OP-ED

The Physician’s Case For Trump

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Brexit has been hailed as a turning point in the history of Western Democracy by a collection of liberal and conservative elites that decry the vote of a disenchanted and ignorant populace.  The greatest threat to democracy in the modern age turn out to be the very same people that make up the democracy.  We are told these are the same forces that propel Donald Trump forward.  It is a convenient narrative that extinguishes any real debate on policy.  If you support Brexit or Donald Trump you are an uninformed, xenophobic bigot.  Yet here I am – an Indian immigrant, a physician, and a lifelong democrat to boot, who sees no other choice than Trump this election cycle.

I must confess that I have no emotional connection with Mr. Trump – his public demeanor, braggadocio, and above all, the coarseness of his manner when he engages opponents are not what are familiar or soothing to eye or ear.  Yet, as a physician who has struggled through the last eight years of policies and regulations that have made my ability to take care of patients more and more difficult, Mr. Trump has taken on the form of an orange-tinged life preserver.

I’ll preface this by saying that I am a liberal who voted for the beautiful dreams of of the rhetorically gifted Barack Obama.  There were too many people who did not have insurance, and health care costs were absurdly out of control.  The silver tongued promise of health insurance for all that would also be cheaper for all was the pipe dream I fell for.  And boy did I fall hard.  It took me years to realize, in somewhat nauseating fashion, that the policy makers never had a clue.  Much is made of a Trump presidency being akin to giving a teenager who doesn’t know how to drive keys to a Maserati.  That’s funny, because in retrospect, that is exactly what happened eight years ago.

The signature achievement of President Obama – Obamacare – has had a massive impact on patients and physicians.  For patients, more people than ever have health insurance coverage.  Yet the quality of that coverage – by design – has meant an ever greater share of health care costs is now borne by patients. Since 2010, deductibles in employer sponsored plans have risenseven times as fast as wages.

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The lowest tier obamacare plan for a 40 year old costs ~$300/month along with a $6,000 deductible.  Since the penalty for not signing up for health insurance is considerably less than this, is it any surprise that those enrolling in Obamacare are sicker and pricier than expected?  As more insurers exit the marketplace, and since the real causes of high health care costs were never addressed, even steeper increases in Obamacare premiums are promised in the years to come.

From a physician standpoint, the early hopes of being the change you believe in have been dashed time and time again. The first clue that the current administration was long  on intent but hopelessly incompetent in implementation was the stimulus package known as the electronic health record (ehr).  While it may have been a success as a stimulus package, it is a good example of a well intentioned policy run amuck.  Almost $30 billion in incentives were appropriated in 2009 to incentivize physicians and hospitals to use an electronic health record (ehr) ‘meaningfully’. This seemed like a good idea, but it became quickly apparent that the meaningful use criteria were anything but meaningful to physicians or patients, and many small practices were simply unable to comply.  Now after spending billions of federal and private dollars to implement the ehr, practices and hospitals are stuck with clunky, poorly designed systems that are meant to bill and comply with regulations rather than help physicians take care of patients. John Halamka, Chief Information Officer at Beth Israel Deaconess notes of current EHR vendors:

“They are devoting their resources to creating software which adheres to the thousands of pages of regulations introduced over the past few years.  One major vendor noted that their programming staff is already booked for the next 32 months just to ensure compliance with existing regulations.    The small amount of free bandwidth that incumbent vendors had reserved for innovation has been co-opted by regulation.”

Unbelievable, the lessons of this abject failure are lost on the current leadership which continues to think the problem with Health IT is not enough mandates.

Sticking with the theme of well intentioned policies that don’t work, 2010 saw the administration push through the Affordable Care Act (ACA), or Obamacare.  The major thrust to lower health care costs was to unleash  an alphabet soup of bundled payment programs – Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), Comprehensive primary care (CPC).  While some pioneer providers have participated in these programs and received generous payments from the government for delivering ‘value’, there is little to suggest that any of these programs will fulfill the original promise to bend the cost curve.  Indeed, after flattening of the health care cost curve relative to GDP growth from 2009-2013, CMS economists noted health care costs rising again in 2014 driven mostly by enrollment in the ACA.  Apparently subsidizing most of the new enrollees in the ACA costs money.  The response from the current administration to these failed programs has been to double down and – I’m not making this up – combine acronyms.  So now we have the CPC + ACO model being sold as the next magical construct by former regulators turned entrepreneur’s.

It is in this climate that Medicare’s new payment system, the Medicare Access and CHIP Reauthorization Act (MACRA) was dropped on physicians.  Perhaps the reason the national media did not pay much attention to what was actually in the document, was because the document is almost unreadable.  Don’t take my word for it. Again, John Halamka, the current CIO at Beth Israel Deaconess, notes:

“the 962 pages of MACRA are so overwhelmingly complex that no human will be able to understand them”.

The attempt made here was to unify the myriad of prior payment schemes that exist, and lay out a timetable for transitioning from volume to value based payment.  Recognize that the primary purpose of MACRA is to cut costs – there must be losers for there to be cost savings.  In this case 90% of solo practitioners are estimated to be penalized (Table 1). Practices with less than 10 physicians are estimated to shoulder 70% of the total penalties.  If I believed that 90% of solo practice physicians were delivering substandard care, I would be somewhat mollified, but in this case penalties accrue based on a physicians access to a performance improvement department, NOT based on quality.

MIPS penalty

The Obama administration, perhaps emboldened by well funded physician advocacy sitting on the sidelines have shown no willingness to fundamentally change course, but instead charge forward with giddy pronouncements.

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Comment on the proposed rule they say, but the underlying message is clear.  The fundamental pillars of the current system will stay, though they may throw some crumbs at patients in the form of tax credits to make the unaffordable care affordable, and at physicians in the form of fewer checkboxes to check off.  It certainly is to be expected that those who designed the current system (with the insurance, hospital, and pharmaceutical lobby at the table) would double down at this stage.  To do anything else would be to admit failure, and these are ideologues, less concerned with the best solution to problem, but rather their solution to the problem.  This is unfortunately not a problem solved by commenting.  If fundamental change is what one wants, this can only happen by firing the current group that guides policy.  Ergo Trump.

While I certainly have misgivings about the bonafides of a real estate magnate turned reality star who has health care bullets rather than a health care plan, I take some measure of hope in Mr. Trump’s willingness to take positions in the health care space that suggest he is not an idealogue.  He has taken heretofore liberal positions when it comes to taking on the pharmaceutical industry with regards to drug pricing, as well as maintaining support for universal health care.  I realize much of what Mr. Trump says may turn out to be magical thinking but as one retired steel worker, (who was a life long democrat) puts it –  “If he accomplishes 10 percent of what he says he’s going to do, then that’s 10 percent more than anybody else is gonna do.”

Much is made of the coming fascist state under a President Trump.  I find most of this to be hyperbole on the scale of Glen Beck warning his followers of the muslim-stalinist state Barack Obama was going to usher in.  Last I checked, over the last 8 years, folks are still able to buy AK-47’s to their heart’s content, and political opponents have not been herded into internment camps.  I have great difficulty believing that the recent Democrat turned Republican who invited Caitlyn Jenner to Trump towers to use whatever restroom she may like will endanger the republic.

So come November, do the responsible thing – Vote Trump.

Anish Koka is a cardiologist in Philadelphia.  Follow him on twitter @anish_koka

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71 replies »

  1. I think the problem with Trump is that he is a carnival barker with no substantive plan to tackle healthcare. If he gives thought to healthcare, it is because someone has asked him a question. A better choice might be the Libertarians who have a structure and a philosophy. At any rate, Obamacare and all it entails will ultimately fail. It’s our job as providers to keep some semblance of sanity by pushing forward in any way we can until this bad tide pushes out to sea. http://www.fixthebus.com

  2. I bet if you voted by mail for Mitt Romney, he’d jump back into the race–even if there were a week to go.

  3. “POTUS has very limited power in this country”

    Trump didn’t get that Memo. “Trust me, folks.”

  4. “By the way, Trump is wayyy to [sic] egotistical to destroy himself in a nuclear war.”

    So, in other words, he’s bullshitting. Like we didn’t already know that about the #BiglyFakeBillionaire broadly. OK, but sabre-rattling brinksmanship gambits don’t always play out well.

  5. Certainly 🙂
    1) The Nixon point was to illustrate that sometimes “horrible” people can do good things for the country regardless of moral judgements we may feel compelled to pass on other people. The opposite is also true by the way. Nixon had his talents and Trump has his (whether you can step back from the propaganda machine and see them or not). At this point in time, we need the Trump talents. I’m a lifelong Democrat, but my party is not something I can be proud of anymore and it’s taking a nasty turn towards something sinister (so is the GOP, but Trump is neither).

    2) Carrying a big stick (and showing up) pretty much guarantees that you won’t have to use it. The reason we are seeing what we are seeing now is that the US has stepped down and left a vacuum in moral leadership. I think that was more isolationist than what Trump is suggesting (i.e. renegotiate deals, not pull out of them; build infrastructure here instead of financing the small war machine that is designed to perpetuate contained conflicts so the military industrial complex can profit from brisk sales)
    I am not advocating for wars. I am advocating for peace. We don’t have peace now. We haven’t had peace for a long time. But I am not advocating for (temporary) peace at any cost.

    3) We disagree Merle, and that is just fine in my book. But please don’t assume that this is an argument between good an evil. Once we do that, we don’t have a democracy anymore, we don’t have freedom and we don’t have liberty. This is a political debate, not a religious one. If your guy wins, I will accept that. If my guy wins, you will have to accept that as well. It’s a privilege to live in a system like this, so let’s not blow it (I decided to NEVER vote for Mrs. Clinton when they asked her in a debate who her enemies are and she blurted out immediately: Republicans – I thought Republicans are my fellow citizens…).

  6. “the entire world is pretty chaotic right now. Much of this is because the U.S. abdicated its exceptional leadership from a fiscal, moral and military strength position. . . .”

    Really? What would you have had the US do? How many wars do you think we can fight at one time? Do you really believe we alone can overcome the radical fundamentalism that has emerged around the world?

    And what do you think an inexperienced, no-nothing Trump can do to overcome today’s international crises? From what he has said, his actions will only increase them! He simply lacks the experience, know-how, vision and temperament to be President.

    Also, glad you brought up Richard Nixon. Your acceptance and/or tolerance of him despite his being a “crook” undermines your very argument for supporting Trump.

    Nixon was first and foremost a master politician who knew his way around Washington and the capitals of the world. He was politically savvy and knew how to get things done. And he understood the importance of international trade. He most certainly was not an isolationist.

    In short, Nixon was the antithesis of Trump—yet you support Trump! Explain that if you can. 🙂

  7. Not so dramatically, as the current President just found out….

    I am willing to give Trump the same “power” all other presidents before him have had, including the “bad” ones (Nixon went to China and ended the Vietnam carnage…. not too shabby for a crook).
    In case you haven’t noticed, the entire world is pretty chaotic right now. Much of this is because the U.S. abdicated its exceptional leadership from a fiscal, moral and military strength position, in favor of ad-hoc appeasement, and blending into the woodwork of “our friends and allies”.
    Speak softly and carry a big stick (not use, just carry) is very good advice and the world relied on America for this. Now we have have a puny stick and speak timidly, and what you see is the result. So let’s make the stick great again…. 🙂
    America is exceptional, and America must be exceptional if you want a peaceful and prosperous world (I don’t like the term world order), but first thing is first…

  8. Indeed, we have checks and balances that limit each branch of government. But the president can use executive actions to dramatically impact and change policy.

    Are you willing to give Trump the power to disrupt and trash the world order? I certainly am not. It’s bad enough that we have some chaos around the world today. If Trump makes only a few of his promised changes, the rest of the civilized world will become chaotic as well. How will this accomplish any of the improvements or changes you are looking for?

  9. Dear Dr. Lundberg (assuming you are the G. Lundberg who served as chief editor of JAMA from 1982-1999), since most of us here are concerned about the state of healthcare, an apology from the AMA may also be in order, given its role in placing doctors and patients in the terrible mess we’re in. Or perhaps a retraction from you for having supported such a self-serving organization?

  10. He never said he’ll do anything on day one… 🙂 Check it out…. He just says he’ll do stuff “quickly”.
    P.S. Do you really want me to start listing the crap the Clintons are engaging in…. while in office….?

  11. Just a reminder, Merle, that we are not anointing an Emperor…. POTUS has very limited power in this country and that’s a good thing.
    I am trying very hard to steer away from discussing the Clintons combo, but when I have to choose between in-your-face grand scale corruption and loud-mouth inexperience, I’ll take the latter every single time. When I have to choose between what was thoroughly proven not to work, and a totally different unknown (opposed by every corrupt actor on stage), I’ll choose the latter every single time.
    People in Ferguson know this patronizing BS isn’t working. People in Flint know they’re being used. People in Chicago know they are the ones doing all the dying and nobody in DC cares. Nobody’s “tapping” into anything here. It’s not fear and “anxiety” that are driving this popular uprising. It’s courage and willingness to take risk so things do change. It’s the same darn thing that elected Barack Obama. It didn’t work the first time around, so we are trying something new… and if this doesn’t work, we’ll try something else…. The more stuff we have to try, the less likely that the status quo beneficiaries will like it…. or survive it.

  12. So Trump Taj Mahal (there’s a name the ordinary guy can relate to) is having a worker strike. Here’s Trump’s opportunity to show us downtrodden pitchfork serfs that he’s for us, that he’ll look out for us and change the way things are and knows how they’re working against us.

    Go for it Trump, sit down and negotiate for your own workers. But wait, he’s a hard negotiator (or so he says) so he’s not there to help anyone but himself – negotiate on Trump we’re waiting for you to take us to Eden.

  13. Have to disagree with you. Her name is Hillary Clinton. Don’t know why you can’t see that.

  14. “I understand and share your concerns about the inexperience of Mr. Trump.”

    Anish, if you understand and share my concerns about Trump, you could NEVER support him!

    While I’m involved in healthcare IT and distressed that we have wasted and continue to waste billions of dollars on systems that will never accomplish total interoperability, I can’t and won’t vote for a US President and Congress based on how they will address a single issue. Their jobs require knowledge and expertise on a wide array of issues facing the US and the world.

    Do you want Trump setting economic and fiscal policy? Trade policy? Foreign policy? Social policy? Immigration policy? Healthcare policy? Do you want him appointing Supreme Court justices? Lower court judges? Do you want him making life and death military decisions?

    The very thought of Trump making such decisions for all Americans scares the hell out of me—and it should scare you, too. Trump isn’t merely inexperienced. He’s a know-it-all who doesn’t and won’t listen to anyone but himself—he said so himself. And you can rest assured that he has only one person’s interest at heart—his own. He simply doesn’t know what he doesn’t know and refuses to learn from those who do!

    You think he’ll improve healthcare. Margalit thinks he’ll help the working class. Others think he’ll help the middle class. How can you honestly believe these fantasies when you look at his record? He screws and sues virtually everyone who deals with him. And he certainly isn’t forthcoming about his personal life. He won’t even disclose his tax returns. Why? Probably because they’ll shatter his contrived image of a successful business man and show how he has taken advantage of everyone!

  15. “he said he’ll cut stupid regulations”

    He apparently missed Article I Day in the Law Skool Department at Trump U.

    More broadly, they ALL claim they’re gonna do stuff like “Repeal ObamaCare and _______________ on Day One.”

  16. I don’t think that the ACA is driving cost up, I know. That’s what the CMS economists said about the 2014 numbers. Apparently if you give more people subsidized insurance they will use it :).
    I’m not against single payer per say – anything that works will do. I have trouble understanding how single payer canada/uk style will reduce cost unless one can figure out the cost side of the equation – why do labs at the local hospital that should cost $10 cost $700? Should we be giving $40,000/year drugs to patients in their 80’s? I don’t pretend to know the answers to these questions, but I do find that the left’s avoidance of the trade-offs that will have to be made by patients is pure unadulterated chicanery.
    Perceptions of intelligence is a subjective matter – you should be careful to label those you don’t agree with as stupid – not because you don’t have that right, but because we are poorer as a society when we silo ourselves in echo chambers.

  17. “I just don’t have faith in these central planners anymore..”

    Some of us never did…

  18. I understand and share your concerns about the inexperience of Mr. Trump. I must point out that the same was said of President Obama, and unfortunately he has demonstrated great naivete over a number of important issues during his term. He implemented a 30 billion dollar emr stimulus which I absolutely supported, but had this implemented by folks who weren’t experienced, and so we basically had a transfer of 30 billion to silicon valley for emr’s designed to do check box compliance – and the information is still silo’d because they don’t talk to each other!! He set up the ACA (that I supported) but left implementation to amateur’s (Read Jim purcell’s excellent THCB post – (https://thehealthcareblog.com/blog/2016/05/08/an-obamacare-november-surprise/) which means the risk pool is screwed up.
    I freely acknowledge this was not going to go well, and I was patient. I believed the smartest guys in the room would certainly figure it out, and learn from their mistakes. That absolutely did not happen. Instead we have delivered to us MACRA. Read Mrs. Clinton’s health care ‘plan’ – I challenge you to tell me if that will make the current situation better or worse. I am not a free market absolutist or a universal single payer zealot, and I don’t make decisions based on imagined personal animosity (I don’t know her at all). I just want solutions that are good for patients and their physicians. For instance, why can’t health savings accounts be used to pay physicians directly? If you are for a health care mandate why shouldn’t there be an option for a catastrophic only plan without all the bells and whistles? Should we stabilize the ACA risk pool by changing the cutoff for age of dependent coverage from 26 to 21? If these were the issues being brought up by Mrs. Clinton I would agree with your contention of her knowledge, and skill. I just don’t have faith in these central planners anymore..

  19. I don’t think it’s selfish or narrow minded at all. He’s actually admitted he’s sorry he voted for Obama. Why does he need to retract or apologize for his choices, it’s a free country isn’t it? You may not agree with him, but he’s put out his reasoning here.
    By the way, Trump is wayyy to egotistical to destroy himself in a nuclear war.

  20. “Eventually people will come for you.”

    Yeah. Again, read Paul Mason, and some David Graeber.

  21. Well, he said he’ll cut stupid regulations that are strangling small business. I would propose that MACRA and all the exploding bureaucracy under HHS should go to the front of the line…. may just be enough to take care of another decade of trust fund solvency…

  22. Beware of those that would make this election a simple choice between good and evil. If I believed as you did that Trump would start a nuclear war, I wouldn’t vote for him. By the way, Nawaz Sharif, the pakistani prime minister currently has ‘first strike’ capability in the powder keg that is india-kashmir-pakistan. I am more worried about him than I am about the liberal from New York who other than Rand Paul is likely the least interested republican in being the world’s police. I’m not an ideologue, I could be convinced by reasoned arguments – make them. Heck, I’d probably still vote on the left, if the mainstream left didn’t just keep doubling down on ‘solutions’ that are not working for the average american. Almost half of all americans are not able to deal with a $400 emergency. I, and you, should be appalled at the current elite on the left and right that continue to push us to play a game that is rigged against the little guy. The call for retraction is unfortunate – we need to protect forums for reasoned debate. I have learned the most from those I have disagreed with..

  23. I’m not a fan and certainly not a boy… 🙂
    40% in the GOP primary is pretty good in a field of (realistically) 8 or so, and either way it is the will of more people than any GOP candidate ever represented. He’s got a long way to go before we can say that he represents the will of most people (or at least the will of the electoral college), and he may never make it that far. The voting suppression machine and its well funded propaganda frontispiece is working flawlessly.

    (See my other comment from a few minutes earlier in reply to Peter for why I am all in on an extremely flawed candidate).

  24. Which is great. That’s why we still have elections. You vote your interests and I vote mine, like Harry Truman said we should do…. It may be useful to note though that the leader you say we DO need does not exist or at the very least is not running in this election… so, yeah…

  25. See my response to your other comment. I think I inadvertently answered these questions there…. I got carried away a bit… 🙂

  26. Actually Blyth doesn’t like Trump at all, but he understands why “Trumpism” is happening.

    I agree with you that these things are cyclical. The American revolution started this way. Those guys did not spend their previous lives (and arguably future ones) defending the people. They just seized a pitchfork moment. How on earth does a rich, slave owner write something like “all men are created equal”? Did he mean it? Did he practice it? Did all the other rich boys in the room mean or practice it? No, no and no. But it worked (on and off) for 200 years. It is perhaps not by accident that he became a fan of periodic revolutions….

    The mob I want to run with is the working class. If you watch what is happening now, Trump is essentially running against both parties. He is not a conservative and certainly not a neocon. He said what needs to be said to get the nomination of the weakest link party. He could have run in the Democratic primaries if the circumstances were different. He is now running to the “left” of Clinton on many issues. I would suspect that he has no ideology in particular, other than “please hire me to fix the economic mess we’re in, because I know how to fix it. I am a shrewd and merciless SOB, made tons of money for myself and I am now pledging my skills and honor to do the same for you because I’m 70 years old and have no mountains left to climb, or because I don’t want my grandchildren to grow up in a banana republic, or alternatively because I want a place in history as the man who restored America to its rightful greatness”.

    Either way, I’ll take it. After the tables are scrambled in DC, and they most certainly will be, we can regroup and figure things out until the next pitchfork moment. I do think that it is imperative to seize this one though, because if globalization is allowed to proceed beyond a certain point, there may never be any pitchfork moments available to “us”. Would I have preferred a Thomas Jefferson? Of course, but we don’t get to pick these things. We never did.

  27. Read the Patrick O’Brian novels of the exploits of Captain Aubrey….extraordinary literature.

    I’m with you Margalit and Dr. Koka…..all in on Trump…..and I am hopeful he keeps Dr. Ben Carson as a close aide as he moves to reform the health care system.

  28. Trump garnered about 40% of the votes in the GOP primary. Definitely not the will of the people. He has the highest unfavorables ever recorded. Not the will of the people. This is a guy who has never done anything for anyone unless he was getting paid for it. Not a man of the people. I really don’t understand you Trump fanboys.

    Steve

  29. “…and also try this for the lynch mob”

    I like Mark Blyth and have watched his other video on austerity – he has good entertaining insight helped by the accent. Doesn’t mean he’d love to live in a Trump world.

    I know “us” underclasses are being played by the monied but that’s history. Each pitchfork moment is led by a self serving politician elbowing his way to the front on the line – only to put us right back to the beginning.

    Look; money, influence, connections, always trump voting. Here in NC we had 40+ years of Democrats who got so corrupt that most people started noticing and threw the bums out for total Republican rule. Now we have their gerrymandering, cuts to public education, anti LGBT hate policy disguised as “bathroom” privacy, more anti union policies, anti local decision policies, less environmental protection and on and on.

    Is this the “mob” you want to run with? Is Trump your, “Mr. Smith goes to Washington”? Is he the guy that has fought for the little people in his 70 years? maybe we’ll all get a free seminar from Trump University, you know, the school to make the rest of us rich.

  30. “I want “my” democracy back”

    Margalit, describe “your’ democracy. Is idea the same as the loonies in the Republican Party who voted in Trump? Is it banning abortions, dismantling Medicare/Medicaid/SS, worse access to healthcare, walling borders, spying on Muslims, trashing international agreements, putting women in their place, a gun for everyone, Christianity for all, ………….?

    If this is your group of democrats then you’d better be careful cause they’re coming for you.

  31. Be careful what you wish for, Margalit. IMO, if Trump were elected and implemented half of his economic programs, the recession of 2008 would look and feel like a walk in the park!

    Yes, we have serious social, political and economic problems but Trump has no understanding of them or how to solve them. His gun-slinging approach, honed in his wonderful business experience, is precisely what the world DOESN’T need. Like it or not, we’re all in this together and I’m not at all willing to elect an egotistical, unprincipled and undisciplined person like Trump as our president.

    What we DO need, is a leader who knows how to right the ship, grow our economy and calm the world order. Trump would do just the opposite!

  32. Sure and you try this guy: youtube.com/watch?v=nwK0jeJ8wxg

    Four glorious minutes that put everything together better than I can ever dream of… and he’s a Professor of political economics, so he’s got credentials (no he’s not supporting Trump, so you’re safe… 🙂 )

  33. …and also try this for the lynch mob (4 minutes of lovely Scottish accent from Prof. Mark Blyth) youtube.com/watch?v=nwK0jeJ8wxg (just copy paste in the browser address bar – it will go there)

  34. Given the way Paul Ryan and the rest of the Republican “establishment” are responding to the Trump candidacy, I don’t think there is any chance in Hades that their agenda is ever going to become law. Besides, Ryan’s new plan is just Ryan’s old plan, complete with obliteration of Medicare, and Trump strongly opposes any changes to Medicare and SSN. [As an aside, what worries me lately is how this administration keeps singing the praise of Medicaid, referring to it as America’s health plan. Another reason to put an end to this particular roadmap.]

    I am actually voting for Trump. I realized last fall that there are only two choices that are representative of the will of the people. I was hoping to see a Trump-Sanders general election… It wasn’t meant to be.
    I wish the two old men could get over their stupid and largely irrelevant or manufactured differences, run on one ticket, and make democracy great again…. We’ can sort the rest out later… Probably isn’t meant to be either…

  35. I can only speak for myself, but I am not trying to convince anybody to do anything, other than perhaps form an independent opinion not mediated by propaganda spewed by the media which is entirely owned and operated by the global money cartel.

    Oh, and I do want to see economic and political chaos, i.e. disruption of the current “world order” where the richest 1% has as much wealth as the rest of the world combined.

  36. “Trump University,” “Trump Institute,” “Trump Network,” “Trump Baja Resort.” Four dispositive episodes of outright (and rather unoriginal) grifter fraud. Beyond his obvious pandemic Dunning-Kruger policy and Constitutional ignorance and all of the other gaudy tertiary crap, add in explicit advocacy of war crimes, that’s all I need to hear.

  37. You have got to be kidding, right? What a selfish, narrow minded post. You would give Trump the right/power to wage first attack nuclear war? To wage international trade war. To rape the economic welfare of naive ordinary Americans? Please publish a retraction along with an apology.

  38. This blog, these comments, Margalit’s blog the other day all astound me! I can’t believe that intelligent, thoughtful, caring people would even think of voting for Trump let alone try to convince others that he is worthy of their support.

    He along with Bernie Sanders has clearly tapped into a well of anger and frustration but, to me, neither understands the issues nor has a clue how to solve them.

    Haven’t you read or heard anything about Trump’s dishonorable, disreputable business activities? He chisels and cheats everyone with whom he does business. Do you know of anyone else who has been sued more than 3,400 times? He’s nothing more than a blowhard huckster who cares about no one or anything other than himself. Would you want to enter into a business relationship with him? He has no integrity, honor or leadership skills, and absolutely no knowledge of the issues or policies that make sense. And you want to entrust him with the most powerful position in the world?

    His isolationist views may appeal to some but if implemented along with his other insane idea of devaluing our debt and imposing tariffs on goods from other countries, would throw the world economy into a recession/depression that would make the Great Depression look like child’s play!

    We need a president who understands what is needed and how to get things done with a Congress blocked by single-issue ideologues. And there is only one person who can do this. It’s Hillary Clinton. She alone has the experience, knowledge and skill we need to lead this country in these incredibly troubled times. You may not like her personally, but she will move us forward and build on our strengths. And she most certainly will NOT lead the world into economic or political chaos!

  39. Okay, but you need to check out those two things I mentioned below in reply to Peter. .. 🙂

  40. For some reason, Peter, I can’t post links here, but please google two things:
    Matt Taibbi in Rolling Stone today: In Response to Trump, Another Dangerous Movement Appears
    HEATSTREET British MEP Daniel Hannan Spent Nine Minutes Smacking Down CNN Journalist

    I understand the problem, Peter. But if I have to pick one, I will pick the lesser evil… I want “my” democracy back and I know it’s a long shot… or maybe no shot at all, but I can’t just sit back and accept this and I can’t just let their “media” define reality for me.

  41. Trump knows very little about health care. He will be reliant upon his Congress to develop any changes. To see what they will look like, go read the position paper just put out by Ryan (link at end). Their “plan” is not very long, or very detailed. Read the whole thing. If you don’t like the large deductibles in Obamacare, you will dislike this plan even more. Not really surprising since high deductible plans have been part of most GOP plans. Remember high risk pools? Have any relatives die while waiting to get into one of those like we did? Yup, they were a failure, but this time they will work just because. Selling insurance across state lines? Insurance companies can do that now. There is a reason they don’t.

    So, as a physician I cannot see any reason to vote for Trump. If you take even a few minutes to read about what will happen, there is zero reason to vote for him. And that is just on health care. He is wrong about so much more. That said, while I don’t understand voting for Trump, I certainly understand voting against Hillary. She is an awful candidate. I can respect someone who says she is so awful that they will vote against her. But actually vote FOR Trump? No way.

    http://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf

  42. LOL. yeah, the TSA “heebee jabbies” lady. It was a McCain event Obama “he’s an Arab” Moment.

    But, “we’re looking into it. We’re looking into a lot of things.”

    BTW, Google “Trump Baja Resort.” The hits just a-keep on comin’.

  43. “my first choice was neutered by the “machine””

    Do you really think the health care industry would have let a socialist supporter of single-pay national health get anywhere? Where have you been for the last 7 years, where Obama has been hog tied by the House/Senate Republicans who think denying him any morsel of success will make the country better.

    It’s all a machine Margalit, a corporate money machine that Bernie was in denial about because he thought he could be king in a money driven faux democracy. Even Obama couldn’t bring himself to jail the mortgage lender crooks – because they provide election money. Do you think Trump would have jailed those who gave him investment “opportunities”?

    But look what happens when the lynch mob votes en bloc – Brexit.

  44. [1] It wasn’t from the media. It was just people in the crowd. It was weird…. He just let people in the crowd ask questions on a whim and he did that before (a lady asked him to apologize to Native Americans back then, and today some old dude started railing against the “Zionists” and some woman complained about TSA hibbies (or something)… I thought he was very gracious in his responses)
    [2] I am not in the Benghazi crowd…. not from that angle. I just feel it in my gut that if this woman becomes president, there will be war…
    I’ve seen war. I hate war.
    Business people rarely go to war. Let him fix the economy…. That’s what he really wants to do. So I say have at it buddy, because it can’t get much worse…

    I agree about the better choices. As I said before, my first choice was neutered by the “machine” (he can’t even bring himself to mention her name now, let alone endorse).

  45. “The silver tongued promise of health insurance for all that would also be cheaper for all was the pipe dream I fell for.”

    You fell for Obama’s fall back plan because the insurance/doctor/hospital lobby would not have stood for what really works – in Britain, and most every other nation – National Health? You’re more naive than you imagine. You think the ACA is driving costs? You think sans ACA we’d have cheaper insurance/care costs?

    Vote for Hitler, he’ll make the trains run on time.

    The fact is the world is getting smaller and harder to control because it’s uncontrolled population is getting bigger and stupid policies are driving refugees of all stripes to places of sanctuary. The deniers think we can all act independently to make our piece of the planet better for us, not them, but can’t see we must act as a planet to make this last as long as natural law will permit. Global warming, another EU trick to take our money.

    How come even Brexit voters woke up the next morning and said – “Oh my god, what did I do”? Why does the chief cheer leader of Brexit, Boris Johnson, not want the party leadership to “guide” Brits to the promised land?

    Brexit was a lie as is Trump, the ultimate flim-flam man. You fall for the easy path sales pitch of a carney huckster. Not sure if you’re more stupid than naive, but your “MD” does not translate to intelligence.

  46. We now have an ex-President and Vice President who cannot set foot in Europe owing to their criminal liability for the suborning of / commission of war crimes. The guys that came up with “extraordinary rendition” and “enhanced interrogation” and “enemy combatants” asserted to be outside the purview of Geneva — EVEN if they were U.S. citizens.

    To the extent that ANY combat technology results in “collective punishment” and/or unintended collateral damage it can be argued to be a “war crime.” And, to the extent that armed UAVs have a “Sensitivity vs Specificity” problem in the wake of ops against individual military human targets is really not actually a new problem.

    Finally, I am 70 years old. I have been paying close attention to politics for more than 50 years. I don’t need help understanding that pols routinely say one thing and then do another. But when Trump repeatedly and unequivocally states his affinity for and intent to order torture as President, I don’t need to hear anything more.

  47. [1] Well, we’ll just have to disagree with respect to what comprises “engaging in vigorous debate.” Taking and summarily blowing off (usually in crude dismissive fashion) hard shots from the media because you just don’t give a shit because you think you have all the answers (that you need not detail), isn’t in my definition.

    [2] w/respect to Hillary, point taken (re the no press conferences thing). To a degree, though. I watched the entirety of her 11-hr testimony before the Gowdy Benghazi committee. When the time comes to throw down with Trump (the only engagement that counts), she will be more than up to it.

    To be clear, I am simply an “Anybody But Trump.” Wish we had better choices.

  48. What disdain would that be? I just watched him today take unvetted questions from a bunch of unvetted people, live in front of all TV cameras. Got served a couple of doozies too… Never flinched… and this is not the first time he opened the mic like that either…. Waiting for similar willingness to engage on the other side(s)…. Crickets….

  49. Yeah… I can understand and respect that. Unfortunately for me, I already voted for someone who, according to some people, is actually committing war crimes. Personally, I am not sure if drone assassination is a war crime, but it has a very unconstitutional flavor….
    Point is, Bobby, that what they advocate or rather rant about on the campaign trail, and what they actually end up doing, are two vastly different things.

    P.S. Just saw Dr. Koka’s response below so I apologize for the duplication.

  50. Not gonna argue with that. Except for the problematic “right of self-defense” wrinkle.

  51. Thanks for the reply. But, let’s not drag in the tu quoque fog machine. And, Trump’s disdain for “vigorous debate” is by now itself beyond any rational debate.

  52. “Perfectionists”? Straw Man. And, as for the poignant Libertarians, they will certainly blow their opportunity here. Count on it.

    I simply will not vote for someone who advocates the commission of war crimes. Whether he “really means it” or not.

  53. Just read your blog – good read!
    I don’t advocate war crimes – and I don’t agree with every single thing that Mr. Trump says – but do you agree with everything Mrs. CLinton or POTUS does/says?
    Do you support drone attacks carried out by POTUS? Could these be classified as war crimes? Israel routinely knocks down the houses of terrorists – I don’t support this, but I certainly understand the challenges faced by Israeli’s with regards to deterring jihadi’s convinced they’re going to heaven. I don’t want to get stuck in the weeds here, but the simple point is that sometimes there are real issues here that deserve vigorous debate and discussion (kind of like what’s happening here) without simply labeling someone a racist/bigot. You note in your blog that Trump is trying to alienate the entire muslim populace, but unfortunately anyone that tried to say that the Orlando attack was related to a brand of islam that would behead the both of us – was also labeled as turning against all of islam. Racism/xenophobia at this point has lost all meaning – is it not ok to say the orlando attack was about Islam AND about guns. Does it have to be one or the other?? Is 53% of Britain driven by racial animus? Defeat Trump by talking about the issues – give the folks left behind by globalization some real options. Give me an option to not do MACRA… not just give my comments on it.

    I’m anxious to have a conversation on healthcare and policy. I know based on your scintillating comments on thcb you’re not a fan of current policy. How can you continue to complain about what is so obviously wrong now, yet vote for more of the same?

  54. …and then there were two 🙂

    To the perfectionists looking for St. Francis of Assisi to run for POTUS, please remember that many of our best presidents in the past were horrific people by today’s self righteous standards, and if this is not good enough, then remember that sometimes one nail drives out another….
    The choice is pretty stark here: do you want House of Cards or do you want Trump Towers? Neither is ideal, but one is worse than the other… pick one…

    P.S. People who believe in good solid government cannot and should not ever vote Libertarian, which is as much (if not more so) a wasted vote as a vote for Dr. Jill..

  55. LOL.

    Seriously, fed-up Hillary haters should vote Libertarian. The Green Party would be throwing away your vote. The #BiglyFakeBillionaire is not a sane choice.

  56. I’m going to vote for Mitch Daniels for president even though he isn’t running.

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