Thursday, May 19, 2016

The Heart and Soul of MACRA

Ms. Jeannie is a 65 years old woman, slightly overweight with mild hypertension that is perfectly controlled. Ms. Jeannie is the office manager at Dr. Abrams, the pediatrician down the hall, who’s been taking care of your kids since you moved here. Ms. Jeannie called earlier because her allergies are killing her today and she’s out of refills for her blood pressure meds anyway. After an uneventful 15 minutes, and a brief chat in the hallway, Ms. Jeannie pays her $15 copay and heads back to work. Medicare will pay you another $60 in a few weeks. On to Bob Burns who is here for his DOT physical and his BP is through the roof… again…

Somewhere in our nation’s capital, someone has decided that when you go about your day like this, you’re doing a lousy job, because you provide very little bang for the buck they pay you. Maybe Jeannie could have seen your nurse instead of wasting your time with trivial things. Maybe she could have just stayed at her desk in Dr. Abrams’ office and talked to your nurse over Skype or email. And why is it that you can’t get a grip on Bob’s blood pressure and make him take his meds and understand that driving a truck is not a form of exercise? You need to provide value, instead of just counting volumes and volumes of expensive visits that may or may not work. This is wasteful. You need to learn how to do better with less money.

This is the heart and soul of MACRA. This is what 962 pages of gibberish are trying to elucidate for those who have the time to read 962 pages of government regulations on a Wednesday morning. You can certainly try to set aside time to pore over the intricacies of how Medicare plans to not pay you the $60 it owes you for seeing Jeannie, but if you have twenty to forty hours to read, I’d suggest taking another shot at Ulysses which may be a more rewarding and less frustrating choice. In Medicare’s defense though, it’s not that they don’t want to pay you anything for seeing Jeannie. No, that would be dumb. The 962 pages of labyrinthine regulations are about $3 that Medicare may be withholding from or adding to your $60 remittance for similar visits with Ms. Jeannie in 2019.

There are plenty of good summaries of MACRA out there (here is a great one), so I’m not going to repeat any of that here, because frankly, it doesn’t really matter. First, the SGR formula which MACRA is supposedly replacing was never implemented. Chances are good that the furious mathematics at the fraying edges of medicine described in the latest notice of proposed rulemaking will suffer a similar fate. Second, even if Medicare spends the prerequisite billions of dollars to implement a national mechanism for withholding your $3, booking one more patient per day will completely neutralize any effects on your practice and your personal income. Alternatively, and particularly if you are “of a certain age” this may be a great opportunity to spruce up your golf game, as Dr. Halamka himself is suggesting.

The Doctor Whisperers

Have you ever trained your pooch to walk nicely on a leash, to sit and stay and rollover whenever you tell him to? If so, chances are that you used those little bits of liver treats to reward good behavior. You don’t reward your pup in training with huge T-bones because he will ignore you for the next hour or two as he enjoys his bone. For obedience training, you use cheap, tiny morsels over and over again, along with profuse words of encouragement, until Rover gets the idea, and then you replace the liver bits with a pat on the head, and then you just assume that the dog is conditioned to always do what you want him to do, without rewards. And that’s how Rover becomes a good dog. The $3 Medicare incentive is your liver bit. Using it repeatedly, every 15 minutes or so, all day every day, is how you will be trained to become a good doctor.

The people who run programs like the MACRA are not stupid. They know, and the math is pretty straightforward, that the $3 training morsels won’t make any difference in Medicare finances, but at the end of the day you will learn to always pay attention to the handlers and respond to nonverbal cues in a reliably consistent manner. For example, many EMRs today have special markings for data fields that must be captured for Meaningful Use or PQRS. Some are color coded, others are marked with little stars and practically all have lists of items that were “satisfied” or not. Those are equivalent to yanking Rover’s choke collar, quickly, gently and ever so slightly. Nobody wants to hurt their “best friend”. We train docs for their own good, because well trained, obedient dogs are happy dogs.

Unfortunately, not all dogs are created equal. Great Pyrenees for example were bred for centuries to work independently, mostly alone, mostly at night, to protect their sheep from big bad wolves. Having shared my home with a few great ones over the years, I can tell you that they find fetching sticks a rather uninteresting proposition. Buried deep in the bowels of the 962 pages is a cute little table forecasting whose chain will be yanked and who will be getting those $3 bits most of the time (page 676). As you would expect, 9 out of 10 solo docs and 7 in 10 docs practicing in groups of less than 10 will be penalized, while over 80% of those working in very large systems, or rather their employers, will get rewarded. The heart and soul of MACRA has no room for independent doctors. They either submit themselves to employment in the service of big corporations, or go their separate way.

Other People’s Money

A century ago, under similar circumstances as we are experiencing today, Louis D. Brandeis railed against the "curse of bigness", and particularly the bigness of bankers who used “other people’s money” to exert undue influence (control) over the nation’s economy solely for their personal benefit and with complete disregard for the welfare of the people. To be sure, Justice Brandeis, as Thomas Jefferson before him, was disgusted with big corporations and big government as much as he was appalled by big banks. Both before and after his Supreme Court appointment, Brandeis experienced significant success in his crusade against bigness, but a century of American politics as usual managed to destroy practically everything he achieved, and to add insult to injury, today it’s not just the big banks that get to play games with other people’s money.

The 962 pages (with more to come) of MACRA regulations are how big government is creating a set of financial instruments that nobody understands (including the authors) to affect 20% of the American economy, not to mention the lives of 300 million people, using other people’s money to benefit the bottom lines of big corporations and for the personal aggrandizement of political appointees. I may be wrong, but I believe Justice Brandeis would be irate at the mere thought that the Federal government is proposing to award 7.5 cents to medical doctors who are “registered for a minimum of 6 months as a volunteer for domestic or international humanitarian volunteer work”. Thomas Jefferson would probably observe that our tree of liberty is long overdue for some refreshments, but I digress.

From its inception, health care reform has been focused on diverting physicians’ attention from patient care, which comes naturally to most of them, to counting things supposedly representing patient care. First came counting scripts sent electronically to pharmacies, then came counting the number of times the mammogram box was checked, the number of times the Pacific Islander box was ticked, the number of times one glanced at this or that list, culminating with the number of dollars patients are costing the insurance company. The MACRA is just the next step in the succession of incremental steps designed to transition Medicare to a Medicount program.  The problem with this strategy is that you are counting other people’s money.

Every dime the Federal government spends on obedience training (or culling) for doctors, is our money. Every nickel Medicare is spending on managing the largest accounting exercise known to mankind, is our money. Every penny commercial insurers spend on adopting the Medicount method, is our money. We are the true risk bearers for this experimentation, and so far we are seeing nothing but downside. Public health expenditures are going up. Private insurance premiums are going way up. Out of pocket expenses are going up. Our life expectancy is going down. Suicide rates are up. Addiction rates are up. Mental distress levels in general are up. And yet we are all compelled by taxation laws to fund our own demise without honest representation, without informed consent and without any legal recourse.

Maybe not this summer, and maybe not this fall, but what do you think comes next?

Monday, May 9, 2016

Health Care is Not a System

The Merriam-Webster dictionary has many definitions for the term system, but the most straightforward, and arguably the most applicable to our health care conversation is “a regularly interacting or interdependent group of items forming a unified whole”. The common wisdom is that our health care system is broken and hence our government is vigorously attempting to fix it for us through legislation, reformation and transformation. We usually work ourselves into a frenzy arguing how the government should go about fixing the system, but I would like to take a step back and question the assumption that health care is, or should be, a system. This is not about splitting the hairs of semantics. This is about proper definition of the problem we wish to solve.

You could argue that we use the term system loosely to refer to everything and there are no nefarious implications to calling health care a system. We have a transportation system, an education system, a legal system, a financial system, a water system, a political system and so forth. Note however that we rarely talk about our food system or auto system, fashion system, hospitality system, etc. We call those industries. Starting to see a difference here? Good. Our government obviously regulates both systems and industries, but it regulates them differently. And systems have distinct characteristics that industries seldom have, such as built-in (systemic) mechanisms for discrimination, and institutionalized (yep, systemic) corruption aplenty.

When we begin by assuming that health care is a system, we assume that health care should possess those same characteristics. We assume that health care in Beverly Hills will be, by design, different than health care in Flint, Michigan. We assume that health care delivered in private settings will be different than health care accessed in public settings. We assume that some areas will have sprawling, on demand health care hubs, while others will have none. We assume that public engagement in health care is for show only, while the billionaire class and its carefully constructed echo chamber get to make all our health care decisions. We assume that health care is, and always will be, rigged. And based on these assumptions, we proceed to fix our health care “system”.

You may be tempted to dismiss these thoughts as specious demagoguery, strawmen, soapbox arguments or just plain exaggerations. After all, health care system fixing includes such socially beneficent endeavors as expanding “coverage” for the poor (Medicaid expansion), subsidizing insurance for the less poor (Obamacare exchanges), granting insurance to the sick (preexisting conditions), and a steady drumbeat of accountability, measurement and reduction in “disparities” for “vulnerable populations”. To that I would respond by pointing you to several recent utterings from public figures empowered to effect health care reforms.

Medicaid for America

Let’s begin with the all-powerful Acting Administrator at the Centers for Medicare and Medicaid, Mr. Andrew Slavitt. The “acting” prefix is there, because for some reason, Mr. Slavitt is running the largest (taxpayer financed) health care insurance entity in the country without proper Congress confirmation. In a recent string of tweets, Mr. Slavitt refers to our “beloved modern Medicaid program” as “America’s healthplan”, proudly reminding us that Medicaid is 72 million strong (“Working people, families, majority white...”) and growing. I think it’s safe to assume that Mr. Slavitt himself is not receiving his medical care through "America’s healthplan", and neither does anybody he associates with.  It is also safe to assume that an accomplished executive like Mr. Slavitt, who is Harvard and Wharton educated, understands all too well that the size of Medicaid is inversely proportional to the prosperity of the American people. If the sheer notion of a senior political appointee in the Obama administration being ostentatiously proud to see working families forced to beg for public charity is not triggering a fire alarm in your head, then I don’t know what will.

One could argue that since Obamacare expanded Medicaid to people above official poverty levels, perhaps a bigger Medicaid does not necessarily imply more poor people, but a more generous society. One could make such argument, if federal poverty levels were a realistic measure of poverty, or if we didn’t have other sources of information. The grim reality is that even middle class Americans are now lacking the ability to purchase decent medical care, or insurance instruments for the same, and hence the Obamacare exchange subsidies for cheap insurance, which is marginally better than Medicaid in some ways, and substantially worse in other ways.

In another insightful tweet, Mr. Slavitt observes that “In exchanges, consumers vote with their feet and with their feet they say unaffordable care is a deal breaker”. Note how elegantly, inability to pay for nice things due to being destitute in general, is now framed as a preference, something you vote for with your feet. This is precisely how establishment henchmen convinced us that we vote with our feet when we shop at Walmart while decently paying jobs are being vacuumed from underneath our very same feet. Being poor and unable to afford eclectic amenities prized by the elites is a consumer preference, one very short step away from arguing that being on food stamps or sleeping under a bridge are merely choices some consumers make.

Health care in America is expensive. Expensive, though, is a relative term, and if America’s working class didn’t see its income consistently go down the 1% drain, perhaps health care would seem more affordable. But American health care is also expensive in absolute terms. Mostly it is expensive because each service and each item is priced higher than anywhere else in the world. Tackling the pricing problem is guaranteed to upset the masters of establishment henchmen, so they worked hard and found a couple of other alternatives to generate cheapness, just in case the voting with feet thingy blows up in their face (as it seems to be the case right now). The trick is to deflect scrutiny from real issues, and assign responsibility (blame) to doctors and the people in general.

The Return of the Broccoli

I’ve written compulsively about the apparent war on doctors in the past, and I am certain I will be writing more, but the war on people is a much more intricate subject. It’s relatively easy to separate a quarter of one percent of people from the herd, paint them as for-profit mass murderers and sic the hungry mobs on them. But then how do you subdue the mobs? For that, my friend, we have government. We have behavioral economics. We have the experts and pundits in that echo chamber. And we have the righteous souls who innocently light the fuse of every calamity.

I’m old enough to remember the debates preceding the Obamacare litigation in front of the Supreme Court, culminating with both Justice Scalia and Chief Justice Roberts pondering whether the government has it within its enumerated powers to make you buy broccoli. Before the broccoli debacle, the same libertarian lunatic fringe wondered if government can order Americans to lose weight, or if the government can mandate that we buy certain products from certain manufacturers. Of course Obamacare and its mandate to buy health insurance or be penalized by the IRS survived these outlandish challenges, and the IRS is doing its best to rake in those penalties. It must be doing a great job too, because it sounds like IRS services for mankind could be drastically expanded.

Steven Findlay is an expert health care policy journalist, with an illustrious record working for the Consumers Union, and one of the handpicked advisors who shaped the Meaningful Use program. Mr. Findlay recently commented on The Health Care Blog, making the following statement: “Hell, I’d support tax breaks for people who quit smoking and/or can document to the IRS that they exercise 3 times a week for an hour each time!” Hell, indeed! But if the IRS can collect penalties for failure to purchase insurance, and grant tax credits for buying Pella windows, why not offer tax breaks for making your body more productive and more efficient?

Was Mr. Findlay writing in jest? Perhaps, but note that Obamacare is already empowering health insurers and employers to offer “incentives” and “discounts” for a variety of wellness schemes, which are essentially paycheck penalties on sick and “non-compliant” people. And note also that these types of shell games are only effective if you are poor enough and forced to vote with your feet every time someone reaches for your empty wallet. I wonder if voting with your feet would be an IRS approved form of exercise…
*****
This is the glorious power of systems. This is the power of a “regularly interacting or interdependent group of items forming a unified whole”. This is why health care must become a system where the “items” regularly interact in formulaic pathways. This is why free range actors randomly affecting the system cannot be tolerated by the centrally installed array of levers and signaling networks.

This is why independent medical practice must die, small hospitals must be euthanized, and managed population health must encompass the entire nation (minus the elite caretakers) down to the minutest detail. This is why each one of us must be systematically tagged, numbered and catalogued in the vast repositories of “precision medicine”. And this is precisely why health care must never be allowed to become a system.

Thursday, April 28, 2016

Comprehensive Primary Charade +

The most powerful persuasion tool in enlightened human society is language. The most powerful manipulation tool in any human society is language. Whereas in ancient times the pen was considered mightier than the sword, now the keyboard can be said to be mightier than any weapon of mass destruction, and nobody is mightier than the government of these United States. When our government wanted to strip citizens of privacy, it passed the Patriot act, because no one could oppose patriotism after 9/11. When it set out to facilitate corporate procurement of foreign slave labor, it enacted a set of XYZ Free Trade agreements, because this is the land of the Free. When it decided to ration health care services for the middle class, it put in place the Affordable care act, because we are all broke. Now that the U.S. government has decided to do away with the medical profession, it is feverishly rolling out Comprehensive primary care initiatives.

Comprehensive primary care is not a fuzzy, in the eye of the beholder, type of concept. Perhaps the most celebrated primary care advocate in recent times, Dr. Barbara Starfield, defined comprehensive primary care as “dealing with all health-related problems or interventions except those too uncommon to maintain competence”, where “common” means “encountered in at least one per thousand patients in a year”. The term comprehensive is an adjective intended to describe the spectrum of problems addressed in primary care without referrals to outside specialists. Comprehensive primary care is what country doctors used to provide to their patients from cradle to grave, and some still do. Comprehensive primary care is what family medicine was supposed to be all about, but it rarely is.

Taken at face value, encouraging primary care physicians to practice at the top of their license (to use a dumb cliché) sounds like a welcome nudge (to use another dumb cliché) towards longitudinal, high quality, relationship based, and lower cost health care.  Comprehensive primary care should mean treating most patients in house, expanding the spectrum of primary care procedures, and avoiding the often disastrous descent into specialty, sub-specialty and invasive care that may add nothing to ultimate outcomes, except grief accompanied by hefty price tags. It also means a return to having one’s personal physician in attendance if and when hospitalization is needed, replacing random hospitalist care and rendering specialty care a truly consultative service in most circumstances.

Unfortunately we cannot take anything our government says or does at face value. Back in 2012, the Centers for Medicare and Medicaid Services (CMS) rolled out the Comprehensive Primary Care (CPC) initiative. Medicare in collaboration with private insurers invested funds upfront and increased ongoing payments to primary care physicians who provide comprehensive care to their patients. There was only one small problem. The CMS redefined comprehensive care to mean the usual and customary concoction of patient engagement, coordination, risk management, same-day access and quality measures, sprinkled with technology fairy dust.

In what must have been a seismic shock to CMS experts (just kidding), the latest evaluation of the CPC initiative, concludes that very little, if anything, has been achieved during the first two years of this sprawling program. The study, commissioned and funded by the CMS, found that neither utilization nor overall costs were favorably impacted by this type of “comprehensive” care. As to “quality”, the study measured a handful of processes (i.e. timely diabetes testing and such) as surrogates for outcomes and found no changes there either. The net cost/saving analysis did not include the initial hundreds of millions of dollars spent by the CMS on consulting services for rolling this particular initiative out. The CMS evaluators concluded their analysis expressing hope that future studies of this ongoing initiative may be helpful to policy makers.

And as is always the case with CMS initiatives, when something is shown not to work as intended, the next step is to double down and do more of the same. One day before the CPC evaluation was published, the CMS announced a brand new, bigger and better, CPC+ initiative. Presumably the + stands for an increase in the size of the initiative, or alternatively, an increase in its comprehensiveness. So let’s count the ways….

Comprehensive Risk+

Risk is the new compassion. All these initiatives, programs, reforms, transformations, innovations, that you see floating around, are intended to train doctors to view patients as risks. All the technology flooding the health care market right now, with much more to come, is aimed at reducing every single patient walking through your door to a risk number. You have a 4.5 at 10am and a 2.0 at 10:30. Risk score will not become the sixth vital sign. It will become the only vital sign, the wonder measure that simplifies health care to something a third grader can understand. You want to pay doctors for value instead of volume? Pay them for reducing their risk scores. We can’t really measure processes or outcomes, but we can measure financial risk, a.k.a. value, or rather lack thereof, and by incorporating big data from all sources, we can calculate risk scores to the second or third decimal place.

Average risk scores for your assigned population are an okay indicator of the value you provide, but can be misleading. A better indicator would be the size of risk percentile groups. For example, on a scale of 1 to 5, if you have no patients above 4.5, and only a handful above 4, you are an excellent value provider. If you can reduce the number of above fours next year, you’ll get a big fat bonus and a whole bunch of stars in some public provider directory, which is a great thing too, because sick people (who are not stupid), will quickly figure out that they need not apply for appointments with 5 star doctors. So you have this virtuous cycle going on now. Eventually the 4.5 and above population will dwindle out by natural attrition (maybe 5’s should be flagged as auto-DNR…) and your historical propensity to inadvertently get in trouble will plummet.  

To the immense delight of pundits everywhere, health care will become more like flying aeroplanes. You, and your computerized team, will run through standardized checklists before anything is done for a patient. If the slightest risk is identified, you get a new aircraft. Only perfect planes ever leave the runway. Only perfect patients get medical care. And health care will become more like the banks too. When you want to buy a car or a house, all that matters is your credit score. If your credit score is good, you get good financing. If your credit score sucks, you get bubkes. You only get a bank loan if you can prove you don’t need it in the first place. Health care will be similarly reserved for the healthy. As to CPC+, you can’t get a dime from anybody unless you slap a risk score on every single patient, which brings us to the next epiphany.

Comprehensive Finance+

More than anything else, CPC+ is a master class in finance. The CPC+ initiative offers two distinct financing tracks, one for less technology savvy beginners and one for savvier participants. Whereas currently you get paid a certain number of dollars per service, with CPC+ Medicare will be providing three distinct payment streams, with the third one signaling the way of the future:
  • Fixed care management fees commensurate with patients’ risk scores and ranging between $6 and $100 per patient per month, which must be used to hire more people, buy technology or pay for training.
  • Performance-based incentive payments ($2.50-$4 per patient per month) will be paid prospectively (before performance is measured) in full, but will be subject to partial recoupment if the practice fails to meet a predefined threshold score for quality and cost/utilization measures. For practices that fall under a predefined minimum score, performance-based payments will be recouped in their entirety.
  • Technologically advanced practices can select to have a portion of their estimated Medicare fee-for-service revenue made payable upfront as well, followed by reduced payments on ongoing claims. The maximum upfront payment is 65% of historically estimated E&M services, and this bulk payment will be marked up 10% (for an overall gain of 6.5%). This upfront capitation is subject to reconciliation on the other side and to recoupment if your patients increase use of outside primary care services, such as the much encouraged retail clinics.
But wait, there is more… The CPC+ is a multi-payer initiative and all participating commercial payers are free to devise their own payment schemes. A practice could easily find itself juggling half a dozen payment methodologies, with dozens of splintered revenue streams, each with its own rules, idiosyncrasies and accounting systems. Not only you have to continue submitting claims as before, but Medicare will eventually require documentation of previously non-billable activities (e.g. phone calls, portal messaging) and categorical proof that all the funds bestowed upon you are used as Medicare wants you to use them.

Yes, you read that right. The CMS, which is a government agency, will not only decide how much to pay you (or if to pay you), but also what you are allowed to do with those payments, which are essentially provisional and subject to recoupment on a whim. Why? Because aversion to loss, is a much more powerful motivator than desire for incentives when mindless conformance and subservience are the ultimate goals.

Comprehensive Acquaintanceships+

As was the case with CPC and practically all health care reform initiatives, CPC+ is encouraging, nay demanding, that the inconveniently personal one-to-one patient-doctor relationship is broken up and replaced by less intense acquaintanceships with care team members. There are good reasons to change the relationship model in health care. First, patients must be rendered receptive to a constant barrage of messaging regarding prevention, compliance and frugality, which is something you want to delegate anyway. Second, and the CPC+ proposal specifically suggests this, you can take on more patients if you don’t have to actually care for them. Third, the more random people you can have buzzing around each patient, sending messages, checking dashboards, managing lists, and conducting meetings to discuss all of the above, the more comprehensive the entire thing appears to be.

One of the few measurable successes of the CPC initiative was a 3% reduction in primary care visits, attributed to the “comprehensiveness” of “wrap-around” electronic and ancillary services. Same amounts of referrals and specialty services, same levels of inpatient and emergency services, and markedly less interaction with one’s personal physician. This is how the CMS defines comprehensive primary care. I know what my thoughts are, and I see how practicing docs feel, but sometimes I wonder what Barbara Starfield would have said about this inexplicable charade…

Monday, April 11, 2016

Hacking Doctors… to Pieces

For decades and decades we have been counting the number of doctors in America. For decades and decades we have been coming up short compared to other developed nations, and some less developed ones as well. A poorly educated person may be tempted to suggest that we should “make” more doctors. After all, there is hardly a shortage of young people willing and able to undergo the rigors of a medical education. But luckily we are not poorly educated, so we devised much smarter solutions. If people can’t get a doctor appointment, it must be the doctor’s fault. Hence, we put our foot down and mandated that doctors see people the same day they want to be seen, or shortly thereafter. It sounds great and it worked perfectly for the Veterans Administration (VA), so it should scale terrifically to everybody else.

Taking a page from the highly respected Samuel Hahnemann, we decreed that physically “seeing” an actual doctor is not only completely unnecessary, but it may very well be detrimental to the healing process. A doctor effect is created by simply having an MD somewhere in the building, and as technology continues to improve, a virtual doctor presence should do the trick. Some have argued that Mr. Hahnemann’s homeopathic fantasy is no better than a placebo, but we have plenty of research showing that placebos are indeed effective. More importantly, unlike Mr. Hahnemann’s distilled water base, our technology solvent is very potent on its own merits. Imagine how successful homeopathy could have been if they used whiskey to dilute whatever the hell they are diluting.

As infallible as our highly educated reasoning may be, there is resistance to its widespread adoption, both from rich doctors who don’t want to see their gravy train derailed, and from simple minded herds of patients who are failing to grasp the infinite power of virtualization. We certainly can move, and are moving, forward with our powerful solution, but it would be easier and more humane, for all parties involved, if the barriers to change could be swiftly eliminated.

Barrier One: Our Doctors

The anachronistic habituation of people to seek help from a doctor when experiencing physical, and sometimes mental, pain and anguish, is perhaps the toughest problem we are facing. There is a bilateral dependency between physicians and patients which must be disrupted. People who tend to the sick and people who are sick refer to this phenomenon as the “patient-doctor relationship”. Our most immediate task is to impress upon the uneducated masses we are protecting that this relationship is one of abuse, exploitation and misplaced trust in professional conmen (and women). Hundreds of thousands of doctors may be scoffing dismissively right now, and as they do, we are half way there already.

The art of the smear goes by the name of “news” or “research” in our instantly connected tabloid society. In a country with a million degreed physicians it is easy to find a rapist, an arsonist, a thief, a drug dealer, a murderer, or any other criminal individual, who happens to be a doctor. Once we find those individuals, the hyperjump to general statements about a group of people is easy peasy, as long as our grouping of people is not along gender, race, ethnicity, religion or sexual orientation lines (except white men who are fair game).

The formula is deceptively simple: find a handful of criminal doctors, write a big exposé about doctors and pepper it with sex, money and drugs stories, add instructions on when to call the police “for, say, sexual or physical abuse”, package it all in a not-for-profit (previously) respected container, and wrap the whole thing in menacing pictures with menacing headlines (preferably all caps, large red font), such as “DOCTOR COULD HURT YOU”. And then you reinforce the message with a constant barrage of civic minded initiatives to address the fear you want to create. We must measure and rate doctors. We must have more transparency. We must improve care, or rather the experience of care (subtle, but big difference). We must take back control over our own health (from those overbearing, overentitled, perhaps criminal, money grubbing doctors).

Will it work? Can an irresponsible and sleazy messaging campaign in service of greed and avarice, overcome centuries of earned trust? It will take time, but look at the “truths” that became “evident” over time. Our teachers are incompetent. Labor unions are destroying our way of life. Police officers are racist murderers. And since the “democratic” election season is upon us, Bernie Sanders is a sexist communist like Guevara or Castro, and Donald Trump is a sexist fascist like Mussolini or Hitler. All you need is a concerted and sustained effort of money and media (a.k.a. “New York values”), which contrary to another artificially generated truism are not controlled by “the Jews”, but are run by a global cartel of egomaniacal sorry excuses for human beings.

Barrier Two: Our Expectations

Over the last hundred years or so, medicine has achieved almost miraculous success and in the process it changed our expectations. We expect to have malfunctioning organs replaced. We expect to not die of HIV and other infections. We expect to live free of pain and even free of wrinkles. We expect tiny babies that fit in the palm of our hand to grow up and go to college. We expect many cancers to be cured. We expect crushed bones, open arteries and charred skin to be fixed. And we expect to have a “good doctor” for all of the above.

These expectations, prevalent throughout affluent Western societies, pose a huge problem for the global money cartel. The Earth is flat, you see, and there are billions of people in this world who have no such expectations, billions of people who produce the finest iPhones, the trendiest footwear, the fanciest apparel, every single computer in the world, and are grateful for the privilege. If this mass of third world laborers begins to develop similar medical expectations, financial calamity is sure to rise from the Earth's flatness all the way up to Mount Davos. It is therefore imperative to reduce medicine to something free or nearly free that can be easily distributed across the scorched plains of humanity.

This is where our technology solution comes in. Google is dreaming of connectivity balloons while Facebook prefers drones as the means to connect billions of laborers to the mobile virtual reality we all partake in. Having Google makes you feel educated and well informed. Having Facebook makes you feel connected, important and well liked. Having virtualized health care will make you feel healthy and well cared for. And it’s all free, infinitely abundant and available equally to all, regardless of socioeconomic condition.  The Internet is your friend, your confidant, your teacher, your counsel, your entertainer, and now it will be your doctor, because the Internet knows you better than you know yourself, is there for you when no one else is, misses you terribly when you stay away, and cares for you as nobody cared for you before. The Internet is you.

You are controlling your information, your social interactions, your opinions, your shopping, your wealth (or lack thereof), and now you should take control of your health (or lack thereof). You can bank with the Internet without tellers and financial advisors, you can buy stuff without cashiers and sales associates, you can learn without teachers, you can fix a toilet without plumbers, you can manage your business without accountants, and you will manage your health without doctors. You will have all the tools at your fingertips in the comfort of your home (or trailer, or hut, or sidewalk under a bridge). You will no longer face the inconvenience and outright danger of going to an antiquated, flawed, rude and dishonest doctor. You will get health services that you and the Internet value most, and much, much more, because less is always more.

Barrier Three: Their Technology

As the two previous barriers are disintegrating before our eyes (or screens), we have one last barrier that is painfully real. We don’t have the technology to hack the doctors. We are certainly talking up a big game while scrambling to put something together that at least looks at first glance like the real McCoy. We talk about tricorders and artificial intelligence. We talk about deep machine learning and veritable oceans of omniscient data. We talk a lot about robots, genomes, bloodless tests and iPhones that deliver intensive medical care. But we have no idea how to mix the doctor solute into the virtual technology solvent to generate the coveted solution we put forward as fait accompli.

Technology in its current state cannot absorb and distill, let alone replicate, highly variable processes that lack both a clear starting point and a predefined endpoint. We don’t know what we don’t know, and in spite of flowery rhetoric, computers can only perform, and can indeed improve upon, tasks we fully understand and are able to precisely codify down to the most minute detail. Simply put, without an atomic level understanding of clinical decision making, we cannot dilute the doctor over and over again, until there is no visible trace of human physicians in our high tech brew of health care. We can however abstract a coarse approximation of relatively straightforward scenarios at the low risk end of the clinical spectrum, and advertise aggressively that the Southwest Airlines or its evil younger cousin Uber of medicine has arrived.

Here is the watershed event to watch for: the first FDA approved app that will diagnose, prescribe and deliver medications to your house by secure drone. It may initially be confined to over the counter stuff, but once that is mainstreamed, simple meds like antibiotics, high end antacids, allergy pills and such, will certainly follow. Next up will be staples such as simvastatin, Lisinopril and metformin, first the renewals and then a slew of new diagnoses of pre-this and pre-that. At the high end of disease, “precision” medicine will isolate one or two rare scenarios that affect one in a million people, script them and execute them flawlessly once or twice without physician intervention. Then we declare victory and spread the gospel to every $5 mobile phone from Guizhou province to the Appalachian Mountains to the banks of the Ganges river.

Médecine sans Médecins

There is no doubt in my mind that we shall overcome the first two barriers at very short order. There is no doubt in my mind that even if we fail to hack doctors in the abstract sense, we will be hacking the medical profession to pieces in the most physical sense. And there should be no doubt in anybody’s mind that whatever these cheap hacks are doing to our health care, the effects will not be apparent for decades, and even then the results will be attributed to the inevitability of external factors such as cultural change, climate change, famine, wars, migrations, solar flares, or random disturbances in the Force. Three centuries later, it looks like John Dryden had it right after all, and “God never made his Work, for Man to mend.”

Sunday, February 14, 2016

Dear Madam/Mister Future President

As I am writing this, you don’t yet exist, and I hope you never will. As I am writing this, at least half a dozen people are still standing in the quadrennial jousting tournament we call elections. Elections in America is that brief and fleeting period of time when Washington DC turns its gaze to the rest of the country feigning passionate interest in our lives. This time around America is staring back at you in seething anger. In the olden days, this would be the proper time for tar and feathers, for pitchforks, and for burning you in effigy. Nowadays, this is the time for Twitter trolling and lack of what you call decorum in public discourse. Like all well fed, self-described benevolent aristocrats in the past, you seem surprised at our indifference to your accomplishments, and shocked at our plebian preference for rough and tumble champions of our own choosing.

Try not to worry too much. Time, and the robust voter suppression machine you and your “donors” built over centuries of enlightened democracy, is on your side. You will prevail. There will be no impractical socialist in the White House, and no vulgar businessman will be allowed to touch the intricate web of global domination your donors weaved over decades of hard work and heroic determination. Not peacefully. Not without a violent American Spring. Not in our lifetime. Not while you have a good “ground game” to get votes. Not while you have big data to “profile”, “target” and “persuade” voters. There really is nothing I want to tell you, or ask of you, because I know precisely what you will be doing in the next four years, but let’s continue this farce where you pretend to be a public servant, and I pretend to be an engaged citizen.

You are obviously “electable”, which means you passionately advocate for nothing in particular, in long erudite sentences that rise at the very end (like JFK). You certainly look “presidential”, which means that you’re not too fat or too old or too short, your nails are trimmed and your hair is combed.  You addressed every policy nook and cranny in your issue-oriented debates, in your canned stump speeches and in your ten point policy proposals that will become obsolete once the last polling station closes on November 8th. But there is one thing nobody is talking about. No clever moderator is asking, no candidate is volunteering an opinion, let alone a “plan” to tackle what is perhaps the defining issue of our times.
“It's about the next 20 years. In the '20s and '30s it was the role of government. '50s and '60s it was civil rights. The next two decades are going to be privacy. I'm talking about the Internet. I'm talking about cell phones. I'm talking about health records and who's gay and who's not. And moreover, in a country born on the will to be free, what could be more fundamental than this?” –Sam Seaborn, The West Wing, Episode 9: The Short List (for Supreme Court appointees), 1999
The events of the new millennium do not seem to support Sam Seaborn’s prediction, and your campaign is stark testimony that privacy is to be forfeited without much pushback from any quarters. We could argue that principled liberals of the previous century were ill equipped to appreciate the true benefits of the Faustian deal we are now making with the Lords of the Global Digital Panopticon. One could also argue that since the days of Sam Seaborn, privacy has become all but extinct, and lo and behold the sky of freedom hasn’t fallen. Or has it?

Let’s take a quick look at your campaign operations. Did you avail yourself of a voter database? Are you paying for special software that “appends the richest set of consumer and interest data, allowing the most sophisticated targeting” of voters? Do you employ an army of techies in the basement of your national headquarters, like the landmark Obama digital campaign did? Do you have an app on iTunes that tracks your “supporters”, their friends and their families, everywhere they go? Is your voter segmentation machine spitting out properly scripted “messages” at the most opportune time for the most receptive individuals? Do you think this is what Thomas Jefferson meant by freedom and liberty? Or do you think that’s what your kindergarten teacher meant by lying and cheating? Do you even care?

Politics in an age without individual privacy is as principled as marketing toilet paper. Your brand is softer, stronger, more absorbent, bigger, smaller, whiter, greener, and very much preferred by wild bears in the forest. You stand for nothing and everything. You stand for moderation in the North and you stand for God in the South, and you stand for Nelson Mandela to offset all the white old men who manage your campaign. You stand for America in the abstract, and use personal misfortunes of citizens to illustrate your history book, but even if your poor mom or dad were of the people, you have long ago ceased to be one of us. The reason we are asked to vote for you is the same reason we are asked to choose Charmin instead of Cottonelle, with the same de minimis consequences.

Now let’s take a look at Obamacare, which you are certain to tinker with, one way or another. In your mind, Obamacare is about money. It’s about premiums, deductibles and percent uninsured, but if that’s all Obamacare was about, it wouldn’t have required hundreds of densely typed pages, and it wouldn’t have triggered a tsunami of lesser legislations now percolating through Congress. In reality, Obamacare is how your donors use the latest technology to ensure that future elections are free from glitches that allow old communists and potty mouthed billionaires to come close to disrupting a carefully constructed world order. Obamacare is not about a human right to health care and it’s not about keeping Americans from dying in the streets, as your rogue competitors seem to believe. Obamacare is how Google, Apple, Facebook, Amazon (GAFA), and their Silicon Valley brethren, take control of human life on earth, and get rich beyond the dreams of avarice.

Obamacare is about replacing personal and slow medicine, with high-tech, high-speed, precision medicine administered through metallic algorithms supplied by your donor community. Obamacare is about managing expectations (you should be familiar with that little game), to make the busywork of tracking and scoring citizens seem like medical care. Obamacare is about shifting the locus of medical decision making from individual people and their doctors to the invisible hand of computerized bureaucracy. Obamacare is to health care what high-speed trading is to stock markets. To this end, Obamacare must unleash a biblical flood of personal information for its doomsday machines to consume, and dutifully share with other stakeholders, such as your campaign software vendor. Any remote notions of physical and mental privacy are therefore obstacles to progress.

Perhaps it is logical that your party and the other party as well, have viciously turned on their front runners in an effort to select a nominee with the best ROI record for those who consider themselves owners of a global humanity.  Perhaps it’s not by accident that Obamacare which was first known as HillaryCare, and then as RomneyCare, may eventually be known as BushLeagueCare. Perhaps, as our own, bought and paid for, disruptive innovators love to point out to their less enthusiastic colleagues, this is all inevitable. Perhaps, but somehow, at some point in this long game, the courts will have to weigh in and decide if the framers of our Constitution intended to set up a government whose sole function is to capture and deliver its citizens to global moneyed interests for lifetime exploitation.

This Saturday, Justice Antonin Scalia died. In this election year the usual and customary horse trading to seat an “acceptable”, thus by necessity mediocre, judge on our Supreme Court bench for life, may not be an option. The insurmountable task of nominating the next Supreme Court Justice may land in your lap, pretty much on your first day in office. There is a bold and beautiful solution to this quandary, a grand bargain that rises above your petty party politics, and for that you’d have to turn again to the liberal fantasy called The West Wing (Season 5, Episode 17: The Supremes, 2004). Unless the Obama administration, which over the years exhibited a peculiar interest in reenacting The West Wing, beats you to it, you will get to appoint (unopposed) two Supreme Court Justices and the rare opportunity to stand “in the gaze of history”.

Unfortunately, whether you belong to Clan Clinton or are hailing from the Bushes, I am having difficulty imagining you giving up any perceived party advantages for the sake of judicial excellence on the Court. I can certainly imagine the angry socialist and the mercurial businessman rising above the pettiness, but this wasn’t meant to be. Not this year. The next four years are yours, and you will need to hurry up and bolt the doors and bar the windows. A really big war, preferably in Europe, would help tremendously. Either way though, your days are numbered. We are no longer progressive or conservative. We are either feeding at your trough or we are not, and there are many more of us than there are of you, and one of these days we will have nothing left to lose. Not even our privacy.

Monday, February 8, 2016

The Era of Value Based Care

The Centers for Medicare and Medicaid Services (CMS) is working hard to transition physicians’ payments from volume to value of services. The current Acting Administrator at CMS is a former top executive at United Healthcare, a commercial health insurance corporation. The previous Administrator at CMS is currently the president and CEO of America’s Health Insurance Plans (AHIP), which is the dominant health insurance lobbying group. It may therefore behoove us to rephrase the opening sentence: The corporate-government health care conglomerate is working hard to transition physicians’ payments from volume to value of services.

In response, health care delivery corporations, which are employing large numbers of physicians, are joining their forces through mergers, acquisitions and other arrangements to better manage the transition of physician payments from volume based to value based models. When you ask the architects of this supposedly tectonic shift from volume to value to explain their enterprise, you get back lengthy dissertations about better service at lower cost due to computerization, analytics and standardization of an industry long overdue for modernization. The basic argument is that health care in the U.S. sucks on many levels, and proper management that employs the latest technologies and business methodologies will fix everything that needs fixing.

But what does it mean to pay doctors for value instead of volume? Does it mean that we don’t pay physicians unless we get better? Does it mean we don’t pay for health care unless we are “kept” healthy by our doctors? Does it mean that we don’t pay a red cent for advice or procedures that we judge worthless? How long do we have, post service, to decide if what the physician did was valuable? Thirty days? Five years or 50,000 miles whichever comes first? A lifetime? The answer emerging from opinion pieces published by members of the corporate-government conglomerate, which are intended to soften the ground before official rules and regulations are promulgated, is much simpler and should be much more familiar to any small business owner, or anyone who visited a restaurant or a hotel.

So here is how this is envisioned to work. Physicians will still get paid a base amount per service provided. If the corporate-government conglomerate judges the work of the doctor to be beneficial, they will throw in a 5% gratuity bonus. Moving forward, if physicians can reduce the overall COGS (cost of goods sold) for the corporate-government conglomerate, they will get a moderate percentage of net profit. Finally, if doctors are willing to take full P&L (profit and loss) responsibility for health care services, they can get a slightly bigger piece of the profit to offset the risk of massive loss. Essentially, if you are a physician, and if you agree to do what the corporate-government conglomerate wants you to do, and if you are really good at it, and if you are willing to put your money where your mouth is, you should expect nothing but financial prosperity in the era of value based care.

The things you would have to do to enjoy the value based financial bounty are not very difficult, particularly when compared to the practice of medicine. The goal is to keep the corporate-government conglomerate happy without distinguishing yourself from the generic woodwork of the new system. There is safety in the herd, and you should aim to be somewhere close to the middle of the herd. Stragglers, and those who venture too far out in front, are usually eaten. Below are a few strategies to help you position yourself for long and uneventful survival.

Percentage Medicine

If you dabbled in the game of tennis, whether as a player or an avid spectator, you are probably familiar with the term “percentage tennis”.  Playing percentage tennis means staying away from corners and lines and spectacular shots. It means playing it safe, taking little if any risk, getting the ball over the net without fanfare, and absolutely no aces on serve. Percentage tennis is how middling players, who lack exceptional talent or physique, are advised to play the game. Serena Williams is not playing percentage tennis. Great champions never do.

If you like to think that you are a great doctor, brilliant diagnostician, or anything else preceded by some sort of superlative, tone it down. This is not about excellence. It’s about percentages. Wasting your precious time on the quickly fading Miss Henrietta Wilkins, who spent the Great War welding big chunks of metal in the shipyard, and a variety of other losers, who will never bring their biometric indicators up to corporate-government conglomerate standards, is not considered good percentage medicine. Ideally, you could ship these folks to the nearest community center, but if you can’t, see if you can reassign them to your NP/PA, or some outsourced care management service, and stay away from direct contact. If you want to personally help people, you should consider volunteering in a soup kitchen on Wednesday afternoons.

Generally speaking, seeing patients one-on-one is not a good use of your time. Your initial efforts should be directed to shaping a robust patient panel that can be managed by your care team working at the top of their license. Later on you should switch to maintenance mode and work the analytic dashboards, Excel sheets, pie charts, bar charts, and all the reports and data provided to you by the corporate-government conglomerate. These things are usually marked with red-yellow-green risk indicators, so it’s not that difficult to get started. Watch your reds. If they’re amenable to change, have your staff change them. Otherwise find a way to quickly remove them from your panel. Don’t neglect the yellows either, because if you’re not careful, they have a tendency to turn red without much advance notice.

This is how percentage medicine is played. This is population management and this is also precision medicine because some of those colored risk scores are accurate to the second, or even third, decimal point which is something your over educated human brain could never calculate on its own. As long as your panel looks green, but not too green, because that may be indicative of gaming, you should be safe. If you feel a sudden urge to jump back in and play doctor, maybe with an ominously red marked patient, resist it. Go take a brisk walk around the block or listen to a motivational TED talk. Try making a nifty Power Point presentation for the next leadership meeting (Power Point art can be very relaxing) or book some travel to a health innovation conference.   

Fake it ‘till you make it

When you see patients, and you will have to for a while longer, you will need to present a caring and expert, yet humble, persona that reflects well in satisfaction surveys. You will have to be persuasive, without coming across as overbearing, when you steer clients towards product lines that are most beneficial to the corporate-government conglomerate, which is either your one true customer, or your direct employer. You will have to cultivate an engaging and compassionate image to elicit the trust of your clients. You will need to be friendly, but not too familiar, to maintain a certain aura of non-threatening expertise. You will need to say please and thank you, and you will need to display properly calibrated humility when apologizing for the shortcomings of the new and improved system, without throwing your superiors under the buss.

Since value based health care is a team sport, you will need to cultivate a non-disruptive, non-elitist image to present to the team. The team of course includes representatives of the corporate-government conglomerate, some of whom you will interact with in person, and others who will be watching you through rolled up dashboards and reports. Read a couple of value based policy papers or newspaper articles (they’re about the same as far as depth and substance are concerned), and memorize a few key words and phrases, such as “transformation”, “lifestyle and behavioral modifications”, “less is more”, “consumers want to be kept healthy”, “patient activation”, “triple aim”, “quadruple aim” (there is no quintuple aim yet, but watch for it soon), “our health care system is broken”, “$3 trillion”, “medicine has always been about information processing”, “the single most important thing to have is good data”. Stuff like that. When in doubt, just prepend “patient-centered” to whatever you plan to say next.

After a while, all of this will become second nature. If you get really good at it, you may want to go for a leadership role within the corporate-government conglomerate. It pays much better, and there are decent opportunities for advancement. Another option is to drop out of whatever is left of patient care and join the entrepreneurial side of the house. You can join a startup, or make your own. You need not be a techie or understand technology in any way. Startups are hungry for MDs, so they can advertise products “built by doctors”. Investors love that type of stuff and potential customers still have some residual respect for physicians. It won’t last long, so do it now or you may miss the boat.

One thing is certain though. A passive-aggressive attitude, or its burned-out martyrdom cousin, won’t do you any good. If you really and truly can’t get on board with the destructive recreation of your profession, you’d better quit. Get out and open a boutique cash-only practice or subcontract with one of those hit and run value based telemedicine services for the healthy or just find something else to do. Write a book, buy a little farm and make organic goat cheese, dabble in politics, start a movement. Have some fun. Life is short.

Monday, February 1, 2016

Iowa is voting on Health Care tonight

In his last State of the Union address, President Obama stated that “anyone claiming that America’s economy is in decline is peddling fiction”. I agree. The American economy has roared back from the Great Recession with 14 million new jobs, a ridiculously low unemployment rate, a booming stock market and 57 brand new American billionaires in 2015 alone.

The American people on the other hand are in a completely different boat. Almost a third of us are not working. Half of us have practically no savings and a record number is surviving on public assistance. Wages are stagnating and the middle class is shrinking. Student debt is skyrocketing and 20% of our kids live in poverty. Whereas in the immediate past the economy and the welfare of the people used to be one and the same, nowadays these terms have little if anything to do with each other.

The President did acknowledge that “the economy has been changing in profound ways” and therefore “a lot of Americans feel anxious”. To allay our collective anxiety, the President announced an unemployment program that will pay up to $10,000 to those who lose jobs to the economy fixing racket, money that can be used to retrain machinists, welders, builders and such, to flip burgers in the booming job market of the fixed economy.  The anxiety reduction program will also ease the transition to a “work-sharing” economy, where lower wages and no benefits, augmented by public assistance, a.k.a. the Walmart and Uber models, are the new normal.

Health Care is about the Economy

After fixing the economy, our government is now full throttle ahead with fixing our health care. My expectations would be that health care will be fixed in very short order, with very similar results. Health care expenditures will plummet, uninsured rates will be near zero, quality measures based on cost and utilization will be stellar, and most people will end up with little if any medical care when they fall sick. To ease our anxiety, or in health care parlance, to provide us with “peace of mind”, everybody will be awarded a Medicaid managed care card, if you’re lucky, or a high deductible insurance exchange plan that kicks in after you go bankrupt.

In the midst of the previous century, when people talked about “the economy”, the term conjured visions of molten iron being forged, of combines sliding gracefully through oceans of golden wheat, of gigantic cranes towering over monumental construction projects, of dusty rugged Americans building and making with pride and determination, of former soldiers poring over text books, of men walking on the Moon. Today, “the economy” brings to mind images of stock tickers, conference rooms with sweeping views of Alcatraz or Central Park, fancy men in fancy suits getting in and out of black limos, and endless streams of brightly colored graphs, percentages and statistical trends. The economy is no longer about us.

Health care is no longer about us. Health care is about waste, fraud and abuse. Health care is about “bending the curve”. Health care is about global competitiveness of corporations. Health care is about carving up a $3 trillion opportunity. Health care is about private equity, mezzanine funding, return on investment, valuations and public offerings. Health care is about the economy, and the economy is no longer about us.

Perhaps this was never about us, but if “time is the fire in which we burn”, America was the one unique experiment where a group of people came together to protect each other’s rights to freely determine how they wish to burn. The idea spread a little bit, but not much, and now it is collapsing under the hubris of an Information Revolution, which looks more like a slow motion coup d'état to transfer control of the burning process from millions of hands to a global “digital assembly line” where physical objects, virtual algorithms and human beings are melded into one efficient production system. This is a kinder and gentler slavery nation.

John C. Calhoun

Historically, the enslavement process was physically harsh and cruel, because back then the work of a slave was physically harsh and cruel, and because the only tools available for recruiting and maintaining slaves were physically harsh and cruel. Today you give a guy an iPhone app and he willingly and painlessly joins the driving plantation. You give a guy a free Internet search tool and he unconsciously and painlessly joins the advertising plantation. This is a major improvement, since as grandma used to say, you catch more flies with honey than with vinegar, and from a respectable distance it looks like you’re generously feeding the dumb little critters.

The grand objective of slavery has always been the amassment of wealth by the magnificent few on the backs of the faceless many. The only things that changed over the millennia are the means by which this is accomplished, and the rhetorical subtleties used to justify the practice of slavery. Notably, health care has been playing an increasingly prominent role in the intellectual quackery employed by evil people towards their evil ends. As early as 1837, John C. Calhoun was extolling the superiority of health care benefits available to the enslaved, especially the compassionate palliative care at the end of life, when compared to the “forlorn and wretched condition of the pauper in the poorhouse”.

It never occurred to Mr. Calhoun that there ought to be a third option, that his own young country has challenged the world order by simply stating that all men are created equal, and challenged the most powerful King in the world, and his mighty armies, precisely so that those equally created men can be free men. But John C. Calhoun was not speaking about us. His oration was about the economy, and the economy thrives on servitude, pauperization, and wretchedness, mitigated only by the “kind superintending care” of masters. If John C. Calhoun were alive today, he would probably be running a billionaire foundation to help “all people lead healthy, productive lives”.

Alexander Hamilton

It must have never occurred to Dr. David Blumenthal either that 200 years after our Declaration of Independence, for a brief moment in time, we had a third option. After watching a Broadway show and perhaps reading one biography of Alexander Hamilton, Dr. Blumenthal found it necessary to write the strangest article in defense of the Hamiltonian version of Calhoun’s “superintending” care, which Obamacare essentially is, or aspires to become with the help of its equally superintending technology bonanza. The article is a case study in demagoguery and the building of alternate realities from partial truths and innuendos, which is how health care reform was and still is being advertised to the masses.

Perhaps we shouldn’t be surprised by Dr. Blumenthal’s admiration for Alexander Hamilton, because Alexander Hamilton was not about us. Mr. Hamilton had great misgivings about the “imprudence of democracy”. He admired the British aristocracy, and insisted with all his might that the “first class” of “the rich and well born” should be awarded a “distinct, permanent share in the government” to counterbalance the bad judgement of the masses, and to prevent change to the status quo. If Mr. Hamilton, the champion of strong central government run by financiers and corporations, were alive today, he would probably be equally smitten with what Dr. Blumenthal represents.

This Night in Iowa

Tonight in the great State of Iowa, we the people are kicking off the only peaceful process available to us to make health care, the economy, and the entire political process, about us. This year we seem to have a bountiful crop of candidates seeking greatness. Some are “rich and well born” asserting their Hamiltonian right to that “permanent share” in government. Many are lifelong corporate servants looking for the next step in their pitiful enterprise. And two are very different than the rest. Two are challenging the status quo, which is so near and dear to the “first class” and its vast infrastructure of minions and pundits, feeding at the commandeered public trough, and whose entire job now is to convince us that neither one of these two men are fit for office.

One is a career public servant, a man of principle, of lifelong held beliefs that health care should be about us, and the economy should be about us, and that central government should be by, of and for us. The other is rich and well born, a swashbuckling traitor to his “first class”, who realized that he cannot possibly have a great country when the great majority is enslaved. The two couldn’t be more different in personal style and fiery rhetoric, but at the heart of it all they both want to reclaim the “permanent share in the government” that was stolen from us by the “first class”, and unlike their corporate serving competitors, who say one thing and do another, neither man is accepting patronage from those who they aim to disempower on our behalf.

For decades the “first class” owned media and punditry, carefully nurtured the appearance of an “ideological divide” designed to keep us engaged in mortal combat over hyped minutia, while the enslavement process proceeded at a brisk pace in the background. Tonight, the people of Iowa have the opportunity to begin refocusing our sights on the real ball. This election is not about Republicans vs. Democrats, it’s not about Planned Parenthood or ISIS coming to kill us in little Toyota trucks, it’s not about men vs. women, blacks vs. whites, young vs. old, educated vs. uneducated or poor vs. less poor. This election is about all of us, it’s about being a nation of free people vs. a replaceable cog in the global “digital assembly line”, and it’s about our hard fought right to govern ourselves, centrally, locally and individually.

We can’t make health care about us until we make the economy about us, and we can’t make the economy about us until we make government about us, and we can’t make government about us until we make the political process about us. We can’t make the political process about us until we dethrone the “first class” from its permanent power perch, and deny the “rich and well born” the ability to buy every election and serve us with a nauseating mélange of sleek and polished John C. Calhoun disciples, promising “kind superintending care” for the rest of us.

Tonight Iowa will vote for Bernie Sanders, will vote for Donald J. Trump, or will vote for the status quo. These are our only choices in 2016. Choose wisely, America.