The Cost of Medicare

The medical care of every U.S. citizen over age 65 is rigidly regulated by the federal government through the Medicare program. Each service, from heart transplant right down to drawing a tube of blood, has a fixed price and its payment is authorized only by absolute necessity. One would naturally expect therefore that the Medicare program would be cost effective. Let's examine whether it is. Basic Medicare is in two parts, Part A, which covers hospital and home health care minus a fairly hefty deductible and Part B which after a deductible covers 80% of costs for doctors, lab testing and medical devices. There are also Medigap plans, Medicare Advantage plans, and more recently Part D prescription plans to supplement Parts A and B, all tightly regulated.

Part A is funded by the payroll tax, taken out of your paycheck, which goes into a Part A trust fund. When Medicare started in 1965 the tax took up 0.3% of employee's incomes. Today it's 10 times that at 2.9% unless you make over $125K in which case it's 3.8%. As of 1994 the tax applies to 100% of your income. Considering all those increases you would expect the Part A trust fund to be in good shape, but it's not. It pays out more than it's takes in every year and the trustees of the fund in this year's report predicted it will be depleted in 2028 at which time all hell will break loose unless something happens before that like increased taxes.

Part B requires the seniors to pay a premium which is deducted from their Social Security and presently is anywhere from $120/mo to $390/mo depending on income. Through the years, and especially in recent years, the premiums have risen dramatically but, just as with Part A, they are falling further and further behind in covering expenses. When Medicare started these premiums were designed to cover half of Part B expenses with the rest coming from the income taxes on the general public. The premium receipts now cover only 25% of expenses with the other 3/4 being added on to the progressively enlarging $20 trillion national debt.

According to the 2016 trustee's report, the cost of both parts are rising faster than the rate of inflation and continue steadily to take up a larger share of the GDP, presently 2.1% and expected by the trustees to rise to 3.5% in 2037 when present 44 year olders reach Medicare age. For the whole Medicare program as it stands today the trustees report that the unfunded liability, which is the amount that is promised in the future for all present eligible citizens but not covered by taxes, is in the range of $40 trillion. Unfortunately there's just no place to get that kind of money.

As was previously described through the years progressively more onerous regulations have been added to the program, primarily aimed at stopping the ever continuing rising cost, to no apparent avail. New, even more complex regulations are scheduled to begin in 2017 in the hope that this time the correct regulatory brew will be achieved. Unfortunately the politicians and bureaucrats seem unwilling or incapable of seeing that their regulation approach is not working and that they are missing the structural problems with the Medicare program.

The original political impetus for Medicare was the presence of a sizable group of seniors who were no longer able to work and had been unable or unwilling to make arrangement to provide for medical care. They received charitable care which was often substandard. In the setting of a strong economy, and without impugning his political motives, Lyndon Johnson and his Democrat congress decided to address this problem by assuming payment for the medical care of all seniors, a much larger task than was necessary. As it has turned out this was the first mistake.

Another costly mistake was the failure to provide for future demographics. Many conceive that the payments they have made through the years are kept in individual accounts from which benefits are paid. But in fact it is the active workers who are paying the present Medicare bill. As the population has aged and the proportion of active workers has declined, the program has thus become somewhat of a Ponzi scheme in which through the years decreasing numbers of workers are funding benefits for increasing numbers of seniors.

But the biggest problem has been the flagrant disregard by intelligent well educated politicians and bureaucrats for the most fundamental laws of economics that can only be explained in my humble opinion by stubborn blind adherence to ideology. Let's realize the implications of all this economic talk. Money wasted, present and future, represents real life losses for you and your family. And in the medical realm it translates into serious interference in the provision of and innovation in your medical care. Stay tuned!

How Medicare Became a Regulation Monstrosity

In a previous post I described the Medicare program as a progressively worsening regulation monstrosity. It did not start out that way. I had a ringside seat for the whole show from 1965 to the present so I can describe what happened. It's important at this point in changing U.S. politics that the public understand this situation.

In the beginning the Medicare program paid doctors their usual and customary fee. Hospitals for their part were paid on a cost plus basis. For the medical providers that was a windfall. My older colleagues described how their incomes surged after Medicare since patient visits increased dramatically and also elderly patients who they previously treated gratis were now able to pay. Hospitals had similar gains and so started new building programs and increased their services. What happened next a 10 year old could have predicted. It was what would happen in any company that told its employees to set their own wages and paid its suppliers on a cost plus basis.

As doctor's fees rapidly increased a new rule provided that customary fees had to be in place for the preceding 2 years. That provision almost cried out for fee increases since doctors were being asked to predict what they wanted their fees to be 2 years hence. Hospitals carried out their mandate by providing nothing but the most and the best and so hospital costs also rapidly increased. So the bureaucrats in Washington inevitably turned to price control.

In 1983 PPS (Prospective Payment System) was started for hospitals. Instead of the cost plus payment system, hospitals have since then been paid a set fee for the patient's diagnosis. So if you have a heart attack the hospital gets the heart attack fee for taking care of you, no matter what it spends. If you ever wondered why hospitals were so anxious to get you discharged now you know. I'm not a hospital expert but I can tell you that government regulations have made things pretty messy. Regulators mandate sirloin steak but Medicare has cut down to hamburger prices. Doctors are constantly pestered to discharge patients. Legions of billers and coders scan the records to come up with adjustments in the diagnosis codes so as to increase the reimbursement. Would any of you be surprised to know that through all this the cost for hospital care dramatically increased, as did the ratio of hospital administrators to actual care providers.

Doctor price control started in 1992 at which point Medicare set the fee instead of the doctor. It was recognized that not all doctor visits are the same. A simple blood pressure check takes less time and trouble than treating someone with serious illness. So Medicare paid 3 different fees for a doctor visit depending on the level of service, and the doctor picked the level. Bring in the 10 year old again to tell you what happened in that arrangement.

So in 1995 Medicare no longer took the doctor's word on what the level of service was and issued guidelines, increasing the number of levels of service to 5 and specifying the number of things that had to be done to justify each level. But the requirements for documentation turned out to be a little lax so in 1997 Medicare revised things and gave doctors a good dose of guideline medicine. To select the level of payment for a patient visit doctors must now enumerate and record multiple aspects of the patient history, exam and something called "decision making". The system is ridiculously complex and nonsensical. As an example significant changes in payment are determined by whether or not your doctor records things about your family, how many different aspects of each body part he examines or such things as whether you have 3 problems he can list instead of 2. In other words doctor visit payment is now less a matter of time and attention paid to you and more a matter of proper compliance with the guidelines and record keeping.

In 2009 as part of the federal government stimulus package electronic record keeping was set as a "critical national goal" and various financial stimuli and penalties were put in place for doctors to adopt computerized records. Regulators specified how the computer programs were to be used. Normally computers are used to decrease cost and improve efficiency but this regulatory effort has produced the exact opposite result, namely increased cost and decreased efficiency. However, one thing computers have done for doctors is to facilitate compliance with the payment guidelines so that guideline documentation and not medical communication is what medical records have largely become.

Although CMS now is exerting exquisite control over the price of each doctor visit (as well as all other services it pays for), there is no control over the number of services. This is the present bureaucratic diagnosis of the reason that Medicare costs continue to rise faster than any other aspect of healthcare. January 2017 will see the start of a new effort to pay doctors and hospitals for quality of services instead of quantity. Time and space will not permit description of the details of this new even more complex program. It will suffice simply to point out that in this new concept quality will be determined by even more documentation and reporting to the bureaucracy. It can be predicted with absolute confidence that things are going to get worse.

If lawmakers and bureaucrats with their regulations can't seem to solve the problems of Medicare, what can? The answer is in plain sight and that will be the subject for another time.

The Regulation Firestorm and Medicare

I did my initial medical training in pre-Medicare days. In those days there was the private service and the ward service where patients who could not afford to pay were treated free of charge in open wards by physicians in training under supervision. Medicare started between my internship and my residency. We liked the wards but the fickle patients abandoned us in droves for the private hospitals and experienced doctors. So it was pretty obvious that Medicare filled a need. But Lyndon Johnson and the Democrats had their sights set on a larger target than just helping the needy and so we had a government takeover of medical care for everyone over age 65. Doctors were skeptical but were in the end bought off, and probably did not have the political power to resist in any case.

The Medicare law provides specifically that: "Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine "

What a blatant falsehood this has become! We are hearing a lot these days about the negative effects on the private sector of excessive government regulation and in this regard the healthcare industry tops the list. For medical practice, Medicare has become a regulation nightmare, producing such high cost and complexity as to be rapidly driving doctors from independent practice to salaried jobs with hospitals and large medical conglomerates.

Since seniors use a disproportionately high amount of medical services, and since all their services are governed by Medicare regulations, Medicare is a dominant force in most medical practices. Payment by Medicare for doctor services is through a byzantine system, with multiple different payment levels each requiring detailed documentation of voluminous extraneous material mostly having nothing to do with the problem at hand. And for the past few years all this documentation must be done by complicated highly regulated computer programs costing an average of $30-35 thousand per doctor requiring thousands more each year for maintenance. Moreover compliance requires medical practices to hire added personnel such as billing and coding specialists.

It would be one thing if such regulations produced improvement in patient care, but instead they are making things far worse. In addition to increased cost they are diverting doctor's time to administrative busywork instead of patient care. Medical records have become a mass of bureaucratic jargon, filled with sometimes erroneous material of no importance. Major new regulations are scheduled to start on January 1st supposedly to improve the quality of medical practice. Quality is to be judged by even more documenting and reporting. But this is nonsense. The quality that patients value more than anything else is the time and attention of the doctor.

This regulation firestorm is becoming bizarre, the stuff of Alice in Wonderland and Franz Kafka. Sadly there is no way to characterize it other than government oppression. And it is becoming intolerable to the point that a small but increasing number of doctors are taking the risk to opt out to DPC, direct patient care, which will be a matter for another time.

Trump's plans to change healthcare

Trump plans to repeal and replace Obamacare. We're going to be hearing about a lot of proposed changes in how government interfaces with our medical care so it's good to know the issues.

Since the 1940's medical benefits from employers have been tax exempt. This amounts to a government subsidy of about $295 billion. Although well intentioned there are several problems with this arrangement. Only those who work for a company which provides insurance get the benefit. Also the subsidy is greater if you have a higher income and therefore pay more taxes.

Although we've all come to think of taking part of our employee compensation as medical insurance rather than wages as a good thing, it's really not that great. As previously discussed paying for things by insurance wastes money and restricts choice. We do want insurance for the big, high risk things but why let your employer pick out what you get? And moving from one job to another is always a medical insurance hassle.

The biggest benefit of getting medical insurance through your job instead of as an individual is that you're part of a pool so that the administrative costs for the insurance company are much less and it's a better arrangement for the occasional employee who comes down with a medical problem.

So we're going to hear about changes to address some of these problems. If the government is going to subsidize medical insurance we should all benefit and the subsidy should be distributed more fairly. You should be able to choose from a wide array of insurance types that fit your individual needs and that belongs to you regardless of your employment status.

But buying medical insurance as an individual in the present system is way too expensive, so other changes will be proposed. Permitting insurance pools other than with employers will be one, including any of the whole host of professional, charitable and small business organizations. And if ever the interstate commerce law should apply to anything it should be to medical insurance so as to bypass all the state insurance coverage mandates.  

Besides all that, cheaper high deductible medical insurance looks a lot better when you're buying your own than when it's part of your benefits. But realistically you're paying the bill both ways, so high deductible insurance linked with a health savings account is the way to go. HSA's are a game changing idea, but the above changes in the insurance market are needed for them to work well. More about that another time.

The last problem is the "pre-existing condition" issue. No one wants to sell insurance to someone whose expenses are going to be more than the premiums. In that case it's not insurance it's charity. Obamacare tried to handle this by transferring the costs to the young healthy people. It didn't work. It's a sticky issue. There are several ideas out there about how to handle it. We'll see what the Trump team comes up with.

Health Savings Accounts

We shouldn't be paying for ordinary expected medical items by insurance. It costs more and restricts our choice. We should prefer compensation for our work to be in higher wages rather than in medical insurance and we should ideally have our own insurance that fits our needs and that we don't lose if we change jobs.Trump's administration plans to lower insurance costs by increasing competition across state lines and allowing insurance pools outside of employers. And high deductible insurance that kicks in only when we run into serious problems is much cheaper. But medical prices are high and what do we do when we need that MRI or colonoscopy.

Enter Health Savings Accounts. Basically it's a bank account that you fund periodically and then draw on for medical expenses. One place you get the money is from what is saved from the lower high deductible insurance premiums. What's the point of that, you say. Aren't I coming out the same in the end? Not at all. Because what's in the HSA is your money, that stays in your account if you don't spend it and that builds up over time. So if you decide on getting only what you really think is necessary and shop around for the things you do want and follow good health practices, then the money you save goes to you and not the insurance company.

In addition it's not just a savings account, but it's more like an IRA since the money in the account is tax exempt. And as you accumulate more than you need to pay your medical expenses you can put the rest into something interest bearing like a mutual fund which is also tax exempt. So it's really a better way to save for the future than an IRA because you can take the money out for medical expenses without penalty. And when you do retire you can actually use the money for any purpose without penalty.

The other good thing is that you don't need to worry about restrictions from the insurance company as to how you use the money other than that it has to be used for health related items. There are some government restrictions like you can't use it to pay for the gym or buy toothpaste but generally they're pretty liberal so that for example dental and vision and taxi rides to the doctor visits are fine.

So the smart thing to do is to get your company to set up an HSA, give you a really high deductible medical policy and put the money saved from the lower premiums into the HSA. When you change jobs the HSA, and the money in it, goes with you because it's yours. And if you have to buy your own medical insurance, do the same thing. The banks that offer them usually don't charge you, they keep track of the fund and you get a debit card and a checkbook to make payments from the account. Generally even if you pay a bill with the HSA it's best to pass it through the insurance since you get the discounted price.

Generally the Democrats have been against HSA's and have tried to slow them down because they tend to move us away from a government controlled medical care system. However even though most people are not familiar with HSA's the numbers of people who have them are rapidly growing because it's such a good idea. You'll be hearing much more about them when Trump and his health care team take over.

Is Medical Care a Right. The Negative Side of the Debate

Let me make the crucial point to begin with which is that I believe that we have the moral obligation to provide basic medical care to everybody who needs it and who cannot or will not provide it for himself.

Beyond the moral obligation I believe there is also a practical basis for this from the social standpoint as well. As Mr. Trump says -- we can't have people dying in the street.

Furthermore I believe that the overwhelming majority or our citizens, including the overwhelming majority of my conservative fellow citizens would agree with this statement especially in the practical setting of someone who required help.

I would hope that this would help at least to some extent to dispel the argument that conservatives,  many of whom are highly intelligent and steeped in Judeo-Christian traditions, do not consider medical care a right because of ignorance, greed or lack of compassion.

I will skip over the philosophical argument  that human rights such as those traditionally envisioned by our founders and the philosophers of the Enlightenment were simply freedoms from oppression by the majority and in particular the force of government. These rights are essentially unrestricted except where they impose on similar rights of others. I also understand the argument raised by the socialists of the 30's as encapsulated by FDR's discussion of the four freedoms that an individual cannot be truly free without being free from basic human needs.

The real arguments against calling medical care a basic human right are practical ones, to wit:

The concept has the inherent contradiction that fulfillment of such a right would oblige someone else to provide it, thus imposing on that person's freedom. In addition this right must be fulfilled by material goods and services which are in limited supply and therefore the question arises as to the whether and in what manner this right is to be restricted. But by far the most important practical consideration is how exactly we are to arrange for the enjoyment of this right.

The usual solution for the method of providing this right is for a collective arrangement supervised and regulated by the government. I would say that the main reason that we have not adopted this approach in the U.S. is our deep-rooted skepticism of government activity, not by all, but by a very substantial portion of our citizenry. Time and time again the government in its activities has proved itself to be venal, wasteful and hypocritical. Politicians claiming to be interested in public service are often more interested in self-service. Many government bureaucrats are sincere and hard-working but at the same time inefficient government bureaucracies are notoriously the subject of common humor.

However I think the more important criticism of collective action supervised and regulated by the government is that in society there is no such thing as common purpose and the common good but only individual desires and needs frequently in conflict with each other. Without going into detailed examples or appealing to the great number of authorities who have discussed this subject, the salient point is that it is simply not possible for government to arrange to provide suitably for the individual needs and desires of the individual citizens in the same manner that they would provide for themselves.

I will gloss over the comparative virtues of the market economy vis a vis the centrally planned economy in providing efficiently and appropriately goods and services at the lowest cost except to say that if there ever was a settled argument this is it. One might argue that it is reasonable to accept the waste, inefficiency and progressive regulation of government central control for the sake of equality of outcome. In response to this I will not bother you with the many examples that government control simply shifts the spectrum of those who receive favored treatment. Instead I would argue that the correct approach for the U.S. (which is a substantially different culture from Europe or Australia or Japan, etc) would be to not interfere with the majority who can provide for themselves and limit government involvement to those who cannot or will not make those provisions. In addition government should continue to act as a facilitator of the market to be sure there is no fraudulent activity or inappropriate hindrance of competition.

I understand the argument that some make about the fairness and the undesirability of a two tiered medical system. It is my personal opinion and those of many others that the major adverse tradeoffs inherent in a full centrally controlled system are simply too severe to warrant this purported benefit. I will leave aside any discussion of the fact that no system, especially a government controlled one, exists which does not favor the wealthy and politically connected. More importantly many argue that the efficiencies and substantially lower cost inherent in a market based system would significantly reduce the number of those who would require assistance. Nevertheless I strongly believe that government care limited to those who cannot or will not provide for themselves could easily match the care presently being provided by the advanced countries with centrally controlled systems, especially absent the government's involvement with other segments of our population.

Much of what is wrong in our present  system is due to undue government intervention. Time would be needed to reverse the effects of the unfair government subsidies dispensed to those working for large employers or who have high cost cadillac medical insurance. Other problems to address over time would be the large government benefits to the non-needy elderly, costly restrictions on the availability and type of coverage of medical insurance, restrictions on type of practitioners, extensive price controls, hyperregulation and many other similar problems which add high cost or inefficiency.

In this regard if one wishes to propose medical care as a right, we should address those economic rights which government is presently restricting. Should we not have to right to decide in what manner to purchase medical goods and services, what price to pay, what records are to be kept of interactions, what type of practitioner I can contract with, whether or not to purchase medical insurance and what type it should be. All of these regulations and restrictions have been judged to be legal but many citizens consider them to be abhorrent and oppressive.

I lay all this out not to convince you to my opinion but simply to convince you that there are reasoned alternative arguments. You speak of the right to medical care as if it were a geometric axiom, not to be denied by any rational being, so obviously true as to incite frustration at the obtuseness of your adversary.

The Economic Problems of Medical Care in the U.S.

What should be done to resolve the economic woes of medical care in our country. Unfortunately just repealing Obamacare will not do it. This misguided experiment added insult to injury but the problem is far more fundamental.

Obamacare sought to provide universal medical insurance coverage which completely misses the point of our problem. The development of the concept of insurance as a way of controlling potential risk of economic catastrophe was a great invention (of Genoese merchants in the 14th century) but it is a terrible way of paying for everyday expenses or even untoward events of manageable cost. What sense does it possibly make to purchase an item or service by giving your money to an intermediary who then deducts an administrative cost and profit and then pays your bill at the same time restricting your choice. 

But that's not the worst of it. When you're looking to purchase something you look at the price and if it's more than you can afford you let it go or look for some cheaper acceptable substitute. If you think it's something you need or really want you at least shop around. Sellers on the other hand want the best price they can get, but so do their competitors. So the best way for them to prosper is to figure out a way to offer you what you want at a price you want to pay at least as well as does their competition. . 

Paying by insurance messes that whole system up. Since the insurance company is paying the bill the sky is the limit. Maybe you're not trying to game the system but if something is sitting there on the shelf and you think you might be able to use it, what the heck, it's not costing you anything. If you think about it that deal also works pretty well for the sellers. So in that arrangement the insurance company has to be the bad guy and do the restricting. Of course the company can always raise its premiums but that can get ridiculous and of course they have competitors too. 

But, you tell me, you're not seeing the full picture. You point out that what I haven't considered is that it's your boss's problem since he's paying for the insurance. No,no,no. When you climb the ladder and look at things from his point of view you'll see that you're slaving away every day just as much for your benefits as for your salary. You're the one who's really paying for your medical insurance!

There's way more to this story but let's stop here for now. The bottom line is that we've developed a system of third party payment for medical goods and services that's tremendously inefficient and producing prices that are way too high. It's my educated guess that, depending on the item or service, medical prices are probably anywhere from 50% to 10 times what they would be in a market system in which people pay for things directly. And the high prices make things very difficult for anyone who really does have to pay out of pocket. Our problem is not too little insurance but too much. 

So yes Obamacare has made things worse by insurance coverage mandates but it's not the fundamental problem. Future installments will cover how we got into this insurance mess and the sad ongoing destruction of our country's medical care by the biggest and baddest insurance company of all, Medicare. Here's what I think is the fundamental problem. Progressive efforts to correct the bad results have made it worse.

Trump's Speech in Cincinnati

Trump's speech the other night in Cincinnati was remarkable. Anyone who didn't see it should bring it up on YouTube and give it a look.

He was preceded by Mike Pence who is an appealing guy with normal political oratorical ability and who gave Trump a rousing introduction to a packed very enthusiastic crowd. The contrast when Trump appeared was immediate. His relaxed style of direct communication with his audience is remarkable to watch.  Instead of the expected ceremonial pomp he started right off with joking comments about the problems the attendees had to go through with the security and he maintained that personal tone throughout.

The speech was about 70% teleprompted and the rest extemporaneous and he has an amazing ability to move seamlessly between the two modes. One can really only tell the difference from the content. This is a communicator to the ordinary man and woman who we haven't seen since Reagan. Obama is admittedly a master of prompted delivery but he's not nearly this good all around.

Alec Baldwin had great fun with his Trump imitation on SNL but Trump outdid him by a mile in his long takeoff of the news media predicting his loss and their pained astonishment when he pulled off the win. The speech is worth watching for that part alone. But the real treat was his message of unity and optimism about overcoming the decline which our country has been experiencing for the past few decades in almost any area you can name. It was a spirit that people felt somewhat with Obama's initial oratory, based on which he was given a Nobel prize, but which he totally failed to deliver.

Diehard liberals will of course be repulsed by Trump's display. But those of us, even those on the political fence, who are disappointed by the steadily ongoing American deterioration toward a dim future take some hope from this remarkable guy. He didn't have to take on this task. In fact it's hard to imagine a motivation for a 70 year old, who I can assure you is starting to see his life as a very finite quantity, other than a sincere vision that this country needs to be turned around and the self confidence that he can do it.

Strict conservatives have opposed the Trump phenomenon as well. They want a minimalist constitutional government with a President who understands his limited role and not a larger than life personality. We will have our checks and balances but especially in bad times our country has always prospered best when great leaders have emerged, starting right from George Washington. Trump may prove to be such a person. He's been a big winner so far.

Things May Be Looking Up for Healthcare

I like to distinguish between "health care" and "medical care". Health care is often a personal behavior matter and from that standpoint much of it is free. Following a sensible diet, staying physically active, getting adequate rest, good hygiene, avoiding tobacco, excessive alcohol and other intoxicants cost nothing and these practices go a long way toward maintaining health and extending life. Medical care, on the other hand, is not free. Doctors, nurses, hospitals, drugs and medical tests and devices must be paid for. How is it that we've been led to buy into the concept that when it comes to getting medical care we needn't bother our heads about the cost. Someone else will pay the bill.

It isn't true! It's us who pay the bill. Who else is there really? And the system we use for payment makes the costs go way up so we pay way more than we should and besides that it restricts our choices, reduces the quality of services and stifles innovation.

Here are some interesting facts. A study done in 2013 revealed that in that year government (that is, U.S. taxpayers) funded 64.3% of medical care expenses and rising. In Canada by comparison the figure was 71%. In 2015 medical expenses took up 17.5% of GDP and this is forecasted to rise to 20% by 2025. That's a fifth of what we earn going just to medical payments. Medical costs continue to rise faster than the GDP. Medicare is 20% of the overall costs and is rising the fastest, even though Medicare controls the prices of every medical service and product that it funds.

Obamacare tried to address the disparities in our system by mandating that everyone have medical insurance and mandating what it must cover. This approach did not lower prices, it increased them. Prices for medical goods and services in our third party payment system are way higher than they would be in a market based system. Moreover usually neither patients nor providers know the prices. This situation is threatening to everybody's financial welfare but is especially problematical for those who are out of the system and must pay the grossly inflated prices out of pocket.

All of these data and economic concepts are well known to medical economic experts but have been discounted by healthcare planners in the Obama administration who have favored increasing government control for solutions.

In my 50 years in medicine I had never seen the morale among my colleagues lower nor the future for medical care looking bleaker. The changes since the recent election have brought me a sense of cautious optimism. Trump has appointed Dr. Tom Price, physician and U.S. Representative from Georgia, as head of HHS (Department of Health and Human Services) and Seema Verma, a medical economic expert formerly serving under Indiana Governor Pence, who will run CMS (Center for Medicare and Medicaid Services). Both of these individuals fully understand the principles described above and are determined to carry out changes accordingly. This will be no easy task and must be done carefully so as not to cause disruption to those who have been accommodated to our present system despite its serious flaws.

The problems of medical care in the United States

As the question of what to do about Obamacare heats up we're going to hear a lot about medical care in our country. I'm going to do a few posts on the subject. As usual I have some controversial opinions but I can't be accused of being uninformed since I know the system well from the inside and from many aspects. Early in my career I spent almost 10 years working in a county clinic in California, seeing indigent patients. Then there were 36 years in solo private practice. Along the way there were stints as a doctor in the army and in the VA system. I even was Scranton's city doctor for a year or two. At present I'm spending some time in the free clinic at the U of S seeing "undocumented" patients. 

I received my training in the pre-Medicare days and observed the transition to the program between my internship and first year of residency. So I've witnessed the full extent of the slow and steady impact of government invasion of our medical care.

The critics of our system say that we're spending twice as much on medical care as the other advanced countries but not getting as much in return. I disagree with the assessment of what we're getting but you'll get no argument from me about the present state of medical care in our country. Medical prices are way too high generally and the way they impact different segments of the population is totally irrational. Medical care delivery has become ridiculously complex and is restrained by our system from serving the public efficiently. 

Some say that the solution is to let the government take over. That is a bizarre idea. To paraphrase the sainted Ronald Reagan, the government is not the solution to the problem, it is the problem. Most people don't realize that government at one level or another already pays for 65% of medical care in our country as opposed to 75% in Canada. Government control is not a way to save money or improve efficiency. 

In the last few years we have been watching the dismantling of small independent medical practice at an accelerating rate. It is now down in the 35% range. Solo medical practitioners are almost a thing of the past. One recent commentary by a health care planner points to the natural trend toward consolidation in other areas of our economy. But what's going on in medicine is not a natural phenomenon. It is rather the result of a grand experiment by the federal agency that controls medical care in our country, the CMS. And it is a tragedy, not so much for doctors, who will get along, but for patient care. I read an article recently encouraging doctors to face their computer screen toward the patient and glance over the top occasionally to maintain eye contact. How pathetic!

Public/private partnership. How the government works.

By almost any measure our economy continues to stagnate, eight years after the bursting of the housing bubble. GDP is 1-2%, labor participation rate is at an all time low, average income is declining and the Federal Reserve has been laboring mightily to keep things afloat by zero interest rates and flooding the money supply.

The keystone of Mrs Clinton's plan to address our troubled economy is to build a "public/private partnership which will make the biggest investment in good-paying jobs since World War II". Public/private partnership -  fine sounding words but what exactly do they mean? I think the idea here is that the really smart people in government know what the public needs and the big business guys know how to make and do things so getting the two together would make everything hunky-dory. However, it sounds to me like something we already have a lot of, what many critics are calling crony capitalism.

What exactly is this government thing that we speak of in the abstract. Leaving aside the judiciary, it's pretty much just a collection of politicians and bureaucrats, and just like you and I each of them are trying to make out as best they can and live as pleasantly as possible. And if you follow the money they're doing pretty well considering that 5 of the 10 richest counties in the U.S. are collected in the Washington, DC area.

These government people refer to themselves as public servants, but just what do these servants of ours do for us and how have they gotten so much wealthier than their masters. Well they do have meetings, give speeches and run agencies so they must have salaries and benefits for that like everybody else but that would hardly make you so much richer than the rest of us. Of course their company is pretty generous seeing that it prints and borrows money without a lot of fuss and has a very efficient collection agency. But the real key to their success is the other thing they do, passing a lot of laws and regulations, most of them having to do with collecting money and doling it out again. And that's where the "public/private partnership" comes in. Controlling tax laws, mandatory regulations and handing out government contracts makes you really popular with the big boys and is the key to figuring out why it costs a hundred million dollars to run for a job that pays a couple of hundred thousand.

Perhaps my cynical view of the federal government comes from watching its steady destruction through the years, now accelerating, of medical practice.  On the other hand what with the pervasive video cameras and hackers it's getting to be difficult to keep secrets in this modern era so that my attitude seems more justified every day.  Perhaps I shouldn't just accuse Mrs. Clinton since both parties are up to their necks in this muck. But she and Mr. Clinton seem to be world class experts at this game and will do everything they can to keep it going. Mr. Trump is a bit of an unknown quantity but he's got some good friends advising him, doesn't have a lot of political obligations and seems like the best chance we've had for a shakeup in a long time.

Is Iraq another Vietnam

I was thinking a lot last night about Iraq and Vietnam. Those of us who are even nominally Republican have to admit that George Bush blew it in the Iraq invasion and initial management of the war. It was not the right response to destroy the jihad that brought us the horrors of September 11^th, 2001. He was badly advised by Rumsfeld and even Cheney. He later made the pretty courageous decision to go with a military surge under General Petraeus and wound up leaving Iraq in stable condition with tenuous but hopeful prospects. At the time of the full troop withdrawal in 2011 Obama labeled Iraq as "sovereign, stable and self-reliant". After the withdrawal, the jihadists reemerged to fill the vacuum and we all know the rest. Now we are back in with 5000 "advisers", without any Status of Forces Agreement, and with war raging.

For those of us old enough to have participated in the social unrest of the Vietnam War era this situation has an eerie ring.  The few thousand troops initially sent by Kennedy were "advisers" also, meant only to help the South Vietnamese government defeat its enemy on its own. Johnson took over after Kennedy's death and then swamped Goldwater in 1964 in an election in which television ads convinced the public that the Republican was a warmonger who would lead us into a nuclear holocaust. But when things turned bad for the South Vietnamese it was the Democrat who converted it to an American war and escalated it. The U.S. superpower, whose leaders fought with politics in mind and an unengaged public, was defeated by a badly outgunned but highly ideologically motivated enemy.  The defeat was a destructive humiliation for our country and a disaster for the people of southeast Asia.

President Obama came to office as a peacemaker, and was even awarded the Nobel Peace Prize on the strength of his oratory. He gave conciliatory speeches in the United Nations, tried a Russian reset, withdrew our planned missile defense sites from eastern Europe and whispered to Medvedev to reassure Vladimir that he would be more flexible after his reelection. But peace has not come to the Middle East, with virtually every country worse than it was, Iran on the ascendency, not to mention Russia, China and North Korea. Candidate Clinton was part of these events and seems likely to continue on in this vein. If anything she seems more bellicose than does Trump. He has promised to fight ISIS with vigor and to strengthen our military but otherwise seems less inclined to engage in military entanglements. He expresses a preference to get along with the Russians rather than to accuse and threaten them.

As I said what's happening in the Middle East today smells a little like what was going on in Vietnam during the 60's. I hope for our sake that I'm wrong.

Clinton's economic ideas

The recent debate clarified the candidate's economic policies, Clinton's somewhat more than Trump's I think, and presented a sharp contrast. President Obama inherited an economic crisis after the bursting of the housing bubble but after 8 years of his presidency the country's economy remains troublesome, a 1% growth rate, a fair employment rate but a very low labor participation rate, stagnant salaries, a nearly $20 trillion debt and interest rates continuing to be kept artif...icially low.

Clinton presented her plan which featured major new entitlements such as free college tuition for most families, pushing renewable energy over fossil fuels with subsidies, a major new government jobs program, a mandated universal increase in the minimum wage and keeping and refining Obamacare. All of this would be paid for by "asking" those who have benefitted most to pay their fair share, that is major new taxes on high income earners. Each of these proposals would be economic poison, likely to stifle the economy and further decrease employment.

For lack of space let's just talk about taxing the rich, a nice sounding something for nothing proposal, sort of like getting comped at the casino. It should be pointed out that as of the most recent figures the top 10% of income earners pay 70% of all income taxes, up progressively since 1986 when it was 54% (http://money.cnn.com/…/12/news/economy/rich-taxes/index.html) so exactly what is the fair share that Clinton will decide on. I suspect that her ax won't fall so heavily on the Wall Streeters who paid $250K for a ½ hour speech, or the Silicon Valley fat cats who paid $50K a plate for her company. So don't be surprised if most of the rest of us in the casino will be included in the fair share.

However the real problem with raising taxes is what economists call the deadweight effect. Raising taxes to high levels incentivizes actions designed to reduce taxable income and the net effect is to decrease market activity and reduce employment. As pointed out by Arthur Laffer in 1974 this effect may actually reach the point of diminishing returns. Famously the major tax rate reductions instituted by Ronald Reagan were followed by a marked surge in the economy and increased tax revenues. It is money in the hands of private enterprise and not government programs that makes all of us better off.

Reagan was great at explaining this phenomenon to the public. Trump is not, although he did make the point strongly that the major economic problems of our entitlement programs of Social Security and Medicare which are linked to our colossal debt would disappear with a change in our GDP from the present anemic 1% to his predicted 4%, similar to our performance in the past.

Probably the most succinct explanation I've heard was given in a short speech by President John Kennedy in 1962 as he explained to the American people the reason for his proposed major tax reduction. Here's the link and it's worth watching.

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Trump vs Clinton. Bimbo Eruption, Wiki-Leaks and Deleted Emails.

Trump is having his bimbo eruption. He categorically denies the whole thing, but so did Bill Clinton until he was foiled by dress stains. The Democrat's outrage seems ideological since they find Trump's behavior deplorable but Clinton's was just a little personal problem and he remains as popular with them as ever. Hillary's well documented role in smearing the reputation of Bill's victims is pushed aside.

Meanwhile the Wiki-Leaks keep rolling out, giving us direct evidence ...confirming what everybody already knew, that there is ongoing collusion between the Clinton camp, the Obama administration, most especially the State Department and the Justice Department, and the major news media. When asked to explain the contents of the emails the Clintonistas respond that the Russians did it. That one is right up there with the dog ate my homework.

However things don't look great for the Trumpster. When you look at him he does seem to have a pretty big mouth. I think it's been stretched from putting his foot in it so much. Two things might intervene to change the trajectory. He could have a bang-up third debate. He seemed to have gotten the hang of it in the second one. Chris Wallace, who will be the moderator has a well-known history of asking tough questions to all concerned, but at least he'll be even-handed so that Trump won't be facing two opponents.

Another possible Hail Mary would be the release of the actual deleted Hillary emails since it seems pretty likely that they contain some bombshells. Going to the trouble of wiping them out permanently in the face of a subpoena and FBI investigation amounted to obstruction of justice so they must have contained something pretty important for her and her staff and lawyers to have decided to take that risk. If they were actually to surface it could be a game changer.

James Comey kept his investigation narrowly focused on the question of handling classified information. So the email deletion issue has not been adjudicated. Whether it will be in the future makes the outcome of the election particularly important for her, as Trump has already pointed out. If she wins she will have gotten away with it, even if the Senate stays Republican, since it seems clear that a great many Republicans are pretty comfortable with the established way of doing things.

Trump the lecher and Hillary the elitist

In this day and age there are no secrets, especially for the high and mighty. Yesterday it was revealed from secret recordings that Trump is (or at least was) a lecher and Hillary is two-faced.

Let's take Trump first. There is a reason why women, even waitresses, and even underage males are not wanted in the men's lounge at our golf club. Not all men talk like Trump's recorded conversation reveals but a great many do, and most do it a little bit. If a well-endowed female sports commentator appears on the TV screen in the men's lounge very little discussion will be devoted to what she actually says. I haven't the slightest doubt that many liberal icons including John Kennedy, Lyndon Johnson and Bill Clinton spoke exactly so in private. Very few men are seriously offended by this type of talk although you can bet that every politician will now claim to be. Some occasional straight shooters, such as Mitt Romney, really are and I have felt that Trump's crudeness is the real basis for Romney's antipathy.

Hillary's fault is definitely not licentiousness. She is revealed to have a sense of personal elitism. She feels that those like her who lead, as she puts it, a complicated life, have little in common with what H.L. Mencken used to call "the booboisie". Thus the person behind closed doors with her wealthy friends is quite different from the face presented to the general public. What she is in reality is anybody's guess, but it isn't at all hard to believe the numerous underground stories from the white house staff and secret service about her haughty disdainful attitude and frequent use of coarse language. Her understandable intense efforts at maintaining secrecy however are presently being foiled by today's pervasive computer hacking and it will be interesting to see what's coming next.

All this being said, I don't think many voter's minds are going to be changed by yesterday's revelations primarily because so many are voting not so much for someone as against the other. Or more precisely for or against policies. I'm for what Trump proposes that his administration will do and dead set against Hillary's plans so I will dutifully pull the Trump lever.

 

Is it Racist to Eat Skittles? Who's More Racist, Trump, Jr. or Barack Obama

The intense focus on race in this country generated by the liberals is really beginning to annoy me. The Donald Trump Jr - Skittles controversy is the latest example.

Donald Junior was making an analogy about the Syrian refugee problem. We feel sympathy for Syrian refugees but ISIS has told us that they intend to infiltrate their number with terrorists and our own government counterterrorist experts have advised us that they are not capable of accurately vetting the refugees. So DT junior likens this situation to being offered a bowl of candies, in which we are told 2 or 3 have been laced with a lethal poison. What fool would take a handful because they looked so good.

Donald Jr is being accused of racism because he's belittling the Syrians. No he's not! He's presenting us with a simple analogy that is trying to clarify the argument. If you disagree with the analogy give your counterarguments but to try to obscure the issue by a charge of racism is as I said annoying. I'd like to use stronger words but I really don't want to offend any of my friends who might be buying into this.

Meanwhile Barack Obama gives a speech to the Congressional Black Caucus telling them that not working to support Hillary would be a personal insult to him. That is not in itself a racist statement but in the context in which it was given it certainly is. And yet I see no criticism in the papers about what seems to be his overt racism.

Personally I'm a strong believer in the founding principles of our country that all men are created equal and in the idea expounded by Martin Luther King that a man should be judged by the content of his character rather than the color of his skin. And it is annoying as hell to be accused of racism if you believe that the government should do it's job and police our borders so that we know who's coming into our country and for what purpose.

Politics They Are A-Changing

So much to talk about but Trump grabs the attention again. I watched his speech presenting his child care plan last evening. It was reported that it wasn't shown on CNN or MSNBC but those who missed it should take a look on YouTube because it is surprising. Trump is presenting himself as the friend of the common man, something like Obama did in 2008 whereas Hillary has taken on the divider role as Romney did with his 47% gaffe in 2012.

Of course the visceral Trump haters will be strident critics, but his new entitlement proposal is also not going to be well received by the conservative intellectuals. For those of you of the liberal bent who do not look at sites like National Review or Wall Street Journal I can testify that you have many friends in those high places who dislike and denounce Trump as much as you do and are trying their best to see that he does not win. I am not as much in touch with the liberal side but, judging from the Bernie supporters who we saw during the primaries, there is at least a small percent who will not support HRC.

And yet, according to the polls, the race is close. Hillary of course has her coalition, minorities, academics, media and entertainment people, etc. But who is supporting Trump, if not standard Republicans? Let us discount out of hand the absurd contention of Hillary and Obama that he has collected all the haters in the country under his banner. That is ridiculous and insulting in the extreme. Judging by personal, anecdotal experience he's appealing to a lot of just plain regular people who are generally more interested in their personal lives than in politics and in fact are disgusted with what's going on in Washington. Some of them, if they voted at all, might have voted Democrat.

This election is unusual to say the least. It definitely is breaking up the old thought patterns in which one could tell a person's opinion down the line on every issue simply by knowing his political party. To my mind that's all to the good.

The Insanity of Third-party Payment for Medical Services

I recently got billed from a local lab for a PSA test for $90+. I had the test done in August since I was getting blood drawn for other blood work. Medicare disapproved it because it was a month early (usually get it around my birthday in September). My wife said I should have known better. So I forgot to say "Mother, may I" and got my hand slapped.
The Medicare reimbursment for this test (i,e, what the lab would ha...ve gotten if I had done it in September) is ~ $25. Having run a little office lab for a few years when we had a 4 doctor group, I can assure everyone that one can make a profit with Medicare reimbursement, even with a little office lab running very part time.
Let me say that I don't consider the lab to be the culprit here. Like every other medical provider their fees are set by insurance reimbursement rather than their cost of doing business and their competition. (This particular lab provides a substantial screening lab package for uninsured patients for a very reasonable price and we send our free clinic patients there to take advantage of it.)
The fee is set to capture the highest insurer reimbursement. The overwhelming majority of their customers are insured and are concerned only about their co-pays and deductables, so the only ones who are discomfited are the uninsured or the bumblers like myself.
There's tremendous more to say about the insanity of our third party payment system in medical care but I'd like to keep it short. Let me just make the point that, if the standard way to pay for this test was directly out of pocket, the price to the consumer would be much, much lower than the Medicare reimbursement and in fact most likely much lower than many present-day insurance co-pays. Furthermore we could have the test done at our convenience without having to say "Mother, may I."
I'd love to have a discussion about this general subject. The public needs to be informed about why medical costs are high and increasing and at the same time why responsiveness to public demand is so limited.

Italy and the Terramoto

The "terramoto" is an old and devastating problem in central and southern Italy. From what I read a fault between Europe and Africa runs right down the Italian spine and is responsible for the formation of the Appenines.

A book I'm reading now, "The Italian Emigration of our Times" by Robert Foerster from the Harvard sociology department and published in 1919 (so 13 years after my dad came over), states:

"To indicate (by way of example) the recent earthquakes of Calabria alone: those of 1854, 1870, 1894, 1905, 1907 and, worst of all, 1908, accomplished a disheartening round of destruction of life and property. Today, ten years after the demolition of Messina, the city, its little wooden suburb notwithstanding, still is a pile of ruins"

I was actually in Italy at the time of the earthquake in 1997 and saw the ruins of the Basilica of Santo Francesco in Assisi. It was very discouraging for my family.

Dr Foerster adds:

"The general destruction of capital is pervasive. Of all consequences however the most serious is probably psychological, the creation of a mood of helplessness, or even worse, of apathy, restraining at once the. impulse to progress and the energies needed for accomplishment."

He counted it as one of the many reasons responsible for the diaspora of the Italian peasants or the late 19th and early 20th centuries.

The destruction is particularly frightful in buildings which are very old and constructed of stone. As I learned when I lived in San Francisco (named of course after the same wonderful man as was the Basilica) most of destruction of the 1906 earthquake was caused by fire. It was only the few brick structures in the downtown that collapsed, whereas the great majority of wooden buildings were flexible and stood through the shake only to be destroyed in the great fire that followed.

Here is a photo of the house where my father was born in 1904, in Palazzo d'Assisi, Italy. Most of the damage to La Casa Vecchia as we refer to it was caused by earthquake.

Trending in Retail Sales

I ordered something on Amazon which was by an outside provider which gave free shipping. It got sent by DHL which is apparently a German company which picks up packages locally and delivers them to USPS. It cuts the price of shipping down.

The retail market looks to me to be moving rapidly toward internet purchase with home delivery. My order was for tape that I use to prevent blisters when I golf. I was getting it at KMart but I got it online cheaper with home delivery. I just had to wait 3 or 4 days but that wasn't a problem.

So we went from everyone living on farms and buying what they needed at the general store, to mail order delivered by Sears and Montgomery Ward, to people herding from farms into cities and going to A&P's and Woolworths, and then as we got more mobile moving to suburbs and going to malls, and then going to Wal-Mart superstores with everything under one roof and now shopping on-line with delivery. It's fascinating. The big winners are those who can anticipate how society is going to move. I wonder where we're going next. Anyone know?

 

Unfortunate present state of Chicago

Recently we spent a few days in Chicago visiting my son and his great family. Here's a photo with Luke, one of their 3 kids. He has a few disabilities but thankfully great parents and siblings who are helping him reach his maximum potential. He is truly lovable and making steady progress.

The photo was taken at the Chicago Conservatory, a spectacular botanical collection housed in a gargantuan greenhouse. Well worth seeing when visiting Chicago.
Unfortunately this great city is having it problems. While we were there the major media focus was on a black teenager killed by the police. What wasn't being mentioned, but what all the residents know about, is the deteriorating financial situation and the horrific violent crime going on in the south and west sides. My kids tell me that no one would intentionally drive on any side street in any of these neighborhoods, even in the daytime with the doors and windows locked.
Deterioration is what seems to be happening in most of the big cities in the Northeast and Midwest. A few years back we tried to travel down memory lane when we were in Philly, where I went to med school. We tried to go to the student apartment building where we lived, which was in the ghetto, but not very dangerous. Emily walked the streets, in the daytime at least, without fear. The neighborhood was now so obviously hazardous that we did not dare to go to our destination.
President Johnson's war on poverty, started over 50 years ago, does not seem to have succeeded very well.

Direct Patient Care - then New-Old type of Medical Practice

I saw an interesting new website, jointhewedge.com. It's trying to develop a listing of doctors accross the country who are joining the growing movement of direct patient care - essentially a cash based practice. Although still small in number increasingly doctors are considering this difficult step as the only way of getting out from under the oppressive thumb of the so called health care planners who are destroying medical practice and patient care in the face of all common sense.

This is medical care on the old model which existed when I started, infinitely better than what we've got today. I'm not talking about all the new technological development which has been amazing, but the essence of the doctor-patient relationship.

These days more patients with high deductables and health savings accounts are looking for doctors whose fees are more affordable and comprehensable, and at the same time who will provide more time and personal attention to their concerns. This is the point of the website.

I hope I get some pushback on this comment since it's an important subject which is likely to be increasingly common as the government introduces even more new drastic regulations and changes to medical practice.

Who's interfering in our politics?

It's a tempest in a teapot, but I'm struck by the irony of commentators decrying the idea of Russia interfering in our political process by releasing the DNC's embarrassing emails. Well somehow Hillary's Russian reset didn't work and President Obama's whispered reassurance to Vladimir never really clicked. So we can't really control what the Russian's do. But isn't the real issue that one of our major parties was the one egregiously interfering in our political process by secretly working against one of its candidates?

Ron Blustein's Well Tempered Clavier Synthesizer

An old friend of mine just surfaced, Ron Blustein. We were friends from residency days in the late 60's at SF General. In those days a bunch of us collected most nights at our house in the Mission District to listen to and make music.
Ron is a musical prodigy. He could pick up almost any instrument and play it with proficiency. Back then Indian music was all the rage. Ron got a sitar from somewhere and played it like Ravi Shankar. He could do anything.
We lost contact for t...he most part but Ron through the years has turned composer. He's done all sorts of stuff which can be played on a synthesizer, but most notably he has done a collection of 24 preludes and fugues in every key that are astounding to me. Of course famously Bach started this with the Well Tempered Clavier, but Chopin and Shostakovich also did it and now Blustein! Of course Bach did it twice.
For anyone interested I added a link to a sample.

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Hillary is not the problem. It is the Democrats!

I wouldn't call Hillary dangerous and sinister as the Dems are referring to Trump. It's more that she is consumed by ambition and will go to any length to achieve her goal. And like her boss, Obama  I think she is smart enough but incompetent. But Hillary is not the problem for me, it is the modern Democrat party which has embraced big government.
I agree with our founder's idea of government as a necessity which must be kept limited. You think government is compassionate? It is not. It is collection of politicians and bureaucrats, each with their own interests. It is for the most part impersonal, inhumane and wasteful.

We all have our own experiences but I have seen what government can do from the inside. I started in medicine just before Medicare and have watched the whole sorry mess develop, decade by decade. Government regulation and policy has virtually destroyed medical practice. Don't think that this is just your doctor's problem. If you're concerned about the high cost, inefficiency and maldistribution of medical care look to the government takeover.
For those of you who think that doctors are dropping Medicare because of greed, think again. It's not an easy decision to let go of a large portion of your paying customers. It's what you have to do to get paid that's the problem. For those of you who don't care to have your doctor sitting in front of a computer entering data instead of taking the time to listen to you, join the club. Your doctor hates it too.
Now I'm not against regulation per se. Life without it would be chaos. But what we've got now has gone far, far beyond all common sense. So for those who are satisfied with the government's fingers in every part of your life, and want more of it in the future, and want to give your hard earned money to pay for it to boot, vote for Hillary. For my part I'll take a chance on Trump. He isn't your standard politician and that's fine with me.

Trump, the Emails and the Russians

The Democrats are telling us to pay no attention to the DNC's hacked emails. The important thing is that the Russians did it.

Yesterday Trump joked that since the Russians are hacking things that they might be able to supply us with Hillary's deleted emails. The Democrats and the media were aghast. I heard one accuse him of treason.

You see when they asked Hillary to turn in her emails she didn't want to bother everyone with silly stuff about Chelsea's wedding and her yoga classes, so she deleted a whole bunch of that personal business. But she didn't delete her emails like you and I would by pressing the delete button. She got rid of them so that even the FBI forensic experts couldn't retreive them.

So some of us are curious about what other little things were in those emails. If the Russians really hacked her servers then they have those emails and us Americans don't. I don't think it's really treason to ask the Russians that if they have the emails to share them with us. That's only fair.

The liberal news media might give us their spin on the story, but I think the regular guys and gals are going to figure this one out.

Let's Make a Deal. The Terror Watch List and the No Fly List.

Trump apparantly is going to meet with the NRA about selling guns to those on the Terror Watch List or the No Fly List. This will be an interesting test of his deal making ability.

The NRA has stated emphatically that it opposes selling guns to terrorists. Who in their right mind wouldn't have that same opinion. Obama and Clinton love to beat that straw horse as if the 2nd amendment supporters want terrorists to have guns.

 

The problem is in the details. I looked up the No Fly List on Wikipedia and the article is full of Kafkaesque stories about people being mistakenly on the list who didn't know they were on it, were unable to find out why they were on it, and had to go through all sorts of hoops to get off it. The ACLU has won lawsuits against it. The Orlando shooter was on it but was taken off it in 2013 so was able to buy his guns. How did this failure happen. I'm sure it's not that easy but do we just say it can't be helped?

 

So what about these lists. How do you get on them? How do you know if you're on them and why? If there's a mistake how do you get off them? It seems to me that in this era of jihadists going after "soft targets" the general public has to get involved. In our society we can't criminalize someone who hasn't yet committed a crime or for speech or beliefs but we should be able to know who among us is sympathetic to the jihadists so we can keep an eye on them.

 

So instead of the President and Hillary angrily berating their political opponents about their supposed callousness, why didn't they use their time in office to address these problems and work out a "deal" that everyone can agree about. It'll be interesting to see what Trump comes up with.

Trump and Pocahontas

So some liberal Indians and the RINO's think "Pocahontas" is an insult. No Dummies, Pocahontas is an early American legend. Trump OBVIOUSLY is using the term as shorthand to remind us that Lizzie claimed she was a minority to gain status and that Harvard publicized her claim to proved they had a "diverse" faculty. Trump is not putting down Indians, he's if anything respecting them by calling out a fraudulent claim to be one.

ANYTHING Trump says will be construed as racist by the liberals. Republicans should not be buying into their racist cant. SHAME on Mitt Romney and his friends. I used to think he was a nice man, but he has a screw loose in his brain.

Trump's Opinion about Gonzalo Curiel is not Racism

Trump is saying that Curiel has personal animosity for him based on his widely known political stance regarding illegal immigration.

He has this opinion based on his impression that the rulings by the judge against him are not reasonable based on the facts of the case. His description of the facts of the case are obviously one-sided but if they are as described by Trump one would wonder what justifies continuing the trial. Trump feels that the judge does not like him personally and that the obvious reason has to do with the judge's own political leanings.

The fact that these arguments have to do with opinions and feelings about illegal immigration is not "racism". If anything one might say that Judge Curiel is being accused of this fault. But that also would be untrue since his personal feelings would be based on Trump's political policy regarding illegal immigration rather than racial prejudice.

What is the truth in this matter? We know Trump's opinion since he expresses it forthrightly, political correctness be damned. It is high time that the press interviewed Judge Curiel to ask him expressly whether he has personal animosity against Trump based on his political policies. If so he should remove himself from the case.

The accusation of "racism" is a cancer in this country that must be eliminated. It is clear as day that the circumstances here do not justify making it a racial issue. (Why are we making "Hispanic" a race anyway --- it isn't one). The Democrats jump to the epithet. It is their stock in trade. But even Trump's supporters are aghast. It is like an electrified third rail. The press talks of nothing else and immediately make the "racist" assumption. How Trump can break through this argument and turn it around will take all his political skill. Simply ignoring the matter will leave it to fester. It will be interesting to see if he can do it.

In Support of Trump

Trump is giving us the big picture of what he'd like to do. Finally, finally get illegal immigration controlled. Restore American strength and respect. Change foreign policy by realigning our relations with friends and antagonists, and resetting policy on use of our military. Diplomatic agreements must be straightforward and generally agreeable to our citizenry. Work on trade policy - yes we want free trade but all must abide by the rules. These are all sensible goals and perfectly appropriate executive functions in accordance with our constitution. His track record in business, tough but practical with many international ventures suggest that he has the ability to be successful in many of these efforts. He certainly has far more experience and proven ability in making agreements than B.O. or Hillary or Cruz.
His domestic ideas are reasonable and would be largely acceptable to the citizenry. His big concerns are our debt and the stagnant, failing economic plight of the middle class. He approaches this by a strong emphasis on jobs and not income redistribution. Yes, he does not rail against big government but nothing in his statements suggest an emphasis on the federal government as a panacea but clearly he favors the private sector. His policy prescriptions are not detailed, although his policy speeches so far are well within the range of acceptability. Those who want detailed domestic policies are forgetting that our constitution relegates that function primarily to congress. We have Paul Ryan who is well positioned to restore the proper balance. Trump expresses his desire to work with congress and his business record gives every indication that he would do so. Cruz, on the other hand, has proved himself in his relations with others to be ideological, inflexible and antagonistic to those whose cooperation he needs.
Trump has given us his ideas on who his supreme court nominees would be and these should be very acceptable to conservatives and constitutionalists. He states that he will reveal a list of names from which he will select his nominees before the election.
What is it exactly that makes Trump so bitterly opposed by the majority of intellectual conservatives. Is it his lack of ideological purity or his brash, impolite and politically incorrect mannerisms? These qualities actually make him appealing to many in our present day free-wheeling society. But are these reasons so cogent that they would accept a third term of far left liberal policies and multiple liberal supreme court picks. Do they fear that Trump will lose? I don't foresee that but even so there was no similar reaction to Dole, McCain or Romney. But that reason makes no sense if they would prefer to accept Hillary over the primary voter's chosen candidate.
Personally I think it is a herd mentality among an intellectual group who all know, communicate and socialize with each other, similar to what goes on among liberals in NYC or SF.

Treatment of Condolezza Rice demonstrates liberal hypocricy

Saw Condolezza Rice this weekend playing at the Pro-Am at Pebble Beach. The way that this highly intelligent, almost unbelievably accomplished lady who rose from real poverty was castigated by liberals is proof positive that liberals are not really interested in the welfare of either women or minorities but only in the promotion of liberal ideology. Sorry folks but you can't explain it any other way.