Saturday, May 10, 2014

Blaming Psychiatrists For Decreased Access - The Ultimate Political Manipulation?

I was trying to mind my own business this morning and focus on my usual PowerPoints but then I happened across the musings of 1BOM and and some of his associations to an article on the fact that psychiatrists accept insurance at lower rates than other physicians.  Interestingly, the authors look at some correlates of this phenomenon and then jump to the following conclusion:

"Nonetheless, our findings suggest that policies to improve access to timely care may be limited because many psychiatrists do not accept insurance."

The only way a sentence like this gets into a journal article is with the necessary qualifiers "suggest" and "may".  Certainly the press and the detractors of psychiatry won't pay much attention to the qualifiers.  I am sure that some managed care executives also see this as a reason for celebration.  At a time when they literally have psychiatry on the run because of poor reimbursement, rationing, and invasive management practices - what better "research" to back up more managed care practices?  It is not the onerous business practices after all, it is those pesky psychiatrists who refuse to accept whatever we want to pay them.

The authors of this article seem to ignore the historical context of 30 years of rationing psychiatric care to the point that inpatient care is generally of very limited value, psychotherapy-at least the research based kind is scarcely available, and psychiatrists trying to function in an outpatient settings are continuously harassed by insurance reviews or restrictions.  Many public systems of care previously under the oversight of psychiatrists are now being run by administrators with no mental health training who have no shortage of ideas about how systems based care should be implemented.  The authors provide an introduction to this research that contains the following paragraph:

"The Centers for Disease Control and Prevention estimates that a quarter of adults in the United States report having a mental illness at any given time and about half will experience mental illness during their lifetime.   In the wake of the Connecticut school shooting and other recent mass shootings, policy makers and the public have called for increased access to mental health services.  For example, President Obama’s “Now Is the Time” proposal, released in January 2013, called for better mental health services, including programs to identify diagnosable mental health problems early so that patients can be referred for treatment, and increased training of mental health professionals."

I really cannot think of a more politically naive statement about the state of mental health in this country or the likelihood that things are going to change.  It is certainly clear to me that we have a standard strategy for mass shootings in this country that does not involve addressing the widespread availability of firearms or lack of availability of a functional mental health system.  The public also seems quite content to accept the idea that violence and aggression are random acts and cannot be addressed from a psychiatric perspective.  The usual photo-op involves politicians showing up, suggesting some serious political work (that never comes to fruition), praising the heroes and then suggesting that we must all move on.  Occasionally there is the suggestion that people were just "in the wrong place at the wrong time".  It is really nothing more than political helplessness in the service of career politicians and special interests.  Torrey and Jaffe have taken a close look at what is wrong with the idea of a President's initiative on violence and aggression and there are many problems.  Transmuting all of these chronic problems into psychiatrists not wanting to accept inferior reimbursement or the additional free work required for insurance business is ridiculous.

In the next paragraph the authors resort to a familiar stereotype of psychiatrists:

"Psychiatrists play an important role in the diagnosis and treatment of patients with mental illnesses particularly because of their training and ability to prescribe medications."

It is well known that 80% of all medications for mental health indications are prescribed by primary care physicians.  Furthermore we are currently caught up in the latest managed care technology referred to as collaborative care that will greatly increase that percentage.  That will be true because of an expected rapid increase in access to antidepressant prescriptions and also because in some models - psychiatrists will not actually see patients or write prescriptions.  The real risk of eliminating psychiatrists is the diagnostic capability.  There are many interests who benefit by not considering the importance of eliminating that skillset.  Let me illustrate how that happens.  For many years, I worked in a Geriatric Psychiatry and Memory Disorders Clinic.  It was staffed by myself, by a neurologist, and an RN who  specialized in geriatrics.  We offered a service to primary care specialists and the community as a resource for diagnosing a full spectrum of cognitive disorders, dementias, and mental health disorders in geriatric populations.  We also offered some research protocols and treatment with what was then state of the art medications for Alzheimer's disease.  We also offered a full spectrum of referrals for psychosocial resources and residential care for patients that we saw and assessed.  We were told at one point that reimbursement for our services did not cover the cost of nursing services for out clinic.  Our nurse was an absolutely critical piece because she would gather information on the functional capacity, behavioral problems, and known medical problems of all patients coming in to the clinic.  She would often gather this information from more than one informant.  That would amount to about 8 hours of telephone work for one 4 hour clinic.  Most of the time was provided free gratis because she believed in what we were doing.  In order to possibly improve the financial status of the clinic, we started to travel out to nursing homes and see people there in person.  That model was not useful because we received dramatically less reimbursement consulting in a  nursing home setting.  We also had unreimbursed travel time with each visit and the cost of transportation.  Eventually administrators told us we had two choices - shut down the clinic or eliminate the nurse.  It was an easy decision for the neurologist and myself.  We barely had enough time to do all of the documentation associated with our services much less all of the collateral contacts.  So we shut down the clinic.

This is a classic example of how quality mental health services are rationed and put out of business.  Our clinic was well known for quality care.  Years later I was still being asked about why we shut our doors.  It is literally a function of how much information that you collect and analyze.  In order to make the necessary diagnoses the full spectrum of functional capacity, cognitive, psychiatric, medical imaging, and laboratory data needs to be reviewed or ordered for the first time and analyzed.  We would see people who were told by other physicians that "there is nothing else we can do for you" and they were wrong.  There can alway be a debate about how much comprehensive services that  utilize the full training and ongoing education of physicians is worth.  It is definitely worth more than a 5 or 10 minute visit, a prescription and a Mini-Mental State Exam score.

1BOM list some associated arguments about the issue of whether psychiatrists should accept whatever insurance companies decide to reimburse.  The most interesting of these is that the field can be parsed into basically psychotherapy and neurosciences.  Further analysis suggests that if psychiatrists want to provide psychotherapy they should accept whatever standard reimbursement a "non-medical" therapist should accept.  It is almost as if non-medical psychotherapy is an option in the training of psychiatrists.  That attitude is certainly counter to the fact that psychotherapy is an integral part of psychiatric training both as a treatment modality and as a necessary technique for studying the therapeutic alliance.   There are similar illogical arguments about transferring the neuroscience and neuropsychiatric aspects of psychiatry to neurologists.  Dr. Nardo in his wisdom points out that basically neurologists don't  want it.  That is why they went in to Neurology in the first place.  It seems that other specialists seem to know the demarcation of the speciality better than some psychiatrists do. 

The overall problem here is very familiar to me.  It is the reason I started writing this blog in the first place.  Everybody has been bombarded by business and managed care propaganda for decades.  One the the strategies contained in that propaganda is that medicine and psychiatry no longer define themselves.  Business defines medicine.  That is why all of my colleagues freaked out in the 1990s.  They heard that "things are different now" and did not know what to do about that.  Even today, the first reaction to the propaganda is to cannibalize your own specialty before thinking clearly about what this all means.  Managed care closed down my clinic because they said my valued nurse colleague was not "cost effective".  Closing that clinic eliminated the availability of two experts who were providing services that were not replaced.  Does that mean we have no need for geriatric psychiatrists, nurses, or neurologists?  The headlines today would suggest otherwise.

We will all remain in the limbo of politicians telling us we need increased access and insurance companies decreasing access in order to increase their profitability.  And that has nothing to do with the fact that psychiatrists need to be trained in neurology,  neuroscience, medicine, and psychotherapy.  Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.

George Dawson, MD, DFAPA

1: Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014 Feb;71(2):176-81. doi: 10.1001/jamapsychiatry.2013.2862. PubMed PMID: 24337499.

Supplementary 1:    The issue of "financial viability" of my closed clinic came up on the 1BOM discussion.  In my experience financial viability is just more managed care rhetoric.  Like cost effectiveness it needs to be rejected outright.  The most obvious evidence is the collaborative care model.  Here we have a model that is strongly promoted by managed care and now the APA that is telling us that there are essentially unlimited resources to see what are called "med management" visits.  They are after all eliminating any actual diagnostic process and putting people on medications as soon as possible.  I am quite sure that some of the patients with complex problems that I assessed are now getting a PHQ-9 and placed on antidepressants.  I have already posted that (based on 2005-2010) data that antidepressants are already being overprescribed.  Collaborative care will result in a proliferation of additional "prescribers" to increase that number.  For that questionable low quality service, the patient will probably be charged around $50 for (at the maximum) a 10 or 15 minute visit.  In fact, in my health plan it can occur over the telephone with no actual patient visit.  If I was in private practice I would probably charge $300-350 for a 60-90 minute evaluation that look at all of the patients medical, psychiatric, and medical imaging data.  The final product is a diagnosis or list of diagnoses rather than a PHQ-9 score and there would be an intelligent discussion with the patient about what to do.  If medications were prescribed there would be a detailed discussion of the risk, benefit, and likelihood of success.  There would also be a detailed discussion of how to avoid rare but serious side effects and when the medication should be stopped and when I should be called if there were problems.

If you want to say that "financial viability" is a legitimate metric that exists outside of the mind of an managed care MBA, I would clearly disagree.  My plumber, electrician, and chimney sweep don't hesitate to charge me $200 to show up and then add charges on top of that.  The information content and technical skill they use to fix or install things does generally not reach the level that I would use in my 60-90 assessment.  Financial liability in a managed care system is basically anything outside of high volume low quality work that the company can profit from.  It is an artifact of cartel pricing that seriously discounts the skills of physicians.  The only reason my tradesmen are financially viable is that they don't have a cartel fixing their prices, forcing them to put out a high volume, low quality product and skimming their profits.

I hope that more and more physicians stop taking managed care insurance and put the financial viability theory to a test.  It certainly has not put tradespeople out of business and they are easily charging on par what physicians charge for reasonable medical care.  We can also learn a lot from our dental colleagues who are usually subject to severe insurance limitations.  I guess that by the managed care definition, dentists are also not financially viable?  

My dentist by the way charges way more than I would charge in private practice.    

Supplementary 2:  A reader suggested that I was erroneously saying that managed care hit mental health services harder than the rest of medicine.  The following excerpt from a report by Floyd Anderson, MD describes the results of the Hay Group report on this issue in the 1990s:

"More recently, the National Association Of Psychiatric Health Systems - Hay Group found that from 1988 to 1997 that a total value of health care benefits for over 1,000 large U.S. employers declined by 10%; general health care benefits declined by 7%, but behavioral health benefits declined by 54%. As a proportion of total health benefit costs, behavioral health benefits decreased from 6% to 3% during that period. This same study found that between 1993 and 1996, the use of outpatient behavioral health services dropped 25%, but use of outpatient general health services increased 27%. Inpatient psychiatric admissions between 1991 and 1996 declined by 36%, compared with a 13% decline for general health admissions during that same period. Mental Health Economics reported in September of 1999, “Despite the robust economy of the past five years, and the growing awareness of disparity between mental health care benefits and general health care coverage, the value of employer-provided mental health care benefits has declined by over 50% since 1988.”

That occurred in the context of overall health care expenses increasing. And do you really need a report? It may be hard to believe, but mental health services were delivered outside of jails at one point in time.  


  1. Hi Dr. Dawson,

    With the outright restriction on healthcare access placed by insurance companies, many people can not afford healthcare when it is not covered by their insurance.

    Yet somehow ironically, so many people in the US seek alternative healthcare from expensive chiropractors that generally do not accept insurance.

    I do not think it is at all possible, however, for a physician to specialize in Infectious disease, Neurology, Cardiology, General medicine, and Psychotherapy at the same time. There are simply too many different bodily dysfunctions in too many tissues, overlapping presentations, and complex test interpretations. An Emergency room for example, operates by using a team of specialists in different fields working under a single physician in charge of the patient. The ER operates on the theory of differential diagnosis; something that can not be fully done by a single physician in one specialty. Psychiatry would probably have to return to being a system of Medical Superintendents rather then a Medical Specialty in order to operate like an ER does today. Many of Psychiatry's social, political, and practical troubles could be solved this way.

    Perhaps things could change some day when a large battery of automated tests could be run inside a device similar to a startreck Tricorder. Policy is human problem though..

    1. Clark,

      I think you are responding to popular stereotypes. The stereotype of the psychiatrist as the pill prescriber. This is certainly used politically ALL of the time by groups interested in minimizing the expertise of psychiatrists - usually so they can prescribe pills. It was even used by a famous blogger to suggest that other people should prescribe pills and that psychiatric education was basically equivalent to a psychopharmacology course.

      In the real world psychiatrists like me (and there are tens of thousands) diagnose illnesses that nobody else does and probably pay much closer attention to what is going on medically with the patient than other specialists. It is the reason why when my wife had surgery and she asked her doctor about drug interaction he said: "Ask you husband. He is a psychiatrist and he knows more about it than I do."

      That does not involve specializing in every area - it involves knowing what part of a speciality overlaps with yours and making sure that you don't miss it. That is a considerable area of information, and if people deny it exists I would question what they have to gain by making psychiatrists look like something that they are not.


    2. That's not quite what I meant,
      although those things deeply concern me. There is a growing field called 'Medical Psychology' that is frightening. They managed to obtain prescribing authority in two US states. It's a worrying addition to what other physicians are already doing.

      I didn't mean to imply that Psychiatrists with medical training can't use that training effectively, or that psychotherapy is useless.

      When psychoanalysis collapsed, the APA should have relinquished control of its medical system back to it's original system of Medical Superintendents. Had they done this, the dangerous subjective market for medical experiments (including ablative treatments) for Psychoanalysis's 'Mental Disorders' would have been discontinued, forced medical experiments could have ceased, full access to medical care and scientific study of the sick could have returned. Instead the UN is now getting involved with a Human Rights treaty.. that's a mess.

      Psychotropic prescription statistics, particularly in children, are just another part of that larger more general rule. At least as it appears to me.

    3. Clark - I think the whole idea of nonphysician prescribers does flow from the psychiatrist as pill prescriber stereotype. The politics of it all focuses on how easy it is and how little you need to know. That is of course nonsense, but stereotyping works in politics including the politics used to routinely disparage psychiatrists.

      Your suggestion that the APA should have reverted to an asylum based system of Medical Superintendent. The APA was actually founded on that system and it was further relegated to history when psychiatry became on the the original members of the ABMS in 1934.

      With regard to experimentation, human subjects committees have been the order of the day for as long as I have been practicing. The APA has absolutely no influence on them or the FDA. As I have posted here many times, the FDA has a pattern of ignoring the recommendations of their scientific committees to approve drugs and that means that more people are exposed to risk than the scientific committee would recommend.

      I know that many people see the APA as the personification of monolithic psychiatry and everything that is bad about psychiatry, but the reality is that they are a politically ineffective organization that probably does not advance what their members want and they are losing members because of it. The best examples are the backing of the PPACA, collaborative care, and maintenance of certification.

  2. I hope you don't mind my essentially reposting a comment I made on 1BOM. The last paragraph of your post says it all, bravo indeed.

    As I see it, psychiatry is ideally a field for generalists, something like primary care physicians (PCPs) of the mind. Wielding a variety of conceptual angles (neuroscience, psychodynamics, cognition) and associated tools ensures that we don’t see everything as a nail because all we have is a hammer. PCPs handle most, but not all, of what comes their way, and are positioned to have the best view of a patient’s overall medical status. Likewise, as a generalist psychiatrist I handle most psychopharm, many cognitive interventions, and all dynamic psychotherapy for the patients I see — but I’m not averse to referring the occasional patient to a colleague whose emphasis skews more toward what that particular patient needs. Some of us focus more on meds, some on therapy — and some on geriatrics and memory loss, or substance abuse — but all of us need to know neurology, medicine, and psychotherapy. And, I would add, at least a little social psychology and humanities as well.

    Insurance and related business interests don’t find traditional primary care cost effective. PCPs are raising hell on sites like KevinMD; they’re choking on paperwork and low reimbursement, they’re highly demoralized and bitter. Fewer med students are choosing primary care, and very few PCPs recommend it as a career choice to their own children. “Direct pay” (non-insurance) practice is increasingly touted as the only viable model going forward.

    It appears many of us psychiatrists simply got the memo a little earlier. Psychiatry, like primary care medicine, is fast becoming two-tier: practiced at the level of professional excellence when business does not define it, and something tragically less when it does.

    1. Steven - agree completely with your analysis. The primary care example is particularly pertinent. Remember that the managed care rationing process started by threatening specialists with primary care as a gatekeeper. I have posted the example of being at the APA Joint State Legislative & Public Affairs Network Institute in Ft. Lauderdale in 1994 and being threatened by a managed care consultant that his advice was to buy up the practices of the specialists and put psychiatry out of business. That was followed by a speech by Arne Carlson the pro-managed care governor of Minnesota who suggested we were "whiners" when he got a question from the audience on the heavy handed tactics used by the industry.

      That all changed when patients got fed up with needing a referral for practically everything (the usual managed care over/micromanagement) and it really changed when managed care acquired all of the means of production including hospital, clinics, practices, physicians and MRI scanners. Now managed care companies see their primary role as managing physician employees to either increase their productivity or achieve some other business goal. They make money by keeping their MRI scanners running 24/7 while talking about trying to control overutilization in the papers.

      In the state of Minnesota, the idea of "cost effective" primary care depends on whether you are working for a managed care company or not. Rural primary care physicians refuse to accept their out-of-network reimbursement. They are labeled as not being "cost effective" and that is used as political leverage against them. I would not be surprised one day to see some law saying that all physicians have to accept the managed care rates.

      The irony in all of this is that primary care physicians can be effective gatekeepers. The NICE algorithm for using opioids in chronic noncancer pain is a good example and it is the way we used to practice in Minnesota before the Joint Commission pain initiative in 2000.

      I can't say enough about the use of cost effectiveness rhetoric and its use to manipulate physicians. There is no managed care reimbursement that I am familiar with that every paid me close to what I have to paid the trades to come out and work on my house. In most cases, I have to pay them $200 just for showing up whether they fix anything or not.

      Cost-effectiveness used against physicians, especially psychiatrists is pure bullshit and it is time to put that tired propaganda to rest.

  3. It seems to me this is an argument for Dr. Dawson's estimable method in his clinic, not an argument for the cost-effectiveness of psychiatry in general.

    While Dr. Dawson's clinic may have been unfairly denied funding, it fell under assumptions about psychiatry fostered by psychiatry itself, which is that only pharmacological knowledge is needed for psychiatric treatment.

    "Managed care" policies do not exist in a vacuum. Psychiatry's own resources were used against it for decades as the APA lobbied on behalf of pharmaceutical interests, who benefited in the $ billions from the idea that just about anyone could safely and effectively prescribe psychiatric drugs.

    We all have our hands on only piece of the elephant. Certainly managed care makes many innovative and appropriate approaches financially difficult. But for decades, organized psychiatry has made the opposite of a value-add argument for training in the specialty.

    Psychiatrists should be tar-and-feathering their leadership over this, not bitching about the gummint. And, oh yeah -- stooping to organize to make the value-add argument for your own profession. Someone with an interest in the continuation of the specialty, which excludes the current APA leadership, needs to be negotiating with Federal, state, and health insurance organizations.

    1. It turns out (as indicated in the Supplementary above) this is not about cost effectiveness at all. Cost effectiveness is just rhetoric from managed care management. They drag is out all of the time in various forms for justifying their onerous management decisions. Like Arby posted on 1BOM, they actually will go to a critical department like pharmacy and tell them that that are a "liability". Poor management clearly knows no bounds.

      This is also not about psychiatry promoting themselves as pharmacologists. I trained during the heyday of so-called "biological psychiatry". Much more emphasis on biology then than there is now. And yet, I received more psychotherapy training during that time than any nonpsychiatrist I have ever encountered. That included training in the prototypical collaborative care model of Stein and Test that has evolved to be the most comprehensive approach to treating people with severe chronic mental illnesses and keeping them out of the hospital.

      You clearly are rewriting history with your positive spin on managed care but I understand your political views on psychiatry. There is not a physician I know who would describe managed care as innovative.

      How can you not make money by denying care, especially quality care to people who are paying you more per year than they pay in property taxes?

  4. "Managed care policies do not exist in a vacuum. Psychiatry's own resources were used against it for decades as the APA lobbied on behalf of pharmaceutical interests, who benefited in the $ billions from the idea that just about anyone could safely and effectively prescribe psychiatric drugs.

    We all have our hands on only piece of the elephant. Certainly managed care makes many innovative and appropriate approaches financially difficult. But for decades, organized psychiatry has made the opposite of a value-add argument for training in the specialty.

    Psychiatrists should be tar-and-feathering their leadership over this, not bitching about the gummint. And, oh yeah -- stooping to organize to make the value-add argument for your own profession. Someone with an interest in the continuation of the specialty, which excludes the current APA leadership, needs to be negotiating with Federal, state, and health insurance organizations."

    I agree with all of this but disagree that managed care is innovative, in fact it is fairly obvious and vulgar in its bluntness. I also think that ACA is eventually going to lead to single payor. When that happens the push for collabo-care and rationing will not go away, it will only intensify. If mangled care is a blunt instrument, government is a dirty bomb.

    You know who is getting the last laugh? The eighty year old cash-only psychoanalyst who sees six patients a week. He predicted this in 1980...

    1. I think that it is just as likely that we are building toward the medical equivalent of the financial services industry. Think about it. Both basically tax the American people at a level somewhere between the level of their property taxes and their income taxes. A 65 year old couple can count on $250K in medical expenses in addition to what they pay out from Medicare and Supplemental Medicare policies. This business is actually more lucrative than financial services knicking you for 1-5% on your retirement investments depending on whether or not you are paying the same company to manage your retirement funds and the individual funds in your account.

      The ACA is after all managed care and as Piketty has taught us all, the people with the big money in this field can be expected to make a lot more. I would not anticipate single payer until all of the carpetbaggers have driven the economy into the ground by draining the middle class of all disposable income.

      I think that there is also a legitimate question about whether the government steps in at some point and declares the private practice of medicine to be illegal. There is a risk of that happening if ACOs can't bring enough physicians under the control of the cartel.

      I think the physicians administrators of MCOs would say they are innovative. After all they have to make it up as they go along - from the primary care gatekeeper to the physician-specialist MCO employee.

    2. I certainly did not intend to say managed care was innovative!!!!

      As a consumer, I have always had a profound distrust of the health insurance companies. Given their greed, government oversight was inevitable. It may make some things better and some things worse.

      The way our shaky experiment in democracy functions, you have to agitate to get your interests recognized. It's rare a group gets anything just because it's the right thing to do.

      My own personal long-term health plan involves assisted suicide. Given my nervous system has been compromised by paroxetine withdrawal syndrome for nearly 10 years and I'm now hypersensitive to almost every drug, medical care in general is high-risk for me. I have no expectations for the kind of treatment I would receive under managed care.

      I think assisted suicide will start to make more and more sense to baby boomers when they realize the kind of care that awaits them when they're very elderly. The younger generations will see good financial reasons to let us go gently into that good night. And managed care will love it.

      Therefore, another inevitability. In a few generations, Soylent Green.

  5. Well, if you're looking for solutions through Marxists like Piketty, you've lost me and, as John Lennon said, you ain't going to make it with anyone anyhow. Ask Piketty how the rich did in 2008. Krugman loves him so you know he's wrong on everything.

    I don't like the financial services industry either, but Krugman and Piketty don't have any answers and they don't for medicine. The primary reason that industry is out of control is regulatory capture, thanks to the government.

    If you think that the insurance industry is going to make a killing when this is all over, I think you are mistaken. They are just holding on for dear life. Harry Reid has admitted this is just a bridge to single payor.

    Looking at Piketty for answers is like looking at the APA for answers. BTW, someone needs to ask him if he is going to share his royalties with all the poor citizens of France.

    1. What do you mean by regulatory capture?

      Also, on insurance companies coming out on top when this is over, I don't think the main players there even consider this as a goal. For all the talk of capitalism (shareholders), the way business rewards are set up, those in power don't even work in the business's own best interest. Short-term only, get in and get out before it all collapses. That is why you see the power/money hungry jump from industry to industry, to government and back, or move to make their industry control others. There really is no end to the damage they can do if left unchecked.

  6. Regulatory capture is like Goldman Sachs backing Dodd Frank, a bill written by the two biggest housing bubble cronies in Washington. Kind of like the Luciano-Lansky organized crime bill, if you will.

    I hate those guys as much as Occupy Wall Street, but they think more government is the solution. We have more government since 2008 and the income gap is even worse.

    The real battle is between the aristocracy with the proletariat (easily moved by demagogues) vs. the bourgeoisie and the middle class. Doctors in private practice are the bourgeoisie.

    That's why I think Pinketty is full of it with his idea for a global wealth tax. The aristocrats will shift the burden to the bourgeoisie just like they made us pay for their bailout.

    Isn't it amazing how wealth inequality has skyrocketed under a very left of center administration? All that happened is that the bourgeoisie (and future taxpayes) paid for the sins of the aristocracy. So more of the same supposed but not really redistributionist nonsense is going to do...what? And how is this going to help health care?

    If plutocracy is a problem, may I suggest ending too big to fail tomorrow. That way they have to deal with fear and risk just like everyone else. And sending a few blatantly obvious criminals like Jon Corzine to prison. Oh I forgot, he's a bundler. Never mind.

  7. I agree.

    I don't wish to go too much into politics here; we can take it up at CML if you'd like. But I will say that:

    1. We will most likely see a global tax (still pushed onto the bourgeoisie/middle class) though carbon credits or a VAT.
    2. Left of center sells because it is easier to deceive the proletariat with it, and there is great potential for huge inequalities even in the most Marxist of systems, so that is just another one of their lies.
    3. I would love to end too big to fail, yet the choice was made to bleed people dry invisibility, and I don't really know what would have happened had there been a collapse.

  8. What would have happened with a collapse is that ethical regional banks that were screwed by Dodd Frank would have taken over the gap left by Goldman and Citi and there would have been the end of moral and psychological hazard. They had an interest in freaking everyone out. We would have been fine if they would have failed. Instead we kicked the can down the road.

    Lloyd Blankfein invents nothing, cures nothing, treats nothing, helps no one but himself. Would love to see worthless Wall St scum get comeuppance instead of rich but not wealthy taxpayer get scapegoated.