Silence Not So Golden

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

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

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

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

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

Red, White, and Blue

Imagine the United States as a red sea with blue coasts and scattered islands of blue.

The sea is turbulent with white -waves splashing up against the blue coasts and engulfing or threatening to swallow  islands of blue.

Imagine these environmental scene in political terms over the last 8 years and the changes it has wrought.  Under Obama, there are 11 fewer Senate sets, 60 House seats,  14 fewer governorships, and 900 fewer seats in state legislatures.  Now that is a sea change. 

Turning the red seat blue again will be difficult.  It will call for changing Middle America's attitudes towards centralized government.   It will pit the forces of prosperity against the forces of equality.  It will call for Americans to trust Wall Street,  progressives,  academics,  and the elite more than their gut and desire for a place in the sun again.   It will be the desire for choice,  freedom,  and opportunity against mandates, controls, and regulations.  It will require Democrats to discard its aging leadership and its Clintonism attitudes for younger leaders who pay more attention to the need for more economic growth in the nation's midsection where pride in America still reigns supreme.

Private Independent Practice; The Way It Was , When Time with Other Physicians and Patients Counted

The November 10 issue of the New England Journal of Medicine has an article :The Meaning and the Nature of Physicians' Work."

It opens with this paragraph:

" Medicine was a fundamental order.   Doctors' lounges were central locations  where community internists, specialists, and surgeons ate together, socialized, and 'curb-' each other for patient consultations.  Charts were dept on paper and were often indescribable."

I expressed this picture in my 1988 book And Who Shall Care for the Sick:  The Corporate Transformation of Medicine in Minnesota."

"Remember the good old days  when your fellow physicians were collegial colleagues; when hospitasl were charitable institutions catering to the sick; when youir success depended on your reputation among  your peers; when you built reputations in a year or two and paid off your banker; when you and your office girl handled all your office affairs; when word of your medical skills spread by word of mouth from one patient to another and from one doctor to another; when you were one of the few specialists around; when marketing was unnecessary because being a doctor with good bedside skills was enough, and when advertising was enoggh.  Those days are over for you and hospitals."

And I might add, the gathering of doctors in hospital staff rooms to compare notes, to make referrals to enjoy doctor-to-doctor camaraderie, to share the jobs of practicing medicine are over over.  Now, as a primary care physician you are forced to stay in your office to make ends meet and to make electronic heath record entries and to make 3ends meet because of Medicare, Medicaid, and Health Exchange cuts.  You now have to hand over your hospitalized patients to hospitalists.

Why is this?  Well. it has to do with the corporate transformation of medicine, and the demands of documentation over the needs of doctoring,  Medicine has become a huge business, comprising nearly 20% of GNP.   And it has to do with the ingress of the Internet and the availability of data to anybody and everybody, including insurers, government officials, and consumers themsleves.  And above all else, it has to do with time - the time formerly  spent face-to-face with colleagues in hospital staff room and time spent with with patients.

As the authors of the New England Journal of Medicine piece comment:

" We believe in the coming years, the U.S. medical community will hve to rethink the human-computer interface  and  merge the real patient with the Ipatient. We hve the opportunity to radically redesigned rmedical record systems; initially created for fee-for-service billing, as our organizations shift towards bundled payments, capitation, and risk sharing.  Perhhaps virtual scribes and artificial intelligence  will eventually  reduced our documentation burden.

And perhaps not.   Perhaps the majority of physicians will switch to direct payment and concierge medicine to escape the time-consuming hassles of electronic health records.  If the Trump election reveals anything, it reveals the unpopularity of EHR data among physicians accounts for much  of physician discontent because it consumes time away from patients.   It reveals data documentation has its limits,  as revealed by the false predictions about the election outcome among across the media, policy makers, pundits, and Silicon Valley aficionados.  Data reliability is limited by human data reliability.   The American middle class and blue color workers between the East and West Coasts in fl-over-land  does not rely on or care bout dta.  They car about their livelihoods, their families,l and their cultural traditikns.


As the New England Journal authors conclude,   Among physicians, "technology cannot restore porfessinal satisfactions.  Our professional will have to rebuild a sense of teamwork, community. and the ties that bind us together as human beings.   We believe that will require spending more time with each other and our patients, restoring  some rituals that are meaningful to both us and the people we care for and eliminating those that are not."

Time spent with one another, in other words, is of the essence, and cannot be replaced with data.

21 Reasons Why Trump Won Election

The American people had grown sick and tired of:

1.  Of being talked down to in condescending, contemptuous, and deplorable terms.

2.  Of being told what to do, how to live, and how to think.

3.  Of being called bigots, racists, sexists, misogynists and for being belittling for using "politically incorrect language of for simply being evangelicals and Catholics.

4.   Of being regarded as "stupid" about politics; as one millenial in Nevada commented for not joining a health exchange that charged twice what it would cost for simply paying a mandated penalty, "We may be young.    We may be healthy.   But we are not stupid."

5.  Of being incapable of  understanding the nuances of politics and money and federal control.

6. Of being over-regulated and over-taxed and over-controlled  by centralized bureaucrats in Washington.

7.Of being mandated to pay financial penalties for not being insured in order to pay for the care of the sick and elderly.

8. Of being promised explicitly and falsely by the President that they could keep their doctor, health plan, and hospital  ant that where premiums would be $2500 less for a family.

9. Of being told that gainful full-time employment would steadily and inevitably rise even though 95 million Americans had quit looking for a job.

10.Of being deprived of the opportunity to choose their own doctor and health plan or that they would only have the choice of one or two health plans.

11. Of being unable to shop for health care outside of narrow networkds and plans outside of their state of residence.

12.  Of not being informed that every region of the country ultimtely had to have a homogeneous standard of care.

13.  Of being lectured that because of the global economy their wages would be leveled or frozen through integration and trade agreements or that thier job might be eleminated.

14.  Of being instructed that America was not longer an exceptional nation of freedom and opportunity and its neo-colonial nature should be a subject for apology.

15.Of being told that a systemic war on women was being waged by American men.

16. Of being conditioned to believe that independent physicians , acting alone without third party guidance, were incapable of delivering high quality care and must be replaced by teams of data-driven supplemented "providers".

17. Of being informed that only the media, political, academic, financial, or management "establishments  had the wherewithal and know-how to do what was best for the health of the American people.

18.  Of being indoctrinated with the concept that a coalition of vocal  minorities could dominate and silence a mute majority.

19,  Of being told that a combination of solar, wind, and electrical cars would  could supplant American fossil fuels as a source of  affordable energy for American households.

20. Of being pounded with the idea that ordinary blue collar workers  lacked the common sense and technical skills to build and sustain an entrepreneurial, innovative, and fair and balanced  capitalitstic  economy for the common good.

21.   Of being divested of the fact that the greatest compromise of the western world,  the U.S. Constitution, with its checks and balances, still is the best instrument for serving a diverse democracy.

New York Times Ridicules Trump

New York Times Ridicules Trump

Well, it’s one day before the election.  The New York Times,  the Bible of Progressives,  is taking its final shots at Donald Trump, portraying him as a dangerous demagogue while praising Hillary Clinton as a demigod destined to save America’s future in a dangerous world.

To wit:

·         Farah Stockman and Nick Corasanti : “The Steep Costs of Bitter Barbs: Global Prestige.”

“America’s image stands tarnished in the eyes of itw own people and the world…Rarely has its political system subjected to such widespread scorn and ridicule…In Europe 85% of people in a recent Pew Research poll have no confidence in Mr.Trump doing the right thing regarding world affairs.’ “

·         Frank Bruni:  “Why This Election Terrifies Me”

“The America on display on this election  isn’t a fair and ethical place and it seethes with hatred…His incendiary words and unconscionable  silences give a green light to bad actors; the anti-Semites who harassed Jewish journalists on Twitter; the white nationalists who threated to intimidate minorities at the polls; the misogynists  who hurled inprintable slurs at Clinton.”

·         Nicholas Kristoff: “Reasons to Sy: ‘I’m With Her,’ “

“There are strong grounds to vote for Clinton regardless of her opponent. ..Of course, for many, the greatest appeal for Clinton is that she’s not Trump.   He simply falls outside the norms:  A Fraudster who seems a racist, who has cheated people at Trump University and regularly through his career, who boasts of sexual assaults and whom 17  women have accused to improper behavior, who has flip-flopped 138 times by one count and who lies every 5 minutes by another, and who has less public servie than any incoming present in history.”

·         Times  editorial board” ”Imagining the Country on Nov.9.”

“It is a history of coded-race baiting that puts the Republican establishment in lock-step with the Alt-right, the Ku-Klux Klan; the racists and misogynists and nut jobs…For some it simply Clinton hatred that allow them to jusifiy support for a candidate that stands for torture, reckless war, hatred of women, immigrants, refugees, people of color, people with disabilities.  A sexual predator a business fraud who runs on a promise to destroy millions of immigrants and to jail his opponent.”

Had enough of left-wing hatred and Trump character assassination.  I have.

In its characteristic fashion,  The Times, its reporters, and columnists fair to mention:

·         The slowest economic recovery from a recession in 49 years,  with no annual growth of 3 %.

·         94 million Americans who have quite looking for work.

·         The highest business profit tax in the world which has caused corporations to park $3 trillion overseas because of the absurd 35% tax on corporate profits.

·         A doubling, even an sextupling of health care premiums accompanied by unaffordable deductions with less choice of providers,  and an explosive doctor shortage.

·         An angry voiceless American middle class crushed by a stagnant economy and for frozen wages who feel a loss of liberty and freedom  under an administration and a successor who vows even more relations and higher taxes.

November Bombshell

Wikileak surprises keep coming, but biggest bombshell may be premium increases, due to kick in on November 1.

Premiums will go up an average of 25% but will increase dramatically in some states – Arizona 116%, Oklahoma 69%, Tennessee 63%, Minnesota 59%.  

These increases are significant because  Obama promised premiums would decline by $2500 per family and consumers would be able to keep their doctor and health plan.  Neither promise has worked out.

So we are left with this situation- broken promises and narrow choices of doctor and premium and deduction spikes the middle class cannot afford.

Bill Clinton says ObamaCare is “crazy” with 25 million  Americans more uninsured being subsidized but many more millions suffering double, triple, or quadruple  unaffordable care.    Governor of Minnesota,   Mark Dayton,  formerly a fervid ObamaCare supporter,  says the health law is no longer affordable and must be changed, even repealed.

What’s gone wrong?

Dubious. Even false assumptions.

Assumptions

One,  ObamaCare would be a step forward towards universal health care.   Instead studies in two states,  Vermont and Colorado,  have shown universal care in their states would be exorbitant and unacceptable to their citizens.

Two,  ObamaCare would prove to popular with public.  Instead more than 500 polls have shown only three polls indicating favorability among the public.

Three,  one could tinker with insurance risk factors, such as excluding those with pre-existing conditions from calculating  premiums  and making it impossible to charge women more than women.  So, we have an unbalanced system with soaring premiums.

Four,  millenials would join health exchanges and pay costly premiums rather than fork up $695 for not being covered.   Wrong again.   Premiums cost twich as much as the penalty. As one millennial said,  “We may be young but we are not stupid.”

Five,   by crowding doctors into Accountable Care Organizations and having those organizations  being led by primary care doctors beholden to hospitals,  one could save Medicare money.  This hasn’t worked out yet,  and many of the original “Pioneer ACOs: have dropped out of ACO program,  including its poster child,  Dartmouth.

Six,   Doctors would accept  pay reductions, based on routine EHR data measuring quality outcomes and proper diagnostic and procedural use,  because they could not do otherwise,  i.e. participate in Medicare, Medicaid, and health exchange programs.   Wrong.   Many doctors, 10% to 50%, are not participating in programs  or are switching to direct pay,  concierge, medicine to avoid 3^rd party regulations,  penalties, and hassles.

And so it goes.   Insurers and doctors are withdrawing from most markets.    Doctors are not accepting federal programs, or or are slowing services for federal sponsored patients.  Talk of a death  spiral of ObamaCare is rampant,  and, if Trump is elected,  ObamaCare will be repealed.   If Clinton becomes president,  she promises big changes, or a public option, as a giant step forward towards total government control.