Thursday, January 12, 2017

Future Ins and Outs

I have been reading, watching, and listening to progressive deep thinkers, heavy social breathers, and alarmed liberal hysterics.   
Collectively, they seem to think the end of the earth may not be near, but you can see it after the Trump election.

These critics believe sun, wind, tide, and bio-based sources of energy are in, and fossil fuels,  fracking,  an drilling for oil are out.  Globalization is in, and nationalism are out.  Collaboration across the social spectrum is in,  and individualism and entrepreneuralism  and taking advantage of economic opportunities is out.   Waste is in and recycling is out.

According to these critics,  Trump and his followers believe(Peter Senge, The Necessary Solution: How Individuals and Organizations Working Together to Create a Sustainable  e World,   Trump et all have these unsustainable beliefs.

·       Energy is infinite and cheap.
·       There will always be enough room to dispose of our waste.
·       Humans can’t possibly alter the global environment. Weather patterns will remain stable no matter how we act.
·       Basic resources such as water and topsoil  are unlimited. If limits or problems are encountered, markets and new technologies will reallocate financial resources so we can continues with our current ways of living and working.
·       Productivity and standardization are keys to economic progress.
·       Economic growth and rising GDP are the best way to “lift all boats and reduce social inequities.

Another deep thinker,  Thomas Friedman, of the New York Times, says larger forces  - Moore’s Law (microchips will double in efficiency every 2 years), globalization (interconnections and interdependence secondary to the Internet), an Mother Nature (climate change and biodiversity loss) are accelerating and will either save us or destroy us.   He says since 2007 we have been changing fast because of Iphones,  advances in silicon chips, software, sensors, and networking, and these forces are transforming society irreversibly.

In health care, critics maintain, only collaboration  between government and NGOs (nongovernment organizations) will save us from our follies/  The solution will require collaboration in the form of accountable care organizations,  medical homes, integrated health organizations,  bundled pricing, and measures of improvement tied to  physician and hospital reimbursements, and universal care. Universality in care will lead inevitably to learning organizations, and the use of artificial  intelligence4  and elegant algorithms that will supplement and supplant clinician experience and intuition  and interpretations.   For example,  artificial intelligence and algorithms will replace interpretation s of radiologists and pathologists to interpret images on ex-rays and slides.

All will be well and better in health care if we oly listen and heed the Big Thinkers.  aim for universal coverage, erase social injustices,   achieve standardized outcomes, and collaborate across all health care spectrums.

If other words, if only we defy human nature and level all playing fields,  we will have harmonious outcomes. 

Friday, January 6, 2017

End of ObamaCare and Mortality Deadline

 J.Oberlander, PhD, a health expert at the University of North Caroline, has ana article in the January 5 New England Journal of Medicine.  It is entitled "The End of ObamaCare."   Oberlander says that with the Trump election, ObamaCare is dead and awaits Republican replacement.  In his concluding paragraph. he says, :The ACA's enactment represented a major toward making health  care a right in the United States. Now after another landmark election, health care reform in the Untied States is headed backward."

This is his opinion and is not shared by the majority of the American public, who, in over 95% of polls disfavored ObamaCare because of its failed promises, spiking premiums, unaffordable deductibles,  and narrowing of choice of doctors, hospitals, and health plans.

Another reason may be the ACA's ineffectiveness in improving the health of the majority of Americans.   The latest evidence of this is the Center of Disease's announcement that the average mortality of Americans declined from 7,89. to 78.8 years in 2015,  the first such drop in living memory.  This decline occurred after 7 years of ObamaCare, whikch was designed to achieve a triple
aim- better health, lower premiums, and enhanced collaboration between health care providers.

What's going on? According to the CDC, the spike in death rates and the decline in mortality is due mostly to obesity (35% of us are obese) and its aftermaths - diabetes. heart failure, and strokes, and to the opioid and heroin epidemic (30,000 deaths in 2015).

These deaths are not necessarily due to ObamaCare, but to cultural factors - overeating carbohydrate-rich diets, lack of exercise, and to economic despair secondary to a slow growth economy, and over-reliance on opioids and cheap heroin to treat pain.tes or regulate health in the face of a slow economy, and ats attendant poverty, social disarrage and violence,  paritisan political divisons.  Nor does enhanced coverage of health care form 20 million SAmericans necessarity ensure better health. lower death rates, or collaboration between health provides.  Health care coverage is not the same as increased access to care , in face of reluectance of doctors to accept more Medicare or Medicaid patients,  unaffordable premium, , co-pays, and deductibles.

Tuesday, December 6, 2016

Winners, Losers, and Moral Victories

Winning isn’t everything, it’s the only thing.

Trump Philosophy, as expressed by Vanderbilt football coach, Red Sanders, in 1953

If you lose, it’s a moral victory.

Democratic Philosophy, after 2016 presidential election

President-elect Donald Trump, during the campaign, said the election was all about America winning again,  thereby making it great again.  Maybe,  but after a close election, winners and losers have two points of view.

Points of View


Republicans – We won, you lost.  Get over it.  Suck it up, Buttercups.  Melt down,  snowflacks.

Democrats  - You won the electoral college, but we won the popular vote.  That is a moral victory for our side.


Republicans -  What American workers think, is what counts.

Democrats-  What the American intelligentsia conceive and believe is more rational, more compassionate, and more moral.


Republicans – Pride in our national heritage beats globalism and produces a greater,  more prosperous economy.

Democrats -   Globalism will win in the end in an interconnected world because economic tradeoffs are necessary  and more compassionate.


Republicans -  Strict adherence to the Constitution is what makes America great.

Democrats -   The Constitution must be a living document,  adjusted to greater trends in the world.


Republicans -  We listened to the silent majority which represents American culture.

Democrats – The new majority is the collective vocal minority.


Republicans  – Winners  win because they understand  the common will.

Democrats  - To win one must pay attentions to what other nations want,   even if these nations may to play for dabbling in American politics.

Republicans – To win a true nation must define and defend its borders.

Democrats – To be a true part of the world community, one must have open borders and accept all comers.


Republicans  - A rising tide, based on lower taxes and fewer regulations, lifts all boats.

Democrats -  A rising tide enriches the rich, leaving the poor to drown without a safety net.


Republicans – Bottom-up enterprises, based on freedom to innovate, bubbles up and enriches all.

 Democrats –  Trickle-down innovation does not work and discriminates.  Only trick-down government control works.


Republicans – Big Media, big Money, and a big Ground Game lost.

Democrats – Alternative Media, alternative financing, and popular rallies lack moral coherence.

When it comes to winning and losing in politics, there are always two points of view, each a little Conservative, and each a little Liberal ,each a little more business-like, each a little moral.

Wednesday, November 30, 2016

Elements of Health Reform: Lessons Learned

The cat is out of the bag,  the toothpaste is out of its container,  and the genie is out of the bottle.

Trump has been elected.  Tom Price, MD,  a fierce opponents of ObamaCare has been selected as head of HHS,  and Republican leaders have declared repeal and replacement of ObamaCare as first on their legislative agenda.

What are lessons learned from this unlikely turn of events, which will doom Obama's signature domestic program and likely lead to a Republican alternative plan,  as yet unnamed?  What will happen to those 20 million Americans now subsidized on health exchanges and Medicaid?  No one knows at this point, and it is unlikely we will know precisely until months after President's Trump's debut.

In my case,  after 50 years of writing about health reform, I have come to these conclusions.

  • The U.S.  Constitution- The U.S. Constitution,  said by one historian as the greatest legislative compromise, in Western Civilization, is alive and well. Its electoral college provision  held up and will not be overturned. And the checks and balance concept has prevailed, much to the chagrin of Democrats.
  • Failure to Compromise in Bipartisan Nation -Largely because President Obama failed to compromise in designing and implementing the health law,  passing it without a single GOP vote, ObamaCare is now destined for oblivion
  • Rhetoric Not Enough -President Obqma,  a gifted speaker and campaigner,  did not achieve his promised results, filed  to build a Democratic leadership team, and did not listen to the people.  Consequently, he left the Democratic party in shambles
  • Center Right- America is a center-right capitalistic nation that believes in personal responsibility,  economic prosperity,  and equal opportunity rather than government control,  economic stagnation, and equal  outcomes. 
  • Limits of Centralized Government -A centralized government cannot manage individual choices at the level of doctor-patient relationship.
  • Health  Costs Difficult to Control   -Health care costs are difficult to control when comprehensive benefts are offered but not deliveredand because everybody wants to live another day and because , in the words of comedian Berle, "When it comes to my health, money is no obstacle.
  • Demand for Lifestyle Improvement-One of the untold tales of health reform is the demand of aging patients for access to life-style technologies - joint replacements and cardiac stents -  that support their lifestyle.
  • Ignoring of Insurance Risk - ObamaCare did not lower premiums or deductibles because it made calculations of actuarial risks impossible  and did not take into consideration that insurance is based on balances the costs of illness against health.
  • Absolute universal coverage, noble in intent but impossible in attain America, which cherishes choice, individual freedom, and access to the best medicine has to offer,  cannot be acheived in America
  •  Nature of Humanity -  People, being human and not robots,  will continue to behave badly and ignore habits of good health in search of earthly pleasures  as long as health technologies offer an out.
  • Freedom of Choice - Freedom of choice of doctors and health plans and hospitals are part of the fabric of American culture.
  • Benefits of Prosperity - Beleif in economic growth as a universal solvent for most problems is embodied in President Kennedy's statement,  " A rising tide lifts all boats, and in the provess etends to soften or paper over social inequities.
  •   Orwellian Observation - In Animal Farm, George Orwell commented, "Some animals are more equal than others." This applies to health reform, even is Big Brotther is watching.
  • Unequal Blessing, Equal Miseries -  Winston Churchill said, Capitalism offers unequal sharing of blessings,  while Socialism confers equal sharing of miseries.
  • Necessity of Organizations -  In the complicated world o health reform.  most advances require organizations managed  growth and perpetuity operating within the matix of indvidual ezcellence.
  • The fuure excellence of American health care  depends on govenment and private orgnization working in trandem with health professinals.
  • America in the future will have a dual system -  one operating within the context of government government regulations and value-based outcomes and the other based on direct cash contracting of patients with doctors.
  • Political Aprodisiac -  Control of health care is a political aprodisiac .  A broad siocui saftey netw will always be necessay.
  • Governent Innovation  -  You cannot bottle or direct or crate innovation at the federal level,  Spontaenous imaginative individuals seeking better solutions form the bottom up is necessay.
  • Pure Ideologies   - Pure ideiologies, either liberal or conservative  do not usuall owrk.
  • Language of humanism - elegant language of humanism, spiced with straight talk, insprirtion, and humility is a necessary is essential for developing a workable system that does not break the national budget.
  • Limits of IT -  Algorihms and appas, no mater what their scope or ingenuity, will never replace or replace,human intellegence and imgination and ablility to cut to the chase.


Saturday, November 26, 2016

Majority in Battleground States and Trump Knew Country Was Headed in Wrong Direction

Why did Trump Win?  Because majority of voters in battleground states knew country was headed in wrong direct?   In poll after poll, nearly 70% of voters in these states said so.  It was a stark statistic, and it rarely changed  by more than  1 or 2 percentage points.
Voters knew something had to change.  And this lust for change elected Trump.
The number foretold where the majority of people stood and how they are likely to vote.
People knew the sluggish economic growth of 2% was wrong.
People knew taxes were too high and regulations were too burdensome for  economic growth.
People know transferring  jobs abroad made no sense.
People know opening up borders to illegal immigrants was misguided.
People know abundant fossil  fuels, especially natural gas and even coal
made for affordable energy and was the engine of American prosperity.
People knew doubling and even quadrupling of health premiums coupled with unaffordable deductions made seeing a doctor, even for routine care, was virtually impossible.
Who, in the main, were these people?  They were the people of Middle America-  skilled workers, small businessmen and women, the common folk – the glue of American society.
The people yearned for straight talk rather than the politically correct jargon of the elite.
The people knew the U.S. Constitution guaranteed that American government was of the people, for the people, and by the people, not of the elite, for the elite, and by the elite. The elite were D.C. politicians, the well-to-do in bicoastal population centers, the newly rich in Silicon Valley,   academics in universities, the college educated and those with advanced,   the heads of corporations, health system, and above all else,  liberal journalists, and media moguls.
Fly-Over Country
The intelligentsia, , concentrated in major cities and on both coast,  spoke mostly to one another.   They were doing fine, getting richer and richer.   They regarded Middle American as fly-over country, populated by consumers of their products and message, a swamp of mediocrity, full of evangelicals deplorables, bigots, misogynists,  racists, homophobes,  none of whom recognized the glories of upper-crust compassion,  globalism,  apps, algorithms,  and the solutions offered by sum, wind, and  fossil-fuel shutdown as the solution to climate change.   They looked upon the middle of America and its ignorant middle class as swamp – a swamp that needed to be drained and converted to higher causes.
The Swamp Fox

Enter the Swamp Fox, Donald Trump..   As a longer-term charter members of the wealth elite, he knew the thinking of the political and commercial establishment.  He sense that that a populist movement as afoot in Middle America- the center right of American politics.  He could feel it in his bones.  He sense in the huge throngs that flocked to his rallies.  He knew that a mix of patriotism,  and a desire for pride in American, and identify as Americans was in the air.   People wanted a return to economic prosperity which he, and he alone, could unleash through tax reductions, loosening of regulations,  repeal of ObamaCare, a plan to make America energy independent ,  and making America proud and great and secure. 
Keys to His Campaign
The keys to campaign were to make Americans proud of themselves,   to promise economic prosperity, to assure them that nationalism transcended globalism,   and to ridicule and outfox his opponents through manipulation of the media.     He mocked his opponents,  lambasted the media, and made himself a constant presence on TV,  social media, and on Twitter.   He questioned the conventional wisdom.  He  declined conventional  funding sources,   he said he did not want to be anybody’s puppet or to be beholden to them.    He financed much of his campaign.  Somehow he became known as the blue-collar billionaire,  the champion of common people.  And, first and foremost, he vowed to drain the swamp  of the  corrupt establishment in all of its form.
Trump promised to retain Medicare and Medicaid, the faster growing segments of the national debt, while opening up health car to market forces  through expanded health savings accounts and erasure to state line.   A competitive system, he maintained, would be wonderful.     He did not say just how – how to cover the 8 million uninsured now insured in health savings accounts, how to  finance th 12 million who joined Medicaid.  He would delegate Medicaid to the states through block grants, and somehow the states would expand access while reducing costs.
According to an ancient sage,  the fox knows many things, but the hedgehog, who is closer to the gou8nd, knows one big thing.  What is the health system’s one big thing?  What combination of government programs and market-based cased will work for the benefit of all?  What will be Art of the Health care deal?  Time will tell.

Wednesday, November 16, 2016

Silence Not So Golden

We usually  measure a man - or a woman- by what they say, what they do, how they act, and by their body language, how they carry themselves.

But we rarely judge them by what they don't say, what they don't do, what their body language reveals and when they remain silent.

These things seem to be different with President Obama. He is being judged by his silence and delayed comments on controversial issues such as  not using the term "radical Islamic terrorists: his failure to comment on Kate's  Law and the Mexican felon who gunned her down;  his muteness to take the side of the police in police assassinations; his not mentioning  the doubling of health care premiums, the quadrupling of deductibles,  and the narrowing of choices of doctors and health plans; and most recently , his silence in the wake of violent protests against the Trump election.

No doubt Obama regards his silences as a subtle protest social injustices, not worthy of a political correct message.   He may be correct, but his critics say his silences are acts of moral cowardness, of hiding behind his true beliefs.

Silence, it is often said, is golden,
Except, of course, when certain events unfolden,
Then one should seek to clearly express
Of one's failed policies to confess,
Then one's embolden critics one is beholden.