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.