moderator of the Network (and signatory of the Common Cause papers, as well). The letter seeks to recall Bishop Duncan to the discipline of the Episcopal Church, and encourages him not to support actions in the diocese to attempt to take it out of the Episcopal Church. You can read the letter here. I'm sure you can read reflections and reactions at all the usual suspects.

Some will see this as threat, certainly. Some will see it as insufficiently stern. I think the effort to write a letter with some sense of pastoral tone is largely successful, and largely worthwhile. I also think it's valid to begin with Bishop Duncan, since he's been so public a leader and advocate in the division within the Episcopal Church, even though other bishops have arguably moved farther and faster.

This letter isn't a surprise, nor, really, is its tone. There are some who have been calling for such statements, and for real consequences, for some time.

Still, I continue to be concerned about "abandonment of communion." I certainly believe the bishops in question wish to abandon the communion of the Episcopal Church. At the same time, what that means, and what that might mean as contrasted with abandonment of the the communion of the Anglican Communion, continues to be murky.

On the other hand, the Canons of the Episcopal Church are clear that violation of discipline (so, Constitution and Canons of the Episcopal Church); violation of doctrine (arguing that a diocese, even as the primary unit of the Church Catholic, can function out of the context of the larger Church that created it); and of ordination vows (which require assent to the doctrine and discipline of this church, and not of some abstract Communion) are clear and consequential violations. They should be sufficient.

We have sufficient clarity of definition in the terms of Title IV of the Canons of the Episcopal Church. We have sufficient evidence, I think, of violations less dramatic but just as important as "abandonment of Communion." If action is necessary (and few of us really think it won't be), let's stay with the concrete. As the central character in The Firm said, "It's not sexy, but it's got teeth."

Newest at Episcopal Cafe

My newest post is up at Episcopal Cafe. It's a reflection for today. You can see it here.