Trump and his future (March 2017)

0

There’s pretty good evidence that there is a contingent of Trump
supporters that will NEVER give up on Trump no matter what he does.
Every stupid lie over a Tweet brings them closer to him. However,
after the events of the last two months, including but not limited to
the fact that he has achieved nothing, especially any of his loud
promises, will result in a cumulative deterioration in that group in
time. It’s a long game.

They were not ALL nitwits, some just thought he would be the one to
“shake up the system”, not realizing he was a full-on sociopath capable
of destroying the system. As time progresses, many of those will see the
light and split to other factions, leaving a bare bones contingent of
those that will always find excuses for Trump’s behavior, and an
open-ended ability to blame others for his gaffes.

Trump thought he was invincible because of his radical core of
supporters would push anything home. He thought his deal making ability
was inviolate.He really thought he could arm twist his way to putting
this ridiculous bill into law. He, like Obama, got introduced to the
realities of congress. The honeymoon, if there ever was one, is
definitely over. Nancy Pelosi smirked that the author of the “Art of the
deal” made a rookie mistake. Now, the entire game has changed and will
not go back to the old days two months ago.

This would-be health care bill is as dead as a roadside roadkill skunk
and will never come back. The Donald, skulking back to lick his wounds,
realizes that. So now the game plan is to “allow Obamacare to explode,
following which the Democrats will come begging us to fix it” (a phone
communication to Bob Costa of the Washington Post yesterday afternoon.)
Of course, the reality is that there is no evidence Obamacare is
exploding, or will do so in the near future. It simply needs
adjustments.

Chuck Schumer hit it on the head yesterday. Obamacare is in place and it
can be adjusted so why not everyone get together and do that rather than
trying to craft a replacement that would take years to make everyone
happy. The incentive to do that may hopefully be approaching, but it
will probably only be after congress is thoroughly shaken up in the 2018
elections which I think is coming.

I think, as do a lot of other experts (not necessarily me in that group)
that this isn’t just a forgettable loss that happens every day in
congress. This is an unqualified Richter 10 disaster that actively
undermines Trump’s ability to lead. Virtually everything he’s done in
the last two months has failed and the number of flat out lies that roll
off his tweet machine continues to astound and continues to undermine
his credibility, if he ever had any. The combination of having
everything he signed tied up in legal quagmire, quietly asking the
taxpayers to fund the impeccably silly and ill-advised wall the Mexicans
gleefully refused to even talk about now combined with his inability to
get ANY health care law passed. Never mind that NONE of it fulfilled
his loud previous promises that everyone would be covered cheaply.

He’s now skulking, contemplating his next move (probably) in his
multi-million dollar estate in Florida wasting millions of dollars of
taxpayer money, disrupting the local economy with hundreds of guards and
restrictions while the rest of his family wastes other millions needing
to be guarded when they take a walk down fifth avenue to window shop.

Well, folks, there are some likely scenarios. I think next up on the
ledger is Trump and his conservative friends fucking up the economy by
cutting out everything and anything that might actually benefit people,
but saving a lot of money to be spent elsewhere. Now that he’s found out
congress is a little tougher than he previously thought, and congress
has figured out they don’t have to be bullied, this will be a very
interesting game, indeed. It’s not out of the question that Cruz et al
will try to sink the government again, but this time Trump is in a
different position than he was a year ago, a position of being
responsible for the ship’s safety.

I think also that Trump’s silly tweets and wild, unsupported accusations
will continue and he will double down on all of them, slowly but
progressively eroding his credibility and also eroding his “base”. At
some point, the Republican majority, becoming more terrified at losing
their majority in 2018 will start doing some interesting things we don’t
really know the nature of yet. I think it’s highly unlikely Paul Ryan
will ever trust Trump again and vice versa, so Trump’s relationship with
congress will be non-existent.

First time, I’m wondering if this continues, will there be an attempt to
evict Trump from office in 2018 simply on the basis of his inability to
lead, much less his ability to fuck up the world. And BTW, we haven’t
seen any world crisis yet this month for Trump to fuck up. We don’t yet
know how bad or how dangerous it could be.

Pence, conservative wog that he is, comes off infinitely more
“presidential”, and might attract a lot of Trump’s more realistic
followers. I’m wondering if this could happen.

Trump as POTUS: an editorial comment

0

unknownWe should have all seen this coming. The favorability ratings of the entire Washington bureaucracy had been in the cellar for years and decreasing. Partisan political activities consisted of bitter hatred of each other’s side and resolve to insure nothing the other wanted ever came to fruit. Ted Cruz worked as hard as he could to completely sink the government and go down with the ship. All progress in Washington stopped dead in its tracks with no potential for moving it.

What we didn’t know was the sheer size of Trump’s support. Michael Moore predicted Trump from the beginning and he never wavered. We should have noticed that Trump won most of the primaries by big votes against all odds. We also should have noticed that none of his support ever wavered for a second despite ALL his antics. None of it mattered. I should have known watching all those Trump signs while riding out in central Pennsylvania. My friend the ICU Nurse laughed and told me he cared nothing about any of that- Trump was chosen to “shake Washington up”.

So to the surprise of all of us, especially the pollsters, all of whom were wrong, we are now witnessing a full blown REVOLUTION in which the population of the USA has spoken loudly. It’s classic democracy at work. The populace is NOT happy with what’s happening in Washington and they have chosen the individual furthest from the archetypical Washington politician, Hillary Clinton, a candidate with so much baggage it would fill a train.

It’s difficult to comprehend anyone less likely to be elected President by an intelligent, perceptive voter. She was projected to win not for her plan but because everyone with an opinion in the media thought she was the lesser evil. But the “real” voters weren’t talking on the media. The “real” voters that knew Hillary would perpetuate the exact situation in Washington they loathed and they didn’t believe a word that came out of her mouth. The pre-election activities were all a waste of time and money. Trump was a self-fulfilling prophecy.

So here we are. The public has served notice that they expect the entire fabric of the Washington bureaucracy to be torn to shreds and a new order emerging, more efficient and favorable to the common man. So that’s where it is as I sit here on 11/11/16. It is a done deal so no use crying over spilt milk. It is what is, so we must now consider where this is likely to go.

Donald Trump will quickly develop some new best friends, conservative politicians, all of whom distanced themselves from him during the campaign. Don’t worry; they’re all back and planning to re-forge the country into an ultraconservative dark age. They now own both houses so there will be virtually no effective opposition to any of it.

No more Obamacare, with nothing of any consequences to replace it, leaving 22 million out in the cold. Repeal the Iran deal, leaving them to continue making a bomb as rapidly as they can. Repealing the climate accord because they choose to disbelieve 99% of the experts. Cutting taxes preferentially for the super-rich, choosing to believe that “trickle down” works (didn’t work for Reagan in 1980). Unlimited weapons of any kind on demand from anyone. Destroying Planned Parenthood and quickly repealing Roe v. Wade, following which an enormous cottage industry of abortion will develop, an underground economy impossible to stamp out. They will of course blame the victims. Getting an ultraconservative judge onto the SCOTUS, rubber-stamping all their plans. Never mind the impeccably ridiculous Mexican wall and goon squads to seek and destroy illegals.

That is EXACTLY what Trump’s new best friends have in mind and they’re all in the process of planning it.

However, there are jokers in this deck. All of Trump’s new best friends might consider that Trump really isn’t a conservative Republican at all. Never has been. He was once a Democrat. He chose to run as a Republican because it was the most expedient path He has frequently opined on policy that is not conservative at all. And it also must be remembered that Trump has an extensive history of only listening to Trump. He’s found out what works and it isn’t free advice, especially from folks he doesn’t trust. So there is no guarantee at all that Trump will blandly follow through with all the plans of his new best friends. He might just have the “right thing” in mind, and the right thing might be more “right” than we currently imagine.

Recall that in 2008, Obama ran on a very solid “change Washington” platform. When he actually arrived, he tried to gather all the Republicans together to talk out their differences and form some kind of body that worked for the best benefit. They all ignored him and vowed to insure nothing he wanted to do happened. The majority speaker opined that their job was to insure he was a one term President and this is exactly how they acted. It’s also very interesting that despite his best efforts, Obama was chewed to pieces by the bulletproof Washington establishment, not even making a dent in it. Washington changed him as it did everyone that came before him.

So there is also no guarantee that Trump will get all he wants in a system that’s preternaturally designed to NOT be changed by anyone. He is more likely to become meshed in the gears to find out that “deals” don’t work the same as in his previous career. He will have to learn an entirely different and unfamiliar “art of the deal”, especially with China and Russia.

So, I think that just like the previous predictions of the election, there is no more likelihood of predicting what Trump will do, or what he’s able to do once in office. All the claims of what he wants to do are now enmeshed in gears he really knows nothing about and when extensively evaluated, may simply not be realistic for Trump to actually accomplish. It will be VERY interesting to see how Trump explains repealing the ACA, even if he’s technically able to do so, to 22 million of those affected, many Trump supporters.

Once into the realities of the world sociopolitical situation, “bombing the Hell” out of ISIS never had any possibility of working. There are probably realities of the Middle East, Iran, Turkey, Syria and Russia that he had no idea about when he made some of his ridiculous vows. He will find out that the realities of foreign policy are extremely dangerous and he will have to tread as lightly as Obama did, with open-ended criticism from all sides.

It should also be obvious that none of the above works for his committed base that want’s it all fixed in a few months, for ISIS and Iran to go away, more money in their pockets, better jobs and unlimited milk & honey. His base in W. Virginia and Kentucky want coal to become the energy of the land. Working class white men want to make more money and promotions. It’s VERY unclear whether Trump will even have a shot at any of that in a Washington that doesn’t run as his previous career did. Making promises is cheap. Delivering them in THAT Washington is a separate issue and he, like the rest will probably learn to obfuscate those promises with great facility.

So, the bottom line of this conversation is that we really know little or nothing about how The Donald will function in the same environment that gutted Obama and others. I’ve mentioned before that like it or now, Trump is OUR President now and continuing to grouse about this or that is meaningless now. It’s time to support the President by simply being reactive to what’s going on. A lot of Republicans are NOT extremely conservative and will not necessarily rubber-stamp every program that emerges from Trump’s new best friends, or even Trump.

There is a lot of sound & fury but in the end these things have a way of settling down. The majority of the public has never supported the Sarah Palin brand of conservative politics. It’s unlikely that they will now. They want “real change”, a political body that serves them. Conservative Republicans don’t serve, they break things and the majority of the public will not allow that.

What Hillary said is correct now. Trump IS the President and he needs a chance to lead. It’s not unreasonable to give him our support while he explores that chance. Who knows, he may actually “do the right thing” to the best of his ability and surprise us all. If he can’t or doesn’t, then another voting cycle will come around in 2018 and 2020. We can then do what Trump supporters did in 2016; assertively change the order of things.

So I say lets all just watch for a while and see how things go. It doesn’t have to be a disaster. When the dust settles, it might be OK and Washington might actually become more responsive to the greater good. There’s at least as good a chance of that as the collapse of society. Society is pretty resilient. I would be inclined to see the glass as half full rather than half empty.

We’ll all see in time.

 

 

 

 

 

 

Some politically volatile comments (personal opinion FWIW)

0

crippenWhat follows is some conversation from the Website:  Med-Events:, a site I moderate for opinions and comments about current events. Sometimes it gets pretty volatile and there isn’t much held back as Events is a closed site. I cannot reproduce any of the opinions other than mine because I don’t have permissions. So I have put forth my opinions regarding certain current events of a volatile nature for whatever interest anyone may have, maybe none. It’s all mine and I opine from the perspective of having been there for some of it and having personally known some of those involved. I was, however, never a member of the Weather Underground and I never participated in any such violence.

It’s fairly long and involuted and I rarely copy-edit anything for spelling or grammar.

 

Crippen on “Protests”, Media” and “Black Lives Matter”. (Med-Events discussions in January-February, 1016.)

LE HAVRE, FRANCE - MAY 21: Anti-G8 activists protest during a demonstration on May 21, 2011 in Le Havre, France. The demonstrators were protesting against the G8 summit, to be held May 26 and 27 in the north-western French city of Deauville. (Photo by Franck Prevel/Getty Images)

LE HAVRE, FRANCE – MAY 21: Anti-G8 activists protest during a demonstration on May 21, 2011 in Le Havre, France. The demonstrators were protesting against the G8 summit, to be held May 26 and 27 in the north-western French city of Deauville. (Photo by Franck Prevel/Getty Images)

Demonstrations, Protests and the Media

Crippen: I’ve seen a lot of demonstrations in my lifetime and participated in a few when I was a younger dog. Here’s how it works. A group gets worked up over some atrocity, real or imagined, and they all congregate to show the public how pissed off they are and to assure their anger makes the 6 pm, 11 pm news and CNN. However, no one watching these news sources cares. Most don’t look up from their issue of People magazine. Whatever it is they’re demonstrating about, it doesn’t touch them and it doesn’t matter to them. It’s somewhere else, and it affects black people. OK, fair enough. Anyone for Chinese? The news services work it up for a while and they to get bored with it and move on to whatever the Royals are doing or how many ISIS sites were blown up.

Then the protesters figure out no one cares and they’re wasting their time. They march and then everything goes back to normal. So they then understand they need to make more of a splash to get the attention of those dulled by most news stories anyway. So the U of Missouri football team refuse to play, and some of the students go on hunger strikes and they loudly call for the resignation of higher-ups in the system. The dumbass higher-ups offer blanket apologies for atrocities they don’t even know about, roll over like weasels, exposing theirs softest parts at the whims of a pissed off MINORITY and skulk off to cheers of equally clueless cheering sections.

This hits the 6 pm, the 11 pm and Anderson Cooper briefly, the viewers look up from their Us magazine, tut-tut and then move on to the Real Housewives of Atlanta. The protesters loudly shout “we won!” and then repair to formulate more demands, many having nothing to do with the original atrocities at their school, real or imagined. Then all goes back to normal again for a while.

Then the protesters understand it’s time to kick the sleeping bear again. This time they obstruct traffic and entrance into major businesses on the busiest shopping day of the year. “LOOK AT US, WE’RE TRYING TO SHOW YOU WE’RE BEING DISCRIMINATED AGAINST”. That’ll show ’em. The public then definitely notices them. The “notice” the protesters get is the exact opposite of what they want. The public is inconvenienced and they don’t give a shit about the principle, they want the road cleared and the businesses non-obstructed.

Finally, the protesters understand that the only way to get noticed and stay noticed is by bombs and bullets. Just like the Weather Underground in 1970. The public will be dragged into an understanding of the problem whether they want to or not. That’s where this is headed.

 

436247168_640David Gilbert and the Weather Underground

Crippen: While in the air and hanging around airports over the last week I read an interesting book on the revolution in this country from the 60s and 70s, a subject I am very interested in as I was there for a lot of it. In my collection, I have almost every book written about this era, most from those involved, including a signed (to me) copy of “Fugitive Days” by Bill Ayres and an original first edition copy of “Prairie Fire: A political statement of the Weather Underground” (1974), run off by mimeograph to avoid detection by the ever vigilant Federales.

Regardless of whether you agree with him on anything, Bill Ayres writes a lot about American culture and most of it is an interesting read:

http://billayers.org

If anyone’s interested, the book is: “Love & Struggle: My life in the SDS” by David Gilbert, a stalwart of the Weather Underground in the early 70s, currently imprisoned at the Auburn Correctional facility in New York for his (non-violent) part in the infamous Brinks robbery in 1981 during the waning years of the WU. David and his wife Kathy Boudin were caught up in a plot to finance future radical activity by robbing a Brinks truck that went completely wrong and people were killed by members of the Black Liberation Army (BLA), a faction that both Gilbert and Boudin stupidly underestimated. Boudin was released in 2003 after 22 years. Gilbert is my age, has spent most of his adult life in prison and will die there as he isn’t eligible for parole until the year 2056. Bill Ayres and Bernardine Dohrn legally adopted Gilbert & Boudin’s son while they were incarcerated. He is a civil rights lawyer today.

http://www.amazon.com/gp/product/B008CID47S/ref=dp-kindle-redirect?ie=UTF8&btkr=1

UnknownThere are several things learned from reading accounts of the “Days of Rage”, specifically the Students for Democratic Society (SDS) and it evolution to the “Weather Underground” (WU) by people that were intimately involved.

  1. The SDS were by and large white children of privilege, reared in families of means, many of them Jewish as were both David Gilbert and Kathy Boudin. Kathy’s father was an ultra-left wing lawyer, counsel to numerous left-wing organizations. Her great-uncle was Louis B. Boudin, a Marxist theorist. Gilbert was an Explorer Scout. In essence, they were all what we would have described then as “Communists” in the purist sense with a Marxist economics inflection. They interpreted many of Marx’s principles of the value of work belonging to workers and not to those who dilute it unfairly.
  1. The SDS started life in the late 60s with the fundamental goal of addressing the inequities of the poor and disadvantaged in a world that entitles white males. Their primary interest was exposing the inequities of minorities including dramatic deficits in education, nutrition, housing, jobs and opportunity for black folk. They developed an accumulating interest in the Black Panther Party (BPP), established in 1966 and mirrored most of their political/social activities. The BPP’s core practice was its armed street patrols to monitor police officers behavior and challenge police brutality in the vicinity of Oakland, California. In 1969, with assistance from the SDS, the Panthers evolved to community social programs including Free Breakfast for Children Programs, and community health clinics.
  1. The complaints brought by either the Panthers or the Weathermen in the late 60s were absolutely righteous. There were, indeed, egregious and terrible offenses against those unlucky to have been poor and especially black. They were herded into ghettos. There was intense job and education discrimination and mostly they were systematically abused by police, who considered them vermin. The WU also “discovered” sexism in society and went to great lengths to resolve in in their own organization, creating great strife amongst the mostly while male factions steeped in sexism from birth.
  1. In their early iterations, neither the panthers or the WU had any particular interest in violence as it pertained to murder. That said, the Panthers were happy to flaunt their right to openly carry weapons, frequently waving them under the noses of police, daring them to respond. This was not a particularly wise action in the late 60s. From 1967-1969, there were at least eight gun battles in which three police officers and five Panthers died. Otherwise, both the Panthers and the Weathermen were committed to social change by publicly exposing social inequities and by participating in non-violent demonstrations. However, the police and FBI overreacted to most of it. J. Edgar Hoover called the panthers “the greatest threat to the internal security of the country” and he supervised an extensive program (COINTELPRO) of surveillance, infiltration, perjury, police harassment, and many other tactics designed to undermine them, quickly extending to the SDS, who reacted by forming the much more aggressive Weather Underground in 1969. The program was also accused of using assassination against Black Panther members, including the death of Fred Hampton and Mark Clark in December, 1969 in Chicago, a seminal event in radicalizing the SDS.
  1. After the deaths of Hampton and Clark, the Weathermen realized that the police could run roughshod over protesters. They also realized that general public had little interest in addressing the problems associated with the poor and disadvantaged, especially of black folk minorities. The Vietnam war was also beginning to rage, an altercation considered by the WU to be blatant imperialism. Simply pointing it out was as ineffective for the BPP and WU as it was for Dr. King much earlier. Both groups then radicalized into factions that would not only point out these societal deficits but do so more forcefully by “getting the attention” of an otherwise apathetic public. This would be accomplished by blowing up buildings associated with Nationalist imperialism and discrimination, of course to be vividly described on National television for a much wider audience than newspapers.
  1. The WU aligned themselves with virtually any other organization dedicated to the aggressive (violent) redesign of American government/politics, end the imperialist war in Vietnam and as an afterthought, to end sexism. It was at this juncture that they made at least two fatal mistakes that would go on to destroy them. They embraced collections of steely-eyed killers whose mission was simply to kill cops in retribution for the ills they had suffered and they thought that simply blowing up buildings would not harm innocent bystanders.
  1. The “Brinks Job” in 1981 that sent Dave Gilbert and Kathy Boudin to prison for much of their adult lives was a terrible miscalculation. Both should have known better, but again, this must be viewed in the persona of the time. While Gilbert and Boudin waited in a U-Haul truck in a nearby parking lot, armed BLA members found themselves accidentally confronting the Brinks guards and a shootout ensued, killing several at the scene. The BLA members transferred $1.6 million in cash transfer into the waiting U-Haul, quickly apprehended by a police roadblock. Gilbert and Boudin surrendered but when the officers tried to search the back of the vehicle Black Liberation A members emerged shooting with automatic weapons, killing more at the site.
  1.   Most of the Weather Underground intimates have never recognized or repudiated their mistakes of the 60s and 70s. In Gilbert’s book, he repeatedly articulates that they were on a mission from God and their quest was righteous, glossing over several realities. In fact, they probably ever had a chance. None of their passionate ideals were of any particular interest to most of the general public. Few in majority America cared much about the plight of the poor and disadvantaged. It is VERY unclear whether “protest demonstrations” actually did much to change anything until those changes evolved naturally over their own good time, particularly anti-war demonstrations. All these protests went on for years but change generally didn’t occur within the time frame of the demonstrations. The Vietnam war didn’t end until 1975 and conditions for black folk, including a lot of them shot by police continue to this day. And again, blowing up buildings to publicize social inequity didn’t work very well, sufficing mainly to build CNN up to it’s worldwide penetrance. A few accidental innocents killed because of being in the wrong place at the wrong time undermined any utility of these actions.
  1. One of the things gleaned from David’s rather eloquent memoirs is the fact that to the truly radicalized, there is absolutely NO concession to any opposition and there will always be an perpetual, open-ended search for discrimination and social inequity. This concept has come to fruit now following the shooting or beating of unarmed (but sometimes aggressive) young black males by police. The reaction to it has been now to “find” discrimination on places normally though to be fairly benign. Discrimination is now defined in institutions where there “aren’t enough” minorities. How many minority administrators are “enough”? (More). In a mid-western university, several top administrators bullied into resigning because their minds weren’t quite right. How right should their minds be? (more than they are). How many minorities should be offered acting jobs in Hollywood? (More). Anything is now “racist” if a “J’accuse” finger is pointed at them by a loud voice popping up on the Internet. When that happens, the accused party is guilty until they can prove themselves otherwise.
  1. We are now liable for a repeat of the events of 1970 because we haven’t learned that little of it worked in 1970. Much heat was generated but little useful work. We now have a stage set for another Black Liberation Army and the events that followed it.

 

-4-panthers-on-parade-at-free-huey-rally-in-defermery-park-oakland-july-28-1968.-photo-courtesy-of-stephen-shames._wide-c2a3c0470820d318da280cf6614412a295d6bbda-s900-c85Black Panthers and “Terrorism”

Crippen: The Black Panthers, Weather Underground and Timothy McVey were clearly terrorists. Anyone who uses violence to terrorize or instill fear into a community to try to effect change is a terrorist.

 

Well, since I knew people involved with the Weather Underground in the early 70s and I have really studies both the Panthers and their successors the Black Liberation Army (BLA) I may not be an expert but I’m more knowledgeable than many.

There are subtle and maybe not so subtle differences between all three of these factions but I would not call any of the “terrorists” in the same sense as radical fundamentalist Islamics.

The Arabs use wanton killings of masses as a tool to spread fear in a population, and it works pretty well. They do so because they want to kill off as many infidels as possible and run the rest of us off the cliff if possible. It’s a global hatred thing of an entire civilization and there isn’t any focus. There isn’t any specific issue. It’s all Americans, or all non-islamics for that matter. Their destruction isn’t focal. It’s anywhere, anytime.

However, the Weathermen of the early 70s were focused specifically on the Vietnam war. They focused damage (not so much death, most deaths were accidental) on public icons and buildings related to the war and it was specifically for publicity value, to advertise their opposition of the war. All of their bombings were warned before the fact.

The Panthers rarely did any specific damage. Their focus was to point out the discrepancy between black america and white America as it applied to jobs, education and opportunity. They created alternative schools and food sources. They liked to wave guns in front of cops and dare them to do anything about it but didn’t they kill anyone that I recall. However, the cops did kill some high profile Panthers.

The BLA was the tactical arm of the Panthers’ social philosophy. They were the reaction to cops killing Bobby Hutton and Fred Hampton. They killed isolated police officers in cold blood minding their own business cruising in cars or walking beats. They were all busted and many of them re-located to Cuba or Africa, where some remain.

Tim McVeigh bombed an isolated building as revenge against the federal government for its handling of the Waco Siege. It was a one-time event by one pissed off individual to simply get quits with the government. Not meant to spread “terror”.

No none of these factions are technically “terrorists” was we understand the term in 2015.

 

13.pngDinesh D’Souza vs. Bill Ayres debate, 2/10/16.

Crippen: This debate was just amazing. Fantastic. Everyone should have seen it. The really great thing was the fact that the University of Michigan had the foresight to put this on in this world of enforced political correctness. To present different viewpoints in an educational forum, not screaming at each other as frequently happens on Bill Maher. The audience was clearly biased to conservativeness but they were well behaved and didn’t boo either debater. The debaters were very polite and respectful of each other in their comments. They both stuck to the issues and not attacking each other…much.

To my observation, D’Souza came off dark, foreboding and very, very angry. He rarely smiled. Frowned frequently and regularly grimaced at Ayres making some point he didn’t like. He was dressed in a formal suit & tie and appeared nervous, beads of perspiration on his face. Dinesh is a self-proclaimed “child of the 80s” (The “me” generation as I recall).

D’Souza was right about the generation gap between them. Ayres is straight up 60s hippie, free & easy, t-shirt, earrings, comfortable even in this hostile environment, laughed and smiled a lot. Jeans, backpack on his back. He has nothing to be angry about, really. He’s been there and done it all, but he makes good points cheerfully and with no particular malice.

The audience was hostile under the surface but the rules were followed pretty much. No booing, no speeches by the audience instead of questions. When one female started making an extended speech they cut her short and she really didn’t have much of a question.

I think best interaction was when some female started espousing the classic conservative line: “I work hard for my money, why should I have to give any of it up. It’s mine to do with as I please”. Ayres shut her down hard (I think), letting her know that the reason she has any money at all is because of all the infrastructure paid by taxes. She wanted to use all that then keep the proceeds, letting someone else support the infrastructures that allowed her to accumulate wealth.

There was another good one. Another female rose to very a smarmy remark that she was offended at Ayres’ “Black Lives Matter” T-Shirt. Very smugly and self righteously opined that “all lives matter”. Ayres nailed her with the reply that “all lives” were not getting shot dead, unarmed, in the street for bad attitudes.

Dinesh actually did make a few valid points though (only a few, the rest of his diatribe was sophomoric mythology). I was a little more impressed with him than I thought I’d be. I thought Bill Ayres shut him down pretty regularly, exposing his faulty logic. The moderator said something about his film: “Obama 2016” being the highest grossing this and the most award winning that. Of course that’s all bullshit Conservative propaganda. That film was laughable garbage, none of it was true at the time and none of it came true later. Every reviewer, those that bothered, trashed it (except of course conservative Republicans). So in the end, Dinesh is STILL the guy that produced and directed that smelly piece of shit and he believes it to this day.

The moderator also pronounced that Dinesh was one of the true great conservative intellectual voices of our generation. That may very well be true, but if it is, I’m not too impressed with that voice. Most of his points made were unsupportable theory and open-ended criticism of any opponents without specifically refuting facts.

They mentioned something at the end about having another “debate” about each others legal woes. Ayres brightened up about that. He’s been defending most of that for years, pretty eloquently. I’d like to see that show.

 

blacklivesmatter-2015“Black Matters Matter” and history

Crippen: I think they go out of their way to portray almost any kind of trouble that blacks get into to reaffirm the ongoing suspicion that blacks are always in some kind of trouble. News services have no interest in news. They have an interest in as many viewers as possible watching their advertisers. They’re interested in taping into the drooling cretins that watch “Kardashians”, “Real Housewives”, “Batchelor” and “Broke Girls” (with it’s ridiculous laugh track).

Dr. King never asked that blacks get an exalted position in American culture. He only asked for an even break and it never happened, then or now despite “laws” superficially assuring it. They know that as black culture progressively recedes from mainstream it’s progressively disliked by the mainstream. It’s a alternate universe, a matriarchal culture with continued job and educational discrimination, too many kids hanging around streets with nothing to do, a drug culture and a crime culture. Mainstream America loves to watch the details on the tube. Scary pictures of suspects. Black on black crime occurring in areas receding from mainstream residential areas. It affirms what mainstream America has always suspected; that they’re dangerous and need to be isolated.

Ayres had a “Black Lives Matter” shirt because he fervently believes that. I give him that. In the 60s, blacks were reliably and brutally mistreated by society in general and cops in particular. The Weather Underground started it’s life on a parallel course with civil rights and only became violent when it became apparent that nothing was changing any of it. Bill Ayres continues to be stuck in the 60s because he’s seen it all and there’s a lot to see.

Black lives DO matter and there is a VERY strong suggestion in the media that they are being shot simply for bad attitudes. I don’t know if “most” cop shootings of unarmed citizens are black. I VERY strongly suspect they are and I’d be interested to see any convincing data to show otherwise.

I do know that there have been a considerable number of blacks shot by cops on film that at least appear that they’re shot for little other than bad attitudes. Cops shooting them for criteria they would NOT shoot a Fox Chapel housewife with a bad attitude for in my neighborhood. All lives do matter too, but the attitude of the female on the Ayres-D’Souza program was that because “all lives matter”, black lives don’t matter so much.

 

screen_shot_2014-08-13_at_8.38.17_pmDeadly Force and young black males

Crippen: Re: justification for “deadly Force”. The reality is that multiple legal challenges from the past, including the SCOTUS have confirmed that it’s the police shooter that determines at the time what a “threat” is, not the TV news the next day. If the officer believes there is a threat to his life or the life of some other innocent he’s pledged to “protect and serve”, his decision is VERY “bulletproof” from complaints after the fact (as we’ve seen from current events).

The problem, I think, is that the decision to shoot young black men armed only with bad attitudes breaks a lower threshold than for solid citizen suburban whites. In Ferguson, it’s difficult to know exactly what happened because of all the highly biased observers on the street, each with a very strong incentives to blame cops for everything and anything. Some observers claimed Brown was on his knees, tearfully begging for his life, whereupon the cop callously shot him in cold blood. Does anyone really believe that? I don’t. It makes zero sense that in an inflammatory situation a young police officer with a family and a career would do that in front of a pissed off audience of witnesses.

90205-fullMore likely, Brown, passionately pissed off at the situation, decided to get into the face of a cop that was hassling him and others, probably threatening all of them with the authority of a uniform. The experiences of young black males on the street with cops is “uniformly” bad. The experiences of cops dealing with pissed off young black males very quick to exert their “constitutional rights” to “protest” by taunting a cop in his face are equally bad.

This sets the stage for both groups that hate each other on sight. But the young black males STILL have not learned that they can NEVER win an altercation with police on the street. They still like to get in their faces, especially in a situation where the cop is outnumbered. But the reality is that if the cop feels threatened, the law is on his side if he chooses to protect himself and he gets to determine if he’s threatened.

It’s highly that Brown, a big kid, pissed off to the max, decided to approach the cop in a threatening manner, not to kill him but to taunt him with his nose inches from his face. The cop interpreted this as threatening and, his threshold for deadly force already lowered for blacks on the street, protected himself before he could find out if the threat to him was dangerous. If it had been a Fox Chapel housewife (blond, great legs, driving a Lexus SUV, got out of a car (stopped for speeding to her hair appointment) and got screaming in the face of a cop on Fox Chapel Road, it’s HIGHLY UNLIKELY she would be shot. And yes, I consider those situations similar.

There is an extensive history of young black males getting in the face of cops. It was the whole point of the Black Panthers in the 60s. They made an art form of it, frequently waving guns in front of the cops nose daring them to do anything about it. The knew (or thought they knew) that the cops would back off rather than make a big stink with the Panthers who were like the “Mighty Ducks”. You screw with one, you screw with the whole flock. And they got away with it for a long time, but as they did, they built up a frustration level in the police force. A frustration level that eventually led to breaking through and the police manufacturing confrontations where the Panthers’ frustrations broke the threshold to actually shoot back, whereupon they were bested by superior tactics and firepower.

FBI Director J. Edgar Hoover called the party “the greatest threat to the internal security of the country”, initiating surveillance and harassment program (COINTELPRO), tactics specifically designed to undermine Panther leadership, incriminate party members, discredit and criminalize the Party and drain the organization of resources. The program was also accused of creating and manipulating scenarios where police could assassinate Panthers after setting them up to appear to be “threatening” officers. Shootouts with police began in which Panthers usually got the worst of it.

On October 28, 1967, Oakland California police officer John Frey was killed in an altercation with Panther Huey Newton during a traffic stop. Newton and a backup officer also suffered gunshot wounds. On April 7, 1968, Panther Bobby Hutton was killed in a shootout with the Oakland police, and Panther Eldridge Cleaver was wounded . Two police officers were also shot. Panthers later admitted that Cleaver had led the police into a deliberate ambush, provoking the shoot-out. On January 17, 1969, Panthers Bunchy Carter John Huggins were killed in a shootout on the UCLA campus. Another shootout on March 17 led to two more Panthers dead.

fredhamptondeadBut the big one, the one that led to the violent focus of the Weather Underground was the killing of Fred Hampton and Mark Clark on December 4, 1969 in a shootout orchestrated by the Chicago police and FBI. A federal investigation reported that only one shot was fired by the Panthers and police fired at least 80 shots. Hampton was shot twice in the head at point blank range. He was 21 years old and unarmed at the time of his death. Coroner reports show that Hampton was drugged with barbiturate said to have been administered by that night by FBI Panther infiltrator William O’Neal. Cook County State’s Attorney Edward Hanrahan, and eight Chicago police officers were indicted by a federal grand jury over the raid, but the charges were later dismissed. In 1979 civil action, Hampton’s family won $1.85 million from the city of Chicago in a wrongful death settlement.

Members of the Chicago Weathermen (including Bill Ayres) were on the scene and viewed Hampton’s body. They were galvanized and instantly radicalized by Hampton’s death. From that point on, they made the strategic decision to begin retribution for the way blacks were treated and the indifferent attitude of White America. Plus of course the continuing mess in Vietnam.

Hampton’s death was also the focal point for the creating of the infamous Black Liberation Army (BLA) around 1970, a group radically different than the Panthers. The Black Panther Party’s original goals were to provide alternate community social programs for the perpetually disadvantaged black community. Breakfasts for kids, alternate health care and education. It was the side actions of their contempt for the police (and pretty much white America) that got them into trouble. The BLA cared nothing about these things. The BLA existed to make the police (and white America) “pay” for their crimes against black america.

Black_Liberation_Army_(emblem)The BLA was mostly composed of former Panthers and their stated credo was “armed struggle”, taking up arms for the liberation and self-determination of black people in the United States.” The BLA carried out a series of bombings, murders, robberies and prison breaks (including my friend and patient Tim Leary in 1971). Expatriate Eldridge Cleaver publicly criticized the BLA as being revolutionary instead of reformist. According to a Justice Department report, the BLA is suspected of involvement in over 70 incidents of violence between and the murders of 13 police officers1970 and 1976. The Weathermen strongly sympathized with the radical Black Panthers. The police killing of Panther Fred Hampton prompted the Weatherman to issue a declaration of war upon the United States government.

Part of the WU manifesto goes: “The most important task for us toward making the revolution, and the work our collectives should engage in, is the creation of a mass revolutionary movement, without which a clandestine revolutionary party will be impossible. A revolutionary mass movement is different from the traditional revisionist mass base of “sympathizers”. Rather it is akin to the Red Guard in China, based on the full participation and involvement of masses of people in the practice of making revolution; a movement with a full willingness to participate in the violent and illegal struggle”.

Now, why do I ply you with this long, dry history? I think because it’s history repeating itself. Police with a low threshold for shooting young black males approaching them in “threatening” poses, legally justified and blessed by Grand Juries”. A gathering of seriously pissed off blacks now with the “Black Lives Matter” logo in he media, greeted by indifference of a large chunk of white America.This sets the stage for blacks figuring out that “Black Lives Mater” isn’t taken seriously (as vividly demonstrated in the Ayres/D’Souza debate Wednesday evening).

The next logical step is for those galvanized blacks to start getting more aggressive in showing white American their displeasure, including getting in the faces of cops as a demonstration that they DO matter. Then cops will continue shooting them and Grand Juries will continue exonerating them. Then the stage is further set for another Black Liberation Activity, just like 1970 when business owners sat guard in front of their storefronts, shotguns propped on their toes.

History shows that this could easily happen and might already be happening. I’m worried that it could, and how it might impact the 2016 election.

Some comments on where critical care medicine is headed in the next ten years

0

Recall several months ago I wrote some editorial opinions on where IIF thought critical care was headed, some of them not too kind. I foresaw a critical care world full of Physicians Assistants (PA) and Nurse Practitioners (CRNP) doing patient care and critical care physicians as their handlers in executive roles. The actual experience and training of the critical care fellows to do that more and more attenuated as they eschew night call and direct patient care the PAs and CRNPs are more than happy to provide.

I see it already in the surgical specialties. I saw the guy that fixed my ruptured Achilles Tendon once, the day of surgery. Everything thereafter was handled by his PA. No way to contact him even if I wanted to. I saw the guy that fixed my femur fracture once, the day of surgery. The followup visit three weeks later was handled by his PA.

I was told a while back by the head of our Department who happens to be a long time personal friend that my weakness was that I wasn’t into teaching the fellows the algorithms and protocols that are ruling critical care, and that direct patient care is becoming overrated as it really won’t be done by physicians much anymore. It will be “directed”. the critical care physicians job will be to know every possible parcel of literature and to be involved in some form of research, because that’s where the institutional prestige (and probably money) is.

My response to that was that the directorial critical care physician will be more of a figurehead as he or she gets less and less hands-on experience, especially at night when all disasters happen. That’s, of course, not to say that these people won’t do an outstanding job. It is to say that either you’re a physician and trained as such or you’re not. That distinction is becoming more and more blurred.

So, as I go down the road, predictably this Paradigm is bearing very visible fruit in my case. First time ever, my “faculty reviews” broke the bottom end of 4 (5 being the highest possible). 3.8 for this partial year (this year has been tough for me). That means bottom end of “Very Good” because of a number of “satisfactory” marks given me (3.0).

Now, you have to understand that this is a lot like “Officer Efficiency Reports” in the Army. If a guy gets a completely fair report, his career is over. The only acceptable report is hugely inflated, and mostly bullshit. Pretty much the same here. The report detailing the statistics for all clinical attending here glows for anything over 4.25 and anything under 4.0 is mentioned only as an anchor dragging the Department down.

So, if you examine my strength and weakness numbers, you see that my highest numbers are involved with the issues of (quotes) “Faculty should promote patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health”. “Faculty should promote knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care”. Faculty should demonstrates respect, compassion, integrity, and altruism in the maintenance of professional relationships with patients, families, and colleagues. Meets all professional responsibilities with regard to patient care. Highest score: Faculty explains the ethical, economic, and legal aspects of Critical Care Medicine as well as the psychosocial and emotional effects of critical illness on patients and family”. Creates an appropriately relaxed, cordial, positive, and stimulating learning environment. Briefly reviews expectations of the fellow at the beginning of the rotation or at the start of time on service.

Lowest scores: “Faculty should promote the ability of trainees to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence.” These scores were low enough to bring my average down below 4, first time ever. A fairly dramatic change from years past.

I’ve cherry picked here as much of this is much more complex but I give you the skinny. What’s happening is that the CCM Fellows are being told what is important. What is important is less hands on direct medical care and more ability to honcho others to do it based on current literature cites and research data. If they don’t feel they are getting what’s important, they downgrade those they don’t think are giving it to them.

So, I think it is happening and it’s happening fast. My fear is we are graduating more intelligent, intuitive doctors that have less and less experience in dealing with direct patient care and more experience bringing forth the latest cite on any subject. Direct patient care will more and more be done by non-physicians. . Unclear where it ends and what the sudden, unexpected aftermath will be. Maybe it will work out fine. If so, the curricula of medical college will begin to approximate that of PhD programs.

Comment:  Much of what has happened is a result of supply, demand and market forces here in the south. Few intensivists, fewer who will choose to be up all night, and relatively plentiful NP/PA who value training and practice in critical care.

This has been a steady process of deterioration here for the past few years and fighting it is impossible since prospective fellows can choose to enter a “Pulmonary, Allergy and Critical Care” fellowship that has NO night call and get jobs identical to those coming out of multi-disciplinary fellowships that demand night call as a learning experience. We actually started seeing a deterioration in qualifications in our applicants until we cut back on night call. I think currently they have to do one night a week and at the rate we are adding PAs/CRNPs, most of that is just hanging out watching other people work.

Comment:  Our challenge becomes finding an effective and efficient strategy to train up those physicians who are willing to work hard to an ever higher standard. My bias–and this is a personal, not corporate bias–is that we need to get to progressively more realistic simulations that expose trainees to more problems and issues in 4 hours than we ever encountered in a fortnight.

I think the pool of those would-be physician trainees is dwindling and dwindling fast. In fact, physician trainees willing to deal with the hassles of direct patient care is dwindling. Why should they. Nuclear medicine and radiology specialists are well paid and they all go home at five. Physical Medicine and Rehabilitation. Rheumatology. Sleep medicine. Hematology. Physician trainees are choosing specialties that come with a built in barrier to being bothered after hours.

So we are building a full compliment of clinical intellectuals who know everything there is to know about subjects that fully insulate them from after hour disasters. Who’s there in the middle of the night when the dying happens. Emergency Physicians, but they are normally not credentialed for in-house care. Hospitalists? Jury out. It will be PAs and CRNPS because it seems they are more affordable. The legacy of affordability has yet to be confirmed but I see the hazy vision as it forms.

Comment:  One view is that the technology to achieve this is “too expensive”. Another view is that whoever pulls it off could create a national sim center that operates around the clock for primary and recurrent training.

This is another factor I’m seeing come to fruit here. My medical students all look at their watches mid-morning during or after rounds and decry they are late to the “sim-center” where presumably they spend the rest of their day. I am on record that if the day ever comes and it might, that students get most if not all their time dealing with clinical emergencies via simulators, we are all in deep, deep trouble indeed. The worst possible place to end up would be a hospital where providers translate virtual reality to real reality.

I landed in a hospital in the middle of the night with a femur cracked from stem to stern, a hematocrit dropped to 26 and hypotensive. Even as a long term attending physician at this institution I took pot luck when it came to a provider that knew how to deal with this issue. When Dr. X cruised into my room, had a look at me and the films and told me he’d take care of this I could have kissed him. By the time I got to the operating room it was something like 4 am and he’d been operating all day. The conversation in pre-op went like this : “Him (Putting his initials on the skin of my leg): “you up for this?”. Me: “better question- YOU up for this?” Him: “(stretching)…..You bet. Lets get this done”. Four hour procedure started at 0400 hrs, masterfully done.

Young guy seven years out of his fellowship in trauma and orthopedics. Literally putting my life and my future ability to ambulate in the hands of someone I don’t know. Trusting him with my life and livelihood? How long do you think we’re going to have these spirited guys willing to beat themselves to death for the benefit of people they never saw before. I genuinely fear we are not headed for more of them.

Comment:  I do not think there’s much point in bemoaning the new division of labor. We need to consider how to concentrate training and broaden experience at the same time. At risk of sounding like a “broken record ” (for the younger list members, please Google this archaic expression), aviation figured out the importance of high-fidelity simulators a while ago.

Dealing with the infinite clinical nightmares all conspiring at the same time is NOT like high resolution avionic training. I genuinely fear for sick people in ten years. Hospitals may or may not have the ability to care for them. I am not optimistic, Tim. Making the best of an inherently bad situation for the worst possible of reasons (diminishing funds) isn’t the same as streamlining provision logically and intuitively.

Here’s what I see happening to critical care in the next ten years.

  1. Insurers will become more and more tight with funds as they discover the multitude of patients transferred to ICUs simply to die after a massive wallet biopsy to chronicle their impending demise. But politically, it’s impossible to “say no” to it so they will find other ways co cut funds for “critical care” that can’t be traced back to bean counters. As a result, the time and energy needed to prove admissions are deserving of “critical care” will become progressively ponderous and difficult. Critical Care physicians will become experts in reimbursement policy and will spend most of their time doing it.
  1. Most if not all of the clinical catering will be accomplished by mid-level providers, PAs and CRNPs, and they will all do a great job because if for no other reason most of the day-to-day patient care isn’t all that intuitive. Busy work looking after numbers, cultures, vitals and so on. Acute decompensation in the middle of the night will be addressed mainly to keep the patient alive until morning when higher levels of expertise will come to bear.
  1. I have always said that the day will come when I can tap into a huge global multi-million patient data base, punch in my patient’s particulars and show the family what the real mortality will be and when it will occur no matter what treatment is afforded. I think that day is close. Similarly, that same data base could be used to create algorithms and protocols showing the best possible outcome according to how those millions in the data base did with any treatment scheme.
  1. Accordingly, morning rounds will consist of input from executive levels of critical care physicians who will select the proper clinical protocol for the patient to be on. Protocols based on “evidence based medicine” (consensus of journal articles on the subject), and there will be one for every possible disorder. Respiratory, cardiac, gastrointestinal, neuro and do on. Of course there will be a trailer at the end of each suggesting that they may be modified by “clinical judgment”, but since the critical care attending has long since lost any experience in clinical judgment, that won’t matter. Variations of response to protocols will be met by more protocols, and if the patient dies, it will be because he had no ability to respond to good, standardized care.

As medicine becomes more complex and the information base has increased beyond the ability of individuals to contain it, we go more to the tender mercies of collective clinical judgement (from the literature). Individual clinical judgment is not amenable to control or standardization which is a situation that can’t be condoned.

When I walk into a patients room, the entire ambiance of illness and infirmity flows into my own personal database. I see and feel things that only someone who has spent 35 years at the bedside sees & feels and I intuitively know a lot of things that I don’t need to test against a computer database of the literature to see if it’s valid for THAT patient.

However, I might be wrong because I also have human frailties. And if I am wrong, then my wrongness will be measured by the database of “evidence based” literature which will always be right, especially since it didn’t need to be consulted for THAT patient.

So, current thought is that in the end, everything will be measured by “evidence based” data. The BEST chance for success is to plug everything into a protocol that reflects “evidence”. Although sometimes brilliant, individual care plans suffer from poor quality assurance. Sometimes they can be lousy and there isn’t sufficient ability to separate the two.

So, the whole point of a protocol is that’s it’s uniformly followed to the letter. Deviations result in uncertainty which cannot be condoned. It’s like letters from the Internal Revenue Service. A half page informing you that money is owed and you have been identified as the person owing it, then five pages of what they’re going to do if you don’t pay up.

Protocols are not for thinking processes of whether they should be followed. Protocols are to be followed or those refusing will die the death of 1000 meetings to explain why to stern faced administrators.

Are protocols a good thing that will improve patient care. Unknown. Will be eventually seen. My personal brand of clinical intuition is clearly dead and if I last the next couple of years before forced retirement, I’ll be lucky.

I am the last of my kind.

  1. There will be no place for medical education as we understand it in this scheme. There will be no point in medical students dealing with these patients because they are cut out of the protocol loop. Medical students will spend 90% of their time on simulators watching the numbers fly by and the robot twitch. Any direct patient care performed by resident staff or medical students will be for routine hospital care. Anything resembling an emergency for a hospital patient will be dealt with by mobile emergency response teams who will arrive at the bedside to usurp the continuity of the previous trainees who will observe the goings-on from the back of the pack.

That this will occur (and is occurring now) is a lead pipe cinch guarantee unless……………..

The big joker in this deck is now political. (FL now suspends previous prohibition against political diatribe temporarily because it is integral to this discussion).

As the cost of health care continues to escalate and the reimbursers continue to find novel and bulletproof ways to cut funding for it, the “real” predictions of how this will all go are just that. The scenario I presented above is what’s happening right now and what will progress all other factors remaining equal, but other factors will not remain equal. Everything is now changed as of the mid-term elections where we now have a radically different power structure and a VERY unclear picture of what the Presidential situation will be in 2016.

The Affordable Health Care Act of 2008 was created to do several important things including to make health care portable and affordable by spreading the cost over all those involved. This became a political football and as of today survived those who would destroy it. However, the barbarians previously at the gate are now in charge and so it is now very unclear whether the AHCA will survive. If it doesn’t, and it may not, then we will drop back to our previous system of “private” insurance for those not eligible for Government health insurance. That insurance has been in the process of escalating the cost of indemnification yearly to as much as 50% a year and will continue to do so as long as demand exceeds supply until it collapses under it’s own weight. When it does, there is nothing else in sight for non-Medicare and Medicaid patients other than “self pay” which guarantees instant lifetime financial insolvency for a routine illness requiring hospitalization or surgery.

I also believe then that if the AHCA fails, the next step is European style National Health Service, which is the ultimate affordable system. It gets X amount of $$ and that’s it. Use it wisely. If and when that occurs, my previous predictions above are dashed on the rocks and we will be sailing through completely uncharted waters.

 

Some comments on the Veterans Hospital situation in May, 2014

0

I have a book somewhere in my library written in the late 70s that details how Vietnam vets got the same treatment as those complaining now at a New York Va. The problem was identical. That facility, however, had a huge number of injured and sick vets referred them from all over the area. They simply rationed so that no population of vets got more than others. They all got the same and there wasn’t enough for anyone.

I prefer not to think that these people are intentionally stiffing vets, although the woman head of the Phoenix VA is now showing signs that she did all this to “look efficient” to her bosses so she could climb the career ladder faster. I think they figured out ways to ration care and hide it from the media (for a while).

I “think” the problem is an overwhelming mass of returning vets with a ton of medical problems and a limited amount of resource to deal with them. There are more doctors than Carters has Liver Pills all over Iraq and certainly Afghanistan. None of these doctors can do much definitive care there but they can “patch up” and send them back to the USA alive but with disastrous issues they would have ordinarily died from. Then they require a ton of expensive care that isn’t available in the system.

This is especially true for neurosurgical injury. If a soldier got a serious neurosurgical injury in Vietnam they died. In fact, if s soldier got an injury that a paramedic couldn’t fix at the scene he still had a pretty good chance of dying. Now they get patched up by doctors at up-front field facilities and sent back to the USA for a lifetime of expensive care and many remain non-functional, requiring some form of welfare support. All this is incredibly expensive and the funds were never available.

Most of the Vietnam vets were sent back with relatively inexpensive health care issues and there was enough resources in the VA system to cover them. When I was a resident in both Indianapolis and New York City, I trained at the VA hospitals in both those cities and I was never impressed that their resources were stretched. I thought patients there got pretty good care and very good training of doctors. Now they’re coming back requiring a LOT of chronic care for injuries that should have killed them and the system is dramatically overloaded.  So what do you do when you have resources for 100 soldiers a week and you have 1000 pushing at the gate to get in?

The answer in a perfect world is you prioritize in some way so those requiring the more acute care get it first and the rest stand in line till their number comes up. But watch the “Wounded Warrior” commercials on TV. They’re all acute and they all need more expensive technical care, ICUs, neuro care, extensive rehab for blown off limbs.

In this country, allowing one group to cut in line on the basis of anything will get vociferous complaints of favoritism and discrimination. So I have little doubt that the VA simply found ways to thin out the demand for services by backing them all up into a barrel and turning the spigot open to allow a defined number of them into the system that could deal as effectively as possible. The rest just backed up waiting their turn. There are lots of ways to do that. What they did in Phoenix is one. Then the media got hold of it and the resulting feeding frenzy didn’t point out the fundamental problem of too many injured soldiers trying to get too few resources. It pointed out incompetence and stupidity which is much better copy.

So how to fix the fundamental problem.

As long as we’re resuscitating otherwise mortal injury in Afghanistan, we will continue to deal with them inadequately in the overheated VA system. Now that the toothpaste is out of the tube in the media, it won’t go away. We have several choices.

1.  Pour a ton of money into the VA system creating a “separate but equal” care system for acute injury and rehab.

2.  Close the VA system for acute injury and spread these patients out through the nearly overheated public health care system and pay for that care via a separate reimbursement provision that the military has in place anyway for veterans who for some reason cannot access a veterans facility.

I “think” that #2 is the logical way to deal with these patients most effectively. The VA system clearly cannot deal with them at all, much less effectively. It would cost a lot more to bring the VA system up to speed than to adjust the “private” system. At any rate, we better do something soon because there are a lot of soldiers out there who deserve better.

I pitch a concept for a cable TV show!

0

Sitting here day after day, it came to me that maybe I had plenty of time to think up a pitch for a TV show, cable of course so the actors could say “fuck” and show their tits. I really always thought I could do that someday.

So the creative juices flowed and here it is:

“Who you calling’ a racist, Bubba??”

A disgustingly rich 80 year old industrial magnate (and of course, a lawyer) living in Bel-Air, LA, accumulates the obligatory 30 year old dumb-as-a-box-of-rocks female with a great body as an “assistant”.  She accumulates four expensive automobiles, a high end condo and an expense account for her labors. Unclear exactly what her duties in this relationship are, but she tends to manage some of his easier to understand archives. Of course there is an estranged 60 year old wife (was 30 with a great body when she originally married our hero).

As it happens, the slightly dim 30 y/o with the great body didn’t enter into this relationship with open ended affection for our hero like Anna Nicole Smith. She thinks there might be something in it for her in the way of becoming some variety of a TV reality star. So she tapes a private conversation between her and our hero in which our hero opines he’s never really liked black guys much even though he’s made a fortune on and for them playing for his sports franchise. She then sends the CD to the local news agency and it hits all the big venues the next day.

Since thought-crimes involving persons-of-color has become a crime rivaling most felonies and the mere accusation has ended careers, the result is swift and predictable. Every person of color that can get near a TV camera and all their friends/colleagues appear shaking their heads sadly to decry the stunning level of racism in this county. Then quickly thereafter howl for heads to roll.

The sanctioning body for the sports team owned by our hero quickly announces that our hero has performed original sin for which there can never be any perdition and sadly pronounces him to become a non-person in the true Orwellian sense. He must sell the team and proceed to the 5th Circle of Hell for eternity, never to emerge again.

Of course, the slightly dim girlfriend is discovered by the media, hoards of which descend on her condo, setting up cameras between the Ferrari and the Bentley. She appears with her face partially hidden and like the Pied Piper, leads them around town until the right one arrives offering her an interview with oh-so concerned, exceptionally socially relevant Barbara Walters who drools at the prospect of this big one to end her career on.

The interview is classic Walters versus a not-quite-with-the-program female with just the right amount of thighs showing to the camera. Barbara is appropriately concerned and relevant trying to get maple syrup out of a stone but in the end the sad girl didn’t understand the concept of how to work Barbara so nothing came of it but a lot of blank looks and non sequiturs. End her 15 minutes.

Next episode, another tape appears leaked to the media, a telephone conversation between our hero and an obvious person of color in which our hero confirms mild to moderate dementia, winding in and out of lucidity. He doesn’t understand the problem as some of his best friends are black guys and he’s certainly made all of them a bundle of money. They should be thanking him and who cares what he thinks about anything in the privacy of his bedroom when pillow talking to his close assistant who hangs on his every word.

He mentions that he got a call from Donald Trump who opined that maybe our hero had accumulated a “girlfriend from Hell” (Donald would know- Marla Maples-1986). Then, quite convincingly informing the listener that no power on earth can force a private citizen sell private property involuntarily in this country and they can all “go fuck themselves”.

But, next episode, of course, there are more females involved. There always are. Within a week, the best friend of the dim girlfriend ends up on Nancy Grace interpreting what she thinks her girlfriend’s motives are (with about the same amount of thigh showing to the camera). An “estranged” but not quite divorced wife gives an interview to the local media in which she assures them she is half-owner of the sports team, she has no intention of selling anything to anyone and they can all go fuck themselves. Thousands of college seniors around the country stopped their career plans and entered law school knowing this issue would be going strong when thy graduated and far beyond assuring job security for years.

Every person of color within sight of a TV camera continues to howl for our hero’s head on a platter, loudly predicting the return of slavery and collapse of civilization. The dim girlfriend retains a lawyer and seeks a book deal. The girlfriend of the girlfriend smiles to the camera and suggests there might be more if the price is right. Oprah discreetly suggests to someone she might be in the market for a sports team full of black guys to support her new TV network. Lawsuits are filed from every faction involved including many not involved but want to get in on the fun.

Last scene of last episode of first year cuts to our hero on an opulent sofa, arm around his estranged wife, both sipping Chateau-Lafite-Rothschild and laughing fitfully at a widescreen TV tuned to “Entertainment Tonight”.

———————————————————————

Teaser for Season 2 of: “Who you callin’ a racist!”

CNN uncovers yet another tape leaked to the media by an as yet un-named source. Our hero claims sexual desire that prompted him to utter remarks decreed by CNN consultants to be racist. He sez a man trying to get laid will say just about anything, much of it contrived for the moment. Unclear how this relates to the charges against him but CNN plays it every 20 minutes all day accompanied by multiple expert commentaries.

CNN consultant Shabazz McMurphy (BS- Black Studies, PhD- “The Black Experience” Howard University) opines that we have arrived at the era where we can no longer tolerate racist crimes of ANY variety, including now the emergence of “thought crimes”.  It’s no longer permissible to tolerate anyone successfully passing for non-racist simply because they keep their mouth shut about their real motives. Our hero demonstrates there are a lot of them out there.

Our hero was thought to be a normal, regular guy, good businessman accumulating a fortune through hard work and got several awards for his acumen and a 30 y. big-titted babe on the side as an appropriate reward for his position. Then his thought crimes broke through the surface and now he fries in the 5th circle of Hell. None of the rest of that history matters. We must now aggressively seek out and destroy secret thought criminals. Thought crime is the one single process that threatens to unravel all the advances in racial progress over the last 100 years.

Starting with each and every person in the public eye, we must seek out everything they’ve ever said or written anywhere for any taint of racism and expose it. We must find and review anything they may have said on any TV screen and have a qualified PhD psychologist (Howard University maintains a list) evaluate for any hint of thought crime that may not have broken the surface yet.  There are literally million of law firm associates around the country building their careers on just such quests. We must think about what they’re thinking and we must assume they will try to hide their true thoughts so this quest must be extensive and aggressive. We must also obtain via the Freedom of Information Act, the full database of all NSA archives to find any evidence of racism.

Another CNN consultant, LaToya Smith ((BS- Black Studies, PhD- “Occult Racism”) also opined that our Hero’s wife needs to be looked at very carefully because living with our hero possibly means she shares many if not all of his biases, otherwise she probably would have married someone else. She needs to be questioned closely under vital sign monitoring for any potential thought crimes she’s foxy enough to keep to her mouth shut (under the circumstances).  Any hint of thought crime must then be dragged out of her by any means necessary so she can join her husband and all the other accumulating masses in the 5th Circle.

A public service announcement appears that evening brought by the American Bar Association urging college seniors undecided about their careers to immediately apply for admission to Schools of Law. The new series “Who you callin’ a racist” has insured full employment for lawyers for the foreseeable future if not into the next century.

Each of the next 14 episodes will be the interrogation of selected news figures including Anderson Cooper, Brian Williams, Barbara Walters, Matt Lauer and selected others.

 

 

 

A few notes on State of Pennsylvania health care politics

0

This missive is an abstract of two letters to a friend asking me to sign a petition urging current Pennsylvania Governor to “do the right thing” and expand Medicaid benefits in our State. Sadly, I think the fate of that issue is not amenable to public or provider opinion, for the reasons outlined below.

———————————————

In order for this petition to have any impact, two variables must be expressed positively.

  1. Tom Corbett must care about the welfare of those that will lack meaningful health care if Medicaid expansion doesn’t occur. There is little evidence that he does. Mr. Corbett is a Republican, which means by political inclination he has little interest in the financial woes of those impacted by Medicaid and has continued to support other Republicans efforts to cut even more of their resources.
  1. Tom Corbett must be amenable to changing his lifelong political inclination on the basis of rational pleas from providers. This would be a lot like pleading with God to cure your brain tumor. If the tumor spontaneously regresses, it’s the work of God. If it doesn’t, it’s still the work of God but we just don’t understand the celestial logic.

Mr. Corbett is also very likely to be elected out of office soon, to be replaced by an increasingly popular Democratic candidate. You can be sure that Mr. Corbett will do everything in his power to hobble or incapacitate that person who will follow him. Not only is Mr. Corbett insulated from rational persuasion, you can be sure that this decision has already been made and the only issue left is how to present it to the public to minimize the political damage to Mr. Corbett and blame subsequent problems on his successor.

As a Republican Governor, Mr. Corbett’s only interest in Medicaid is cutting it, and since his money connection is the same as all of them, extreme right wing factions, he’s very unlikely to do anything not in the best interest of his political future.

So, unfortunately, we will have to live with the Medicaid issue, or hope an incoming Democratic Governor can cobble together something from the ashes.

————————-

Sure. Be happy to sign the petition, but you must keep in mind that this is a political issue not amenable to coercion from special interests (health care providers) for  lot of reasons.  This decision and many others like it were made long ago. The only residual is how to assure political opponents get the blame for unpopularity with those affected after they’re implemented.

Again, Corbett is a more or less as it suits him “conservative” Republican which means among other thing (1) he’s committed to insure the rich get richer on the backs of the disadvantaged and (2) he lays awake every night praying and dreaming of how to get rid of the Affordable Care Act of 2008 (see #1).  So, Corbett has already decided that the only way he will approve any help for the poor is if he can make them pay more or work for their pittance. Yes….sickly single mothers of three and chronically ill old people up every morning to report to a WPA-like assignment.  Why not whips and chains.

The only public coercion that would move Corbett is if he figured some of it might hurt him politically. Unlikely for at least two reasons:

  1. Corbett is a lead pipe cinch to be dumped in 2016 and replaced by a popular Democrat (Wolf), so the opinions of those affected by his decisions always quickly transfer their ire to the most proximal victim, not the one that made the decisions (Obama in 2010).
  1. Paradoxically, although Republicans are quick to defend richer citizens (doctors), they (we) have managed to get bad enough press that it puts us into a different category- need to cut expenses to show fiscal responsibility. So as the media portray us as greedy abusers of Medicare (millions made ramming patients through “clinics” illegally, we become ripe targets to cut fat from a system with little fat to be cut elsewhere. Besides, Doctors complain a lot but they don’t strike so they’re paper tigers and can be effectively ignored, unlike Teamsters.

This is why since 1997, there has been no permanent fix of Medicare reimbursement policies, instead trying to find a way to tie cuts to the desired demise of the ACA of 2008.  And by the way, all of it is said to be financed by cuts to providers.  By rejecting joint/federal Medicaid expansion under the ACA, Corbett becomes the 11th Republican governor to stiff poor recipients of these funds in a hope of somehow dismantling the ACA.

 

Corbett would cheerfully toss two-bits at a homeless guy and snarl: “get a job”.  His path to do similarly to Medicaid recipients is pretty clear as well. He’s happy to humbly accept petitions for anything and might even actually have one of his flunkies read and summarize them before they’re trashed. Like Nixon’s response to 200,000 Vietnam vets demonstrating under his window on April 24, 1971 (I was there).

 

On this day in 1970

0

filo_kent_state_pulitzerOn this date, May 4, 1070, four unarmed students were shot dead by National Guardsmen using live ammunition at (then) Kent State College, Kent, Ohio.  Some of the students killed were protesting against then President Nixon’s hostile excursion from Vietnam into Cambodia. Other students who were curious bystanders and had nothing to do with the protest.

Richard Nixon was elected President of the United States in 1968, possibly on his promise to end the Vietnam War quickly. However, the war continued unabated and reports of atrocities (the My Lai Massacre in November, 1969) prompted increasing protest movements, especially among students.

At Kent State College, about 500 students protested publically on May 1, 1970. That evening, skirmishes occurred at several local bars involving property damage and frustrated Kent students, resulting in the local police force responding. Beer bottles were thrown at the police, prompting the Mayor to declare a “State of Emergency”.

Rumors abounded that there were committed terrorists on the Kent campus and lives were at risk as well as property, prompting Ohio Governor to call out a contingent of the Ohio National Guard.  By May 3, the protest had escalated to over a thousand persons, not all students, throwing rocks and bottles at police and Guardsmen. Then Governor Rhodes vocally called protesters: “revolutionaries set on destroying higher education in Ohio”.

On Monday, May 4, college officials tried to ban further protest gathering, a gesture that was ignored.  2,000 people gathered on the university’s Commons chanting and singing protest songs.  Soldiers from the Ohio National Guard Armored Division then attempted to disperse the students by intimidation. The protesters responded by throwing rocks. The soldiers then dispersed tear gas into the increasingly angry crowd, continuing to throw rocks and gas canisters back at the Guardsmen.

Guardsmen then “fixed bayonets”, and advanced on the crowd which split up into several groups as they retreated. Now, let me at this point step out of context and tell you what “fix bayonets” means. In a combat scenario, it means you’re out of ammunition and facing a relentlessly advancing, numerically superior enemy and you’re reduced to eye-to-eye fighting to the end, probably your end. One of the most terribly frightening things a human can face. In this situation, it means the Guardsmen intended to use bayonets at close range against unarmed students.

The Guardsmen pursued the protesters but became confused as to the landscape and ultimately became more or less sequestered in a tight area allowing some of the students to surround them continuing to throw rocks and gas canisters.

At 12:24 pm, according to witnesses, Guardsmen open fired with military issue .45 pistols an M1 Garand rifles at random students. In 13 seconds, a total of 67 rounds were fired. Four students were killed nine others seriously wounded.

Immediately after the shootings, a full-on riot nearly erupted that might well have incited well-armed Guardsmen to take more lives. Faculty members at the scene plead with all involved to stand down before that eventuality occurred. After about 20 minutes, the students left the Commons followed by the Guardsmen.

Photos of the dead at Kent State found their way into the International media and amplified the frustration against the war in general and Nixon in particular. Kent State photojournalism student John Filo captured a photo of a fourteen-year old runaway, Mary Ann Vecchio, screaming over the body of a dead student that won a Pulitzer Prize.  On viewing the photo of the dead student in a newspaper, musician Neil Young purportedly wrote “(Four dead in) Ohio” on a café napkin in one sitting, performing it with Crosby, Stills, Nash &Young several weeks later.

A week after the Kent State shootings, 100,000 protesters in Washington, D.C demonstrated against the war and the killing of unarmed students. Nixon’s life was thought to be threatened and he was quickly moved to Camp David. The Urban Institute conducted a national survey concluding that the Kent State shooting was the precipitating factor for over 4 million students protesting in 900 American colleges and universities. President Nixon’s reaction to all of it was perceived as “callous and insensitive”.

A Gallup Poll taken after the shootings showed that 58 percent of respondents blamed the students, 11 percent blamed the National Guard and 31 percent expressed no opinion.

We were a country at war with itself. It was arguably the first and last time in history that a major youth uprising against a political regime occurred with such singularly and coordinated organization.

The Vietnam War did not end until five years later.

 

 

 

 

 

The impending death of inadequate health insurance

0

On 21 Dec 2013, at 0:32, From Med-Events

>  Hey Dr. Crippen, isn’t this the equivalent of the Flo insurance you were

> talking about recently? Apparently, it’s not so bad to be able to

> get catastrophic insurance only, as long as it covers Obama’s butt.

Not equivalent as I have had crap insurance polices like “Progressive” and “Safe Auto” explained to me by my State Farm agent. That highly paid huckster from Progressive holds up a “gun” and loudly proclaims the would-be insured can simply name their price to “get insurance for less”.  What she pointedly doesn’t say is that as the gun spits out lower prices, Progressive cuts out anything that might cost them, or pays peanuts for it. So the customer is pretty happy with that deal. They’re “insured” because the popular huckster says so. Once it comes to signing on the dotted line, the “closer” may explain the fine print. Maybe not.

So when “Safe Auto” does it, they “keep you legal for less”. And they do…until you run into the back end of a Porsche with your rusted out 1984 Ford Pickup. If that truck deposits a speck of dust on the back of that Porsche, it’s US$500 for the dealer to flick it off. If the fender is actually dented, it will be somewhere in the range of US$5000 for someone just to look at it. Maybe US$10,000 to actually fix it and probably a complete repaint. So Safe Auto” in keeping you legal for less, will gladly pay up to US$500 for that Porsche injury, and the insured will pick up the rest. The Porsche owner will then sue the insured and set up a court date to garnish his or her wages indefinitely. Sometimes for as much as 25% of wages or more.

Similarly, Garish, loud pitch woman “Flo” is happy to get you in the room looking for “insurance for less” and the “closer” will also explain in not much detail how you’re now “insured”. Then you get unexpectedly get sick or injured and find out you live in the most expensive place in the world, tens of thousands of dollars a day, US$20.00 for a Tylenol tablet to finance those with no “insurance”. Then your spouse reads the plaques on the wall of the attending physician’s, radiologist’s, pathologist’s and emergency department’s wall: “Patients are responsible for all expenses incurred that “insurance rejects”. Junk policies like Progressive pays a small fraction of the invoice or completely ignores some/many expenses or pays a pittance, following which you are financially responsible. The practical difference between being “insured” and “going bare” is academic. If you have a ten-inch hemorrhoid, shrinking it to 5 inches isn’t much help.

Mostly Democrats have been trying to come up with a holistic health care coverage like every other civilized country in the world as far back as LBJ. And of course, Republicans have been trying to trash that idea on a parallel course. Hillary got her head handed to her in 1993. So, come on, give the devil his due. Obama pulled a fairly reasonable plan off, and left to the way it started out, it had a pretty good chance of doing the job.

Obama made at least two very bad tactical mistakes. First mistake was not using the bully pulpit to jam the original plan down congresses throat sideways while instilling the mortal fear of him in all of them, LBJ style. His laid back professorial affect allowed his mortal enemies (the ones he thought would work with him for the good of the country) to dilute the original plan down to it’s present watered down form. Obama had the vision but not the means. And if you read “The True Believer”(Eric Hoffer), it would have been clear that the visionary is never the one to effect the vision. Obama needed henchmen like Rahm, lots of them out there ripping the throats out of his enemy list. The alternative was giving them footholds, which never should have happened. If you’re going to be in charge, then be in charge for better or worse. Let history decide after you’re gone.

His second mistake was not understanding the reality when he assured everyone that they could keep their insurance if they liked it. That applied to me, not much of the rest of the country. I have incredibly good insurance I have no intention of ever dropping for anything. A few years ago my youngest daughter had brain surgery.  I never received a bill for anything but co-pay for office visits. If “Flo” got the bill for that, she’d burst into flames.

Obama thought everyone with health insurance was like me, but in fact there were a TON of “underinsured” out there just quietly languishing, not breaking the surface of visibility until everyone looked a little closer. Obama also correctly built a plan that would assure no one would go broke instantly if they got sick. That isn’t to say they wouldn’t have to pay some out-of-pocket, but it would be affordable. Obama didn’t have any idea that when he forcing them to come up to minimum standards, two things would happen; those paying low rates for junk polices would find out they weren’t “really” covered and they were going to have to pay more for real coverage.

This of course was a perfect opportunity for Fox News to seek out angry talking heads loudly complaining on camera that Obama screwed them out of health insurance by raising the price. Of course, Fox doesn’t mention that they were never actually insured anyway, it was only an illusion.

So, here we are perched on the brink of 2014 and several things are clear. Despite the Republicans making careers of trying, The ACA of 2008 persists and people are signing up.  Those that had/have junk policies are forced to bring them up to the Egyptian Minimum whether they like it or not. Endless blogs complaining about the evils of Obama from lint on his jacket to bad breath are floating around out there bouncing against desensitized ears. In the end, we have the rudiments of some kind of meaningful health care indemnification in place, it isn’t going to be razed and it will grow and evolve into something better.

It is UNACCEPTABLE that we have a huge portion of our population rendered instantly in hopeless debt or financially wiped out if they get sick or injured. NO other civilized country in the world allows that and they all offer some kind of meaningful indemnification for an affordable price. Do the rest of the countries have problems?  Is the care they offer completely free from glitches?  Are there waiting lines for some services? Sure. But everyone gets care and no one goes to the poorhouse if they get sick. We callously ignore a portion of our population and our life expectancy isn’t any better than Portugal’s. UNACCEPTABLE.

So, like it or not, there are some realities in delivering health care and a previously complacent public is finding them out, however harshly. “Insurance” does not and will never cover every dime of every expense. It is in the process of evolving to catastrophic indemnification where the insured participates in risk.  UPMC is evolving there as well, and I feel it in my pocketbook. But I don’t get a bill for US$100,000 for a surgical operation.

Flo will have to get over it and set the magazine in her price gun to reflect the realities, not the dreams. It will be a painful prescription for the public, but they’ll get over it, just like they got over mandatory insurance for motor vehicles and mortgages.

Latest revelations on the Affordable Care Act of 2008

0

Dr. Crippen, I am reading your blog post about the ACA right now, I have one month to decide, as I am now 26, to purchase private insurance though (current employers insurance).  The deductibles are insanely high, as well as the premiums…or wait for the January ACA kick in?

———————————–

What we have now is a situation where the cost of health care is escalating out of control with no end in sight, fueled by providers (yes doctors) that can create demand for their services and then supply it. As this process progresses, the affordability of health care insurance decreases commensurately. So insurers must cut more services to remain viable and employers must pass on the cost to you. Many employers will eventually stop providing health care services for employees. There is simply no way *private* insurance can be maintained. It will crash. Not a matter of if, but of when.

The issue of “junk” health care plans that were promised would remain viable after the onset of the ACA don’t directly apply to you. The law says that “junk” policies that allow you to pay a very small premium and fail to cover needed and necessary medical conditions is just what it is. You’re either insured or you’re not.

The law says policies must cover all potential illnesses but there can be varying amounts of co-pays and deductibles to keep the price down. In he ACA, if your illness lands in an area that is not covered at all in a junk policy, that area is at least covered to some degree, even as a catastrophic. This is a better deal than a junk policy.

So here’s my current opinion:

1. You do NOT want to go bare for any length of time. Yes, you’re young and healthy and you don’t think much about getting sick or injured, but an unexpected hospitalization, especially if it involves surgery or ICU care is so mind-alteringly expensive you have no conception of it. You would never be able to pay it off in three lifetimes, and you can be sure the hospital would be there to dun you for it for the entirety of those lifetimes.

2.  Expect to pay out of pocket for most of your health issues now and in the future. It’s just the reality. The issue of being *completely* indemnified for health care is vanishing. No insurance will be willing to pay for *all* of it, or even most of it. You will pay more every year and get less.

Ultimately, insurance will only cover what amounts to “catastrophic coverage”.  You will pay out of pocket for everything except disasters for which you are hospitalized.  Those out of pocket expenses will then seek out incredibly expensive deductions and co-pays.

3.  Given that the above is true, then it becomes a matter of *shopping around* to get the best deal possible for what you have to put into it. I assume your options are either your current (medical center based plan) or the ACA.

a) Your current medical center based insurance plan is extremely large. The good thing about insuring with a large employer is that they are “too big to fail”. They will always be offering health insurance no matter what the economy does. So it’s unlikely they’ll arbitrarily drop you when they run out of money, but they can and will make you pay more every year. You’ll break before they will.

b) As much of a political football the ACA is, it’s still here and its still recruiting patients.  Attempts to kill it at every social and political level have failed, including a presidential candidate that promised to kill it if elected and an attempt to shut down the government. Now the question comes up, will Republicans and other Philistines be able to kill it (after you’ve paid) in the future?  I say probably not. Enough people have signed up to make it impossible to negate their service, and more are signing up every day.

So, what the ACA seems to do is let you shop for a policy you can afford, and that’s a good thing for you, exactly what you need to do. Before, shopping around was time and labor intensive. Now because of the Internet, you have a unique opportunity to meticulously shop around and see what’s out there.

My humble personal opinion is also that the ACA is here to stay and will start to thrive once the word spreads and the website is 100% up to the task. I do not believe it is possible to kill it now.

The reality is simply that you will draw a metaphorical line graph. One line will describe the minimum and maximum you have to spend on a health care insurance policy and the other line will describe the cost and availability of such indemnification. Where those lines cross is the point where you will purchase a policy. It’s about as simple as that.

Bottom line:

* Don’t even dream of going bare.

* Expect to pay more for less

* Budget some mad money for unexpected out of pocket costs

* Get the most policy you can afford and hope for the best