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Category: Health Policy

America the Schizophrenic

By KIM BELLARD

I must admit, last week’s election took me by surprise. I knew all the polls predicted a close race, but I kept telling myself that the American I believed in would not elect such a man, again, knowing full well all the things he has said and done – in his personal, professional, and political lives.  I was giving us too much credit.

Democrats might tell the public that Wall Street was hitting record highs, that GDP growth was among the best in the world, that unemployment was low, and that inflation was finally back under control, but voters didn’t believe them. For most people, the economy isn’t working.

When two-thirds of voters say the country is on the wrong track (NBC News), when almost three-quarters of Americans are dissatisfied with the way things are going in the U.S. (Gallop), when 62% of voters think the economy is weak and 48% say their personal financial situation is getting worse (Harvard CAPS/Harris) – well, threats to democracy tomorrow don’t compare to the price of eggs today.  

Let’s face it: we are on the wrong road. We’re not on a road that is good for most people. We’re not on a road that is getting us ready for the challenges and opportunities that the 21st century is bringing/is going to bring us. And we’re kidding ourselves about the America we believe in versus the America we actually live in.  Our views about our country are delusional, they’re disorganized thinking, they may even be hallucinations. I.e., they’re schizophrenic. 

For example:

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Medicare’s Hidden Information Hurts People & Policy

By MICHAEL MILLENSON

Open enrollment season for Medicare, which began Oct. 15 and ends Dec. 7, triggers a deluge of information about various options. Since I’m a health care consultant and researcher as well as a Medicare beneficiary, I’ve looked critically at what we’re told and what we’re not. Unfortunately, information crucial both for the individual and for the broader policy goal of moving toward a “value-based” care system is often difficult to find or not available at all.

The most glaring example involves Medicare Advantage, the increasingly popular insurer-run plans that are an alternative to traditional fee-for-service Medicare. Plans receive a quality grade from one to five stars from the Centers for Medicare & Medicaid Services. Those grades are designed to incentivize providing the highest quality care for the money ­— the very definition of “value.” A high grade triggers both a boost in payment from Medicare and a boost in enrollment. Not surprisingly, almost three-quarters of people chose a plan with a 4-, 4.5- or 5-star rating, according to CMS.

Those ratings, however, should come with a large asterisk attached. It’s not just that the methodology can be controversial, particularly when a lower grade is meted out. It’s that the star ratings aren’t anchored in geography, as one would naturally expect; i.e., the rating is for the plan offered in my area. What is colloquially called a “five-star plan” is actually a plan that’s part of a five-star Medicare contract ­­— and those two typically are not the same thing.

For instance, one large insurer contract that I tracked included at least 17 plans scattered across the country. It defies common sense to believe that care quality is identical among plans in, say, Rhode Island, Mississippi, Illinois, Colorado, and California just because they all share the same government contract number.

If you’re wondering who benefits from this not-very-transparent transparency, some insurers have been known to improve the rating of a low-performing plan with a small number of members by merging it into a contract with more members and a higher rating.

In 2024, nearly 33 million people, or 54% of Medicare beneficiaries, were enrolled in an MA plan, according to KFF (formerly the Kaiser Family Foundation). KFF expects that number to increase to nearly 36 million in 2025. It’s a long-accepted truism that “All health care is local.” Medicare beneficiaries deserve local plan information.

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Heat-related illnesses are preventable; here’s how

By PHIYEN NGUYEN & KRISTINA CARVALHO

As we enjoy the crisp air of fall, a harsh reality remains: our planet is heating up. With more frequent and intense heat waves, 57.5 million Americans are living in areas with dangerously hot summer conditions, yet many states remain unprepared for the heat crisis already unfolding.

Impact of Heat on Health

Extreme heat poses a growing health threat, causing more deaths in recent years in the United States than any other weather-related event. Heat-related illnesses (HRIs), such as heat exhaustion and heat stroke, are on the rise, particularly among the elderly, children, outdoor workers, and individuals with certain preexisting medical conditions.

Not all communities are affected equally. Low-income neighborhoods and communities of color, often situated in urban “heat islands,” face greater exposure and have less access to cooling resources.  Moreover, extreme heat worsens air pollution and spreads disease-carrying insects, exacerbating health risks.

Without stronger protections, HRIs will continue to escalate, especially among populations who are already at increased health risks. Heat standards are a key part of the solution.

What are Heat Standards?

Heat standards are regulations that protect workers from excessive heat by requiring breaks, water access, and emergency procedures to prevent HRIs. Yet few states have heat standards in place.

In 2005, California was the first state to implement a mandatory HRI prevention standard requiring water, shade structures, and rest breaks for outdoor workplaces when temperatures exceed 80°F. Employers are also required to educate their workers about HRIs and have additional precautions in place when the temperatures exceed 95°F. A few months ago, California even expanded protections to include indoor workplaces when it is over 82°F inside.

Washington, Colorado, and Oregon followed suit with similar policies, though without indoor regulations. On the other hand, Minnesota’s heat standard only applies to indoor workspaces. But it’s unique in that it also applies to care facilities such as nursing homes and daycares, protecting the elderly and young children. Lastly, Maryland just passed a heat standard that applies to all outdoor and indoor workers across all industries.


All other states, including warm ones like Arizona, have no established heat standards. Texas and Florida have even tried to prevent their cities and towns from mandating that employers provide heat protections like water breaks.

Heat Standards Work!

Although formal studies are limited, there’s enough observational data to suggest that heat standards are effective at keeping people safe and healthy.

For example, California saw a 30% decrease in reported HRIs following implementation of its heat standard in 2005. Similarly, HRI-related medical visits in Oregon dropped by 75% in the year after the state enacted its standard. What’s more, that was in spite of having more days with temperatures above 80°F as well.

In short, HRIs are preventable. And they’re also cost-effective.

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Engineers: Heal Thyselves (and Health Care)

By KIM BELLARD

The article I can’t get out of my head is one by Greg Ip in The Wall Street Journal: Crises at Boeing and Intel Area National Emergency.

I’m old enough that I remember when the Boeing 707 took airline passenger travel from the prop age to the jet age. I’m old enough that I remember that we all wanted PCs with Intel chips when companies starting giving office workers their first PCs. I’ve read enough history to know the storied engineering background and achievements of both. I mean, those B-52s that have been the backbone of the U.S. Air Force bomber command for the past 70+ years: those are Boeing planes.

To younger people, though, Being is the company whose doors pop out mid-flight, or which abandons astronauts in space. When they think of Intel – oh, I’m just kidding; when younger people think about chip companies, it’s NVIDIA or TSMC. Intel’s stock is doing so badly it may get kicked out of the Dow Jones Industrial Average.

So, as Mr. Ip says: “A generation ago, any list of America’s most admired manufacturers would have had Intel and Boeing near the top. Today, both are on the ropes.”

He goes on to add:

The U.S. still designs the world’s most innovative products, but is losing the knack for making them.

At the end of 1999, four of the 10 most valuable U.S. companies were manufacturers. Today, none are. The lone rising star: Tesla, which ranked 11th.

Intel and Boeing were once the gold standard in manufacturing groundbreaking products to demanding specifications with consistently high quality. Not any longer. 

What is most frustrating, Mr. Ip points out, is: “Neither fell prey to cheap foreign competition, but to their own mistakes. Their culture evolved to prioritize financial performance over engineering excellence.”

As an example, in a Blockbuster-could-have-bought-Netflix parallel, The New York Times reports that Intel could have bought NVIDIA in 2005, but the reported $20b price was considered too expensive. NVIDIA is now worth $3.5 trillion. Whoops.

Boeing’s new CEO, Kelly Ortberg, admits: “The trust in our company has eroded,” and that Boeing needs “a fundamental change in culture.” It doesn’t help that its machinists have been on strike almost 2 months, with the union rejecting Boeing’s latest offer last week. Boeing is slashing some 17,000 jobs, considering selling off its Starliner business, and trying to raise as much as $25b. 

Intel has also cut jobs, is trying to beef up its manufacturing through a revitalized foundry business (which some believe Intel should spin off), and has seen its stock crater (down 52% YTD), but CEO Pat Gelsinger vows: “We see the finish line in sight.”

Intel is still waiting for some $8.5b in CHIPS Act funding, “There’s been renegotiations on both sides,” Mr. Gelsinger told The New York Times. “My simple message is, ‘Let’s get it finished.’” But, as former Commerce Department official Caitlin Legacki noted: [There is fear that] Intel is going to take chips money, build an empty shell of a factory and then never actually open it, because they don’t have customers.”  Its much-hyped plants in Arizona and Ohio have both faced setbacks. 

Meanwhile, the vultures are circling: there are rumors that Samsung and Apple may want to acquire Intel.

The trouble is, which is Mr. Ip’s point, neither has any real domestic competition; if either would fail, it would throw even more of our economy to the mercy of foreign manufacturers (or, in its space business, make the U.S. even more dependent on Elon Musk’s SpaceX). That’s the national emergence he is warning about.

My point with all this is not so much to add another lament about the decline of U.S. manufacturing as to emphasize the decline of the role of engineers. Earlier this year Jerry Useem, writing in The Atlantic,  argued: “When the wave of Japanese competition finally crashed on corporate America, those best equipped to understand it—the engineers—were no longer in charge. American boardrooms had been handed over to the finance people.”   

 Mr. Useem points out that a revitalized GE “is belatedly yielding to the reality that workers on the gemba [Japanese term for the shop floor, where value is actually created] are far better at figuring out more efficient ways of making things than remote bureaucrats with spreadsheet abstractions.” That sounds a lot like what Mr. Ortberg is saying: “We need to be on the factory floors, in the back shops and in our engineering labs.”

So what, you might ask, does this have to do with healthcare? 

It turns out that there is something called a healthcare engineer.

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My Father and Arnold Palmer – Embodying Honesty and Respect

By MIKE MAGEE

My father and Arnold Palmer had a great deal in common – and none of it involved golf. They were both men of faith and lived into their 80’s. My father was Catholic, and Arnold Palmer was Presbyterian. But on the day that Palmer died (September 25, 2016), Benedictine Archabbot Douglas R. Nowicki of St. Vincent’s Archabbey in Latrobe, Pennsylvania, was at his bedside.

Nowicki and Palmer’s friendship dated back a half century. He and his wife would often attend 7:30 a.m. Sunday Mass at the abbey.

At the time of Palmer’s death, the Benedictine monk said, “Arnie sort of appealed to everyone. There were no barriers, race, color, creed — those were things that never entered into his mind. He was welcoming to everybody and treated everyone with tremendous warmth and respect.”

But eight years and one month after his death, Palmer’s daughter, Peg Palmer Wears felt compelled to rise up and defend her father’s honor. In the Latrobe Airport, named after him, Donald Trump (according to FOX News) “discussed the golf legend’s manhood and how other players would react to Palmer in the showers.” Specifically, in an effort to relate to the local audience, Trump said, “He was all man. This man was so strong and tough, and I refused to say it, but when he took showers with the other pros, they came out of there; they said, ‘Oh my God, that’s unbelievable.’”

The reaction from his daughter, a registered Independent from North Carolina, was swift. She labeled his words, “disrespectful” and “inappropriate”… “appropriating someone he admires to bolster his own image, people deserve better.” Her words in defense of her father, who was no longer there to speak for himself, called to mind my sister Sue’s Eulogy to our father. It focused on the values and qualities in him that she admired – honesty, hard work, compassion, integrity, humility, kindness, and love for others.

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Health Care’s Endless Loops

By KIM BELLARD

Last week the Federal Trade Commission (FTC) issued its final “click-to-cancel” rule, making it easier for consumers to cancel various kinds of subscriptions, such as gym memberships or streaming services. It will require enrollments to be as easy to cancel as they were to enroll.

“Too often, businesses make people jump through endless hoops just to cancel a subscription,” said Commission Chair Lina M. Khan. “The FTC’s rule will end these tricks and traps, saving Americans time and money. Nobody should be stuck paying for a service they no longer want.”

Oh, boy, Chairperson Khan: if you want to talk about jumping through endless loops, let’s talk about health care.

The FTC rule was part of its effort to modernize its 1973 Negative Option Rule. It had issued a preliminary rule in March 2023, which drew some 16,000 comments. Laura Brett, vice president of the National Advertising Division of BBB National Programs, explained the need for the rule to CNN: “(Consumers) had to jump through hoops online to find out where to cancel. Other times they might’ve been able to sign up online, but in order to cancel they had to call and talk to a representative. Other kinds of memberships required them to actually show up in person to cancel their subscription,”

The new rule is also part of a broader Biden Administration Time Is Money initiative, “a new governmentwide effort to crack down on all the ways that corporations—through excessive paperwork, hold times, and general aggravation—add unnecessary headaches and hassles to people’s days and degrade their quality of life.”

Predictably, not everyone agrees. The U.S. Chamber of Commerce called the whole Time is Money initiative a heavy-handed effort to micromanage business practices and pricing, and warned it would lead to “fewer choices, higher prices, and more headaches.”

But of course they do; I mean, if you asked an AI to create a Chamber of Commerce response to virtually any regulation, it would probably sound much like that.

Critics see politics behind the rule. In her dissent, Melissa Holyoak, one of the FTC’s two Republican commissioners, wrote: “Why the rush? There is a simple explanation. Less than a month from election day, the Chair is hurrying to finish a rule that follows through on a campaign pledge made by the Chair’s favored presidential candidate.” The same could be said of the Biden Administration’s new proposed rules to make over-the-counter birth control to be covered by insurers at no cost to patients.

Be that as it may, we all have more subscriptions than we probably really want, the gym membership scam has been going on so long that there was a Friends episode about it almost 30 years ago, and who among us hasn’t gotten caught in endless loops with supposed customer service representatives – if you can ever reach a live person – about some problem with a company?

Which leads me to health care.

Providing health care has always been complex, as physicians like to remind us, but just trying to receive health care has grown more and more complex over the past several decades (while growing drastically more expensive). Time is Money, the Biden Administration tells us, but in health care, the only people whose time is valued are the people billing us. We are, after all, patients, so we are supposed to be patient.

The FTC, and the Biden Administration more generally, has this right: Time is Money, and that’s our time and our money. The initiative specifically included healthcare – “…the unnecessary complications of dealing with health insurance companies…” – but I don’t think that goes far enough, fast enough.

I like the precept that things should be as easy to get out of as they were to get into, although I want to use that more as a parameter than a restriction in expanding the discussion to healthcare.

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The big guys can’t do HLTH right

By MATTHEW HOLT

This is the week where the digital health landscape debunks to the HLTH Conference in Vegas to meet, do deals, listen to superannuated rappers and generally have a great time. Speaking as the guy who ran the digital health conference before HLTH emerged, I remain extremely jealous of how Jonathan Weiner, Rich Scarfo, Jody Tropeano and team have managed to pull 10,000 people together when Health 2.0 never got past 25% of that size! (And I won’t even mention the premium price they charge!).

I have written pretty extensively about how digital health has failed to develop an alternate to the incumbent hospital, specialty & procedure-based system. 90%+ of digital health companies are now desperately trying to get the incumbents to buy their stuff. It’s as if Jeff Bezos in 1998 was going cap in hand to Barnes & Noble asking them to put in his new online ordering system.

But there is something else that HLTH has not been shy in doing, and that is giving a place on the stage for big companies to explain what they intend to do to change the health system. Amazon, Walmart. Walgreens, CVS, Optum and many more have used that premium real estate to explain what they are going to do. And much like the digital health upstarts, the reality has been very different.

Almost all of those companies’ new strategies are in deep trouble.

Amazon was going to build a hybrid telehealth/home based delivery platform. It got up and running and had some sizable employer clients. It also had a strong relationship with Crossover Health which had great worksite clinics. Not hard at all to imagine that becoming a nationwide primary care platform that could take risk and really cut into the business of the incumbent non-profit systems. After all Dave Chase at Rosetta Stone has been preaching this forever. But at the first hint of trouble, Amazon cut & run and bought One Medical. It’s as if their play in grocery was to go mass market but then they decided that they could make more money from the high end Lululemon crowd that shops at Whole Foods. Oh yeah, that was their play in grocery too.

Walmart, Walgreens and CVS were all going to create mass-market primary care, and move to accepting risk primarily from Medicare Advantage. I interviewed Walmart’s then head honcho of health care, Cheryl Pegus, on stage at HLTH two years ago when she waxed lyrical about how Walmart was the answer to the lack of primary care all over the deep South and rural America. The joke was that by the time of that panel she had already quit and was moving to fresher pastures at JP Morgan! Around a year later Walmart declared that it couldn’t staff its clinics, was losing a fortune on each one, and it tossed the whole business.

Walgreens paid a fortune for VillageMD, then even more for Summit Medical (which included CityMD in NYC). At one point in late 2021, VillageMD CEO Tim Barry told me that their main issue was the execution risk of having to open more clinics per week then Starbucks did at the height of its expansion. Walgreens made a minority investment then kept doubling down on its bet. But three years later it has written off the whole amount ($8bn or so) and its stock price is in the toilet. It’s worth less now than doctor network Doximity!

Both of these companies and CVS have shown that it’s really hard just to get the basics right opening clinics in retail stores. That’s despite the fact that most Americans have no primary care doc and can’t get an appointment with a regular one, and that there’s a captive audience walking into their stores every day picking up their meds.

CVS has the added issue of trying to integrate a decent sized insurer into its operations just at the time when the Medicare Advantage gravy train looks like it is running out of steam. CVS’ CEO Karen Lynch took over Aetna recently and then this past week was dispatched to the cheap seats herself. (Don’t feel too bad for her, she’s getting $4m a year to “consult” with the board). Two things have hit Medicare Advantage. First the government is starting to look into risk adjustment upcoding. CVS, you may recall, bought Signify Health, a company specializing in sending nurses into seniors’ homes to perform said upcoding. Secondly, Medicare Advantage plans had surprisingly little information about and control over their members who were being cared for by their non-risk bearing delivery system (which is to say, most of it). They appeared to be totally surprised that post pandemic procedure numbers ratcheted up and were powerless to stop it. Well, Wall Street noticed.

Similar problems have hit Optum, the engine behind United HealthGroup’s profitable growth for the past decade or so. It’s not just the biggest health tech company in America, it’s also the biggest medical group owner—even if CEO and bumbling Englishman Andrew Witty doesn’t seem to know how many doctors it controls. They are being exposed in Stat on a weekly basis for basically semi-frequently causing their doctors to lie about their patients’ health status, just as the Wall Street Journal accuses their associated health plan of inventing diseases and procedures—all to bill the government more. You can argue back and forth but it does appear that the strategy of buying every medical group it can see and provider fracking appears to have hit a bumpy road.

So if the venture-funded digital health upstarts are no longer changing the world, and the big retailers and Optum aren’t setting the world alight, who is taking the upper hand? Well, I expect that intermingled with the ex-pop stars and amazingly beautiful actresses on stage this week (sorry, but I love Halle Berry!), we’ll see a rash of big incumbent non- & for-profit systems. Look at their numbers. Procedures are heading up. ERs are filling up. Operations are profitable or in some cases, very profitable, corporate jets are being bought, and “reserves” –AKA hedge funds–are growing well due to being stuffed full of Nvidia stock.

All of which leads me to believe that sadly HLTH isn’t about the future of health as much as it’s a retread of its past. Still, I’ll catch you at the parties if you’re there….

Matthew Holt is the founder and publisher of THCB

Kamala will Win The Popular Vote And No One Is Pointing Out That Absolute Certainty In The Popular Media 

By GEORGE HALVORSON

I have been railing against the Electoral College (and the Senate) as anti-democratic forever, and no one much cares. Turns out George Halvorson noticed–Matthew Holt

We all need to remember that Joe Biden got 11,110,258 California votes in the last election and we need to know and remember that Donald Trump got 6,006,409 votes in that state.    

Kamala Harris is on the same track as Biden in every survey and that means she will beat Trump by at least five million votes in that state and she will win the national vote total by at least that many votes because the other vote counts are basically tied and have many fewer voters than California.  

The vote differences in other states like Arizona and Georgia are a few thousands votes but only California and New York have million vote differences and she is clearly winning by millions of votes in each of those states.  

That means that Trump is guaranteed to lose the popular vote total again by millions of votes. 

It’s not clear yet if they can somehow create an electoral college win from those vote totals but it is very clear and absolutely guaranteed for him to be millions of votes behind to start that process.   

Large numbers of Americans will be extremely angry and upset if he loses the popular vote by almost ten million votes and somehow manages to get into the White House with that huge loss and pretends that he actually earned that victory with real votes. He will obviously be the biggest loser on the popular vote  because there’s no way to make up the California and New York numbers.   

That loss is absolutely guaranteed because those two states are doing for Harris exactly what they did for Biden and they are both even less supportive of Trump than they were against Biden. 

The people who see him lose by ten million or more votes and then somehow claim and win the White House will probably protest that result with very visible descriptions of their unhappiness and anger and his ability to lead credibly in the face of that anger will probably be badly damaged and clearly labeled with brand damaging and clear description of what happened.  

It would probably be better for the country if the electoral college results followed the actual popular vote.  

Election night is going to be interesting.  

The huge popular vote win will be visible very early because both California and New York numbers are so inevitable and so overwhelmingly against him that we won’t have to wonder or guess about those numbers at any point in the process. 

The news media should be ready for that massive popular vote difference because we know now that those numbers are absolutely going to happen.

George Halvorson is Chair and CEO of the Institute for InterGroup Understanding and was CEO of Kaiser Permanente from 2002-14

The Clinical Enterprise is the Beating Heart of Health Systems

By JEFF GOLDSMITH

As health systems struggle to emerge from the post-COVID financial crisis, the importance of the clinical enterprise to these systems has dramatically increased.  Healthcare organizations are getting larger, as failing enterprises are absorbed into growing systems. 

Yet clinicians of all stripes but particularly physicians feel a deepening sense of alienation from the expanding care systems in which they work.   In many “wanna-be” health systems, the clinical “enterprise”  is a loosely connected roll-up of independent practices held together by RVU-based compensation plans and a common corporate logo on the door. 

A roll-up is not a credible foundation for a system, but merely a holding action.  If you have lost your clinicians, you do not have a franchise!    

In an age when clinician burnout and moral injury threaten the well-being of care givers, how care systems foster caregivers’ commitment to their enterprise has become the central strategic challenge.  When one looks at the leading enterprises in healthcare- from the Mayo Clinic to Johns Hopkins Medicine – they have one thing in common.  They are not only led by clinicians, but the clinicians there work together both to maintain high clinical standards and develop and propagate clinical innovation.  

This commitment has a direct financial consequence for health systems.  In an environment where an increase percentage of health care revenues are “risk” revenues, having affirmative control over the cost of delivering care is the key to the organization having a future. Ultimately, that control comes not from clever compensation schemes, but from how clinicians behave in working together to manage their patients. 

To be clear, the clinical enterprise does not mean that all clinicians are salaried employees.  In some organizations like Kaiser Permanente, for example, clinicians are employees of the Permanente Medical Groups, a closed panel entity which provides most of Kaiser’s clinical care.   

But in many organizations, clinicians may be independent practitioners or members of affiliated medical groups, but are still actively involved in the governance of the clinical enterprise.  In academic institutions, not all members of the clinical enterprise are full time faculty.  And not all of them have MDs after their names, but are advance practice nurses and other clinicians with post-graduate degrees.  

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Can Someone Actually Be Responsible?

By MATTHEW HOLT

I was having a fight on Twitter this week and it hit me. America 2024 is Japan 1989. 

The topic of the fight was right-wing VC Peter Thiel. In 2001 he put a ton of Paypal stock allegedly worth less than $2,000 into a Roth IRA. The Roth IRA was designed so that working stiffs could put post tax cash into an IRA, grow it slowly and take out money tax-free. (For traditional IRAs you put in pre-tax money and get taxed when you take it out). You may have read the story in ProPublica. Magically Thiel earned less that year than the max allowable income limit (around $100K) to contribute to a Roth IRA, and magically that stock was within weeks worth much more and then, later, hundreds of millions more. Since then Thiel has invested those Paypal returns in Facebook, Palantir and much more, and that Roth IRA has billions of dollars in it that can never be taxed.

My twitter adversary was saying that Thiel obeyed the law. I doubt it, but that’s not really the point. When the Roth was introduced it wasn’t meant to be a loophole that Silicon Valley types could use to hide billions from tax. But neither my twitter “friend” nor Peter Thiel want to take responsibility or pay their fair share.

Japan in 1989 was wealthy and successful and heading off a speculative cliff which it’s since taken 3 decades to dig out of. There were numerous academics pointing this out, but the most interesting analysis was The Enigma of Japanese Power written by a Dutch journalist named Karel van Wolferen. Here’s a summary from wikipedia with my emphasis added

Van Wolferen creates an image of a state where a complicated political-corporate relationship retards progress, and where the citizens forgo the social rights enjoyed in other developed countries out of a collective fear of foreign domination….Japanese power is described as being held by a loose group of unaccountable elites who operate behind the scenes. Because this power is loosely held, those who wield it escape responsibility for the consequences when things go wrong as there is no one who can be held accountable.

In Thiel’s case a collective network of tax accountants, junk philosophers, and purchased politicians like JD Vance ensure that no one has to be accountable. Ultimately Thiel doesn’t feel responsible for paying what he owes. Of course the exposure of Trump’s tax cheating shows that he doesn’t either. And many people find this OK.

Meanwhile I got into it a little with Jeff Goldsmith on last week’s THCB Gang about why hospitals are still paid per transaction when it would be much better for them to be paid some kind of global budget for the services they provide and for doctors to be paid a salary to exercise their best judgment rather than be tempted into providing care just because they get paid for it. Both COVID and the recent Change Healthcare outage put health care providers in a terrible situation financially because they depend on being paid fee-for-service via claims for individual transactions. Did the leadership of America’s hospitals and doctors come out asking for a change to the system? No, they just got a government hand out and begged for a return to standard operating procedure. No one can rationally look at how we pay for health care in America and say “give us more of the same” but there’s no leadership to change it at all.

Talking about lack of leadership, Amber Thurman died in Piedmont Henry Hospital because no-one on the medical team was prepared to give her the D&C that she desperately needed. They were scared of going to jail under Georgia’s draconian anti-abortion law. There are many, many guilty parties here.

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