Medicare For All Can't Be Done

As a 15 year Medicare beneficiary I can testify to its appeal. With standard Medicare and a supplemental plan one shows his card and by and large that's it. From then on you get high tech care with no direct cost, extremely wide availability of providers and very timely services. The out of pocket costs for the coverage are heavily subsidized and therefore affordable. I don't think any other national plan I have heard of matches it, and I have friends in various countries around the world whom I have quizzed about their circumstances. Once a month I get documentation from CMS showing me the services I have received, the usually grossly exorbitant prices I was charged and  the markedly lower payments that Medicare has approved, assuring me that I have been protected from the storm. Beneficiaries accept the present level of services as they stand and have little appreciation for the waste and inefficiency built into the system. 

What politician of either party worth his salt wouldn't salivate at the thought of providing this benefit to all his constituents. The reason we don't have Medicare 4 All today is that it can't be done. If it could be we would have had it long ago. But the politicians have a big problem. The Medicare system we have now, with all its gross ignoring of the basic laws of economics, is hurtling toward fiscal destruction. The CMS bureaucrats are flopping around like fish in a net trying to discover some new method of service delivery, risk shifting or management technique which would allow them to realize their vision of central control nirvana. 

There is no possible way that Medicare as presently delivered to the seniors can be extended to everyone and they know it. Any attempt would involve unacceptable increases in taxation, as well as major cuts in the availability and quality of providers and services. This would especially be the case if the thing was done wholesale as its proponents advocate so that people could still recall what they formerly had. 

So I think there is time. And as the foundation of our present overall system continues to crumble I think the best idea is to continue widespread efforts to provide working alternative examples of medical care without third party interference, and to vigorously promote and extend the opportunity for individual saving for future medical expenses through HSA's. I greatly fault the Republican legislature for falling down on this end while they had the opportunity. 

The Argument over President Trump

The election of Donald Trump was a shock, both to his enemies and supporters, in the main because we had been led to believe by the major media and pollsters that Hillary's victory was a foregone conclusion. Immediately after the election, efforts began to reverse the result by recounts, attempts to change the votes of the electoral college and calls for impeachment. Failing that, collusion with "The Russians" became the new battle cry, somewhat ironic in that President Obama was overheard whispering to Vladimir that he would be more flexible after his election and generally placated Russia in multiple policy decisions.

 

Those of us who voted for Trump did not do so because of his moral virtue. We had tried this with Mitt Romney, a squeaky clean goody-goody whom the Democrats and media turned into a haughty aristocrat who mistreated animals and held women in disdain. We wanted Trump because he promised in his many campaign policy pronouncements to end the decades long slide of our federal government into a self-serving oligarchy with the concurrence of both political parties. The ideas and opinions of the east and west coast metropolitan areas were dominant and the concerns of the rest of us deplorables were being held in contempt.

 

In less than 2 years the President has more than fulfilled the expectations of his supporters on many levels. This is partly due to his governing style. He has been skillfully able to use tools that were unavailable to his predecessors, social media and other means, to communicate directly with the public, over the heads of an overtly hostile major media cabal. But his enemies are powerful, wily and relentless.

 

Evidence a special prosecutor investigation, purportedly for the purpose of identifying Russian interference in the 2016 election and now gone far afield to the point where it is unmasked as an effort whose obvious aim is to bring down the President. There seems to be little interest in the strong evidence that leading members of our own government's intelligence community themselves consorted to interfere in the election, exonerating Mrs. Clinton and seeking to undermine the Trump campaign.

 

What's going on now is very reminiscent of the attempt of the Republicans in the 90's to bring down Bill Clinton. That impeachment did not work out well, and Clinton was reelected handily. However Trump's sins pale in comparison with Clinton's. Although not the stated issue of his impeachment Clinton was credibly accused of rape and unwanted genital exposure to an unsuspecting campaign worker, things that landed Harvey Weinstein in prison, as well as using his dominant position to take advantage of a 21 year old intern in the oval office itself. Trump's purported dalliances occurred years ago and involved fully adult and consenting women. He took measures to avoid scandal by monetary inducement whereas Hillary resorted to an all out campaign to threaten, smear and destroy the reputations of the women who were Bill's accusers. Failing to uncover Russia collusion the special council has put incredible pressure on some of the President's aides, obviously more directed at catching up Trump than the accused themselves. Now it's said that his past business dealings are being scrutinized. These have been well documented in many biographies but it's impossible that anyone's activities involving years of complex financial and political maneuvering could avoid something controversial.  

 

Trump's enemies, liberals and many establishment Republicans, despise him in particular because he has been so successful in advancing his policies, and broadcast their animosity at every opportunity. His supporters, on the other hand,  tend to hold back, not being consumed by politics and to some extent disliking the invective they receive if they speak out. That's how I have felt about it personally. I don't like the bitter hostile responses, generally avoid them and when they inevitably arise try to handle them lightheartedly. However I'd like to make one serious point. I voted for Mr Trump wholeheartedly. I did not vote for him because of his moral qualities, although generally I don't find them more offensive than many of his predecessors, just more open, and I think most of the charges against him of ignorance and personal prejudice are obviously false on their face. I didn't vote for him because of his flamboyant style, although I feel that much of it is necessary in today's politics, and I find his forthrightness and openness to be a refreshing change in our politics. I, and millions of others like me,  voted for him because I viewed the situation in our country on many levels to have gone seriously astray, especially in our federal government. He campaigned on an platform of doing something about my concerns and so far he has performed much to my satisfaction and I want him to continue. I understand that many others don't agree with that opinion and wish to change course again. That's their right. But Mr. Trump won the election, fair and square, because those like me voted for him. The accusations that outside interference played a role have so far not amounted to much and in fact much has been revealed about possible election tampering by members of our own government that are seriously concerning. Other elections are coming soon and Trump's opponents should focus on trying to achieve their desires through that mechanism and forget once and for all about trying to remove the President from office by other means. In trying to get around the American system they are forgetting that the rest of us are watching, 

 

Medicare, the American Central Payer System.

There is no need to speculate about what American "central payer" would be like since we already have the bona fide model, Medicare, up and running and refined with the government's best efforts for 50+ years. Just as in the other advanced countries, it's so pleasant to simply present your card and all is taken care of. Who can argue that the same should not be extended to everyone. But there are some problems lurking in this scenario. 

Money will be saved say the proponents. And yet the details of Medicare's financial woes are well known but summarized best by the trustee's estimate that the unfunded liability, viz. the amount promised to present day citizens which is not covered by the present taxing structure, is in the range of $50 trillion. Consider that the benefits to today's elderly recipients are being paid for by present day workers. What will be the result of the Medicare for All system that is being called for so blithely wherein the present day funders would as well become the beneficiaries and we would all be paying for each other. Incalculable! So much for the vaunted cost benefits. 

What about the administrative efficiencies. Since there is no fear of business failure, Medicare is not constrained by the problematic actuarial details faced by private insurance. But a major administrative cost of Medicare is in the form of mandated regulatory compliance. Studies abound detailing the massive waste of time and resources devoted to such effort which has only increased over the years. Are we to believe that this will be lessoned by extending the system?

But the most problematic results of our Medicare system are the severe consequences implied in any centrally controlled system that have been detailed by the liberal economists.

 

Prices in the Medicare world have lost their signaling function. Medical providers do not compete to offer the most efficient economical services, but instead attend to maximizing income through fitting their services to the regulations. Medical records now have documentation for compliance as their primary function. Doctors have limited idea of the cost consequences of their decisions and decide based on other considerations. Their patient consumers act likewise and accept anything that is offered that is not too inconvenient or unpleasant. There is no such thing as shopping for the lowest price. 

Prices are fixed by central committees and are often grossly unrelated to reality. Providers rush to perform overpriced services and ignore underpriced ones. Our medical offices actively resist modern methods of communication with patients since only face to face encounters are paid for. How many millions of hours are wasted as a consequence while committees all over the country go through the farce of debating whether telemedicine should be permitted. 

Drug and device manufacturers focus on efficacy and devote limited R&D attention to innovations in manufacturing so that, unlike the computer industry, new medical products are always more complex and more expensive. Like the rest of the system they are focused on what arrangements they can make with the third party payers. And so we have the spectacle of multiple drugs with the same mode of action from different manufacturers that are heavily advertised but with no discernable open price competition. 

As doctors rush in droves to employment with large medical conglomerates which are tapped into government funding how many articles are written decrying the plight of primary care, the pressure to see more patients in less time, the burgeoning number of medical administrators. Who knows what primary care should be? A free market would sort the problem out far better than any expert committee. 

The U.S. is not Canada or England or France. It is a behemoth of a free wheeling, highly demanding, legalistic and contentious public catered to by a very unwieldy, often self-serving political and bureaucratic class. As a model of central payer the anti-competitive, wasteful, inefficient, fiscally unsound Medicare system is the best we can do. To extend it to all would be a disaster and then where do we go. 

Trump, the Democrats and the Illegals

The President acceded to the media storm as well as probably to the
feelings of himself and his immediate family and has now ordered that
the children of aliens caught sneaking over the border may remain in
the detention centers with their parents. The new policy does have
problems in that it conflicts with a previous judicial decision
precluding children remaining in such detention for more than 20 days.
This decision from the liberal 9th circuit appeals court resulted from
a case brought forward by advocates for the illegals so it's unlikely
they will be satisfied by the President's decision. It appears that
what these militants want is a return to the previous policy of "catch
and release" in which those crossing the border without permission
were simply given an appointment for a future court appearance and
released into the country. Very few such persons ever returned for
their hearing, which isn't surprising considering that they felt
comfortable flaunting U.S. law in the first place.

The administration's zero tolerance policy requires treating entry
into the country outside the legal entry points as the illegal act
that it is, in keeping with our immigration laws, as well as those of
most other countries in the world. The cases of those legitimately
seeking asylum from political oppression or violent unrest must be
addressed but it appears that only a small minority fit into that
category and even in such cases asylum seekers are obliged to apply at
a legal entry point. Those caught illegally crossing the border will
now be detained until their cases can be adjudicated, and unless they
are legitimate asylum seekers will be returned to their country of
origin.

The new procedures are costly and time consuming but are in keeping
with the law and make more sense than what went on before. "Catch and
release" has resulted in an influx of massive numbers of unskilled,
non-English speaking individuals into our population whose whereabouts
and means of support are largely unknown. There has been a recent
estimate of 50,000 per month being caught at the border and presumably
many more escape detection. And of course, aside from the recent
furor, the great majority of minors sneaking in are unaccompanied.
Such individuals live in the shadows, often working at low paying jobs
without benefits, with for example their medical care relegated to
emergency rooms or the free clinic where I volunteer weekly (so that I
know something of what I speak).

What the demonstrating "immigration advocates" seem to really want is
unfettered entry into the country. They do not distinguish between
legal and illegal immigration. They seem to feel that the U.S. should
not have the right to determine its own immigration policies. They
hold up signs saying such things as "Humans are not illegal". Under
cover, this view appears to be shared by some in the business
community who benefit from uncomplaining cheap labor. Another major
factor in this situation are the governments in the countries of the
migrants who welcome the money flowing back to their homes as well as
the social problem release valve and therefore seem to encourage the
migration. Mexico, despite its own strict immigration policies, seems
to have no problem permitting a large flux of migrants through its
territory en route to the U.S.

The immigration position of the Democrats is obscure. It appears that
at present they are mostly trying to placate the left wing of their
party since there are widely available past videos showing both Bill
and Hillary, President Obama, Leader Shumer and Speaker Pelosi all
decrying the evils of illegal immigration. They presently are
primarily advocating a rejection of whatever the President wants,
regardless of the fact that the policies he is advancing were primary
reasons why he was elected. But what is it they do want? They reject
the building of a wall, saying that it's too expensive and won't be
effective but their attitude suggests that their real fear is that it
will be effective. They call for "comprehensive immigration reform".
But what does that actually mean? Certainly our present immigration
laws are outdated and should be revised. And the issue of how to
handle the millions of illegal immigrants already well entrenched in
our country is a serious one. But it seems incomprehensible that they
actually favor continuing the situation of easy access across our
southern border of large numbers of unknown individuals, not to
mention drugs and other nefarious things? We know what President Trump
wants. They should state clearly what they want so that in the coming
mid-term elections we will have a basis to choose.

Thoughts on the Big Summit. Trump vs Kim

Successful deals are not successful because of complicated paperwork (a la the Iran Deal). When I was in practice I made lots of deals with other colleagues, including several years of sharing office space with 3 others, and never did anything but a handshake. On the other hand I signed a complicated contract with a big medical company, which I won't name, and got screwed. Deals work when both sides get something they want that they would otherwise not have, not because of complicated diplomacy.

What's in it for Kim. Well it appears that throughout the last 3 administrations the Norks kept working and now have Nucs and ICBM's, and a year ago were showing off their prowess. Their problem, however, is that Trump loudly made it known that if Kim dared to push his red button that it would be the last thing he ever did. (I love it that Trump does his negotiating in public). Kim isn't a religious fanatic like the Mullahs so I don't think that result was too appealing to him, but he could still sell his technology and make a few bucks. But "how you gonna keep him down on the farm after he's seen Paree", or even better S. Korea and Singapore. (How about the background scenes of Singapore on TV.) Trump pushed the real estate value pretty hard and how do you ignore that. I'll bet Kim liked it and has a few visions of sugarplums dancing around in his head.

So what do we get. Well the elimination of an unscrupulous regime with Nucs is a no brainer. But a prosperous N. Korea, less dependent on China for its every breath and morsel of food would also not be a bad outcome. We would like that as well as S. Korea, Japan and the other players in the region, but what about China. It's said they like having a local puppet to screw us up, but I don't know how much of a prize it is with a desperate population and crazy scientists playing around with Nucs right next door. I don't know much about Nucs but they've got to be tricky in the wrong hands. Also I think we have more leverage over China than we give ourselves credit for. Who else is going to buy all the stuff on Amazon.

I think Trump just might pull it off. It's all very public so we'll know soon enough whether Kim is just joshing around. I don't think Trump is in it for a Nobel Prize and that he'll walk away in a New York minute if there's any horseplay on Kim's part. I read his "Art of the Deal" and just finished Conrad Black's biography. The guy is a master strategic thinker and dealmaker and after a year he knows the job better and now has a great foreign policy team. Anyone who still thinks he's a moron and a fool should reconsider.

The "Caravan", Asylum Seekers and The Wall

Here's something that really puzzles me about the "caravan" of refugees from Central America. They worked their way all through Mexico and are now clustered at the border fence just outside Tijuana. Apparently there's an international convention that we signed in 1980 that obligates countries to give asylum to people fleeing violence and oppression for various specified circumstances. According to the New York Times in the U.S. there's been a giant surge in such claimants in recent years, overwhelming the court system that's supposed to decide whether their claim is legitimate. So people are caught and released until their court date never to be seen again.

But here's what puzzles me. Isn't Mexico a country that's subject to the same convention? In fact it's a pretty big country with a moderately successful economy. So if these refugees from Central America have reached Mexico why aren't they seeking asylum there? You'd think it would be better for fleeing refugees to take their refuge in an environment that shares their language and culture.

It makes you kind of wonder, doesn't it, if these refugees are less trying to get away from somewhere and more just trying to get into somewhere. In other words if you and your family are in such danger that you're forced to leave the shelter of your home, isn't the idea just that you want to get to a place where you've escaped the danger, such as the country just across your border. Getting to the absolute best place, where you get the most benefits, shouldn't really be the issue. Not to mention waving the Salvadorean flag. What's that all about?

I read a couple of articles in the New York Times about the situation. The reporters detail the plight of the refugees, the passionate statements of those organizations advocating for them, the complexity of the legalities they face in the U.S. courts and the intransigence of the Trump administration, but nowhere is it mentioned why asylum isn't being sought in Mexico rather than the U.S.

But the photos in the articles raised my interest about another subject. They show fencing along the border which wouldn't stop a really determined trespasser but is enough to cause all the "caravan" people to collect on the Tihuana side. I looked it up and it turns out that there's actually fencing along 635 miles of the southern border, although much of it isn't very effective. Where it has been effective, along 46 miles of the 60 mile border of southern San Diego County, apparently there was a drastic drop in nighttime sneak-ins along that part of the border after it was put up. The photos also show that for some reason even that fence is covered with wire mesh along the Mexican side, making it fairly easily scalable by a young healthy guy. Trump's prototypes appear to be much less inviting.

The 635 miles of border fence has been there for decades, mostly in the area not bounded by the Rio Grande River. So the opponents of Trump's wall don't really seem so much to mind a barrier as long as it isn't effective in preventing sneaking into the country. But isn't one of the big arguments of the wall opponents that it would be a waste of money because it wouldn't be effective? That seems to be a contradiction but somehow that part doesn't puzzle me.

The Attack on Assad and the TV News Media Response

President Trump, with his military advisers, and with the participation of France and England, carried through with his warning to President Assad that his use of poison gas would have serious consequences. A year ago a similar attack destroyed much of Assad's delivery capacity. This time it was the chemical weapon manufacturing and storage facilities. Apparently the attack was carried out with great precision and without involving civilian casualties or involving Russian assets which would have complicated the matter. 

President Trump was specific about his threat and followed through with it in an astute manner. This was in contradistinction to President Obama who issued the same warning to Assad but did not follow through. He and his surrogates explained at the time that the reason for this omission was that he had obtained the agreement of the Russians that they would see to it to remove chemical weapons from Assad's arsenal. Events have proven that President Obama's compliance with and trust in the Russians was misplaced. Unfortunately he allowed the Russians to become deeply embedded in the region. 

I have for some time now stopped paying much attention to TV news shows, including those on Fox News, finding them to be excessively focused on boring Washington political infighting. I tuned in this weekend to find out the details of this attack because of its potential importance. On the Jesse Watters show on Saturday, the night after the attack, I watched a Democrat commentator complain that while he had no disagreement with the attack, that President Trump was inconsistent because he had expressed his intent to get American forces out of Syria. This was a pretty far reach to be critical but not unexpected. It didn't tell me much. 

On Sunday morning I tuned into Fox News Sunday which I had always considered to be "straight news" as opposed to the obvious repetitive anti-Trump bias on the other networks. There I saw Chris Wallace repeatedly press the question as to why Trump responded to chemical weapons and not to Assad's use of conventional weapons. I watched as Jonah Goldberg, a long time conservative "never-Trumper" smugly accused Trump of responding mostly to things he saw on TV. 

The world was so revolted by the pervasive use of poison gas in WW1 that such weapons have been considered beyond the pale ever since. Every person with normal sensibilities understands the consequences of letting that cat out of the bag. Thus the negative reaction of both Presidents Obama and Trump to Assad's use of poison gas. On the other hand the Syrian civil war is a morass, with the anti-Assad forces being a very mixed bag. Trump's desire to extricate American troops from that situation as soon as is feasible is probably shared by the large majority of Americans. Chris Wallace's apparent misunderstanding of this basic distinction suggests to me that he is being provocative for the sake of provocation. Goldberg's misplaced attitude of superiority seemed ridiculous.

None of these people had to face the real decision about the event, the importance of it relative to overall national policy, what should be our response, how and with whom it should be carried out, what might be the collateral consequences of our actions, how would our friends and adversaries respond, how should it be announced to the world. To my mind the thing was carried out expertly all around. Good for Trump. Back to the waste basket for the TV news yappers.