The United States 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 423 and other
protections 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.
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