He also refused to create a health care exchange, an online market allowing the uninsured to shop for coverage.

You can just see him pounding his chest as he composed the letter to U.S. Health and Human Services Secretary Kathleen Sebelius: “Both represent brazen intrusions into the sovereignty of our state.”

He included the requisite talk of guns and the obligatory thrashing of the Medicaid program. He thanked God and the founders for his right to reject the federal “power grab.”

It takes some kind of chutzpah for a governor of the state with the highest percentage of uninsured — 1 in 4, or about 6 million Texans — to draw a line in the sand and announce that nothing’s going to change.

This cowboy swagger is amusing in an Austin City Limits ad, but in a letter from the head of a sovereign state to a member of the Cabinet?

Perry seems to be in a time warp, stuck somewhere between the American Revolution and the Wild West.

It would be humorous if it were not so disastrous.

In the 11-county Central Texas region, 360,000 people are uninsured.

Central Health, the Travis County hospital district, could have saved $7 million to $8 million a year, which could have been used to more effectively provide primary care.

People’s Community Clinic could have earned $1 million for primary care (more than 10 percent of its budget).

Some of the most frequent emergency room users will continue to be the mentally ill.

Costs will continue to be shifted to taxpayers and consumers through higher insurance premiums.

Expanding Medicaid would give us $76 billion between 2014 and 2019, with Texas putting up about $6 billion from the state budget for its share. That $6 billion is far less than Texas hospitals now spend in a single year for uncompensated care.

In the last paragraph of Perry’s letter to Sebelius, he wrote, “I look forward to implementing health care solutions that are right for the people of Texas. I urge you to support me in that effort.”

Really? For 12 years, public health care providers have waited for Perry to do something about health care.

All we’ve seen is a failed executive order to inject all sixth grade girls with a vaccine to protect against a sexually transmitted virus, an immunization made by the drug company for which Mike Toomey, his former chief of staff, lobbies.

Toomey also ran the pro-Perry super PAC during his failed presidential campaign.

In an interview Monday on Fox News, Perry said that the federal government doesn’t like us anyway and their data is just “fake and false on its face. The real issue here is freedom.” Really?

As a neonatal nurse, I’ve taken care of lots of sick and premature babies and their families, and I talk to plenty of Texans outside of work.

I have never once heard anyone express concern about Texas’ sovereignty.

I have, however, heard from a whole heckuvalot of Texans worried — make that panicked — that they might not be able to get insured, they lost their insurance with their job, they can’t find a primary care provider, they might go bankrupt with medical bills, or they will have an accident or illness in which they would have to come with the $10,000 they would owe before their deductible were to kick in.

There are babies at Dell Children’s Medical Center whose care may cost $4 million to $5 million in a year, yet their insurance coverage has a $1 million annual limit.

The hospital is out that money, and their parents are hopelessly in debt. Fortunately, by 2014, annual limits will be completely prohibited thanks to the law.

On any given day, the emergency room at University Medical Center Brackenridge — and every other public hospital in Texas — is full of people waiting to see a doctor for primary care. Without insurance, they can’t just pick up the phone and make an appointment.

I invite you to try doing that. It’s a real eye-opener.

Nurses see the tragedies every day of uninsured people who have put off seeking care until it’s too late.

Lives are shortened, quality of life is destroyed and hearts are broken.

Texas legislators must see this, too, because of the 254 counties they represent, 185 are considered medically underserved and parts of 46 others fall under the designation.

Maybe when the Legislature convenes in January, its members can turn this around and take the federal government up on its offer.

Without executive leadership, it will take real guts, but lawmakers could drag Texas off the bottom of the statistics heap and get their neighbors the medical care they need.

If Lyndon Johnson had been alive on March 24 when President Barack Obama signed the Patient Protection and Affordable Care Act into law, he would have remarked from experience that the battle for health care reform had only begun.

We remember the July 30, 1965, signing of Medicare into law as the smooth establishment of a popular program. But that’s not at all how it went down. The program was nearly destroyed by doctors and hospitals threatening to boycott it.

Calling it “socialized medicine,” the American Medical Association waged war against the program before and after it became law, with doctors warning their patients against it, thus threatening the public support that Johnson needed.

Johnson outmaneuvered them by giving the AMA a seat on an advisory council that oversaw rules and regulations, one of which was setting physician fees, and the doctors acceded. Thus began wealth among physicians.

Many hospitals, especially in the South, were segregated and threatened to boycott because of the provision that hospitals be integrated. Johnson allowed no compromise and set up a battle council.

He had Vice President Hubert Humphrey telephone mayors to pressure resistant hospitals. In the final weeks before Medicare’s beginning, the hospitals integrated rather than lose federal dollars. LBJ sent hundreds of inspectors to ensure hospitals receiving Medicare funds were indeed integrated.

Thus began Medicare.

Fast forward to 2010. On the campaign trail for president, Obama got his strongest applause when he spoke of insuring all Americans and keeping insurers from denying coverage based on pre-existing conditions. The brightest minds in health care drafted a plan that would achieve those results.

The bill enjoyed the support of organized doctors and hospitals. Insurance companies were the holdout. When the public option was ultimately dropped in favor of insurance exchanges, the companies jumped on board, and the bill was passed.

Unlike the interest-group battle over Medicare, this law is threatened by party politics. The ads from this election cycle show how prominent the issue weighs and how ugly the rhetoric can get. The fact that the provisions in this law kick in more slowly than Medicare leaves it even more vulnerable to attack.

If the conservatives regain power, they’re not likely to repeal the law. But if they strip away critical, easy-target elements — such as the requirement that uncovered individuals be required to buy at least a basic policy and the subsidies to make sure they can afford them and/or the requirement that large employers provide health benefits — then coverage for the uninsured will be effectively gutted. With 21 states, including Texas, suing to stop parts of the reform, a showdown looms.

The major objection is the insistence that it is unaffordable. When Medicare became law, health care represented 6 percent of U.S. economic output. Today, the figure is an unsustainable 18 percent. Our health care system pays for the quantity rather than the value of care, and it should be clear to everyone that without fundamental change, the same trend will continue.

Included in the overhaul is a Center for Medicare and Medicaid Innovation where local hospitals can do what the hospital where I work did. Within six years, we reduced our term infant birth trauma from 0.3 percent (half the national average) to 0.01 percent. We did this by bundling best practices and improving interdisciplinary communication in the delivery room.

In 2003, we billed $1.5 million for birth trauma. Last year, we billed $25,000. While representing a loss for our hospital, it’s a huge savings for Texas, which foots much of the Medicaid bill.

Rather than a government takeover of health care, the law frees communities and local health systems from existing payment rules and allows them to experiment, as my hospital did, for ways to deliver better care and ultimately lower health care costs.

The midterm elections seem to be all about exploiting the down economy and taking aim at those who courageously cast a vote to overhaul an unsustainable system. They should not be targeted and punished. People would do well to remember the fury and acrimony that surrounded the passage of Medicare.

This law is designed to insure nearly all Americans while increasing the value of care. If allowed to stay intact, it may well be as momentous as Medicare.

Undoubtedly overlooked by most, that statement struck me as profound and rocketed me back to 1992. The gods had smiled upon me, and I found myself at the LBJ School of Public Affairs, out of place among 10 promising graduate students chosen to take the last policy seminar taught by the late Barbara Jordan. The first African American elected to the Texas Senate since Reconstruction, Jordan went on to a distinguished career in Congress, ended her public service teaching at the LBJ School of Public Affairs.

U.S. Representative Barbara Jordan opens the impeachment hearings on July 25, 1974. Her brow remained unfurrowed during the electrifying eight-minute and 45-second speech.

I was old enough to be my classmates’ mom, but I was as bendable as a wire hanger. We studied policy from every conceivable angle, dissecting it into many parts — politics (not a dirty word), democratic pluralism, congressional prerogative, the U.S. Constitution, the presidency, leadership, vision, interest-group impact, agency roles in the policy process, the judiciary and more. To this day, Jordan’s reverence for our democracy is as ingrained within me as her conviction that public service is a high and honorable calling.

One important lesson we learned is that Americans are not comfortable with fundamental policy change, and that’s clearly been in evidence during the past year’s health care reform brawl. The nation has not legislated fundamental change since the 1960s, and, unaccustomed, emotions have run high.

Members of congress yelled “you lie” and “baby killer” from the chambers of the people’s House. Congressmen were spat upon and were the target of racial and homophobic epithets by angry protestors as they walked the steps to the Congress to cast their difficult votes.

After the bill was signed into law, all hell broke loose. Several representatives who voted for the bill have received death threats, profane voicemails, white powder mailed in envelopes and bricks hurled through their home and office windows with hateful notes attached. Three days after the vote, attorneys general from more than a dozen states, including Texas, filed suit asserting as unconstitutional the mandate for individuals to buy insurance.

The late Jake Pickle, who represented the 10th Congressional District from 1963 to 1995, knew firsthand about difficult votes. As a new congressman, he was confronted with the 1964 Civil Rights legislation. His constituency was bitterly divided on the issue. He knew in his heart that forbidding discrimination based on race and sex was the right thing to do. He also knew as a new congressman, a “yes” vote could well cost him his seat. He voted his conscience: “Aye.” He remembered that vote in his 1997 memoir, “Jake,” as his gutsiest, proudest moment in the U.S. Congress.

The health care legislation was never about socialism, red versus blue, a public option, abortion, government takeover, poll numbers or midterm election fallout. Those are all abstractions or side issues. All along, this legislation has been about uniting around the principle of equality, so that, like all other industrialized nations, in America health care will be available for everyone, not just the privileged.

In her keynote address to the National Democratic Convention in 1976, Jordan said with her voice and wisdom ringing from the mountain top, “First, we believe in equality for all and privileges for none … But this is the great danger America faces: that we will cease to be one nation and become instead a collection of interest groups — city against suburb, region against region, individual against individual. … But a spirit of harmony will survive in America … if each of us remembers, when self-interest and bitterness seem to prevail, that we share a common destiny.”

We also learned in Jordan’s class that true leadership is rare, that it requires a vision for the people along with the trust, skills, faith and perseverance to carry it out. How I wish she had lived to see a young visionary black senator swept into presidential office with the promise of “real” (meaning fundamental) change.

How proud the congresswoman would be that within 14 months of inauguration, Obama accomplished what three presidents had failed to do. Franklin Roosevelt, Harry Truman and Richard Nixon each placed universal coverage high on their agendas and fought valiantly for it. The late Sen. Edward Kennedy called it the last great unfinished business of our society.

The president rightly could have added to his remarks, “This is what leadership looks like.”

I chose neonatal intensive care as my professional home because it’s the perfect world. It’s a wonderful mix of high technology and caring, and every infant needing intensive care has access because the care is universally covered by private or public insurance. I could never work in an area that people couldn’t access because of lack of insurance.

Close to 50 million middle-class Americans are uninsured. That’s unacceptable. A year ago, we had a new president and a new national consensus to fix our broken health care system. We were united around the principles of covering all Americans and leveling or bringing down costs. Reform bills passed both houses, and each covered 30-plus million more Americans.

My euphoria was dashed in January by the Massachusetts Senate election to the seat held for 47 years by Ted Kennedy, the champion of national health insurance. In a macabre irony, the state that in 2006 enacted near-universal coverage elected Scott Brown, who campaigned on a platform to defeat health care reform. Since then, I’ve watched with horror as the national discussion of moral imperatives descended into the ugly refrain of “government takeover of health care.” Now it looks like the majority of Americans oppose reform and that political reconciliation is the only hope of passage.

A serious observer would never call the reform proposals a government takeover. It is not proposed that government provide health care. That’s called socialized medicine. And it’s not proposed that government pay for all health care. That’s called a single-payer system.

The conventional wisdom was to base reform on the system we already have — a mix of private and public insurance, and that’s precisely what the architects of both bills did.

With our health care system incapable of correcting itself, both proposals simply suggest government oversight. The uninsured would be required to enroll from insurers offering their policies in organized health-insurance exchanges, with the federal government acting as the equivalent of the employee benefit department of large employers. Low-income Americans would receive subsidies to help them pay for it. Both bills leave the employer-based health insurance system — which 80 percent of privately insured Americans have — untouched.

As for rising health care costs, we need to look at tort reform and at profiteering by pharmaceutical companies, niche hospitals, medical device companies and physician specialists.

We can limit costs and tragedy if we figure out ways to deliver care that achieves a better outcome. We can do that. I’ve seen it done.

Where I work, the saddest thing I (used to) see at work was a great big, beautiful brain-dead infant lying on an open warmer, with tubes everywhere — the result of birth trauma.

In 2003, our term infant birth injury rate was 0.3 percent, half the national average. One injured baby is too many, so the health care team set about to eliminate such tragedy. By 2009, we had reduced our preventable birth trauma injury rate effectively to zero by bundling best practices. We improved delivery room communication and implemented protocols for the use of oxytocin (a drug to start or continue labor), forceps and vacuum extraction.

Putting safety above profits, our hospital system went from billing payers $1.5 million in 2003 to currently $25,000 for birth trauma. It’s a huge savings for Texas, which foots much of the Medicaid bill. Just imagine the savings nationwide and the human tragedy avoided.

I became a nurse in 1979, 14 years after the passage of Medicare and Medicaid. Back then, health care represented 7.2 percent of our gross domestic product.The last time a serious attempt to reform health care was made in 1993 when health care accounted for 13.4 percent of the GDP. It’s now 17 percent; without reform, it’s projected to reach 38 percent by 2050.

We cannot afford to wait to fix our broken system. Do not underestimate the power of universal coverage. How much healthier would we be and how much more efficiently would we spend health care dollars if everyone could get the care they need when they need it?

According to tobacco companies’ filings with the Securities and Exchange Commission, Prudential Insurance Company (the largest supplier of health insurance and the largest owner of for-profit HMOs in the United States) has $248 million invested in tobacco stocks; Travelers, $88 million; CIGNA, $77 million; MetLife, more than $15 million.

A July 8 article written by Harvard physicians in the British medical journal Lancet likened this investment strategy to the slogan of a combination veterinarian-taxidermist: “Either way, you get your dog back.”

Some may say, “Morality aside, isn’t this a good investment?” Darn right it is. You figure a pack of cigarettes nets a large profit, has incredible brand loyalty, and it’s addictive. Furthermore, even though 1,000 U.S. smokers die each day from their addiction, the industry recruits 1,000 replacements daily by promoting their wares to children and people in the Third World.

What child could possibly resist the fabulous Joe Camel? Apparently not many. A study of children found that a staggering 91 percent of six year olds identifies Joe Camel as a symbol of smoking, and in the past four years smoking among eighth-graders rose 30 percent.

But to be fair to the HMO investors, they are flooded with profits, have billions of dollars to invest, and “have no choice but to invest in what the Standard & Poor’s index invests in” (according to a CIGNA spokesman in a July 8 Associated Press article). And after all, the market is amoral. Corporations answer to the shareholders, not patients.

Medicare and Medicaid programs are subcontracting to for-profit HMOs, Blue Cross plans (formerly not-for-profit) are selling themselves to investors, and Columbia/HCA (the world’s largest hospital chain) gobbles up hospitals faster than you can say “Philip Morris”.

Let’s face it: America is on a fast track toward becoming the world’s first corporate-run, for-profit health care system. We’re at a crossroads in health care, and the incongruity of the health insurance-tobacco connection epitomizes the collision of values.

I recently attended a forum on healthcare reform at the University of Texas at Austin. Dr. John Howe, president of UT Health Science Center in San Antonio, decried the effects of market-based changes on physician practice. Pharmacist Lee Strandberg discussed healthcare rationing in Oregon. Dr. Ron Anderson from Parkland Hospital lamented adverse market changes on hospitals. Dean Dolores Sands from UT-Austin Nursing School spoke from the heart and deplored the effects on patients and their families.

Last, Dr. Reuben McDaniel, a stately gentleman and professor at the UT-Austin Business School came to the podium and said, “If any of you in the audience were to keel over, I am the only one up here who cannot help you…. Since the medical community allowed costs to sky-rocket out of control, and government attempts at healthcare reform failed, that left business – the insurers – holding the reins. By default, we make healthcare policy and decisions.” What a sobering moment that was.

Be that as it may, it must never be forgotten that health care is a human service, not just a widget to be callously bought and sold. It is wrong for a healthcare interest to encourage and participate in the prosperity of tobacco companies, whose products addict and eventually kill people. Business that profits at the expense of society should at the very least feel our scorn. After all, shareholders and consumers also represent a principled citizenry.

Conspicuously absent from the Statesman editorial was a call for more advanced practice nurses (APNs) to fill the void. In the 1960s physicians began opting out of general practice for the more lucrative specialty practices, and since that time APNs have answered the call to serve economically disadvantaged and medically underserved populations in rural and inner city areas. Obviously someone must do this work. APNs number about 100,000, and their preparation, which extends about two years beyond that of a registered nurse, emphasizes prevention. Nurse practitioners (NPs) have a 25-year track record of providing high-quality, cost-effective primary care services, such as physical exams, screenings, immunizations, well- and ill-baby care, and treatment of acute and chronic illnesses.

The antiquated regulations constraining nurses’ practice date back to the 1930s when nurses, who were mainly women, were seen as assistants to physicians, who were mostly men. In many states, NPs must be supervised by physicians, even if physician services are not needed; NPs may not be allowed to prescribe even simple medications; NPs may not have financial autonomy, so that physicians bill Medicare and insurance companies and then compensate NPs at their discretion.

Clinton’s proposed Health Security Act, as well as other health care reform bills, both Democratic and Republican, call for the removal of barriers which currently exist at state and federal levels to better enable advanced practice nurses to provide many primary health care services. APNs have significant autonomy in many states such as New York, Arizona, Oregon, and Alaska.

The American Medical Association (AMA), which does not represent all physicians, takes a very dim view of this prospect. The AMA attacks the credibility of nurse practitioners by insisting that nurses are not qualified to practice medicine without the direct supervision of doctors. In light of their glaring inability to produce enough providers to meet the needs of all citizens in all geographic areas, one must question why this group of physicians would oppose nurses filling the void. Could it be control? More specifically, control over healthcare dollars?

Nurse practitioners have been subjected to hundreds of effectiveness studies for more than 20 years, and virtually all of these studies have demonstrated that the quality of care rendered by APNs is at least equivalent to that provided by physicians for comparable services. The 1986 study undertaken by the Office of Technology Assessment is the most comprehensive study to date of APNs. This study found that with relation to patient satisfaction, APN care was superior to that of physicians, especially with regard to shared control, quantity and quality of information given, reduction of professional mystique, and costs of care. The study also noted that successful malpractice cases against NPs are extremely rare.

In this millennial age, may the new year bring policy-makers the courage and wisdom to act in the consumer interest and cease the perpetuation of the formal provider hierarchy created by the medical profession. May health care reform result in the full utilization of nurse practitioners to better this nation’s health by preserving quality and improving access while reducing costs.

Will the economically disadvantaged babies that I have so lovingly and painstakingly cared for over the years have access to medical treatment for the fevers, sore throats, and earaches of childhood without their parents’ resorting to emergency rooms?

Your August 13 editorial, “Nurses’ Lib,” was right on mark in supporting the proposal of Hillary Rodham Clinton’s Task Force on Healthcare Reform to remove barriers constraining advanced practice nurses (APNs) from serving as primary care providers. These nurse practitioners are well prepared and suited to fill the void created by the shortage of primary care physicians to treat common ailments.

If national healthcare reform results in basic health care becoming universal for all Americans, many more providers of primary care will be needed to care for the 37 million people who are now uninsured.

Nurse practitioners have repeatedly demonstrated their ability to increase access to primary health care while preserving quality and reducing costs.