“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?

A SPEECH I WON’T BE GIVING

“For everything, there is a season. . .a time to keep, and a time to cast away. . .”—Ecclesiastes 3:1, 3:6

“It’s time.”  –Cal Ripkin, Jr., September 20, 1998, on his decision to stay out of the Baltimore Orioles’ starting line-up after playing a record setting 2,632 consecutive major league baseball games.

In the spring of 1994, Dr. Bill Hunter, the Associate Dean of Creighton’s Medical School, asked me to give a talk titled “The Art and Science of Medicine” to the incoming first year medical students. I shrugged and thought sure, why not?

I’d barely arrived at Creighton and was new to the academic world.  My previous practice had been in rural hospitals, either caring for patients or trying to pass on practical information to future small-town docs.  I was the last person to be giving this talk to a bunch of medical students.

So I agreed.  It was no big deal.  Besides, it would just be one year.  Instead, I wound up giving the talk to incoming students for the next 29. 

But I won’t be giving the speech this year.  Or the next.

And not because I wasn’t asked.  Once again, my friend and colleague Dr. Mike Kavan requested that I speak.  This time I said no.

Why?  Because like Cal Ripkin, I realized it was time.  Time for someone who was younger.  Time for someone more relatable to the students.  Time for a new face and some new energy.

I’ve often wondered how many students—now practicing physicians, some of whom may have even retired themselves by now—actually remembered my talk.  A mix of humor and seriousness, it was meant to set students on the right track as they moved forward in their careers.  I hope it did just that.  And I hope whoever gives a similar talk in the future will do the same.

I usually gave the speech “live” each year to the new students.  But fumbling around in some old computer files, I found a copy of my talk the year of the pandemic.  It was delivered to a computer screen, recorded, and later viewed by students.

I hated doing that.  I’m not much for talking to screens.  I just hope I got my message across.

Many of the issues I touched on—social justice, caring for others, competing with yourself instead of getting wrapped up in competing against others—also apply to life in general, and not just to medicine.  If you happen to listen to the link below, there might be a little something there for all of us.

Be forewarned.  If appearances are a big deal to you, you’ll be disappointed.  I was getting some serious dental work done, and my teeth looked pretty bad.  The lights also go off in the middle of the speech, and I had to get up and figure out where the switch was.  Hopefully that didn’t detract too much.

So if you have the time, and want to listen/watch some of the presentation, the link is below.  I’ll be back in a few days to talk about one of the deadliest and most neglected health care risks in America.  It’s called pregnancy.  See you then.

Art & Science of Medicine with Dr. Frey (panopto.com)

CHINA AND FLORIDA:  WHERE TRUTH GOES TO DIE

“There is a price to pay for speaking the truth. There is a bigger price for living a lie.” -Cornel West, author and philosopher

“Truth-tellers are not always palatable. There is a preference for candy bars.” -Gwendolyn Brooks, poet and journalist (1917-2000)

“Once a country is habituated to liars, it takes generations to bring the truth back.” -Gore Vidal, writer (1925-2012)

The question was simple enough.  The Americans had just stepped out onto the huge open expanse of gleaming concrete that stretched from the Forbidden City past the Monument to the People’s Heroes all the way to the Chairman Mao Memorial Hall.

“So this is where it happened?  Right here?”

The gracious Chinese host smiled, and seemed excited to answer.  “Yes!” she said, “Here is where Chairman Mao announced the formation of the People’s Republic of China in 1949, to a throng of many thousands.”

“No, I mean the protests.  Where so many people died.”

The host looked puzzled.  “What protests?” she asked.

“Well. . .when thousands of people marched and protested against the government. . .”

Now the host seemed utterly baffled.  “I’ve never heard of any protests here.  You must be mistaken.”

There was a long moment of awkward silence.  Then the group turned and began to walk out across “The Gate of Heavenly Peace,” otherwise known as Tiananmen Square.

All of that was over ten years ago.  And to this day, I don’t know if the host’s appearance of being completely baffled was because of a well-rehearsed denial strategy, or whether she honestly didn’t know what had occurred.

Not that it really matters.  Either way, the result was the same.  The actual truth was buried for political and nationalistic reasons.

Suppressing the truth.  It’s been going on for years.  And in so many ways, it keeps getting worse.

Let’s look first at history.  Someone once said “experience is the ability to not make mistakes, and the only way you gain experience is by making mistakes.

All countries, no matter how noble, have made mistakes.  Some have learned from them, others have not.  But you can’t learn from mistakes if you erase them and pretend they never happened. Like June 4, 1989.

Go back in time a moment.  Protests against the Chinese government had swelled to a massive crowd in Beijing’s Tiananmen Square.  Despite orders to disperse, the gathering only grew.

The government had had enough.  Martial law was declared, and on June 4, troops attacked the protestors.  To this day, no one really knows how many were killed.

But you won’t find this in any Chinese school book.  In fact, just mentioning June 4^th could get you arrested, which has led some government critics to sarcastically call the date “May 35.”

Nationalism, conformity, and don’t step out of line.  It’s not only happening in China.

In India, publishing a map showing the disputed region of Kashmir as “disputed” is illegal.  So is any other depiction that isn’t in line with the government’s official cartography.  India’s nationalistic tilt has also impacted its schools, where science texts no longer feature the Periodic Table (developed by a Russian), evolution (described by an Englishman), or magnetism (also discovered by an Englishman).

Don’t expect to find anything critical of government policy in Russian textbooks, either, nor any mention of Stalin’s deliberate starvation of millions of Ukrainians. 

Article 301 of the Turkish Penal Code makes it a crime to “insult the Turkish nation.”  You can guess how that impacts Turkish textbooks and how they cover, among other things, the Armenian genocide.

Be careful what you say about the Holocaust in Poland, home of Auschwitz, the most infamous of all Nazi concentration camps.  There, the official party line is that the killings were carried out solely by Germany, and that Poland played no role in the death camps.  In truth, some Poles did actively support the murders.  But say that now, and you can go to jail.  

Germany is a different story.  All German school-aged children are required to learn about the Holocaust.  Their nation’s role in perpetrating millions of murders isn’t denied.  Neither is its history of supporting the Nazi regime.

But alarmingly, this obvious issue of educational importance is being threatened by the far right.  The Alternative for Germany (AFD) party openly opposes teaching the Holocaust.  One AFD leader dismisses the Nazi killings as merely “a speck of bird poop on an otherwise glorious history.”  Others have derided Berlin’s monument to those murdered in the Holocaust as a “monument to shame.”  Still others have openly supported Holocaust deniers.

Some of the AFD will end up in government positions.  Others will become teachers.  Imagine the impact they could have on Germany’s future generations.

In his chilling book 1984, George Orwell wrote “He who controls the past controls the future.”  Which brings us to Florida.

I’ve already written my opinion on Florida overall , but education in Florida, America’s third most populous state, is entering a time of peril.  Under Governor Ron DeSantis, laws have been enacted that don’t just threaten educators, they put teachers in a straightjacket.

If you are a teacher, you are breaking the law if you teach anything about race that might make a student feel guilty or embarrassed by their own race.  That’s right—it doesn’t matter that you didn’t tell a student they should feel guilty, just the possibility that they could feel guilty means you are a criminal. 

The world should be glad that DeSantis is only screwing up Florida.  If he were Chancellor of Germany, he’d probably oppose teaching about the Holocaust, because it might make those German kids “feel bad.”

Just a note on hypocrisy here.  If a student from a liberal family felt offended by something they heard at school, what would the DeSantis crowd be saying?  “Snowflake!  Suck it up, Buttercup!”

But when it’s a sensitive little conservative Johnny or Suzie, it’s a different story.

Of course, “teaching critical race theory” is also out, even though there’s zero evidence that it’s ever been taught in Florida schools.

Somewhere north of 350 books have been banned from Florida school libraries.  DeSantis bristles when this is brought up, and insists that the state itself hasn’t banned any.  But in truth, the state legislature set in motion the process that allows individual schools to deep-six books on the basis of parental complaints.  In Duvall County, don’t try to find biographies about Hank Aaron or Roberto Clemente—they were removed because parents complained.

Ditto Beloved and I Know Why the Caged Bird Sings in several counties.  The Kite Runner is unavailable in still others.  Of course, The Handmaiden’s Tale is out, along with The Life of Rosa Parks.  Apparently, in the Duvall Counties of the world, not having your feelings hurt is way more important than whether you can think critically.

What is critical thinking?  It’s the ability to take different sets of facts that seemingly are at odds with each other, and logically analyze the information into a usable form.  But it’s tough to critically think about something if it’s been pulled off the shelves.

I’ve talked about the whole book banning thing before  When I was younger, I read everything I could get my hands on.  I was reading books written for teenagers when I was in the second grade, and adult books a couple of years later.  Did I make my mother nervous when I read all 872 pages of Norman Mailer’s The Naked and the Dead when I was thirteen?  She never said a word, despite knowing that the word “fug” appeared over a thousand times in the book.  She understood the author’s message was far more important.

In Florida, textbooks must be approved by the State Board of Education, which recently turned down over 50 math books because they supposedly had inappropriate racial content.  What’s race got to do with math?  I don’t know, but if you see Ron DeSantis maybe you can ask him.    

Because of Florida’s large population, their schools purchase a significant number of America’s textbooks. So if you’re a publisher, the last thing you want to do is be shut out of the Florida market. Thus, the “banning” movement has had a chilling effect on what gets published–and therefore what gets taught.

And a chilling effect on the truth.  One history text for Florida children removed any reference to Rosa Park’s race.  Better to sell a watered-down version of history than to sell no books at all.

What did the final version say?  Just that Rosa Parks was a lady who was “tired.”  No mention of her as a civil rights pioneer.

Of course, it doesn’t stop there.  A vaguely worded piece of legislation called the “Parental Rights in Education” bill (its detractors call it the “don’t say gay” bill) restricts gender related discussion, and opens the door for any parent to sue the school district if they think their little Johnny or Suzie has been offended, with the school district (meaning the taxpayers) left to pick up the legal tab.

An advanced placement course in African American Studies was banned by Florida’s all-knowing Board of Education.  The reason? It “lacked educational value and was historically inaccurate,” according to the Board.  Just what about it was inaccurate?  The Board wouldn’t say.

Don’t say gay.  Don’t talk about race.  Don’t use the wrong Math book.  Don’t check out the wrong library book (even if you could). Water down history.  Is it any wonder Florida has a shortage of over 5,000 qualified teachers?  As if being paid salaries that are next to the lowest in the nation weren’t enough, teach the wrong thing and you could well be sued, or even fired.

But if you are a gay school teacher, Florida is quick to point out that your sexual orientation can’t be grounds for dismissal.  You can even have a picture of your gay family in the classroom.  But you’d better not talk about that picture with your students.  That can get you canned.

Make no mistake.  You can’t embrace critical thinking if you exclude any topic you don’t like.  You can’t critically discuss ideas if you keep locking them up.  You can’t arrive at a true picture if you insist that a part of the picture stays shrouded from view.      

Throughout history, there’s been a sure-fire way to shoot down an idea before there’s even a word of discussion.  Create an impossible-to-define term, call it evil, then use it to smear anything you choose.

Woke! Woke-ism! CRT! CRT-ism!  Cultural Marxism!  Undefinable words that can be used as an excuse to ban just about anything you don’t like.  In Florida, Ron DeSantis and company have done a masterful job in this arena.  But be forewarned.  The ultimate victim of these policies won’t just be students.

It will be the Truth.

Because in Florida, each day is starting to look more and more like May 35^th. 

AMERICA IN 2050

“It’s tough to make predictions, especially about the future.” ― Yogi Berra

Although many people may roll their eyes when I say this, the city of Omaha, Nebraska has a lot going for it.  In the midst of the corn, the beef, the College World Series, the Berkshire Hathaway money, and the Union Pacific railroad, it’s also the home of the Free Speech Society.

The group is open to everyone, and seeks to facilitate respectful, open dialogue around the most important issues of the day.  It meets once a month, usually with a speaker who addresses a topic and leaves time for a lively discussion.   The coffee and doughnuts aren’t bad either.

And for June of 2023, the topic for discussion is thought-provoking:  Will we recognize the U.S. in 25 years?

Several questions were suggested by the Society’s leadership: 

• How will America’s ethnic makeup impact future policy?

• What will be America’s standing in the world?

• How might AI impact how we live and work?

• Will the U.S. be fiscally sound?

• What will be the state of national and regional politics?

• What will healthcare look like?

• What will immigration look like?

At the risk of pre-empting any discussion, and for the benefit of anyone who might not be able to attend, let me give my thoughts on each.

First, fair warning: I’ve always been someone who’s lived by the dictum “hope for the best and prepare for the worst.”  So let’s look at how these topics will play out in America, year 2050, from both a best case and worst case scenario.

HOW WILL AMERICA’S ETHNIC MAKE-UP IMPACT FUTURE POLICY?

Best Case:   Through focused programs in financing and employment, the gap in income and net worth between white Americans and non-white Americans has narrowed significantly from its 2023 level.  A focus on advancing educational opportunities in poor neighborhoods has resulted in improved educational performance.  Numerous colleges have Black or Hispanic leadership, and government/private partnerships have enhanced opportunities for trade skills that have significantly improved unemployment.

As predicted, a majority of Americans now identify as Black, Asian, or Hispanic.  More and more corporate leadership roles have been filled by those once considered a “minority,” serving as role models for young people.  Public education has played a vital role in this process, where schools that were predominantly white just thirty years ago now have a majority of non-white enrollees.  A national focus on Civics and history now engages students from all background in participatory citizenship.

Although the playing field with regard to educational and employment opportunities is still far from level, much progress has been made.

Worst Case:  Since the Keep America American (KAA) party broke-off from the Republican party in 2025, national policies have been established to prohibit discussion of issues such as social justice, slavery, and references to Jim Crow and the Civil Rights movement.  Students are taught that any areas of inequality have been the direct result of now-illegal Affirmative Action programs.  This has caused heightened tensions at many schools, especially where teachers have been fired for pointing out that the rising income gap between white and non-white Americans, as well as reduced funding at inner city schools, has led to reduced college acceptances for non-white students.  Teachers are required to teach that racial prejudice no longer exists, equal opportunities are available for everyone, and any difference in income is solely the result of a lack of work ethic.  Yet despite this, society appears to be unraveling more and more along racial lines.

WHAT WILL BE AMERICA’S STANDING IN THE WORLD?

Best case:  Following the 2024 withdrawal of Russian forces from Ukraine, and the subsequent costs of post-war rebuilding, the world has been forced to take a hard look at its future.  America has been a leader in this effort. 

Over the last 25 years, the world has gradually grown to trust the United States once again.  Unlike earlier in the 21^st Century, when America’s foreign policy would swing wildly to the left or right depending on which party was in power, thus leaving the world guessing as to what (if anything) the country really stood for, America’s Republican and Democratic parties have now embraced similar values:  democracy, open trade, free elections, human rights, and respect for law.  Although some American foreign aid is still directed toward military funding, a greater amount is distributed toward the goal of promoting international economic and humanitarian stability, particularly in South and Central America.  This has resulted in, among other things, a reduction in undocumented immigration (see below).

The U.S. has taken a lead in focusing the United Nations on problem solving.  International efforts to address climate change, displaced persons, and free trade have been led by America.  Although a few regressive regimes remain, including Hungary under its 87-year-old dictator Victor Orban, nearly every other country agrees the world is a safer and more stable place, compared to 25 years ago, thanks in no small part to American leadership.

Perhaps most significantly, the conviction 25 years ago of former President Donald Trump for compromising highly classified military intelligence reassured our allies we took the security of the world seriously.

Worst case:  Since the American withdrawal from NATO and the United Nations, the world has become a much more dangerous place.  Following NATO’s devolution, and the subsequent Russian victories in Ukraine, Moldovia, and the Baltic states, the world has struggled to find super-power leadership.  Despite grave reservations, many nations have felt they have no choice but work with China in this regard.

With the KAA party firmly in power, it appears unlikely that the U.S. will re-engage in meaningful efforts to address these issues, other than building up its own military forces.  By now, the country has withdrawn from virtually every international commission/agency, and actively discouraged its citizens from participating, as well.  The recent arrest at Dulles International Airport of three attendees returning from the U.N. Climate Study Conference is deeply concerning.

The rising influence of the RIC coalition (Russia-Iran-China), especially through their heavy-handed conflict resolution process, is particularly worrisome.  Unfortunately, with America’s influence effectively sidelined, there’s little the world can do.  This has been worsening since the round of not-guilty verdicts in the Donald Trump trials 25 years ago, which sent trust in America plummeting throughout the world.

HOW MIGHT ARTIFICIAL INTELLIGENCE (AI) IMPACT HOW WE LIVE AND WORK?

Best case:  Thanks to the work of America’s AI oversight committee, the dire predictions of AI causing human extinction have not been fulfilled.  The committee, a public-private partnership of representatives from business and government, approve research and monitor AI development.  So far, their “first, do no harm” pledge has been honored.  Although AI has shifted some jobs, it has created far more.

It’s difficult to find an aspect of American life that hasn’t been impacted.  Energy, health care, education, transportation—all have been revolutionized through AI.  Our military has maintained its strength by matching research with the rest of the world, enabling our armed forces to be more fully prepared to recognize both cyberattacks and assaults by conventional forces.

Worst case:  As companies use AI to primarily displace workers, seeking short-term profits over long-term growth, unemployment has skyrocketed. The recent riots at the Tesla factory on the old Disneyworld campus in Florida, when Tesla announced a 70% reduction in its workforce, may only be the first such event as industry cuts back further on human employees.

The KAA-sponsored citizen surveillance program has produced an AI controlled network that effectively monitors all activity within our borders, and issues AI-produced arrest warrants if any irregularity occurs.  Despite the claims that thousands of innocent citizens have been detained through overly-aggressive AI algorithms, the KAA insists the net benefit of the program is positive. 

WILL THE U.S. BE FISCALLY SOUND?

Best case:  Much has changed since the President’s landmark “Shape Up or Ship Out” economic speech 20 years ago.  Tax revenues have expanded and spending has been cut, with enough change occurring to earn both cheers and boos from nearly everyone.  But one thing is clear—America now has a balanced budget and is no longer encumbered by debt.

Taxation rates, which had become more and more focused on the middle class since 1980, have been reimposed at 1950s levels.  America entered into the International Corporate Tax agreement, which set a uniform baseline for corporate taxes, thus removing incentives for developed countries to “off-shore” their operations.  Tax havens have been shut down, tax-dodgers have been prosecuted, and for the first time in memory, America actually collects all taxes legally owed by its citizens (something thought impossible back in the 2020’s).

Worldwide trade has been enhanced, and American goods are sold throughout the planet.  Health care costs have declined (see below) and a healthier, more invigorated work force is more productive.  An expanded minimum wage has put more dollars into the hands of workers, where the multiplier effect of those dollars produces far more growth than the previous process of enhancing the wealth of corporate owners, where dollars were used primarily for stock buy-backs, yachts, and vanity space ships (see Musk, Elon).

Worst case: As America’s deficit has spiraled, attempts by government to deal with it have grown more desperate.  The KAA’s ten-year tax rescue plan, which mandates that tax rates must be lowered by 3% every ten years, has not produced the economic growth the KAA insisted would occur.  Instead, unemployment has reached 15%, poverty is at an all-time high, and what little is left of what was once called the “social safety net” has vanished.

Despite eliminating Medicare, Medicaid, and social security, spending continues to outstrip declining revenues.  This has led the KAA to institute further tax cuts, arguing that business will grow, employment will improve, and revenues will thus be enhanced (what was once called “supply side economics”).  Unfortunately, this has not proven to be the case.

Business has been further compromised by the massive tariffs the KAA has imposed on at least 40 countries that the KAA insists have not respected America.  The tariffs, along with the threat to use the U.S. Military against violators, has caused world trade with America to plumet.  This has led to increased prices for many goods here at home, and further increased poverty and economic decline.

To counteract this, the KAA has pledged to decrease taxes once again next year.  But other than the ten American trillionaires, few others expect this to improve America’s debt-ridden situation.

WHAT WILL BE THE STATE OF NATIONAL AND REGIONAL POLITICS?

Best case:  Although it would shock anyone from twenty years ago, American politics have moved from the extreme to a more reasonable center.  Ranked choice voting, open primaries, and a not-infrequent shifting of party loyalties have produced an environment in which over 70% of all bills have passed Congress with bipartisan approval.

The 29^th Amendment, limiting Supreme Court Justices to two 8-year terms, has provided a greater diversity of legal opinion to prop the “third leg” of the American government.  Annual strategic planning sessions between majority and minority congressional leadership has led to unified goal setting and more effective government.

America is once again the model that the world looks to for government that works.

Regionally, pockets of intense political polarization continue to exist, but this is largely limited to the southeast and the west coast.  In Nebraska, for example, a wave of successful petition initiatives overturning more than a dozen Legislative bills apparently got the attention of officeholders.  Real (as opposed to token) public input now plays a much larger role in legislation.

The Redistricting Task Force, set up after the U.S. Supreme Court struck down seven highly partisan attempts at state gerrymandering, now approves Congressional redistricting on the basis of geography and demographics, rather than politics.  At both the state and federal level, this has led to an upsurge in voting, in contrast to 20 years ago, when the only votes that seemed to matter were limited to so-called “swing districts.”

Worst case:  Through a series of Supreme Court decisions upholding the creation of “virtual” districts, the KAA has been able to amass a Congressional supermajority, as well as the presidency for the past 20 years.  All 9 members of the Supreme Court have been appointed by KAA administrations, and KAA dominated states have regularly overturned elections, claiming they were rigged.  This has led to states such as Texas, Florida, and West Virginia getting the bulk of all federal aid programs, with California and New York experiencing significant cut-backs.

Although it is clear that a plurality of Americans do not support KAA policy, the party nonetheless holds power through gerrymandering, successful voter suppression, and an interventionist Supreme Court.  As much out of despair as anything else, voter participation has dropped to barely 20%.  The world, of course, sees all of this clearly, and wonders what has become of this former-democracy called America.

WHAT WILL HEALTH CARE LOOK LIKE?

Best case:  With the passage of the Health Care for All America (HCAA) act, basic coverage has become universal.  Americans are now paying less in health care taxes than they were previously paying in premiums and taxes combined.  Access has improved, and American life expectancy, declining for years earlier in the century, is now rising significantly.

The Act was initially opposed by many, as manifested by the 2-week doctors’ strike in Florida and Texas, but since that time public approval of the program has soared.  A few private companies sell supplemental policies to add benefits to standard programs, but by and large the power of private insurance to dictate health care has declined.  The 600,000 health insurance employees whose positions were eliminated in the conversion to the HCAA quickly found employment in a private sector that boomed when the costs of insurance premiums were removed from their gross revenues.

Business has expanded, the number of uninsured has dropped to near zero, and with access to primary care now available to all, the number of emergent procedures has declined significantly.  Other than a few CEO’s who had previously been paid multi-million-dollar salaries in the private insurance world, everyone agrees the current system is working exceptionally well.

Worst case:  Since the passage of the KAA sponsored “Liberty Vouchers” Act, which eliminated Medicare and Medicaid, the number of uninsured has risen significantly.  Currently, 75 million Americans have no health insurance, and a similar number have bare bones policies that simply aren’t enough to cover essential care.

This was not the legislation’s intent.  However, the voucher subsidies are fixed, and have not kept up with inflation.  Consequently, most elderly Americans claim the vouchers are essentially worthless, since they cover only a fraction of premium costs for available policies, and, they claim even these policies don’t provide the coverage of the old Medicare program.  Nonetheless, the KAA is adamant they won’t turn back to a socialist program like Medicare.

Hospitals in inner city and rural areas continue to close, as available revenues dry up due to uninsured patients.  Doctors continue to preferentially practice in suburban areas, where reimbursement is highest.  Despite KAA assurances that things will improve, American life expectancy continues to plummet.

One area is doing well though—private health insurance.  United Health Care’s 2048 profits exceeded $100 billion, and the NFL now awards the United Health Care trophy to the winning Super Bowl team.

WHAT WILL IMMIGRATION LOOK LIKE?

Best Case:  Although applications for immigration still exceed available vacancies, the applicant number has decreased.  Illegal border crossings have diminished as the U.S. has helped rebuild Central American economies.  America has helped lead the International Refugee Board, which seeks to provide a rational approach to immigration world-wide.  With increasing climate disasters, the number of displaced persons in the world has risen to nearly 200 million. However, using world-wide resources, this population is being resettled in the most effective way possible.

Although initially opposed by many as too expensive, the Central American Partnership Plan, which has modernized Central American police forces and boosted employment, has led to a significant improvement in the standard of living in those respective countries.  Everyone now agrees this was money well spent. Clearly, it has brought about a reduction in those seeking to immigrate from those countries.

As has been the case for over 200 years, immigrants have been assimilated into American society and workforce.  They now contribute more to the social security trust fund than native born Americans, and first-generation immigrants are recognized as among the most patriotic of all Americans.

Worst case:  Since the KAA shut down legal immigration for all non-European immigrants, the number of people seeking to enter the U.S. from the southern border has skyrocketed.  Despite a declining workforce and pleas from American business, the KAA is adamant that immigration must be halted.

What was previously known as “replacement theory” has formed the backbone of American policy.  Though it’s not official, statistics are clear that Black and Hispanic immigrants are more likely to be deported than those from European origin.

The unfortunate incident last month at the southern border when border patrol officers opened fire on border crossers and inadvertently shot 3 Mexican soldiers has led to a deterioration in our relationship with our southern neighbor.  The announcement that Mexico has shut down its own border crossings in reprisal for the shootings, along with the loss of cross-border trade, has been a crushing blow to American industry.  The report that Mexico has signed a priority trade agreement with China in retaliation for our immigration shutdown has rocked the world. 

Where all of this will end is anybody’s guess.

BOTTOM LINE:  Will any of this happen?  Will none of it?  Are these scenarios too dark or too rosy?  Who knows?

Feel free to make your own predictions and then discuss them with others.  Think about ways we can move toward the common good, and avoid the outright disastrous.  Not that any of this will affect me personally.  In 2050, in the unlikely event I’m still around, I’ll be 98.  But how all of this will affect my children, grandchildren, and the world I love is a different story.

And if you think any of these scenarios seems too improbable, remember this:  What were you thinking in 1998?  What were you doing?  What were you envisioning?  Could you have foreseen the changes that have occurred in our country?  The radical Supreme Court decisions?  The normalization of mass shootings?  The rise in authoritarian governments in countries that had previously been democratic?

Probably not.  All the more reason to consider where we are as a nation, where we are headed, and how we must change course.

And all the more reason to talk about it.

Sunday afternoon, the end of another long boring week in America.  Keep on walking.  Nothing to see here.

At least nine people dead in a mass shooting in Texas.  Nothing new.  Last year alone, Texas had 55 of ’em —better than 1 a week. Besides, there’s already that little episode a couple of weeks ago where the guy took an AR to his neighbors.  They’d asked him to please stop firing it since it was making their baby cry.  Only five dead bodies in that one, including a nine-year-old.  Nothing new here.  Just keep on walking.

Oh, yeah, I guess there was also that family up in Oklahoma, the highway shootings in Maine, the ongoing road-rage, the. . .  Well, yeah, you get the idea.  Just 17 mass shootings this past week.  No big deal.  This is America.  Get used to it.

All of this is probably assuring my Swiss relatives that their country is moving in the right direction.  Once (inaccurately) described by the National Rifle Association (NRA) as a nation with guns everywhere, Switzerland has now dropped to nineteenth in the world in gun ownership. 

But maybe the NRA can have a new poster child for gun ownership—Serbia.  It ranks third in gun ownership among countries with at least a million citizens.  And in only 2 days, they’ve had 2 mass shooting.  Who says American values can’t be spread abroad?

Ironically, just today, a letter in the Omaha World Heralddrew attention to the fact that 20% of Nebraskans will experience a mental health condition in any given year.  That’s no different from the rest of the nation—at any given moment, 1 in 5 adults is experiencing significant depression. But should they be carrying guns around?  Of course!  Besides, that just gives us all an excuse whenever someone gets shot.

The NRA is right—people kill people.  And the more drunk, high, depressed, angry, sad, bitter, disappointed, confused, belittled and hopeless people who have guns in their hands?  The more Americans are going to wind up dead.  But that’s OK.  Because we can always T.A.P.-out.

Just abbreviate it like that.   Thoughts and Prayers.  We say it so often these days, we might as well just shorten it.  Thoughts and Prayers.  Thoughts and Prayers.  Thoughts and Prayers.  TAP, TAP, TAP.  TAP, TAP, TAP.  TAP, TAP, TAP.

Nothing new here.  Just TAP-out and walk on by.

But this just gets us started for the week that was.  In other news, the U.S. Congress is engaged in an ever-escalating pissing match over the debt ceiling that has the potential to devastate the economy of the world’s strongest, richest, and most important nation.  Republicans, who care deeply about the deficit (but only when Democrats are in office), seem content to let the country default on it’s debt, turning us into a dead-beat nation.  Never mind that every economic analysis has indicated that unemployment will skyrocket, our economic output will fall, and the country will profoundly suffer.

Do we need to cut our spending and increase our revenues?  Of course.  But any decent business manager can tell you, an organization that manages by crisis isn’t going to last long.

Ditto governments.  Congress needs to dispense with all of the Jr. High drama (OK, it’s Middle School now), raise the debt ceiling so we can function as a nation, then do the hard work of fixing the budget.  It’s way overdue.  In the past, neither Democrats nor Republicans have shown any interest in it.

But the news keeps getting better and better.  Traditionally, the American people have believed that regardless of who controlled Congress and/or the White House, at least the Supreme Court could be an impartial arbitrator of justice.

And despite numerous biased and purely partisan political decisions by the Court this past year, many Americans still believed they could count on the institution for justice.  But any remaining hope for The Court went out the window this week with the mounting evidence that Court decisions were essentially bought and paid for by wealthy conservative donors.  From what we know, Clarence Thomas (https://www.newsweek.com/clarence-thomas-tangled-web-gets-worse-worse-senator-durbin-1798894) and quite possibly John Roberts have been on the receiving end of big dollar influence.

I’ve already commented on Thomas, but Roberts really saddens me.

Most of us have seen a picture of the statue of Lady Justice.  Blindfolded, she holds a sword in one hand and a set of scales in the other.  She is supposed to represent absolute fairness in the Judicial System.  But after this week, Thomas has turned her into an image of a stripper with a wad of dollar bills in her G-string.

Around the country, state legislatures are wrapping up their sessions.  Most of them haven’t bothered to spend time on such mundane issues as health care, mental health services, public education, women’s health, poor nutrition, and inadequate infrastructure.  Instead, it’s been a frenzy of anti-abortion, anti-gay, anti-trans, anti-public education, anti-public health, and anti-public safety legislation.  And in far too many states, there’s also been a far-right Governor salivating to sign them into law.

Of course, all of this just scratches the surface.  At the border, thousands of desperate asylum seekers are waiting for COVID-era Title 42 restrictions to expire.  They’ll be begging for a chance at a better life.

Can we take them all?  Of course not.  That’s why troops have been deployed.  But we can legally take a lot more than we’ve been taking.  Businesses are desperate for employees.  Unemployment is at record lows.  It only makes sense.

But one thing is certain.  Whatever the number of legal immigrants, it will be too many for those who want to use immigration as a political club to bludgeon their opponents, regardless of the human suffering that occurs.  Immigrants are usually poor and powerless.  They make perfect scapegoats for demagogues. 

But on the positive side, unemployment continues to fall, inflation is coming down, and the grass is starting to green-up.

So let’s ignore all of the other stuff.  Just keep on walking and pretend it’s not happening.  Nothing to see here.  Nothing to get upset about.

Ho-hum.  Just another week in America.