Without getting into details, I’ve had to deal with some health issues this past month.  I haven’t written a damn thing.

Any Midwesterner can tell you that once you’ve lived through a drought, those first drops of rain that hit your face feel so good they almost make you dizzy.  So it is with writing, I guess.  I don’t know when I’ll write again.  But right now, it feels pretty good.

My home state of Missouri has produced an array of authors. Langston Hughes, T.S. Eliot, Tennessee Williams, Dick Gregory, and of course, Chuck Berry.  Most came from the more cultured Eastern side of the Show-Me State.  My own Northwestern corner, in contrast, is better known for Harry Truman, Walter Cronkite, and everyone’s favorite outlaws, the James boys.

But of all the Missourians who ever touched their pen to a page, none could really hold a candle to Samuel Clemens, aka Mark Twain. 

Volumes have been written about Twain.  They sit alongside the volumes he himself wrote.  There’s no need to recapitulate his life here.  Suffice it to say he ranged from Hannibal, Missouri to Nevada to California to Connecticut to New York and eventually throughout the world.  From the time he could walk, he soaked up everything he saw.  And in his work, he spilled it all out like a flood.

He wrote compulsively, page after page.  Editing carefully, he never minced words, but never strung them out either.  In language as plain as worn denim and manure-stained boots, he threw the world at his readers.  The joy and the pain.  The humor and the tragedy.  The humane and the inhumane.  The racism and the kindness.  The people who were beaten down and the people who were incredibly wealthy for no other reason than just being lucky as hell. 

Yes, he made damn good money doing it.  Much of it he blew.  But in the end, he was someone who simply had to write.

And all of it in longhand, thousands of words each day.  As he aged, his dominant right arm became so arthritic he could barely use it.  So he forced himself to learn to write with his left.

Faulkner called him the Father of American Literature.  Hemmingway went further. “All modern American literature comes from one book by Mark Twain called Huckleberry Finn,” he declared. “It’s the best book we’ve had. All American writing comes from that. There was nothing before. There has been nothing as good since.”

And Twain did it all with no formal training in the art of writing.  No classes in literature.  No creative writing courses.  He was forced to drop out of school in the fifth grade to support his family.  All he could do was devour every book he could get his hands on.

He’s often remembered for a sarcastic wit that could to make you fall out of your chair.  But beneath it all, was the pain of someone who’d seen tragedy after tragedy after tragedy.

“The source of all humor,” he wrote, “is not laughter, but sorrow.”

He hated racists, colonialists, and imperialists.  He raged against the Spanish-American War.  He insisted Teddy Roosevelt was a bag of hot air, who didn’t do nearly enough to reign in turn-of-the-century Wall Street financiers. 

His words could cut down the high and mighty like a scythe through ripe wheat.  “What if I were an idiot?” he once asked.  “And what if I were a member of Congress?  But I repeat myself.”

Later it was “First God made idiots.  Then he made School Boards.”

Wouldn’t he have a field day with those two institutions today.

The human ego was likewise his target, as was religious pomposity.  “I believe the only reason God created man was because he was disappointed with the monkey,” he quipped.

He travelled to Hawaii, and couldn’t understand why Christian missionaries couldn’t just leave the Islanders alone.  In Australia, India, and South Africa, he was outraged at how Europeans treated native peoples.  “Man is the only animal that loves his neighbor as himself, and then cuts his throat if his theology isn’t straight,” he grumbled.

In what many consider the greatest novel ever written, a young boy named Huckleberry Finn rafts down the Mississippi River with a runaway slave named Jim.  Over time, they bond, and Huckleberry learns the reason Jim has run away–he learned that he was about to be sold down river, and possibly separated forever from his wife and daughter. 

Jim misses his wife and daughter terribly and worries about their future. The pain is so powerful Jim sometimes cries himself to sleep at night. He’s determined to somehow gain his freedom, find a job, and save enough money to buy his family out of bondage.

But Huckleberry is terrified by what his religious upbringing has taught him.  Preachers in Missouri insisted that slavery was ordained by the Almighty, and to assist a runaway slave was sure to bring about the wrath of God.  Hell and damnation would be waiting.

This makes Huck tremble.  An eternity in hell?  He’s torn as to what to do.  Finally, while Jim is sleeping, Huck writes out a letter to give to the authorities explaining that Jim is a runaway.

But after the most intense soul-searching a young boy can do, Huck makes his decision.  He tears up the letter, and refuses to betray Jim.  In what may be the most profound seven words ever written, Huck says simply, “All right, then, I’ll go to hell.”

In an era of hypocrisy, extreme nationalism, and wild-eyed religiosity, how many today would have the courage and insight of that scruffy kid from Missouri?

Since his death, Twain has been both praised and scorned, his books sometimes promoted and too often banned.  He’s been called a saint, a sage, and a genius by some and a scoundrel, a blasphemer, and a hypocrite by others.

But through it all, his words still stand.  Plain, often unsophisticated, sometimes vulgar, and frequently uncomfortable.  Just like he was.

We could only wish that another like him would emerge at time when this world needs them most. 

And if any of you would like to respond, and have your own favorite quote(s) by Twain to add, feel free to do so.  

WHY ARE WE OVERPAYING FOR OUR MEDICATIONS?

Our local newspaper, The Omaha World-Herald, sometimes runs editorial pieces from other publications.  These pretty much run the gamut from liberal to conservative, and each one usually gives someone something to disagree with.

Recently, the paper published an opinion piece that had appeared in The Wall Street Journal, essentially mocking an effort by a U.S. Senate committee to investigate drug prices in the U.S.  It was my turn to disagree.

Most Americans have become so accustomed to hearing about how expensive our medications are compared to the rest of the developed world, that such information just goes in one ear and out the other.  But these costs are a real hardship for many Americans.

So here’s the original editorial Bernie Sanders Wants a Pharma CEO Show Trial , as well as my response below, published today in the Midland’s Voices column of the World-Herald.  I use an analogy that previously appeared in an earlier post Guns, Drugs, Geezers, and Money but it’s still relevant.  You might keep it in mind the next time you pick up your prescriptions.

Oh, and I did add an editorial comment here on the singer Jelly Roll that didn’t appear in the paper.  Feel free to disagree if you’d like.  It’s not meant to take away anything from his testimony about the dangers of Fentanyl, but his appearance isn’t exactly a textbook promotion of sobriety. . .

And no apologies for the Ron DeSantis comment, either.  Anyway, the extended version is below, and you can see the original newspaper piece here: https://omaha.com/opinion/column/midlands-voices-americans-deserve-to-know-why-their-drugs-are-so-expensive/article_a81f4576-ccfb-11ee-855b-eb6f1532d92e.html

AMERICANS DESERVE TO KNOW WHY THEIR DRUGS ARE SO EXPENSIVE

Donald R. Frey, M.D.

The author is Professor Emeritus of Family Medicine at the Creighton University School of Medicine.  His comments do not necessarily reflect the views of Creighton University.

Let’s say you need to pick up a few things at your local grocery store.  You grab the items, toss them into your cart, and head to the check-out line.  A couple of your neighbors are in line ahead of you, and you notice they have exactly the same things in their carts, too.

The cashier rings up their individual purchases, and charges them each $49.  But when your items get rung up, your bill is $108.

You’re stunned.  You’ve just been charged over twice as much for precisely the same things your neighbors bought.  You’re confused, hurt, and angry.  Don’t you at least deserve some answers?

Apparently not, if you believe the recent Wall Street Journal (WSJ) piece, carried by the World-Herald on January 25, 2024.

As has been well documented by multiple sources, Americans pay over twice as much for prescription drugs as citizens of comparable countries.  We’re talking about the same drugs, manufactured in the same way, by the same companies, and used to treat the same diseases.

Over twice as much.  Why?

That’s the question the Senate Health, Education, Labor and Pensions Committee is seeking to ask pharmaceutical CEOs on behalf of the American people.  But according to the WSJ, this is somehow all just a “socialist show trial.”

Really?  At a time when we’ve seen a parade of Congressional witnesses ranging from university presidents to UFO buffs, public health officials to a guy who changed his name to “Jelly Roll” (who looks to have about a half-gallon of ink sitting under his skin, and enough metal on his teeth to build a lawnmower engine), asking those responsible for high drug prices to explain their actions hardly seems unreasonable.

What kind of money are we talking about?  According to research by the Peterson Institute and the Kaiser Family Foundation, Americans pay $1,126 per year for prescriptions.  Other developed countries average $552—for exactly the same drugs.

All of this has real life consequences.  The same Peterson research also revealed that one out of every three American adults has forgone taking prescribed medication due to costs.

Most other countries use their collective purchasing power to manage drug costs.  By negotiating directly with the manufacturer, these countries can drive a harder bargain and bring down prices for their citizens.

And it works.  Europeans, Canadians, and Australians all buy the same drugs for half as much.  And it doesn’t hurt the drug companies one bit.  They still reap gross profit margins more than twice those of S&P 500 companies.

Research and development (R&D) costs are often used as an excuse for high drug prices.  But this argument doesn’t hold water.  All major companies have R&D costs, regardless of their industry.  And if pharmaceutical research really is so expensive, why is it that only Americans are being asked to pay the price?

The good news is that our government is just beginning to conduct direct price negotiations with some pharmaceutical companies.  These carry the real possibility of reducing prescription costs for hard working Americans.

Yet, this is precisely what the WSJ derides as “sham negotiations behind closed doors.”

Whether these negotiations, along with the Senate hearings, produce results remains to be seen.  But political ideology should not be an excuse to shut them down.

After all, if the Ron Desantis-led state of Florida is resorting to importing drugs from Canada, the reality of this problem should be obvious to all of us.

The only question is whether we have the collective national courage to address it.

THE LONG SHADOW OF NUREMBERG

“The thing we learn from history is that no one ever learns from history.”—Otto Von Bismark, German Chancellor, 1815-1898.

“Where one burns books, one will soon burn people.”—Heinrich Hein, German poet, 1797-1856.

It is impossible to visit the city of Nuremberg, Germany and not come away shaken.

At the eastern edge of the city, you can walk around the Nazi Congress Hall, a huge semi-circular structure that, once completed, was intended to look like a Roman Coliseum and seat over 50,000 people.  Once you’ve huffed and puffed your way around the half-finished stadium, you realize you’ve only scratched the surface of what once stood here.  The rally grounds, the Zeppelin Field, the crumbling reviewing stand, are all yet to be seen.  Over six square miles in all.  It would take you a half day to walk around all of it.

Hitler himself gave some of his most terrifying speeches here, to crowds of over 300,000.

300,000 cheering admirers.  A regular Nazi Woodstock.

It was here that the German Reichstag put into place the Nuremberg Laws, officially known as the “Law for the Protection of German Blood and German Honour,” which forbade relations between Germans and Jews, Blacks, and Roma (“the Gypsies,” to some people), as well as the “Reich Citizenship Law” which outlawed citizenship for anyone other than ethnic Germans or those of “German blood.”

It was here (as in 34 other cities) that Nazi adherents marched with torches and burned books that were deemed “decadent,” “immoral,” and “anti-German.”  This included texts describing homosexuality and transgender issues—along with the works of such nitwits as Albert Einstein.

If some of this makes you feel a little uncomfortable in light of current events—good.

Nuremberg was neither the headquarters of the Nazi Party (that was in Munich, Hitler’s old stomping grounds) nor the seat of German government (centered squarely in Berlin).  However, it was a city known as a hot bed of antisemitism and German ultranationalism.

How did Germany wind up with the Nazis?  It’s a complex question, and one that we ignore to our own peril today.  It begins with World War I.

The First World War, the conflict that was supposed to end all wars, took place between 1914 and 1918.  Four long, tortured years.

Most of the fighting took place in trenches in France and Belgium.  Hundreds of thousands of young men would charge out of the trenches, incurring enormous casualties.  They’d gain a few yards of ground, only to be driven back days later by the opposing side, who’d suffer an equal amount of carnage.

Incredibly, no fighting occurred in Germany.  No bombs fell on German homes.  No enemy was at the gate.  Other than food shortages, Germans had absolutely no way of knowing first hand their nation was losing.

When it was over, 9 million soldiers had been killed, 23 million others wounded for life, and over 5 million civilians were dead.  It was a war of attrition, and Germany gave up first. But to many, their nation’s surrender came as an absolute shock.

One of these shocked German was a non-descript army corporal (and failed street artist) who was recovering from a Mustard Gas attack.  He would later claim he was so dumbstruck by the surrender that he went temporarily blind.

In his view, there was no way the German army could have been defeated.  They had to have been sold out by traitors, foreigners, and corrupt officials.  He would later come to personify this group with an age-old scapegoat.

Jews.  They had screwed Germany.  And he was going to by-God do something about it.

Historians still argue about when Hitler’s antisemitism evolved into mass murder (it had been a Jewish German officer, after all, who’d earlier recommended the corporal for military promotion).  But there’s no question that it was Germany’s surrender—and its humiliating aftermath—that further incited his rage for Jews, Roma, Communists, Socialists, immigrants, and anyone not of German stock.

That is, anyone who wasn’t a “real” German.  No way were those outsiders going to “replace” real Germans.

The aftermath of World War I was a gut-punch to the German people.  Besides losing all of their worldwide colonies, much of their European territory, and most of their self-esteem, they were forced to pay off both their own war debt, and that of the France and Great Britain.  The economy began to crumble.

Germany had no choice but borrow money.  Lots of it.  And through a series of missteps, the nation entered one of the worst episodes of hyperinflation in history.

How bad was it?  At the end of the war, it would take 8 German Marks to buy one U.S. dollar.  By 1923, it took 4.2 trillion.  Go to work in the morning, labor all day, and get paid in money that was essentially worthless.

Slowly, the economy stabilized.  But in 1929, the Great Depression hit.  A hungry, humiliated nation was desperate for new leadership.  Most of the poor and working class supported far-left groups, such as the Communists.  This horrified the business community.  They coalesced around a small group of right-wing radicals called the National Socialist German Workers Party, and poured money into its political machine.

The Party also went by another name.  The Nazis.

Perhaps they greatest error we can make in trying to understand the Nazis is to believe they were somehow unanimously elected on a platform of “Let’s go out and kill all the Jews and take over the world!”  Instead, it was much more basic.  Something that hit home to an angry and demoralized nation.

The world is trying to destroy our German values, the Nazis warned.  We are the true guardians of western civilization, and the world is trying to water down our traditions with decadence and vulgarity.  Non-Germans are poisoning our blood and threatening to replace us.  Jews, communists, homosexuals, Poles, Slavs, and (of all people) Jehovah’s Witnesses are vermin, and a threat to our nation.  We’ve been bullied, laughed at, and disrespected long enough.  It ends now.

We’re going to Make Germany Great Again. 

And once they were in power?  The Nazis devolved into utter madness.

Nuremberg learned this, too.  On January 3^rd, 1945, over 500 British Lancaster bombers reduced most of the city to rubble.  Five months later the war was over.  The gigantic Swastika atop the Nazi reviewing stands was blown to pieces  

Of course, Nuremberg’s story doesn’t end here.  One of its few major public buildings to survive the bombing was the Palace of Justice.  The Allies selected it to house one of the most famous trials in history.

Over the next three years, a parade of Nazi defendants were brought to trial in Nuremburg.  Many were found guilty.  Some were executed.

For the first time, a new legal term was introduced to the world.  Crimes Against Humanity.  Crimes so heinous they were described as “deliberate acts, typically as part of a systematic campaign, that causes human suffering or death on a large scale.”  If you have not seen the award winning 1961 film Judgement at Nuremburg, it is well worth your time.

The judges and witnesses at Nuremberg hoped this would be the last the world would see of such crimes.  Of course, they were wrong.  The long shadow of Nuremberg still touches humanity today.

The year 2023 has seen its share of Crimes Against Humanity, and its perpetrators should be brought to justice.  Mohammed Deif, military commander of Hamas, and the terrorists who murdered and mutilated innocents in Israel should be tried as war criminals. 

So too should Benjamin Netanyahu and the Israeli commanders who have murdered innocents in Gaza and the West Bank by indiscriminately bombing homes, refugee camps, and schools, and even blocking food shipments while malnutrition worsens. 

Don’t forget Vladimir Putin, whose cruel war against Ukrainian homes and hospitals has left thousands dead, wounded, and freezing.

Will these criminals ever be brought to justice?  Who knows.

But let’s look closer to home.  The shadow of Nuremburg reaches our own country, as well.  When presidential candidates describe fellow humans as “vermin” who are “poisoning the blood of our country” it should send a chill through our hearts. 

When you hear immigrants and political opponents derided as “replacing real Americans” you should know what’s coming next.  Governors of Texas and Florida are already rounding up immigrants, shipping them to northern cities, and dumping them on the streets like so much garbage.

This is America 2023.  Not Germany 1935.

Or is it? 

Think about that when you cast your vote.

If one day you have the opportunity to visit Nuremburg, I hope you take it.  The city’s lessons will stay with you forever.

And just for the record, their beer and sausages are pretty good, too.

Happy New Year, everyone.  Here’s hoping 2024 will be a step forward for all of us.

CHRISTMAS 2023

For the past couple of years, I’ve penned an imaginary letter from Jesus (Christmas 2021) and Christmas 2022).  This year’s no exception.  Believe whatever you want about the guy, but his teachings seem to get more relevant with each passing year.    

So at the risk of upsetting anyone, let’s check in again.  And remember, this isn’t meant to promote Christianity nor deny it.  It simply tries to look at what Jesus might be saying in the context of our present-day world.

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Hello everyone.

Well, it’s me again.  And it’s Christmas.  The day when you claim to celebrate my birth.  The season when you decide whether you give your money to help the less fortunate, or send it off to Jeff Bezos in exchange for a cardboard box of transient items that someone’s just going to steal off your porch anyway.

I guess that’s your choice, isn’t it?

For some reason, midnight seems to be a big deal for you folks.  Midnight Mass, midnight Services, prayers at midnight.  I’m not sure where you get this stuff.  I certainly didn’t say anything about it.

But if you’re going to offer prayers at midnight, at least be decent about it.  Forget about praying for yourself.  Forget about praying for a new car, a new house, or that the Royals win another World Series (like that’s ever going to happen).

Pray for something that matters.  Like the hostages in Gaza who are hungry and terrified.  Like the people of Gaza and the West Bank being killed by the thousands, some outright, others from thirst and starvation while they’re buried under rubble, calling out to their loved ones.

Send a few prayers for the people of Ukraine who try to survive amidst bombs, freezing weather, and war.  Don’t forget the Uyghurs, the Rohingya, the Haitians, the Sudanese.  The millions fleeing terror, murder, and poverty in Central and South America, running a gauntlet of violence, rape, and fear, who still may be turned away at America’s southern border.

Pray for the thousands of American children killing one another with guns each year.  Pray for those imprisoned in China, Iran, Russia, and North Korea for saying the wrong thing at the wrong time.  Pray for their families who may be imprisoned, tortured, and killed for what their relative said, and not for anything they themselves did.  Pray for the people of Palestine who are having their houses and farms bulldozed and leveled, leaving them homeless, for no reason other than living in a spot someone else covets. 

Pray for the 110 million people who are refugees because of war, famine, or natural disasters.  Maybe pray that some of your more self-righteous pundits will accept responsibility for what you people are doing to your earth and its climate, and quit blaming it on me all the damned time.

O.K., that’s a lot to pray for.  And I think you know I could keep going on and on.  But the clock is going to strike, the service is going to end, and you’re going to want to go home.  Now comes the hard part.

Start working to make those prayers actually happen.  Prayers are fine, but they don’t mean much if you just say “Amen” and then go back to doing just the opposite of what you prayed for.

I was never that big on public prayer, anyway.  I never taught that Congress, school meetings, and worst of all, political rallies, should be opened with prayer.  If you paid attention, you’d know that I taught that prayer was a private thing—between you and God.  It was never meant to draw attention to yourself or your new clothes.

In fact, I was never that big on organized religion, period.  Or even governments, for that matter.  Kings, Queens, Emperors, Presidents, Popes—they never impressed me much.

Which brings us to this whole thing that Americans call “Christian Nationalism.”  I’m not going to say much about it, because if I think about it too long, I’ll probably get so pissed I’ll knock your whole world right off its axis (for those science deniers out there, yes, that would be a bad thing). 

Just let me say this:  any political “movement” that attaches my name to an agenda of hating your neighbors, belittling others, promoting violence, or promoting oppression, is no “movement” of mine.

Call it “Self-Righteous Nationalism,” “Bigoted Nationalism,” or even “Ethnic Nationalism.”  But keep my name out of it.

But let’s get back to the more important issue—I care a lot more about your actions than your prayers.  So what you do this Christmas season means a lot more to me than what you pray for.

You know what I mean.  I’ve already talked about this.  There are plenty of people all around you who are hurting.  Plenty of people in need.  Spend some time with them.  Listen to them.  Touch them.  Give them something extra.  An extra tip.  An extra bit of time.

Do that and see what happens.  See how they smile.

Now go do it the rest of the year, too.  And think about all of this when you go to work, when you come back home, when you’re out with your friends.

And yes, when you vote, too.

And as far as that Hallelujah Chorus thing. . .  Well, you already know what I think about that.

See you down the road.

Jesus      

“The only function of economic forecasting is to make astrology look respectable.”—John Kenneth Galbraith, 1908-2006.

One of the most enduring myths when it comes to health care is the notion that if we just increase the supply of medical services—that is, if we just had more doctors, more hospitals, more scans—health care costs will come down.  In other words, those same “market forces” that restrain costs for lemonade, toilet paper, and bubble gum would operate no differently when it comes to health care.

I was reminded of this a few weeks ago when I overheard a couple of friends talking.  “You know,” one said.  “If we just had more doctors there’d be more competition, and health care cost would come down.  The American Medical Association (AMA) knows this and that’s why they restrict the number of doctors.  This is all the AMA’s doing.”

There are a lot of misconceptions in this statement, maybe more than can be addressed in a single post, but I’ll try.  First, the AMA isn’t exactly a powerhouse organization.  Barely 15% of American doctors even belong to it (I sure don’t).  The number of doctors America produces is dependent on the number of students who graduate from medical school, and the AMA has nothing to do with that number.  Instead, a group called the Liaison Committee on Medical Education (LCME) accredits medical schools, and must approve the opening of new schools and the expansion of existing schools.  The LCME’s job is to ensure that new and/or expanded schools have the resources to properly educate physicians.

I know all about this.  While I was Vice President for Health Sciences at Creighton University, we expanded our medical school to include a campus in Phoenix, Arizona.  It wasn’t easy.  We had to satisfy the educational requirements of the LCME, the Higher Learning Commission (the HLC—more letters, I know, but who’s counting), as well as the Arizona State Board of Education.

It was meetings, paperwork, and hours and hours of documentation.  But nowhere along the line were we ever told “don’t do this because it might increase the number of physicians.”  In fact, for the past thirty years medical schools have been encouraged to grow and expand.

But during the 1980’s, it was a different story.  Why?  We’ll get to that in a minute.

For now, though, let’s look at the competition issue again—the idea that the more lemonade and hot dog stands you build, the more prices will come down, and that same concept should also apply to doctors and hospitals.

I describe this competition fallacy in Chapter 2 of my book (if you don’t have a copy, see if you can steal one somewhere.  If you buy it on Amazon, I’ll only get a couple of bucks anyway, and the rest will just go toward Jeff Bezos’ next yacht or spaceship).  In a nutshell, the decision to buy or not buy hot dogs and lemonade is pretty straightforward, and the market works fine.  Besides, it’s not like you’re going to die or something if you don’t buy a hotdog.

But that’s no true in health care.  If you don’t get it, you may die.  That puts the patient (or the “consumer,” if you will) in a pretty powerless position.  And because health care involves expensive technology, combined with complex decision-making that even many doctors struggle to understand, those hotdog stand-style market forces of increasing the supply to bring down costs simply don’t work.

You want examples?  Exhibit A—Kearney, Nebraska.  Exhibit B—Grand Island, Nebraska.

For those unfamiliar with Nebraska geography, Kearney and Grand Island are towns of about fifty thousand, about an hour apart, smack dab in the middle of the state.  Both have had active, community-based hospitals for decades.

Then things began to change.  Ownership of both facilities transitioned to a huge national corporate entity.  Some doctors got angry.  So did some of the public.  And in both communities, a competing investor-owned hospital was also built.

For the record, these were full scale, competing facilities, each with their own operating rooms, emergency departments, and medical beds.  Each with its own nursing staff, administrative suite, facilities management, human resources, and overhead.  If we were talking about hot dog and lemonade stands, this competition should bring down prices, right?

But it didn’t.  If you don’t believe me, try this.  Go up to someone who lives in Kearney or Grand Island, and ask them, “Gee, now that you have two hospitals, isn’t health care in your community a lot less expensive?” 

That person will probably stare at you for a moment, then either laugh out loud, or punch you in the face.

No, there’s no evidence that bringing in competing hospitals has improved the quality of care or reduced prices in these Nebraska cities.  What has happened is that resources have been stretched thin, overhead increased, and costs simply shifted or expanded.

Those vaunted market forces failed to deliver.  Just like expanding the number of doctors alone won’t deliver lower costs, either.

But let’s get back to that earlier question of how many doctors do we really need.  And are we doing everything we can to meet that need?  Let’s look at some basic numbers.

From 1950 to present day, the population of the U.S. has basically doubled.  But during that same time, the number of physicians has increased five-fold, because starting in the 1960’s, medical schools expanded significantly.

This expansion occurred so rapidly that by the 1980’s, some economists began to worry that, at the rate numbers were growing, the country might be heading toward a doctor glut.  An excess of doctors, as we’ve seen, doesn’t bring down the cost of health care.  In fact, evidence was showing that by ordering more tests and performing more procedures, a physician glut would add to the already spiraling health care inflation.  You could understand the concern.  Remember, from 1960 to 1980, the percent of US GDP needed to pay for health care doubled.

As a result, medical school expansion dropped off.  Again, this wasn’t because of the AMA or some sort of deep state doctor conspiracy.  Rather, it was an attempt to slow a rapid expansion in physician numbers.

By the 1990’s, though, it was clear that societal need for health care was expanding faster than physician production.  Medical schools started expanding again, and that continues to this day.

So let’s get back to the original question.  Will simply cranking out more doctors and building more hospitals bring down the cost of health care?  No.

But several other questions remain.  How many doctors do we really need?  And what kind of doctors?  Where should they practice?  What should they practice?

How long should it take to train them?  Today, almost all medical training takes at least 8 years after high school, but a few schools have reconfigured their curriculum to do it in 6.  During the second world war, with a need for more military doctors, some schools successfully cranked them out in 5.  

Should we be doing that now?  Could we?  How might that affect our overall health care quality?  And how about those medical school tuition costs?  Why are they so expensive?

Along with many others, I’ve written about the similarities and differences between the U.S. health care system and those of other countries, including what we can learn from one another.

But can we also learn from other countries’ systems of medical education, as well?  Are we really convinced that our doctors are “better” than those of other countries?  Why or why not?

What evidence do we have one way or another that our medical schools are better?  How do other countries compare?  What can we learn from them?

More questions than I can answer in one post.  Maybe more than could be answered in several posts.

I don’t know.  Maybe someone should write a book. . .

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As some of you may recall, last year in the middle of America’s most painful season, the “Oh-gee-call-our-toll-free number-no obligation-we really-really-want-to-help-you, just-look-at-all-of-our-great-benefits, and-whatever-you-do-don’t-look-at-all-the-stuff-we-don’t-cover-if-you-do-happen-to-actually-get-sick” Medicare-Advantage enrollment period, I wrote a post about this stuff.

And since we’re now in the middle of our current 2023 Ho-Ho-Medicare Advantage season, I could certainly warn you about all of that again.

But I don’t have to.  My friend and colleague Dr. Josh Freeman, long-time Professor and Chair of Family Medicine at the University of Kansas, has recently posted a devastating article on the significant risks of signing up for Medicare-Advantage titled The Insurance Company Mafia and Medicare Advantage:  Taking Your Money and Denying You Care   I’d urge you to read it.

See you next time with a new 2023 Christmas letter.

IS AMERICA LURCHING TOWARD BECOMING A FAILED STATE?

“I do not expect the Constitution to last for more than 20 years.”—George Washington, Virginia delegate to the Constitutional Convention, 1787, and later First President of the United States of America.

“It does me no injury for my neighbour to say there are 20 gods or no God. It neither picks my pocket nor breaks my leg.”—Thomas Jefferson, Third President of the United States of America.

“There is a Providence that protects idiots, drunkards, and the United States States of America.”—Otto von Bismark, Chancellor of Germany, 1871-1890.

Listen to some current politicians, and they’d have you believe that the United States is perfect.  We can do no wrong, we’ve been chosen by God, and we can’t possibly fail, because the Constitution was handed down directly from heaven, like Moses and the Ten Commandments.

Sorry, but it didn’t work that way.  The Constitution was developed by men (that’s right, no women—that may have been its biggest mistake right off the bat) who were flawed, combative, and often petty and vindictive.  It wasn’t zapped down from on high.  According to Washington, if it got us twenty years down the road, we’d be lucky.

Of course, it’s gotten us a lot farther.  On balance, it’s held us together through wars, depressions, and catastrophes.  And for many, that means that the United States is therefore destined to last forever.

In reality, nothing lasts forever.  And to say we’re currently in a precarious and threatening time would be an understatement.

On January 6, 2021, a mob of thousands, egged on by a defeated President, stormed the American Capitol, threatening to hang the Vice President and do harm to sitting members of Congress.  It didn’t work.  Officers laid their lives on the line, and eventually the mob dispersed, but only after they’d vandalized and defecated on the Capitol itself.

Any rational observer understands the whole thing could have been much worse.  The occupation could have easily grown into an armed conflict that could have split the nation apart. 

Yet some still maintain that the rebellion’s failure was proof that “the system worked.”  Well, maybe.  Or maybe we just got lucky.  Damned lucky.

In science and industry, when a disaster is barely averted, we have a term for it.  It’s called “a Near Miss.”  Two planes nearly collide.  The wrong surgery almost happens.  The wrong drug is nearly dispensed.

It’s not a time to celebrate and say, “See, the system worked!”  Instead, it’s a time for some clear-headed analysis of what went wrong, and how to insure it never happens again.

If we think that the January 6^th insurrection was no big deal, and that the Constitution will always magically protect us from disaster, we’re wrong.  Next time we may not be as lucky.  The Providence Bismark described may run out.

And the Constitution alone won’t save us.

Let’s start with some basics.  The Constitution established a legislative branch that consists of two bodies, a House of Representatives and a Senate.  Both must agree on a piece of legislation before it can move on for the President’s signature and become law.

Even then, just five life-time appointees to the Supreme Court can still declare virtually any law unconstitutional, based on whatever convoluted reasoning they can concoct.  History has revealed this to be the case for both previous left-leaning Courts as well as our current far-right batch.

The legislative body with the most power, though, is clearly the Senate.  Made up of two Senators from each state, regardless of how large or small the state happens to be, it gives remarkable power to individual Senators to block legislation, and stall progress.

I won’t go into detail, but there are numerous historians that maintain that the configuration of the Senate was a compromise (remember those flawed, combative men I mentioned earlier? Yes, sometimes even they compromised) to appease southern slave-holding states.  In any case, we still see its impact on our Nation today.

Currently, one Senator is holding up 300 promotions of military personnel.  In a time when threats are growing throughout the world, ex-football coach Tommy Tuberville of Alabama is blocking critical appointments within our armed forces.  Was this really what our founding fathers had in mind when they created the Senate?

And the House doesn’t seem to be doing much better.  The Republican majority can’t seem to maintain a consistent Speaker, and the one currently in office (at least as of today) is an adherent to an extremist philosophy known as “Christian Nationalism,” which maintains that Christianity alone should shape our laws.  It’s tenets regarding women, gays, immigrants, and non-Christians (along with any Christian who isn’t “their kind of Christian”) are frightening.

Speaker Mike Johnson also aligns himself with the election-deniers who promoted the January 6^th insurrection, and to this day denies the reality of democratic elections.  I wonder what Jefferson would think of someone of Johnson’s persuasion?

Keep in mind, Johnson is second in line to the presidency.  Anything happens to the current President and VP?  Then an election-denying far-right fundamentalist is in charge.

The current two-party system, where a candidate is nominated, usually by a mere fraction of eventual voters, and is then shooed into office simply because of their party affiliation, hasn’t helped.  Extreme candidates tend to turn out primary voters.  General election voters usually follow party lines.

This has led to a deeply divided nation, and a deeply divided government that is bordering on incompetence.  Former Speaker John Boehner has called members of his own party “political terrorists.”  It probably doesn’t matter.  Over the last few years, political moderates from both parties have been leaving Congress in droves, either because they were “primaried” out, or because they just couldn’t take their colleagues’ crap any longer. They’ve been replaced by voices far more extreme.

Forget about changing the Constitution any time soon.  An Amendment requires passage by a two-thirds majority of both Houses, as well as ratification by at least 30 states.  In today’s environment, an amendment that said apple pie tasted good couldn’t run that sort of gauntlet and pass.

There are a few glimpses of hope, however.  In the 2022 election, a smattering of extreme candidates on both sides who had primaried out more moderate Congressional members were defeated.  And in Colorado, the radical gun-worshiper and Pee Wee Herman wannabe, Lauren Boebert, was nearly defeated by a more moderate political unknown.  This time she may not be so lucky.

The best we can hope for is that an epidemic of common sense will hit the country sometime soon.  Under Speaker Johnson, Congress seems clueless as to how to pass a budget, thus raising the possibility of our nation defaulting on its obligations.  The criminal invasion of Ukraine is entering its second winter, and the Israeli-Hamas War is creating shocking casualties in Gaza and the West Bank, which Russia, China, and Iran are keen to exploit.

If there ever was a time for American leadership, it is now.  Yet we can’t even get our act together around passing a budget.

Washington harbored no illusions about the future of the Constitution, or the country. He knew both could easily fail—whether in 20 years or 235 years.  If he could see us now, what would he be thinking?

And don’t forget Bismark.  When he made his sarcastic remark about America, Germany was at the peak of its power.  Yet just a few years later, the German Republic would collapse under the weight of war and infighting.  In its place, a demoralized and angry nation put into power a man who promised to Make Germany Great Again.

You know the rest of the story.  For God’s sake, let’s not repeat it.

Editor’s Note:  The comment regarding Lauren Boebert was not intended to be an insult to the distinguished deceased actor and comic Paul Reubens, AKA Pee Wee Herman.  Rather, it was simply to note similarities in the theatre-going behaviors of Boebert in comparison to those of Mr. Herman.

Piling up Bodies

There are a lot of things happening here in America.  Another Ho-Hum-Yawn-What-Else-Is-New mass shooting in Maine, brought to you by The Friends of the AR-15.  The election of an extremist Speaker of the House of Representatives who now stands second in line to the Presidency.  And of course, the opening of the annual Medicare enrollment period, when private insurance companies spend small fortunes trying to convince you (if you’re a geezer like me) to turn your tax dollars over to them in return for inadequate health coverage.

I’ll have plenty to say about all of those things.  In the meantime, the ongoing killing in the Middle East grows more critical by the day.

Yes, I know I wrote about this in my last post.  But now things are even worse.

First, the recap.  Over three weeks ago, Hamas unleashed a brutal, immoral, and horrifying attack on Israel.  1400 Israelis were killed, including non-Jewish Bedouin tribesmen.  Hundreds of Israelis were taken hostage.

In response, Israel has dropped 4,000 tons of bombs on Gaza, killing over 8,000 Palestinians in Gaza, while hundreds more have died in the occupied West Bank.  Of course, this is just the tip of the iceberg.

Gazan hospitals are running out of medicine, food, and electricity.  According to one Pediatrician, dead children are piling up so fast in a makeshift tent-morgue it threatens to contaminate drinking water.  How many additional bodies are buried beneath the rubble is unknown.

Israeli tanks and troops are pressing into Gaza, and Israel is advising the al-Quds Hospital to evacuate immediately.  How do you evacuate hundreds of sick and injured in the middle of a war?  How do you run ventilators and operating rooms without power?

Officially, the purpose of Israel’s upcoming invasion is to defeat Hamas.  Unofficially, Israel has threatened to “turn all of Gaza into rubble.”  Israeli Prime Minister Netanyahu has declared this will be “a long war.” Hamas continues to fire rockets at Israel.

At that rate, there’ll be a lot of rubble—and a lot of bodies.  And to what end?

Hamas may get wiped out, but the anger, frustration, helplessness, and humiliation of Palestinians will continue.  History is clear—keep a people beaten down long enough, and bad things will happen.  The next confrontation will be even worse—for everyone.

Is there a way out of this?  Certainly Palestinians should be entitled to their own homeland.  But just saying this will upset many.  Some supporters of Israel maintain that Palestinians should be assimilated into other existing countries, and all territory controlled by Israel permanently annexed.  Some Palestine supporters maintain that because Israel was carved out of Palestinian land, it’s only fair that they, and not the Israelis, should have all of their original land returned.

Neither of these approaches will work.  Nor will maintaining the status quo.

All nations should demand an immediate ceasefire, the return of hostages, and the withdrawal of Israeli forces from Gaza.

Of course Palestine needs to be recognized as an independent nation.  Argue all you want about what the specific boundaries should be.  But it must happen.

Israel must be recognized by the Palestinians.  Just like most everyone else reading this piece, I live on land that was stolen from its rightful owners—the American Indians.  Restoring that now would be impossible. 

West Bank Israeli settlements, though, are a different matter.  They must be dismantled, and the region restored to Palestinian control. No Israeli soldiers, no checkpoints, no roadblocks.

Hamas leadership must resign immediately, as should the extremist government of Netanyahu.  Can Hamas transition to a purely political entity?  That certainly seems doubtful.  But in Northern Ireland the Sinn Fein militants who carried out bombings and terror attacks to drive out the British eventually made peace with England, while Northern Ireland still remained British. 

The United Nations should provide security for Palestine, but also be empowered to arrest terrorists and confiscate rockets.  New elections should be held and monitored by the U.N.  All countries, including the United States, should fund the rebuilding of Palestinian homes and businesses, much like the Marshal Plan at the end of the second world war (which, more than any American military action, stopped the spread of Communism in its tracks).

All countries should recognize, support, and promote the success of both nations.  This will mean extensive work to unwind the hatred, and the belief that the “other side” is always responsible.

Can this occur?   I don’t know.  But I do know that the status quo will only insure more war, more death, and more bloodshed.  And it will only get worse.

Many Palestinians don’t support Hamas and the terror attack on Israel, just as many Israelis do not support the invasion and indiscriminate bombing of Gaza nor the settler attacks in the West Bank.  Can both groups coalesce around a solution?  I don’t know that either.

What I do know is that the current situation is headed toward a terrible conclusion for the entire world.  It is already further tearing apart a deeply divided America.  Attacks on both Muslims and Jews have increased dramatically here in the U.S. in the past month.

If not extinguished soon, the flames of this war will continue to burn for decades.  The destruction those flames can wreak are far greater than any of us can imagine.     

THE MIDDLE EAST’S DESCENT INTO MADNESS—A GLIMPSE OF HUMANITY’S FUTURE?

“We will expel the Arabs and take their place. In each attack, a decisive blow must be struck resulting in the destruction of homes and the expulsion of the population.”  David Ben-Gurion, 1937.  Eleven years later, Ben-Gurion would become the first President of Israel.

“Israel is a disgraceful blot and the regime occupying Jerusalem must vanish from the page of time.” Mahmoud Ahmadinejad, upon assuming the position of the 6^th President of the Islamic Republic of Iran, 2005

“Israel will exist and will continue to exist until Islam will obliterate it.” from the Preamble to the Hamas Charter, 1988

“To me, the Palestinians are like animals, they are not human.” Israeli Knesset member Eli Ben-Dahan, 2013.

“You’re here by mistake, it’s a mistake that Ben-Gurion didn’t finish the job and throw you all out in 1948!”  Israeli Knesset member and Finance Minister Bezalel Smotrich, 2021.

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“An eye for an eye, and one day the whole world will be blind.”  Mahatma Mohandres K. Gandhi, Hindu Leader and Pacifist, whose philosophy of non-violent protest inspired, among others, Dr. Martin Luther King, Jr.  Gandhi would soon be assassinated by a radicalized member of his own faith. 

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“The Eastern world, it is explodin’/Violence flairin’, bullets loadin’. . ./And even the Jordan River has bodies floatin’/And you tell me, over and over again, my friend/You don’t believe, we’re on the eve, of destruction.”  From Eve of Destruction, by P.F. Sloan, 1965.

There are no words to describe the horror of what is currently happening in the Middle East.  Terrorists from the Hamas faction entered Israel and brutally murdered over a thousand Israelis.  Hostages were taken.  Lives were destroyed.

Those murdered were not soldiers.  These were civilians who’d done nothing wrong.  Many were women, children, and babies. 

This terror was unleashed from Gaza, a tiny strip of land where over two million Palestinians are packed into what some have described as an open-air prison, with inadequate water, power, health care, and opportunity.

In response, Israel unleashed a massive arial bombardment of Gaza.  Over a three thousand Palestinians have been killed thus far.  Most are not soldiers.  These are civilians who’ve done nothing wrong.  Many are women, children, and babies.

Additionally, Israel has shut off all food, water, and medicine to Gaza.  Who will suffer most?  Women, children, and babies.

Let’s be clear.  No baby deserves to be killed by Hamas machine guns.  No baby deserves to be killed by Israeli bombs.  No baby deserves to be killed by Russian missiles, in Ukraine, Syria, or elsewhere.

But it’s happening.  And the world seems powerless to stop it.

A thirst for revenge.  It’s among mankind’s most powerful and deadly motives.  The notion that “I’ve been wronged and by-God I’m gonna get some payback!” has probably killed more humans down through the ages than anything else.

But whose getting revenge against whom?  And what if each person in a fight is absolutely convinced that they and they alone have been wronged by the other?  And with each blow that’s struck, each combatant becomes even more convinced that anything they do to get revenge is justified.

Which brings us to the Israeli-Palestinian conflict.

Many readers will have their own ideas, passions, and beliefs regarding the events of history, and I’m not one to say you’re right or wrong.  But here’s a brief recap of how we got here.  It’s intended to be very general. But for some, even these elements may be open to debate, as is anything that carries religious overtones.

So here goes.  According to Jewish tradition, the area surrounding Jerusalem is the ancestral Jewish homeland. Is this indeed true?  Beats me.  Sometimes history and religion coincide, sometimes it doesn’t.

But Jews have dreamed of going back there for centuries.  And a few did.  Some Jews have remained in the region for years, though they were in the minority compared to Muslims and Christians.

By the 1800’s this began to change.  Modern transportation allowed more Jews to come to a portion of the Ottoman Empire known as Palestine.  They were viewed by the local Arabs as immigrants.  The Jews viewed themselves as the rightful owners.

This presented an obvious conflict, and from time-to-time crimes were committed on both sides.  But nothing like today.  By and large, the two groups eyed each other warily, but mostly co-existed.

The question for many Jews was whether living as a part of a larger Arab-majority region was acceptable, or whether they should be a part of a Jewish-only entity they wanted to call Israel.  Most Jews favored the latter, but not all.

At the end of World War I, the German-allied Ottoman Empire was dissolved.  In its place, the countries we now call Jordan, Lebanon, Syria, and Iraq were created, all under the control of either France or Great Britain.  So, too, was Palestine.

As more Jews entered the region, tensions with the local Arabs grew.  Those who desired to establish a Jewish state (called Zionists) became more aggressive and violent in their tactics (go back and read the first quote that opened this piece). 

Gradually, the make-up of the region began to shift, but still remained majority Arab Muslim and Christian.  But then along came Adolf Hitler.

When the war ended, and the world saw the shocking devastation of 6 million Jews murdered by the Nazis, it seemed understandable that many Jews would want to get the hell out of Europe and establish a Jewish homeland.  Suddenly, what had been a trickle of Jewish immigration turned into a torrent.  Conflict with regional Arabs, and especially occupying British troops, increased.  And as always, terrorism and atrocities abounded.

In 1948, after much controversy and hundreds of deaths in terrorist attacks, British forces withdrew, and Israel declared itself to be an independent Jewish nation.  Nearly a million Arabs were forced to flee or were killed.  To Israelis, this was the culmination of a centuries-old dream.  To the Palestinians, it became known as the Nakba—“the catastrophe.” 

War ensued and Israel expanded its territory.  Then came more wars, more atrocities, and the cycle kept repeating.  And each time, Arabs native to Palestine wound up in ever-shrinking regions of Gaza or the West Bank region of the Jordon River.  Often, this meant being consigned to live in abject poverty.

It’s not hard to understand the hardening of positions.  To Israelis, it was “the world’s been trying to kill us off for centuries, and we’re going to by-God establish our own country and defend ourselves, and the Arabs just need to deal with it.”  To Palestinians, it was, “you’ve stolen our homes, our livelihoods, our land, our identity, everything—and we had nothing to do with the holocaust.  Hitler was a damn German, not an Arab.  We don’t deserve any of this.”

You can understand each view.  Over the years, I’ve trained doctors from all over the world.  Many were Jewish or Muslim.  Some were Israeli.  Some were Palestinian.  All of them were kind, honest, sincere human beings.  Each had their own story.

An Israeli doctor who talked about his family’s suffering during the horrors of the holocaust.  A Palestinian doctor who told of her parents being forced to leave their home and business because of death threats when Israelis moved in.  Another who spoke of non-Zionist Jews who were killed by Israelis for not supporting a Jewish state.

With each death, each threat, each deprivation, a zeal for revenge grew on both sides.  Today, it would be hard to find an Israeli who hasn’t had a friend or loved one killed by a Palestinian.  It would be even harder to find a Palestinian who hasn’t had a friend or loved one killed by an Israeli.

For each, revenge feels justified, no matter what course it takes.  It’s an eye for an eye—and soon we’ll all be blind.   

Which brings us to today.  An inhuman mass killing in Israel, and what will likely be an inhuman mass killing in Gaza.  Already, an Israeli missile has struck refugees trying to flee Gaza along what was supposed to be a safe corridor, once again killing women and children.  If this was deliberate on Israel’s part, it was an act of terrorism, no different from the Hamas massacres. 

Israeli tanks and troops are massing at the border in preparation for an invasion.  Over a million Palestinians have been ordered to leave Gaza with less than 24 hours’ notice.  But there’s no place for them to go.

I can’t imagine the town I grew up in being successfully evacuated in 24 hours.  And it was only a thousand people, less than one tenth of one percent of the affected Gaza population.

Americans have been killed in Israel, and some taken hostage.  Americans have been killed in Gaza, as well, and the homes of their families reduced to rubble.

Make no mistake, terrorism is terrorism, and must be punished.  Hamas must be held accountable for what they have done.  But just as Hamas had no right to kill innocents in retribution for the wrongs Palestinians have suffered at the hands of Israel, so too does Israel have no right to kill innocents because of the actions of Hamas.

But that’s not what’s going to happen.  Thousands of Israelis will carry the memories of the Hamas murders with them for the rest of their lives, teach it to their children, and demand revenge.  Thousands of Palestinians will carry the memories of the Israeli killings and the obliteration of their homes with them for the rest of their lives, teach it to their children, and demand revenge.

An eye for eye, until all the eyes are all gone.

During my residency training, I worked with a young doctor from the Shenandoah Valley of Virginia.  His parents were Mennonite farmers.  He was raised in the Pacifist tradition of his people.

I once asked him, “You say you’re a Pacifist, but if someone was going to kill you or someone in your family, and you knew it, couldn’t you kill that person to save your family?”

I remember he paused a moment, then shook his head.  “I don’t know,” he said.  “I really don’t think I could do it.”

I am neither a Pacifist nor a Mennonite.  But at this point, I wish there were a lot more of them around. 

My heart breaks for the mothers and children of Gaza and the West Bank, just as it breaks for the mothers and children of Israel.

Just as it breaks for the mothers and children of Syria, the Ukraine, Haiti, and Afghanistan.    

Where are we headed as a human race and a civilization?  What will become of each of us?  Perhaps we should remember the words of Nietzsche, “Be careful how you fight a dragon,” he said.  “Lest you, too, become a dragon.”

And be warned.  The next eye you pluck out may turn out to be your own.

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“Can’t you understand what I’m tryin’ to say?/ And can’t you feel the fear that I’m feelin’ today?/ If the button is pushed, there’s no runnin’ away/ There’ll be no one to save, with the world in a grave/ Take a look around you, boy/ It’s bound to scare you, boy/ Yet you tell me, over and over and over again, my friend/ You don’t believe, we’re on the eve, of destruction.” Eve of Destruction, P.F. Sloan, 1965.  In many parts of the country, the song was deemed too controversial for airplay, and was banned by many midwestern radio stations in the 1960’s.

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Further reading:

 Opinion | I’m Going to War for Israel. Palestinians Are Not My Enemy. – The New York Times (nytimes.com)

DRUGS, GUNS, GEEZERS AND MONEY

For a lot of reasons, I haven’t had a chance to write much lately.  In the meantime, lots of things are crashing all around us—some good, some not so good.  For now, let’s focus on three (actually, any one of these three could be a topic in and of itself, but time grows short).

Older readers will recognize the title of this piece as a play on the old song title “Lawyers, Guns, and Money” by an off-the-wall songwriter named Warren Zevon, who, like Jimmy Buffett, is no longer with us.  But references aside, let’s look at what recent news has to say about the cost of prescription drugs, the fall-out from new gun laws, the outlook for the future of older Americans, and what all of this is costing.

And if you’re younger?  Sorry, but you can’t relax.  All of this will hit you a lot sooner than you can imagine.

PRESCRIPTION DRUG COSTS

Let’s say you walk into a grocery store with a list of items you need to pick up.  You grab what’s on the list, toss them into your cart, and get in line at the checkout counter.  You notice that the person in line just ahead of you is your neighbor Charlie.  He has exactly the same items in his cart as you. 

The cashier rings up Charlie’s groceries.  “That’ll be $49.15,” the cashier says with a smile.  Charlie pays for the groceries, and leaves.  The cashier next rings up yours.

“That’ll be $112.08,” she says, with the same smile she gave Charlie.

You’re stunned.  “Wait, I got the same things as Charlie!  This has to be a mistake!”

“No mistake,” she says.  “That was Charlie’s price.  This is yours.”

“But you can’t do that!  I shop here all the time!”

“I know,” the cashier politely says.  “But we always charge you more than double everyone else.  Edna, Frank, Bill, Lucy—all of your neighbors.  We’d charge them $49.15.  Just not you.”

“Why?”

The cashier shrugs.  “Because we can get away with it, I guess.  You don’t seem to notice.  And we have lots of expenses that people don’t realize, and we don’t want to trouble your neighbors.  But if we didn’t charge you a lot more, we just couldn’t stay open.

“That’s bullshit!” You rage.  “This store makes plenty of money!  I see where the store’s owner lives and the kind of car he drives.   You’re just gouging me to make even more!”

The cashier smiles.  “Well, maybe.  But you keep paying it, don’t you?”

Tell me—if that happened to you, would you ever shop there again?

But this is exactly what you’re doing when you pay for prescription medications.  The same drugs, manufactured by the same companies, rolling of the same production lines are sold to you for over twice the price paid in other countries.  And those drugs aren’t some kind of cheap, dangerous knock-offs.  They’re the same pills, gels, and liquids.

Why?  Keep in mind that drug companies are multinational.  Pfizer (an American based company), sells Lipitor all over the world.  Novo Nordisk (a Danish company), sells Ozempic all over the world—and not just to rich Americans.  In fact, of the twenty largest pharmaceutical companies in the world, the majority aren’t even based in the U.S.

It’s important to point this out, because the excuse we always hear for high drug costs is that companies need to charge through the ceiling in order to fund their research.  The facts, however, tell a different story.

Pharmaceutical companies spend more on marketing than on development.  In other words, they spend more money trying to convince you to take the blue pill than they spent actually developing the blue pill in the first place.  In addition, they make more in actual profit than what they have put into research.  And more often than not, the basic research behind the drug was actually government funded (either by the U.S. or elsewhere).

But as long as they can convince you that if you don’t overpay for your prescriptions, then all research will vanish and it will be the end of the world as we know it, they’ll keep making out like bandits .

So let’s go back to the grocery store example.  What if you found out that the reason your neighbors could pay so much less was because they got together and negotiated with the store for a lower price?  You’d insist that you should be included, too.  Why should you foot the bill when they don’t?

This is what happens virtually everywhere else in the world.  The country negotiates directly with a drug company, uses its group purchasing power, and drives down the costs to its citizens.  It works.  But in the U.S, it’s illegal.

Why? Because in 2003, President George W. Bush signed the Medicare Modernization Act, which, with the backing of the pharmaceutical industry, outlawed direct negotiations.  With the stroke of a pen, Bush insured that Americans would overpay for medications for decades to come.

But that’s beginning to change, and the drug companies are throwing a fit.  The Biden administration recently announced they would negotiate directly for ten costly drugs to bring down costs, Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and Fiasp.

You’ve heard of most of them.  They’re advertised constantly on TV, but according to their manufactures, allowing American consumers to pay less—and to pay no more than the rest of the world is paying—is just asking too much!  And all the while, these same companies are spending billions of your money on marketing.

Let’s face it.  There are only two real possibilities.  Either the drug companies are right, and they have to charge us more for the same medications as anywhere else in the world to fund research (which is highly doubtful), or they’re deliberately misleading us as an excuse to charge us more and rake in more profit (which is far more likely).

Take your pick.  But either way, we’re being taken for a ride.  And if we allow this to continue, we should just get a big ink pad and stamp the word “STUPID” in all caps in the middle of our forehead.  We have no one to blame but ourselves.

THE NO-PERMIT NO-QUESTIONS NO-THINKING CONCEALED CARRY LAWS

Earlier this month, Nebraska joined an increasing number of states (including my childhood home of Missouri) in allowing anyone to carry pretty much any gun any place at any time without a permit.  The thinking, beyond the usual “this is my right and I don’t give a damn how it affects anyone else but me!” reasoning is that carrying a gun will somehow make society safer.  I’ve already written here and here about the serious flaws in this logic.

Ironically enough, almost to the day that Nebraska changed its law, a major study was published which reviewed gun deaths in West Virginia before and after institution of a law allowing permit-less concealed carry.  It found that firearms mortality jumped by 48% after their law was passed.  Whatever you might want to believe, the law didn’t make things safer.

No, West Virginia isn’t every state.  But it gives us a cautionary message that gun laws make a difference.  I’ve already talked about Florida, where gun deaths have increased 32% since the passage of so-called “stand your ground” laws.  As the data keeps coming in, it’s becoming clearer and clearer that America’s gun fetish is actually killing more and more of us.

All of this has enormous implications for all of us, but especially our police officers who now must confront the fact that our streets may be loaded with untrained, angry, uninformed people who are packing loaded handguns.  They will have to weigh this fact every time they approach a citizen. 

Is this the kind of country we want?  We should think about that long and hard.  That is, if we still care about the truth.

GEEZERS AND MONEY

I don’t think any textbook explicitly states when geezerhood begins, but there’s no question that I am there.  Knee replacements, hearing aids, and dental implants. It’s not great, but it does beat the alternative.  As someone who’s lectured for decades on the topic of geriatric medicine, the fact that all this stuff is now happening to me frankly sucks.

As many of you know, and others will one day find out, Medicare was created to be a safety net for medical expenses for geezers like me.  For many of us, it’s been a godsend.

But Medicare has been scapegoated by the political right for generations (at least since 1965).  Conservatives have been decrying the program since it began. All along, they’ve claimed the program’s costs would destroy it.

They’ve also tried to kill it through various other means, the leading ones being bleeding the program through the promotion of so-called Medicare Advantage, and as I mentioned at the top of this article, funneling Medicare money to boost pharmaceutical profits.

Regardless, Medicare has continued to meet its commitments, despite all of the doomsday pronouncements.  But last month, financial reports revealed something no one saw coming.  Over the past ten years, Medicare spending per enrollee has stopped growing.  In fact, it’s actually receded. 

In 2011, Medicare spent $13,159 per recipient.  At that rate, it was expected to hit $22,006 by 2023.  Instead, current spending is flat at $12,459—barely half of the predicted sum, and even less than 2011.

What happened?  We simply don’t know.  Are geezers like me using fewer services?  Probably not.

Is America’s declining life expectancy a factor?  After all, if people aren’t living as long, they won’t be going to the doctor as often.  This might be a small issue but can’t really explain the $10,000 per person gap.

Here’s a possible reason.  The Affordable Care Act (ACA) or Obamacare, if you’d prefer.  20 million Americans who previously had no insurance now are covered.  The ACA requires that preventative services are paid for.  As a result, millions who might have forgone care in their 40’s and 50’s because they couldn’t afford it, now have access.  Could they be entering the Medicare program with fewer delayed (and more expensive) health care problems?  After all, the more cases of high blood pressure you can detect and treat early on, the fewer strokes you’ll have to treat later.  The more cases of diabetes you can detect and treat early, the fewer amputations you’ll have to do later.

How long this will last is uncertain.  Right now, a far-right Trump appointed judge in Texas is doing everything he can to strike the provision down.  Apparently, he doesn’t think screening for cancer, diabetes, etc., is something worth paying for.

At some point, Medicare costs will once again start rising, as everything ultimately does.  But in the meantime, despite hemorrhaging money to private insurers through Medicare Advantage, paying exorbitant dollars to big pharma, and being nickel and dimed by the far right, Medicare is holding its own.  Get rid of the twin impediments of Advantage plans and overpayment for medications (as the new rule allowing direct Medicare drug negotiations is intended to do) and Medicare’s outlook is even better.

That’s good news if you’re a geezer like me.  But even better news for all of you future geezers who may be out there. 

AMERICA’S DWP CRISIS:  DYING WHILE PREGNANT

Over the past 20 years, the world has seen remarkable progress in medical science.  Gene editing, cancer immunotherapies, improved antibiotics, and robotic surgery—these just scratch the surface of our scientific breakthroughs. 

Yet discovery hasn’t always translated into improved health care.  And for one group of Americans, health care isn’t just sliding backwards, it’s falling off a cliff.

I’m talking about women who are pregnant.

Earlier this month, an analysis in the Journal of the American Medical Association (JAMA)revealed a shocking truth for American women.  From 1999 to 2019, maternal mortality hasn’t just stopped improving, it’s actually worsened by over 100%.

That’s right.  A pregnant woman today is more than twice as likely to die as a similar woman 20 years ago.  In one of the world’s richest nations, how is this even possible?

First, let’s look at the study.  Researchers poured through twenty years of records and compared pregnancy related deaths to the number of annual pregnancies.  They used the standard definition of maternal mortality—deaths from complications during or just after a pregnancy such as bleeding, infection, eclampsia, etc.  They looked at geographic distribution, regional variation, and racial make-up.  

In every corner of the country, for every ethnic group, outcomes worsened.  By 2019, deaths per 100,000 pregnancies (the benchmark measure) had increased from 12.7 to 32.2.  For Black and American Indian women, the picture was much worse.  Their mortality skyrocketed to 55.4 and 49.2, respectively.

And this study counted deaths from medical causes only.  It didn’t include pregnant women who died from firearms and auto accidents.  According to an earlier analysis, homicide takes the lives of more pregnant women than any other cause.  Add in those deaths, and mortality for U.S. pregnant women soars even further.

Only in America.  What the hell is wrong with us?

Maybe we’ve reached the point where we should give this condition a clinical name.  DWP.  Dying while pregnant.

Make no mistake.  American outcomes were nothing to brag about before the study began in 1999.  Even then, our rates were the worst in the developed world.  And since then, we’ve only lagged further and further behind.

Since the study’s 2019 conclusion, maternal mortality has risen even further. Will we as a nation have the courage to acknowledge and address the root causes of these unnecessary deaths?  Or will we continue to ignore our racial, economic, gender, and geographic disparities, choosing instead to label them just an unfortunate coincidence?

Next month, thousands of future doctors and nurses will begin their training in institutions around the country.  Hopefully, this new generation of professionals can address our maternal mortality crisis.  But it won’t be easy.

Answers won’t be found in any laboratory.  No technological breakthroughs will provide magic solutions.  Progress will only come through taking a hard look at why pregnant women are dying, and what can be done to prevent it.  It will require honest questioning as to why mortality is worsening even further for minorities and the economically disadvantaged.  It will require a concerted effort from all of us.

But such progress won’t occur if every time an issue is raised it’s shouted down with cries of “you can’t talk about that, that’s critical race theory!  That’s wokeism!  That’s cultural Marxism!  That’s socialism!”

No, it’s not any of those things.  It’s about young women dying.  And that needs to change.

And progress will be further hindered in states that prioritize embryos over the lives of mothers.  Regardless of how you may feel about abortion, radical laws are being proposed throughout the country that greatly endanger women.  Last year in Missouri, for example, the legislature debated whether to outlaw surgery for ectopic pregnancies (an embryo that implants in the fallopian tube instead of the uterus), even though such pregnancies are 100% non-viable.  Apparently, the near-certainty of a mother’s tubal rupture, internal bleeding, sepsis, and death, wasn’t particularly important.

Make no mistake, how we deal with America’s DWP crisis may be the most important factor in determining the future health and well-being of our daughters and granddaughters.  Right now, maternal mortality is headed dangerously in the wrong direction, and must be corrected.  I’m optimistic that those future nurses and doctors will be up to the challenge.

The real question for the rest of us is, will we?