Wednesday, April 27, 2016


In One Era and Out the Other
Now this is not the end. It is not even the beginning of the end. But it is perhaps, the end of the beginning.
Winston Churchill (1874-1965)
I listened to Donald Trump and Hillary speak after their sweeping victories in the East, and to Donald Trump’s foreign policy speech.   
From these listenings,  I sense the end of  the era of centralized  government and the Nanny state,  big  political establishments left and right,  traditional  elitist and intellectual dominance ,  a timid and hesitant  foreign policy ,  strict liberalism  and stringent conservatism,  top-down media messaging,  health policies dictated by HHS and CMS and  ACOs,   collectivism imposed from above as opposed to individualism bubbling up from below. 

I do not sense the end of dominant hospital systems.  In Connecticut, where I live, two huge hospital systems,  Yale New Haven and Hartford,  each with revenues over $1 billion, have the lion's share of medical markets, both inpatient and outpatient through their central hospitals, acquired hospitals, and peripheral facilities, which feed  the mother ships. 

Elsewhere,  however,  I sense the beginning of an era of dispersed and customer-oriented  markets,  smaller  and more flexible economic entities, a bolder and more decisive foreign policy,  a mix of liberalism and conservative views, more migration of businesses across national borders,  the economic rise of the IT-skilled and the a fall of those not skilled workers, and  an increase in hacking and terrorist related  crimes  and a decrease in physical violence and large scale wars.    

A Dual System
In health care,  I sense the rapid emergence of a dual health system.

One  will be dominated and controlled by government –Medicare, Medicaid, ObamaCare,  and large integrated hospital organizations.  These systems are generally reimbursed through 3rd parties,  and for the general run of patients,  have a significant flaw, high deductibles, which, for many patients, rules them out as a source of care.

The other  part of the system will be  characterized by cash-only and direct care delivered by individuals, small groups, and entrepreneurs offering convenient, personal, and direct care at multiple sites where efficiency is more important than power or size of the organization.  
In many cases,  these smaller outlets will be more economical for health care customers because of skyrocketing health premiums and deductibles, which render routine car unaffordable. 

ObamaCare will survive in the dual system because it has taxpayer dollars to prop it up. But because of surging premiums and deductibles and  UnitedHealth backing out of 34 markets, it is in trouble and financially unsustainable.     Its fate depends on public approval which has dropped to 44% and to politics.   Republicans have vowed to repeal either its mandates or the law as a whole. 

Transitions to More Market-Based Entities
The transition  to a dual, information and data- geared health system,  will not be easy, particularly among those who lose status, income, and benefits.   There will be suspicious and hostile to the information elite, rich people, the well-educated, the  immigrants,  and those with  disappearing jobs, and loss of income and status.
Among some, particularly the millenials,  I sense a revolutionary attitude. The millenials  are now the large demographic group in the U.S.  Many will throw up their hands and shout, “Let the government do it.  Let the government equalize incomes. Let the government tax the rich and the prileged.   Let the government provide Medicare-for-all and free college tuitions.” 
But the past era will  not be resuscitated.  It is breathing its last, for we are witnessing the end of  big government as we know it,  With the downsizing of government and politics,  will come the rise of efficient markets outside of government power and control.

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