Iowa Is Voting On Health Care Tonight

flying cadeuciiIn his last State of the Union address, President Obama stated that “anyone claiming that America’s economy is in decline is peddling fiction”. I agree. The American economy has roared back from the Great Recession with 14 million new jobs, a ridiculously low unemployment rate, a booming stock market and 57 brand new American billionaires in 2015 alone.

The American people on the other hand are in a completely different boat. Almost a third of us are not working. Half of us have practically no savings and a record number is surviving on public assistance. Wages are stagnating and the middle class is shrinking. Student debt is skyrocketing and 20% of our kids live in poverty. Whereas in the immediate past the economy and the welfare of the people used to be one and the same, nowadays these terms have little if anything to do with each other.

The President did acknowledge that “the economy has been changing in profound ways” and therefore “a lot of Americans feel anxious”. To allay our collective anxiety, the President announced an unemployment program that will pay up to $10,000 to those who lose jobs to the economy fixing racket, money that can be used to retrain machinists, welders, builders and such, to flip burgers in the booming job market of the fixed economy.  The anxiety reduction program will also ease the transition to a “work-sharing” economy, where lower wages and no benefits, augmented by public assistance, a.k.a. the Walmart and Uber models, are the new normal.

Health Care is about the Economy

After fixing the economy, our government is now full throttle ahead with fixing our health care. My expectations would be that health care will be fixed in very short order, with very similar results. Health care expenditures will plummet, uninsured rates will be near zero, quality measures based on cost and utilization will be stellar, and most people will end up with little if any medical care when they fall sick. To ease our anxiety, or in health care parlance, to provide us with “peace of mind”, everybody will be awarded a Medicaid managed care card, if you’re lucky, or a high deductible insurance exchange plan that kicks in after you go bankrupt.

In the midst of the previous century, when people talked about “the economy”, the term conjured visions of molten iron being forged, of combines sliding gracefully through oceans of golden wheat, of gigantic cranes towering over monumental construction projects, of dusty rugged Americans building and making with pride and determination, of former soldiers poring over text books, of men walking on the Moon. Today, “the economy” brings to mind images of stock tickers, conference rooms with sweeping views of Alcatraz or Central Park, fancy men in fancy suits getting in and out of black limos, and endless streams of brightly colored graphs, percentages and statistical trends. The economy is no longer about us.

Health care is no longer about us. Health care is about waste, fraud and abuse. Health care is about “bending the curve”. Health care is about global competitiveness of corporations. Health care is about carving up a $3 trillion opportunity. Health care is about private equity, mezzanine funding, return on investment, valuations and public offerings. Health care is about the economy, and the economy is no longer about us.

Perhaps this was never about us, but if “time is the fire in which we burn”, America was the one unique experiment where a group of people came together to protect each other’s rights to freely determine how they wish to burn. The idea spread a little bit, but not much, and now it is collapsing under the hubris of an Information Revolution, which looks more like a slow motion coup d’état to transfer control of the burning process from millions of hands to a global “digital assembly line” where physical objects, virtual algorithms and human beings are melded into one efficient production system. This is a kinder and gentler slavery nation.

John C. Calhoun

Historically, the enslavement process was physically harsh and cruel, because back then the work of a slave was physically harsh and cruel, and because the only tools available for recruiting and maintaining slaves were physically harsh and cruel. Today you give a guy an iPhone app and he willingly and painlessly joins the driving plantation. You give a guy a free Internet search tool and he unconsciously and painlessly joins the advertising plantation. This is a major improvement, since as grandma used to say, you catch more flies with honey than with vinegar, and from a respectable distance it looks like you’re generously feeding the dumb little critters.

The grand objective of slavery has always been the amassment of wealth by the magnificent few on the backs of the faceless many. The only things that changed over the millennia are the means by which this is accomplished, and the rhetorical subtleties used to justify the practice of slavery. Notably, health care has been playing an increasingly prominent role in the intellectual quackery employed by evil people towards their evil ends. As early as 1837, John C. Calhoun was extolling the superiority of health care benefits available to the enslaved, especially the compassionate palliative care at the end of life, when compared to the “forlorn and wretched condition of the pauper in the poorhouse”.

It never occurred to Mr. Calhoun that there ought to be a third option, that his own young country has challenged the world order by simply stating that all men are created equal, and challenged the most powerful King in the world, and his mighty armies, precisely so that those equally created men can be free men. But John C. Calhoun was not speaking about us. His oration was about the economy, and the economy thrives on servitude, pauperization, and wretchedness, mitigated only by the “kind superintending care” of masters. If John C. Calhoun were alive today, he would probably be running a billionaire foundation to help “all people lead healthy, productive lives”.

Alexander Hamilton

It must have never occurred to Dr. David Blumenthal either that 200 years after our Declaration of Independence, for a brief moment in time, we had a third option. After watching a Broadway show and perhaps reading one biography of Alexander Hamilton, Dr. Blumenthal found it necessary to write the strangest article in defense of the Hamiltonian version of Calhoun’s “superintending” care, which Obamacare essentially is, or aspires to become with the help of its equally superintending technology bonanza. The article is a case study in demagoguery and the building of alternate realities from partial truths and innuendos, which is how health care reform was and still is being advertised to the masses.

Perhaps we shouldn’t be surprised by Dr. Blumenthal’s admiration for Alexander Hamilton, because Alexander Hamilton was not about us. Mr. Hamilton had great misgivings about the “imprudence of democracy”. He admired the British aristocracy, and insisted with all his might that the “first class” of “the rich and well born” should be awarded a “distinct, permanent share in the government” to counterbalance the bad judgement of the masses, and to prevent change to the status quo. If Mr. Hamilton, the champion of strong central government run by financiers and corporations, were alive today, he would probably be equally smitten with what Dr. Blumenthal represents.

This Night in Iowa

Tonight in the great State of Iowa, we the people are kicking off the only peaceful process available to us to make health care, the economy, and the entire political process, about us. This year we seem to have a bountiful crop of candidates seeking greatness. Some are “rich and well born” asserting their Hamiltonian right to that “permanent share” in government. Many are lifelong corporate servants looking for the next step in their pitiful enterprise. And two are very different than the rest. Two are challenging the status quo, which is so near and dear to the “first class” and its vast infrastructure of minions and pundits, feeding at the commandeered public trough, and whose entire job now is to convince us that neither one of these two men are fit for office.

One is a career public servant, a man of principle, of lifelong held beliefs that health care should be about us, and the economy should be about us, and that central government should be by, of and for us. The other is rich and well born, a swashbuckling traitor to his “first class”, who realized that he cannot possibly have a great country when the great majority is enslaved. The two couldn’t be more different in personal style and fiery rhetoric, but at the heart of it all they both want to reclaim the “permanent share in the government” that was stolen from us by the “first class”, and unlike their corporate serving competitors, who say one thing and do another, neither man is accepting patronage from those who they aim to disempower on our behalf.

For decades the “first class” owned media and punditry, carefully nurtured the appearance of an “ideological divide” designed to keep us engaged in mortal combat over hyped minutia, while the enslavement process proceeded at a brisk pace in the background. Tonight, the people of Iowa have the opportunity to begin refocusing our sights on the real ball. This election is not about Republicans vs. Democrats, it’s not about Planned Parenthood or ISIS coming to kill us in little Toyota trucks, it’s not about men vs. women, blacks vs. whites, young vs. old, educated vs. uneducated or poor vs. less poor. This election is about all of us, it’s about being a nation of free people vs. a replaceable cog in the global “digital assembly line”, and it’s about our hard fought right to govern ourselves, centrally, locally and individually.

We can’t make health care about us until we make the economy about us, and we can’t make the economy about us until we make government about us, and we can’t make government about us until we make the political process about us. We can’t make the political process about us until we dethrone the “first class” from its permanent power perch, and deny the “rich and well born” the ability to buy every election and serve us with a nauseating mélange of sleek and polished John C. Calhoun disciples, promising “kind superintending care” for the rest of us.

Tonight Iowa will vote for Bernie Sanders, will vote for Donald J. Trump, or will vote for the status quo. These are our only choices in 2016. Choose wisely, America.

Margalit Gur-Arie is a THCB contributor based in St. Louis.

61 replies »

  1. Perhaps that is why a somewhat libertarian outlook along with a textual view of the Constitution is a good thing. Unfortunately it seems too many have the dreams of the left and forget the horrid reality seen in the twentieth century.

  2. “ In my opinion, health care has evolved into a business where benefited individuals and/or corporations have found a way to profit off of the burdens of the working class. They found an illegitimate loop whole, made it legitimate, slapped a name on it, and called it “being fair”. ”

    That is exactly what is happening. In fact some of the postings on this blog are little more than self serving promotions of their for profit business model or businesses. Just look around at all the sharks feeding off of government largesse and asking for favors. Look at how the costs of healthcare keep spreading to more and more support and less actual healthcare.

  3. I find this blog quite interesting with a lot of correlation between the yesterday America and the today America. I have to say, I agree with on the view of the “old economy” verses the “new economy”. This is a democracy, not a monarchy and one should not receive special governed treatment because of his/her economic status. In order to make health care adequate for everyone, it has to be about everyone. According to Harriet Komisar, (AARP.org, 2013), “rising costs for health care services and health insurance premiums represent a growing burden for middle-class families across all age groups. The growth in health care spending is crowding out other important priorities such as saving for retirement and for children’s education.” In my opinion, health care has evolved into a business where benefited individuals and/or corporations have found a way to profit off of the burdens of the working class. They found an illegitimate loop whole, made it legitimate, slapped a name on it, and called it “being fair”. The view of the “old economy” has indeed been swept under the rug, but the hard particles of it still, and always will exist, which needs to be recognized. Great blog.

    Komisar, H. The Effects of Rising Health Care Costs on Middle-Class Economic Security. (2013). Public Policy Institute. Retrieved from http://www.aarp.org/ppi/issues/security/info-2015/impacts-of-rising-healthcare-costs-AARP-ppi-sec.html

  4. Margalit, if the government keeps interfering in healthcare the way it has we will continue to end up worse than before. This decline has been going on for over 50 years and costs seem to go up everytime government again enters the picture. It’s time to take a new route. The individual should own his own insurance and the market should focus on becoming freer. Instead of a public option we need targeted subsidies and the safety net, Medicaid.

  5. I think Allan, that if we don’t make a conscious decision to go the Medicare for all route, we will indeed incrementally and by default end up with Medicaid for all.
    I am not advocating for anything drastic, like nationalizing health insurers. Instead, just open up a “public option” and let people who want to, buy into Medicare, just like they buy Anthem or United Healthcare. Furthermore, to eliminate corporate entitlements, if we subsidize people, we should only subsidize the “public option”. That’s all I’m asking for, within the Obamacare parameters. Let the chips then fall where they may….

  6. Perry, I don’t see them as being content only unwilling to fight. All of this is creating physicians who are agents of big companies and the patient has been left out in the cold.

    Those that think things will be better with ‘Medicare for all’ in my opinion haven’t thought things out too well. Why would such a solution be Medicare for all? Why not Medicaid for all which is probably more of what we get should we decide to go on the ‘Medicare for all’ route.

  7. There is no difference on the coin flip and I can’t draw any conclusions based upon what is known, but the confusion demonstrates a lack of transparency in how the decisions were made. That is dangerous because it opens up feelings noted in the title of the piece.

  8. “Something smells in the Democratic Party”

    The headline differs from the reality of the story. Both my link and yours (if fully read) show no significant one sidedness of flipped coin decisions in the final outcome.

  9. Yes, I agree on questionable “efficiency” of this system and it’s needed multiple billing clerks, but think of the bad debt size if patients only paid cash. The size of the herd does make a difference.

  10. So does Medicare, through contractor entities that are not at liberty to set prices. As to collections, collecting from insurers is not much easier (if at all) and you still have to chase patients until high deductibles are met, which is a huge issue now, and then for copays… Not sure there’s any efficiency here….

  11. “what is the exact “value” of insurers?”

    I question that all the time compared to a single-pay one stop payment system, but insurers organize premium payers and pay providers so that the doc isn’t collecting overdue payments from each patient.

  12. I don’t disagree that physicians, and specialists in particular, are making big bucks comparatively, but what that “tether” does is not beneficial to patients, and certainly not beneficial to docs. We keep talking about value, what is the exact “value” of insurers?
    I can feel a new blog post forming in my head… 🙂 good conversation here….

  13. Peter,
    I realize many are going “off the grid” and are quite happy about it.
    I would pose to you that while doctors have done and do well financially,
    there are also many of us who genuinely like what we do and are willing to forego some extra money for more autonomy and less intrusion from gov’t or insurance companies. I like the idea of being able to do what needs to be done in consultation with the patient, not depending on what some agency or company says I can do. I have some restrictions because I mostly do Worker’s Comp cases, but those docs in routine primary care have many more restrictions.
    There are many out there doing DPC for a very reasonable fee.
    And yes, Allan, there are many new docs who want the great hours and “guaranteed” pay, but with all the new pay methods being devised by CMS and finding they will be beholden to the ACOs and hospital policies, we’ll see how long they are content.

  14. Again, they can’t expect the big bucks from insurance then also want to be free from that tether – life just doesn’t work that way for anybody.

  15. The cash thing works well for, say, a primary care doc, but there is no way a cardio thoracic surgeon for example can go cash only, because no matter what he personally charges, the hospital/drug/device costs are beyond most people’s reach. We keep thinking about primary care when we talk about these things, but primary care makes about 4% of total health care expenditures. It’s the other 96% that is killing us…

  16. Why only for a few – because they charge so much only a few can afford cash?
    They can’t have it both ways Margalit. Either they see less patients for more money/less hassle, or see more for less money/more hassle.

  17. Oh, they desire to be entrepreneurs, but of a different kind, and instead of being physicians, not along with it.
    As to employment, yes, it seems to be more widespread, but much of this is happening because independent private enterprise is purposefully rendered untenable by colluding government regulators and big health care corporations.

  18. Cash only is an option for very few specialties. All others will have to find another way to fight the “machine”… It will take time, though.

  19. Perry, I believe there has been a change in the way new doctors view things. I don’t know how much they desire to be entrepreneurs along with being physicians and I don’t know that they dislike the more regular hours seen today.

  20. Perry, docs have always had a way to “go off the grid” by going cash pay only. I don’t a doc “revolution” would benefit patients.

  21. My reference to revolution wasn’t literal such as heads rolling and shots heard round the world, I think more in the fashion of revolting against status quo in politics. I think physicians will soon be revolting against the lunacy of the current state of Medicare, Medicaid, insurance, MOC, inadequate EMRS etc. I hope so.

  22. Margalit rightly recognizes that in many instances both the Democrats and the Republicans end point is nearly the same. What isn’t agreed upon is the means and the actual recognition that some ideas are merely dreams that can never be realized in a fashion the dreamer perceived.

    Perry discusses the idea of “revolution”. The results and aftermath of the American revolution was the exception not the rule so I am not sure that is the right way of going about things. There can be a lot of pain involved such as seen in the French Revolution or tremendous turmoil and death as seen in the “revolutions” of Hitler, Stalin and Mao. We must take note that Hitler was elected.

    It will be an interesting election year.

  23. We do need such a candidate, and I would argue that the setup of our elections process is not conducive to allowing this to happen, to put it mildly… see my comment above in response to Perry.

  24. Yes, the debate moderators… The media we have today is very much at fault for this. Newspapers always took sides in political debates, but there was some integrity out there. Now it’s about clicks and real time need for 24/7 breaking news coverage and that means gotcha type of stuff….
    When CNN feels compelled to spend 2 hours discussing a tweet with dozens of “experts” and focus questions on trying desperately to trip someone to say something nasty about someone else, so CNN can tweet about it… or whatever… one has to wonder….

    For example, who invented this notion of “electability” or “looks presidential”? Did Andrew Jackson look presidential? How about Taft? What was Jefferson’s perceived “electability” with all those scandals? Was JFK electable? Was Truman without a college degree electable, or did he look presidential? Heck, we wouldn’t even have Abe Lincoln up there, due to his flawed character and “melancholy” (they’d probably medicate him with something today to make him act “normal”).

  25. I wish the PACs (and candidates too) would ‘discount” the abortion/guns, racist/socialist type of stuff. I remember a past WV race where the NRA went in full bore against a candidate on gun control, virtually saying WVs needed more guns not affordable, accessible health care – they bit the bait.

    It seems each election cycle candidates rail against the “establishment” but voters consistently return incumbents to office.

    You’ve got some good analysis Margalit, what we need is a candidate to voice that argument – but I’ve learned people can either have the truth OR they can have hope, not both. People always choose hope over truth.

  26. Indeed, Margalit I think we need to get past the guns/abortion/gay marriage issues for the time being. This is after all America, and people have the right to their opinions and beliefs. It’s very discouraging because the debate moderators and the press like to home in on these divisive issues which will have little import if our economy tanks, if we’re overrun by ISIS terrorists, and we have runaway health care costs that only the Donald and Warren Buffett can afford. I don’t necessarily agree with Bernie’s fixes, but I think he is right about needing a “revolution”.

  27. As Allan said, the people voting for either side have the same problems, but this year, it seems the candidates are also raising largely the same issues.

    If you listen to the leading candidates on the R side, and discount the obligatory pandering, you hear that the middle class is being decimated, that campaign funding is a sham, that lobbyists are corrupting Congress, that trade agreements are taking jobs away, that immigration is lowering wages, that the war in Iraq was a mistake, and that health care is too expensive even for the insured. Not much different than what the D side is railing against.

    They differ on their analysis on why these things are happening and in some cases on how to go about fixing them. If you compare just Trump and Sanders side by side, without the bombastic junk and the aspirational things that will never happen on either side, it’s even more striking, including alignment of some proposed solutions, such as the strengthening of SS, Medicare and the VA, fair trade, reduced immigration and such.

    If you discount the abortion/guns, racist/socialist type of stuff, I think we have plenty of room to work together, and perhaps it’s not by accident that in New Hampshire, it looks like Trump and Sanders will be competing for the same independent voters.

  28. Yes, the two of them are funded by others than corporations and the like.

    The problem is that Bernie is an ideologue supreme and that doesn’t work out in the end because the numbers don’t follow his dreams. Trump is anyone’s guess.

  29. “Tell me how you get those sides together?”

    An interesting question. You left out the people.

  30. One side says we have too much government and let the corporations have their will, the other side says we need more government control and less corporate greed and influence. Yet you say both sides are suffering the same economic struggle.

    Tell me how you get those sides together?

  31. Bernie is funded by the people. No corporations and no super PACs. Trump is funded by Trump and by the people (about 1/3 of his money comes from small donations). Everybody else is beholden to the corporate/Wall Street gravy train. That’s what makes these two unique, and note that they agree on many policies as well, including campaign finance reform.

    I agree that who will win in November is anybody’s guess right now, but even if both lose, I think they are paving the way for the next guy/gall to come in and finish the job. Of course, we have to clean up Congress too… one by one….

  32. Who will win is anybody’s guess, but I would say all 4 of the Republicans mentioned are anti establishment though Rubio once the Tea Party Hero has moved towards the base of the Republican Party. He is hispanic something not generally associated with the Republican Party. So is Cruz who was hammered by the establishment. Ben Carson an African American who addressed a breakfast or something similar for Obama has never held office and neither has Trump.

    These Republican’s and Sanders are all outside the mainstream members of their parties. Sanders flow of money seems at present to be coming from large numbers in small amounts, but if the money trail is what you call establishment then if he takes hold he will be part of the establishment as well. The only one not funded by the so called establishment is Trump for he is self funding.

  33. Hard to say. The establishment is fighting back with everything and the kitchen sink. Historically, the house always won. I am not optimistic.
    I also don’t see the woman, 2 Hispanics and the African American as anti establishment, although they certainly love to say that they are, because they are essentially fully funded by said establishment. It’s an optical illusion, no doubt in my mind that this is by design too.
    If I were a betting person, I’d say we’re looking at Clinton the 2nd and more of the same as far as the eye can see, or until we can put our petty differences aside and kick the bastards out.
    One of these days the Bull Moose will come to fruition 🙂

  34. There is no question that the establishment is under attack. Despite the fact that Hillary has the public eye, the Clinton machine, money and the claim to represent the woman of America she couldn’t decisively beat the charisma challenged socialist Bernie Sanders who was mostly unknown to the American public and caucused by himself. There was even talk of a challenge to the vote counting and some even accused the Clinton machine of cheating. 6 times the vote seemed even and was decided by a coin toss. All 6 went to Hillary who represents the establishment that voters are so suspicious of. 1:64 possible, but many feel unlikely.

    On the Republican side 4 candidates shared the bulk of the votes outshining the others. All were antiestablishment. One a white guy totally non PC, 2 hispanics and an African American. There is even an anti establishment female, but she is running behind at this time.

    Thus your feelings about the establishment were proven to be wide spread at least in Iowa where the establishment was beaten. Will it last?

  35. The Supreme Court (without discussing any particular case) is rapidly clouding the meaning of the law as it exists under the Constitution. At present, though there is more complexity now than in the past with regard to equality under the law, I think equality under the law is today’s best definition for the situation you are discussing. A Supreme Court decision is the law.

    Unfortunately many of the rules made by the bureaucrats create new laws that strangely enough need not be approved by Congress. Many of these laws are undefined and very much open to interpretation and political gamesmanship. Laws can be foolish, but if all can easily understand how to follow the law and the law is Constitutional then there is equality under the law.

    It is up to the Supreme Court to maintain the law based upon the Constitution. Your gripe is a constitutional one. Pass a constitutional amendment rather than permit laws to be interpreted differently based upon who may or may not be breaking the law and who may or may not be in power.

  36. The politicians on the fringes seem to thrive on the differences,
    but I agree with you here.

  37. I couldn’t agree more. It would be so much more productive if we could make a list of what we all agree on and start working on that, instead of obsessing about our differences….

  38. I think, Peter, that people whether Republicans or Democrats want very similar things. I think they disagree on the means to achieve their pursuits, and I think they disagree on the reasons why their pursuits are thwarted, with one glaring exception: our political system is no longer serving the people because it was hijacked by an “establishment” supported by big money.
    I think we can come together to solve this one problem, and sort out our differences later. I have a hunch that once special interests quit stirring the pot of hate, we won’t have too much trouble reaching equitable solutions to satisfy everybody, except perhaps the lunatic fringes on both sides.

  39. “The American people on the other hand are in a completely different boat. Almost a third of us are not working. Half of us have practically no savings and a record number is surviving on public assistance. Wages are stagnating and the middle class is shrinking. Student debt is skyrocketing and 20% of our kids live in poverty. Whereas in the immediate past the economy and the welfare of the people used to be one and the same, nowadays these terms have little if anything to do with each other.”

    Margalit, are, “the American people” Republicans fighting for the same things as angry voters supporting Bernie?

  40. My niece wants to vote for Bernie because he’s for “free” college education. I want to ask her what she thinks that means. College kids are smart, but sometimes I don’t think they understand that nothing is “free” (at least nothing that’s worth anything, Bobby McGee).
    I am all for equal opportunity. While not everyone can be a Donald or a Ben Carson, this country should provide that possibility. It should also reward people for hard work and ingenuity, keeping a safety net for those less fortunate, but teaching them how to fish rather than just keep giving them fish.

  41. The law is about who has the most money, and thus, the most lawyers/lobbyists.

  42. Perhaps the time has come… 🙂

    I’m a lifelong democrat as well, but I will “cross the aisle” in a heartbeat to beat special interests. I view Bernie as the spearhead for what needs to happen, for putting the horses in front of the cart for a change. Yes, throw the robber barons out first, because nothing will change if we don’t do that first. If this “political revolution” achieves nothing but this one thing, it was worth it… Others will follow after him…. I’m just dreaming out loud here of course… 🙂

  43. Equality under the law is too simple of a definition during our times. Is the Citizens United vs. FEC ruling equality under the law? Is flooding the software industry with foreign slave labor, while dismantling unions, equality under the law? Who makes the law? Who upholds the law? Laws that grant favorable taxation rates on capital gains are applied equally… to those who have capital. Mortgage interest deductions are applied equally… to those who have money to buy a home. Are these examples of equality under the law?

    I agree that we should think about local governing bodies, because the corruption there supersedes the one in central government. We tend to discuss central government more often because its decisions are affecting all discussants, as opposed to decisions by the city counsel in Tuscaloosa, which is of limited interest to people in Peoria. And I do understand that those local decisions may very well be much more important (and so does ALEC, or so it seems).

  44. Epic article. Thanks for sharing. As you can probably imagine, I take issue with the general bend, mostly because I think there is another, much larger and equally disenfranchised, “class” that the author neglected to mention, and because his analysis is not 100% applicable to a global economy ruled by multi national corporate giants. You can certainly argue, and I would certainly agree, that these corporations were created by the ruling class, but it’s too late now to shove the cat back in the bag,

    If I had to identify with one olden philosophy, I would classify myself as Jeffersonian (and by the way, the dismissive/insulting attitude towards Jefferson and Madison in Dr. Blumenthal’s article is what triggered the above rant). In view of last night’s Iowa results, and assuming they hold going forward, we will end up precisely where we are now, in which case that tree of liberty may require some refreshing down the road, or it may just wither and die on our shores (most likely).

  45. Sounds great. I’ve told you in the past that you’ve got my vote :). I’m not sure after listening to Candidate Sanders that he has an understanding of the issues beyond “throw the robber barons out”. He’s anti-establishment for sure, but I have significant worries about the establishment he would put in place. Can’t agree with you more about needing repudiation of the current system that isn’t good for patients, physicians, or the national bottom line. I’m a lifelong democrat.. but I’m now convinced that a vote for a democrat in this election will be viewed as an endorsement of meaningful use/macra/mips. We need deregulation at a physician level, a kick in the pants as you say.. perhaps the time has come for that other guy..

  46. “The big question in my mind is what does “equal opportunity” really mean?”

    That is a big question for many, but rather simple if one isn’t a socialist at heart. Equality under the law. Otherwise ‘equal opportunity becomes nothing more than a tool for government to gain more and more power. Why when thinking about government do we have to think about the large central government rather than the smaller state and city entities?

  47. Thank you for raising this heart breaking issue. I can’t imagine that the “savings” from kicking 18 year old children out are more than a rounding error on the managed care CEO paycheck, and let’s contrast that with the ACA provision allowing more fortunate kids to stay on their parents insurance until they are 26 years of age.
    Where on earth is the fairness here and where is our basic human decency?

  48. I do not want macro-socialism or anything reminiscent of failed communist governments. I don’t want nationalization of industries, or one large multi-specialty national plantation.
    That said, I think most of us would agree that government has a role to play, mostly in leveling the field for all citizens to have equal opportunities.The big question in my mind is what does “equal opportunity” really mean? Perhaps the wealthier the nation is the more assistance with opportunity we can provide, and if the wealth was not extract to such appalling degrees, maybe we would have enough resources…
    I’m sure there are many ways to skin this cat, but we can’t even begin the process under the current political system.

  49. Hello,

    I concur that healthcare is no longer about the people, but about a catchy phrase that appears to be concerned with the public’s health. The notion that healthcare is driven by economy is evidenced by how managed care for teens who have aged out of foster care. Youth in foster care are categorically covered by their state’s Medicaid program, but whether this coverage continues after they age out depends in part on where they live. The 1999 Foster Care Independence Act allows but does not require states to extended eligibility for Medicaid coverage to former foster youth until their twenty-first birthday if they were still in foster care when they turned eighteen (Dworsky, Ahrens & Courtney, 2013). Personally, I do not feel that this should be an option for a state. If a child is aged out of foster-care that means that they have spent their childhood with instability and lack of support, why add a basic right such as healthcare to their worries? Healthcare is still a business and therefore involves funds that most teens who are aging out of foster care simply do not have. I think this supports your statement that “Health care is about private equity, mezzanine funding, return on investment, valuations and public offerings.” Because we, as tax paying citizens, generate the funds that support foster care, versus foster care being a business that generates money back into the government, the needs of this sector get ignored. Insightful Blog!

    Dworsky, A., Ahrens, K., & Courtney, M. (2013). Health Insurance Coverage and Use of Family Planning Services among Current and Former Foster Youth: Implications of the Health Care Reform Law. Journal Of Health Politics, Policy & Law, 38(2), 421-439 19p. doi:10.1215/03616878-1966360

  50. Yes, “serious campaign finance and gerrymandering reform”…

  51. I’ll take it from the bottom up:
    There need not be rules aplenty, and certainly nothing like MU. My go to examples for this are Germany and Switzerland. Not single payer, per se, but government moderated universal coverage, with an overwhelmingly private/independent delivery system (small practices and such…). The prosperous “socialist” countries do not tend to nationalize industries, but to regulate them just enough to benefit the public (e.g. no profit extraction from health insurance, negotiated drug prices, etc.)

    Also, I am not necessarily advocating for the “socialist” choice.
    There is that other guy 🙂
    I just think our system needs a jolt, a kick in the pants if you will…..

  52. This election is about all of us, it’s about being a nation of free people vs. a replaceable cog in the global “digital assembly line”, and it’s about our hard fought right to govern ourselves, centrally, locally and individually.

    I agree with much of what you say, but I’m puzzled how you conclude that the champion of democrat socialism otherwise known as the state-knows-best returns power to the physician. Power does need to be wrested from the private sector, but not sure the state will be that benevolent. I get single payer with private physician groups.. But I imagine there will be meaningful use like rules aplenty in this set up.

  53. Ms. Gur-Arie is correct. Tonight’s IOWA vote largely revolves around two major issues- health care and income inequality. Yes- the choice tonight is also about outsiders (major change) vs. the status quo ( more incrementalism). Ms. Gur-Arie is also correct that we are hopelessly stuck on all issues in the US (including health care) without serious campaign finance and gerrymandering reform. The big medical story is still a long way off from being considered or accepted. I call it Organized Medicine’s “BIG LIE” which means that what organized medicine delivers only plays a small role in health outcomes. This has been known for decades but little publicized. A good site that explores this reality is http://www.unnaturalcauses.org.

    Dr. Rick Lippin
    Southampton, Pa

  54. I love your writing but you imply that you want macro-socialism which never works….does it?

    I do think we could make in-patient care a public good run by hospital districts or counties or maybe states. We don’t have enough dough to pay for outpatient care in toto (with exceptions). Put everyone including administrators on salaries. Monopsonize drug purchases. No billing or any paperwork in hospitals except clinical records. Poor districts can merge with wealthy districts until costs < revenue. Feds could help poor districts if totally excluded from control. [laughter here] Ambulatory care would be covered by any method people want but the government would be out of it. The main goals would be to cover–without any transactional friction or hassle–any illness that might 1. kill a patient or 2. disable her or 3. cause her to go bankrupt. Eg lupus would be covered but not ordinary psoriasis. Triage experts would determine admission. Docs are good at this. We need to exclude ambulatory care generally, not only because of its cost but also because it reflects a lot more moral hazard and we need a venue where we can experiment with competition and shopping behavior. However, mental health has probably got to be covered within hospital care.