Tuesday, November 8, 2016

Foreign Policy Implications Of The Business Takeover Of Medicine

Don't worry.

This post is not about the current Presidential election.  I have no horse in the race.  Nobody to vote for.  I have been a staunch 3rd party voter for a long time and there is not even a third party candidate that I would currently vote for.  I know that opens me up to criticism from major party partisans who commonly accuse independents of either losing them the election or being too arrogant to hold their nose and vote like everybody else.  I trust my nose more that I trust that kind of rhetoric.  The current campaign highlighted everything that is wrong with the political process including a lack of focus on real issues, a lack of inspiring candidates,  and plenty of dishonesty on both sides.  I want to focus on one real issue and that is national security.  And I want to get at it from a perspective that is described primarily on this blog.

Early in the 21st century, I involved myself in a lot of political debates.  As an example, I was very active in the debates about whether the United States should have invaded Iraq under President George W. Bush.  At the time there was the unfounded belief that Iraq had weapons of mass destruction and a push to invade even though UN weapons inspectors under Hans Blix had really not found any positive evidence.  Minnesotans is a state with active political dialogues.  Senator Paul Wellstone and his fellow Democrat and current Governor Mark Dayton were two of the few Senators who voted against authorizing the use of force in Iraq and the rest is history.  Unnecessary wars, massive military spending, and an ongoing drone war carried on by the Obama administration.  The longest continuous period of warfare in the history of the USA.  The end result is that we are in a continuous war against terrorists,  continuous cyberwarfare against China and Russia, and we are current seeing significant military build ups by those same countries.  All of this against the backdrop of President Eisenhower's remarkable farewell address to the nation televised January 17, 1961.  The relevant sections include (my emphasis added):

"..........A vital element in keeping the peace is our military establishment. Our arms must be mighty, ready for instant action, so that no potential aggressor may be tempted to risk his own destruction.

Our military organization today bears little relation to that known by any of my predecessors in peacetime, or indeed by the fighting men of World War II or Korea.

Until the latest of our world conflicts, the United States had no armaments industry. American makers of plowshares could, with time and as required, make swords as well. But now we can no longer risk emergency improvisation of national defense; we have been compelled to create a permanent armaments industry of vast proportions. Added to this, three and a half million men and women are directly engaged in the defense establishment. We annually spend on military security more than the net income of all United States corporations.

This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence -- economic, political, even spiritual -- is felt in every city, every State house, every office of the Federal government. We recognize the imperative need for this development. Yet we must not fail to comprehend its grave implications. Our toil, resources and livelihood are all involved; so is the very structure of our society.

In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.

We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted. Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together........"      

Eisenhower was a genius -  decades ahead of the current thinking on conflict-of-interest and its problematic results.  Going beyond the famous reference to the military industrial complex, Eisenhower's speech was about balance, conservation, and mutual respect. Disarmament described as being necessary because another war could destroy civilization. It was a speech made by a military expert turned statesman - balanced and very reasonable.

But despite Eisenhower's best intention, the American military has marched on with three unnecessary wars in my lifetime and continued record amounts being spent on the machinery of war.  In 2105 the US spent $596 billion dollars - more than the next 7 nations combined.  The Department of Defense is the largest single employer in the world.  The defense budget has long been the subject of cost overruns and overspending.  The word corruption is rarely used appropriately in American politics, but what would Eisenhower call  a $640 toilet seat?  From that same timeline - cost overruns alone add an additional 25% to the cost of weapons systems.  It seems clear that top down management massive budgets in a political atmosphere dominated by funding concerns, lobbyists, and special rules that favor the major parties is a recipe for inefficiency at best and corruption at the worst.

Parallels between what happens to the military budget and healthcare funding are undeniable.  In health care - the politics is clearly on the side of large businesses that were put in place as proxies by the federal government for containing costs - despite the clear evidence that has not happened.  Professional organizations also lobby they are generally ignored relative to business interests.  Per capita health care spending in the US is roughly 40% more than the next highest nation with no incremental increase in quality and much worse access to health care.  All of this mismanagement flows from politicians and bureaucrats at federal and state levels who talk about the constant need to reform health care.  The only notable reforms have been the use of large health care companies as inefficient proxies for government control,  selective rationing of specific areas of health care like psychiatric and addiction services, ballooning administrative costs, and placing an intense, costly level of administrative control over the physicians who are delivering the service.  Instead of learning from the past 30 years, the managers at all levels are doubling down with more requirements and regulations.  We have an endless supply of $640 toilet seats in the health care system and at the same time entire states where a person cannot get adequate treatment for an addiction or a psychiatric problem.  The government and business side of the equation needs to cling to the myth that this type of management is necessary, despite the fact that it was unequivocally demonstrated in 1998 that it was not and the more important long term trend that these business managers add no value to the system as all - apart from what they can make up as advertisements.

Does that sound like a system that can manage foreign policy or military strategy?  Somewhere along the line Americans are led to believe that we have competent military leaders who are advising Congress and the Executive branch.  In order to accept that advice a lot of political demagoguery that occurred in the election campaigns must be set aside.  A lot of past mistakes must be acknowledged and corrected.  A lot of the accusations about immoral and criminal behavior do not inspire the confidence of Americans or other citizens around the world. The scare tactics about whose finger is a safer finger to put on the nuclear button needs to be stopped and a more sober discussion about stepping back from high alert nuclear status and disarmament needs to happen.  Warfare and aggression should never be the default position.

The major difference between the military and healthcare funding is that the financial drain on the averagae family for military funding is less transparent that healthcare.  With costs being transferred to the working class under high deductible plans, the average retired couple paying and average $250K in retirement for healthcare, and now exploding costs for Obamacare, working class families are tired of paying excessive amounts for healthcare.  Any head of household who has survived the tech bubble stock market crash, the housing bubble crash, and the associated Wall Street scandal where hardly anyone was prosecuted and all of the major players were essentially unfazed.  Everybody knows some working class person who ended up fined or sent to jail for cheating the IRS.  It is also common knowledge that these infractions are trivial compared with tax breaks and questionable financing by the affluent.

Although the major parties have certainly played a role in orchestrating this dramatic fiasco - they don't bear complete responsibility.  At many levels American culture is poorly equipped to deal with tough problems.  There is a love of technology but a focus on impoverished data sets.  There is a limited understanding of current problems and potential solutions.  The best solutions are rarely reached by political compromise and the end to those arguments typically results in wrapping oneself in the flag and declaring that there has never been a better system (or country) invented.

Rather than putting it all behind us and uniting behind the next President like we all traditionally do - I hope this ugly campaign gets Americans contemplating the larger issues instead of what is commonly referred to as "the narrative".  We need to get back to the real story itself rather than the narrative.  The issues are there and they are not going away just because some politician is trying to buy your vote with money, a job, an empty promise, or special interest politics.  The issues are there no matter how we get "handled" by the managerial classes.

That is what we all have to keep in focus.

George Dawson, MD, DFAPA  

Supplementary 1:

I filed the above piece on Election Day, at least 8 hours before the New York Times election site started to predict that Donald Trump had a "greater than 95% chance" of winning the Presidential Election.  Since then I have been shocked at the number or reasonable people who are outraged by the election result and suggesting that this election is an indictment of the American character.  I won't list the specifics but they are easily viewed elsewhere.  Maybe I am just a hardened Minnesotan who can still clearly remember when professional wrestler named Jesse Ventura shocked the major parties in the state by being elected Governor.  Looking at the debates he had with those candidates - the outcome should have been predicted.  Both the Democrat and the Republican in that race found themselves agreeing Ventura on most of the major topics.  As I drove into work the next day, I listened to a major party legislator predict a catastrophe due to a professional wrestler rather than a career politician.  And guess what?  No catastrophe - in fact - a seamless transition.  The Governor's Office ran well.  Ventura's  only error (and it was a big one) was not to make the most of this victory and prove once and for all that the major parties can be superfluous in the process.

The failure of the polls to predict the election result, is instructive for any students of sampling and statistics.  If the sample is inadequate, don't print the headlines based on the inadequate sample.  I don't think the second question about that has been answered yet.  That question would be whether enough people are "off the grid" or uncooperative with the sampling process enough to make these polls predictably unpredictable.  Is it safe to say it was a failure of Big Data?

From what I know about the political process I see this playing out a few ways:

1.  Trump makes a seamless transition to office in a manner very similar to Ventura.  It will actually be easier for a Trump transition because he is technically a Republican,  even though many Republicans clearly dislike him.  Ventura was a member of the Independence Party and both parties disliked him and yet he was able to form a reasonable cabinet and nobody noticed that there was not a Democrat or a Republican in office.  He maintained a populist position by provided tax rebates.  The real potential for damage from a Trump administration will be a ballooning federal deficit, but even then it is a matter of degree.  There is no way that any Democrat or Republican will establish a precedent of actually paying for the expenditures on their watch.

2.  I have been stunned by the naivete that some people have about how men talk.  Trump's 'locker room" talk is what I am referring to.  I had a discussion last week about this very issue.  One opinion was that this kind of talk was a "generational thing" - in other words done only by dinosaurs like me.  I have certainly talked with men of all ages who refer to women in a crude manner.  I certainly don't use those terms myself and never have.  I don't "approve" of these references, but I also realize that men who talk that way are certainly not waiting on my approval.  I know this type of discussion exists.  I also know the meta-language involved.  In other words, the language has different meanings in different contexts like most language does.  I will let the linguists come up with a detailed analysis, but at the common sense level it is clear that a lot of people could ignore it.

3.  Trump has been conciliatory in his early remarks since the win.  The key question at this point is whether he can maintain that demeanor.  If he does not become antagonistic and uncompromising he has a great opportunity to seen what he can accomplish. From the political debates, it was clear that the Trump campaign was more about process and rhetoric that it was about content and a mastery of the issues.  He needs to take a lesson from Governor Ventura about what not to do when you unexpectedly get into office.

4.  Most but not all of the pundits seem to have missed the point that a lot of the Trump emotionality was directed at the working class and the working class has not fared well in American politics for decades.  Wages are flat, unions have disappeared, health care costs have increased and were set to explode with Obamacare.  Against that backdrop, the major parties have really done nothing but shore up Wall Street.  The working class has been a traditional mainstay of the Democrats.  As my grandmother used to say" "They are for the little guy!"  That has not seemed to be the case to me for a long time.

5.  Most Trump supporters do not take him literally - this is my speculation and it is in direct opposition to opposition to other more radical theories of the motivations of Trump supporters.

Just a few early observations about why a Trump presidency is not necessarily a catastrophe and also - how it happened.....        


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