A few notes on State of Pennsylvania health care politics


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


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


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


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

Some personal observations on the events of Nov 22, 1963


It was the year 1959 AD. My dad was the only general surgeon in a town of about 10,000 souls located in northwestern Wisconsin studiously picked for his hunting and fishing passions.

He was a very conservative Republican as most if not all doctors were at that era. The “up by your bootstraps” age selected for them. The best government was no government, and in the escalating post war, post-Eisenhower age of prosperity, that seemed attractive.

Credit cards were virtually unknown. Gas was 29.9 cents a gallon, a mortgage on a nice house was a hundred bucks a month, a nice car cost US$2000 and virtually all health care was affordable out of pocket. There was no Medicare or Medicaid.

But the Eisenhower era was closing and a new era of cold war paranoia was emerging with the Presidential election of 1960. The world was becoming a dangerous. I was a sophomore in high school and my only interest was girls and cars, pretty much in that order. My interest in politics was yet to emerge so I was pretty much a disinterested observer.

The two candidates that emerged for 1960 were polar opposites, Richard M. Nixon, a crusading anti-communist from California and Kennedy, a relatively new senator from Massachusetts.

In the first ever TV debates in living black and white, he looked sneaky, dark and foreboding as opposed to the other guy, Kennedy, who brightened up the screen with an articulate vernacular. Even to my naïve eye, Nixon looked positively sinister.

Seemed like a pretty easy choice to me, but there was a problem. Kennedy happened to be a Catholic, a big problem in 1959 American culture. Catholics were very much discriminated against in mainstream America, thought by many to be as much a cult as “Christian Scientists” or “Scientology”.

Catholic. That’s all my bible thumping conservative Baptist mother needed to hear. So I could hear from my bedroom the fervent pleas that Richard Nixon would save us from being ruled by the Pope. But it wasn’t to be. Kennedy was elected by the thinnest of margins and my dad had to pull my mothers head out of the oven.

But in the end, Kennedy went on to become possibly the more revered President in American history, maybe rivaled by Bill Clinton. Interesting that they shared the same vices, but with different media access saturation.

But no matter. Kennedy was perhaps the most intelligent, articulate, funny President our country ever had. If he had shortcomings, all downplayed them. He and his family formed a veritable dynasty that was almost immediately equated with the Camelot legends of King Arthur. It is impossible to overestimate the love this man accumulated by the American public, (never my mother).

It was an idyllic scene unsullied by the eventual cultural revolution of the late 60s and the war in Vietnam. A relatively brief period of quietude and prosperity that was destined to collapse under it’s own weight, but it was extraordinary while it lasted. My only worries were girls and cars.

Cut to November, 1963. I had flunked out of the University of Wisconsin the first time (long story) and had eased into a job as an “orderly” at the local hospital where my dad practiced general surgery as I plotted my next move. The then Director of Nursing was the venerable and formidable Miss Myrtle Worth who watched me closely. After she died the hospital was re-named after “Myrtle Worth Memorial Hospital”. But that’s another story.

Sometime in the early afternoon of 22 November I was perambulating down the hall of one of the hospital floors on my way to some chore, probably carrying a bedpan, when one of the TV sets in the rooms I was passing by suddenly proclaimed a “We interrupt this program”.

This was a little unusual as these kinds of interruptions rarely justified breaking into regular programming. So I stopped and backed up in time to see Chet Huntley (NBC News) solemnly announce that President Kennedy had been shot in Dallas and no details were available.

Everything in the entire hospital instantly stopped cold. Every nurse, every administrator, every doctor all stopped what they were doing and congregated around the nearest available TV. Shortly thereafter came the famous spectacle of American’s most trusted TV commentator, Walter Cronkite, sadly proclaim with tears in his eyes that the President was dead.

There are no words even in my formidable vocabulary to express to you the emotional and cultural disaster that followed. This was absolutely unprecedented on every level. Camelot by its nature was impenetrable. No one ever thought in their wildest dreams that Camelot was vulnerable. To have it come crashing down was a cultural train wreck of immeasurable consequences. Like an out of control LSD trip, there was n way to process it.

What was to follow was unbroken ground, chronicled minute to minute by the unblinking eye of network TV in living black and white. Everything in the country stopped dead in its tracks, and I mean EVERYTHING. Every radio station carried only continuous funeral dirge music. There was no traffic anywhere. All businesses were closed including gas stations.

Everyone in the country sat ensconced before a TV set watching the funereal progression, the caisson, the riderless horse with boots reversed in the stirrups, the lying-in-state under the Rotunda, the unimaginable grief and horror of his wife preserved on.

It was like a nuclear winter until after the funeral when things slowly came back to at least baseline, but never actually back to normal. Even my mother was in tears. We then went on to the further culture shock of Bobby Kennedy and Martin Luther King, further illustrating the danger society never dreamed of on November 21, 1963.



The ACA of 2008 as whipping boy


On 2 Nov 2013, at 8:29, Lisa XXXXX wrote:

> We actually have a really good policy with United HeatlhCare, which is
> getting cancelled – we have had the insurance for almost 15 years now. Also,
> the insurance at my work will (because of Obamacare – it says so on the
> paperwork they sent) no longer cover my spouse if he can get coverage through
> his own employer (which he can). Also, because of Obamacare, the premiums
> are going up under my company’s insurance (yes, it says that on the
> paperwork, too).

Insurance companies that are strapped because of ever increasing medical care prices (with no end in sight) are more than happy to blame their impending bankruptcy on anything other than they can’t make the same profit the had been making. If Obamacare had not come along, it would have been something else.

The fact is they have been increasing their cost to employers every year, and various thresholds are eventually met where employers can’t afford it anymore and still make their own profit margins. Obama is the best diversion that ever happened to them. It gives them an excuse.

In fact, what I *think* I see is that Obamacare really is just a signpost along the way to full single payer government health care in the USA for several convincing reasons:

1. The price of health care shows no signs of any *real* decrease in price over time. It continues to climb yearly and the occasional smidge dip lower than usual means nothing. It’s like celebrating because the price of gasoline went down five cents from four dollars a gallon to three ninety five. The long term is that it’s going up and will continue to do so as long as we run a “customer satisfaction maxim”.

2. The private sector of health care insurance will eventually find that it can no longer make a profit. Most will tank for the simple reason that they cannot risk-manage. If they MUST accept every applicant and they can’t charge the sicker ones more or dump them like auto insurers do, think about how long that situation can last.

3. When the day comes that the private health insurance sector gives up the ghost, and that day will come, there is only ONE sector that can accommodate taking care of the entire citizenry, warts and all, without going broke from feeding the endless desires of the endlessly sick. The government because it can simply tax it away, or hide it with the already big national debt.

4. Everyone now is fixated with the seeming evils of the ACA of 2008, which stripped to it’s essence is not really a bad plan. Especially not if you compare it to what’s coming. If the forces of *real* evil, the same guys that literally want to take the food out of the mouthes of the disadvantaged are successful in killing the ACA, then in one step we go right back to the private sector that refuses to insure or underinsure at least 30% possibly 40% of the American public.

5. A third of the American public at risk for financial collapse if one of the family unit gets unexpectedly sick is a VERY VERY big problem for the country. Every nickel it WILL take to keep them literally alive will come out of the tax base. So pay me now or pay me later as the band plays on.

6. Those standing in front of CNN camera holding big “No Government Medicine” signs are clueless. Guess what? Fully 50% of the American population, possibly more are already covered by some form of government medicine, including I might add, the same Republican senators and congressmen that want to destroy it.

7. A big majority of the rest of the world manages to indemnify their ENTIRE population with (their) government sponsored health care and last time I looked, they’re still managing. these governments have in the past learned the lesson we’re about to learn, that open-ended demand for health care services cannot be sustained. It must be rationed in some form, hopefully intelligently designed.

So, Lisa, I very strongly suspect the change, when it comes, and it will, possibly in my lifetime, will be that you’ll be complaining you have to wait a month for a non-emergent MRI and also a month for non-emergent surgery. But what you won’t complain about is if you get unexpectedly sick because your former employee insurance has dumped you, you’re liable for financial ruin forever.

Forward to the past: Come walk with me


I send this remembrance out every year at this time. This and Timothy Leary and “Alice’s Restaurant”, the theme song of a generation that my Fellows know nothing about threaten to be forgotten, like Vietnam.

Let me bring back the vibrant remembrance because it’s important.

August 28, 1963 is the date of one of the most important and profound communications ever uttered by a human.

I have been a student of the 60s for most of my life, having lived and participated in much of 60s culture. I’ll spare you the details this time of my own experiences standing twenty feet from Dr. King during a speech in Atlanta in 1965, but if you have an interest, you can check out my first book on the subject:


The eBook version is free.

I lived in Georgia for a huge chunk of the civil rights years and I experienced and participated in much of it. Someday I’ll write the full book on it, but for the moment, just walk along with me.  I’ll paint you the color commentary as we maneuver through the throngs toward he stage. I’ll interpret what’s going on from the vantage of a participant.

This day, August 28, 1963, produced the “I have a dream” speech by Dr. Martin Luther King, a communication rivaled only by Lincoln’s Gettysburg Address at Gettysburg, PA, November, 19,1863, 100 years earlier. There are similarities and differences between the two speeches.

Like King, Lincoln explored the principles of human equality, but proclaimed the Civil War as a struggle for the preservation of the Union necessary to frame principles thereof.  But unlike the King speech, Lincoln’s mood is described by Ken Burns as a quiet, almost whispering matter-of-fact tone directed at no one in particular within the relatively small group present.  At the time, it was virtually ignored. There is only one photograph from the Matthew Brady collection of Lincoln delivering the speech and it was from a distance.

The enormity of Lincoln’s speech is contained in the words, not the enunciation. Conversely, Dr. King’s speech occurred at the largest and most important civil rights demonstration in history and it was loud, covered by all three major TV networks. At the time of the demonstration, two thirds of the nations persons of color were not allowed to vote, attend integrated schools or use public facilities. 250,000 participants jamming the National Mall demanding civil rights legislation that was only to come two years later.

King took the stage just before noon with a prepared speech and began reading from it word for word. The text decried the fact that “fivescore years ago” Lincoln’s Emancipation Proclamation on July 1, 1863 freed the slaves in the ten states that were still members of the Confederate States of America, applying to a relatively small number, around 4 million slaves at the time.

But King goes on to lament: “100 years later the negro is still not free!”  “Lincoln’s promises were a bad check and “we’re here to cash it!” Then about halfway through the text something important changes. King looks up at the crowd sensing an opportunity to pontificate extemporaneously, as he did frequently in other speeches. The text did not match the emotion required at the moment and King simply went with the flow as he felt it, acting more like a Baptist preacher on a roll than an interpreter of a prepared text.

King was the undisputed master of grabbing audiences and holding them spellbound. On this day, he found his theme and worked it mercilessly, alternately chastising the crowd then raring back smugly, basking in himself. His words did not exist in any text. They were created in his soul for the occasion and they flowed freely, some of the most important words ever uttered by a human, relegating King to every history book.

 “I have a dream that one day on the red hills of Georgia the sons of former slaves and the sons of former slave owners will be able to sit down together at the table of brotherhood”

“I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character”.

“I have a dream that one day every valley shall be exalted, every hill and mountain shall be made low, the rough places will be made plain, and the crooked places will be made straight, and the glory of the Lord shall be revealed, and all flesh shall see it together”.

At this point, King is totally consumed by unrelenting passion and running completely on maniac fervor.  A shoddy analogy might be watching Neil Young play “The needle and the damage done” on The Johnny Cash variety show in 1971. Young doesn’t know where he is or who’s in the room. He doesn’t know where the chords come from. He’s completely consumed with the story he wants to tell and everything accompanying it flows like a wild river.

“I hit the city and

I lost my band.

I watched the needle

Take another man….

Gone, gone, the damage done……”

But I digress.

Dr. King continues:

 “From every mountainside, let freedom ring. And when this happens, when we allow freedom to ring, when we let it ring from every village and every hamlet, from every state and every city, we will be able to speed up that day when all of God’s children, black men and white men, Jews and Gentiles, Protestants and Catholics, will be able to join hands and sing in the words of the old Negro spiritual………”

At this point King is close to emotional collapse. Those around him stare with slack jaws.

(Rising tonal cadence)  “Free at last! Free at last! Thank God Almighty, we’re free at last!”

King collapses into a chair, staring blankly at Ralph Abernathy. For a moment, the audience was shocked silent. John Kennedy allegedly turned to an aide and muttered: “Damn, this guy’s good”.

The “I have a dream” speech was he high point of his career, changing his public persona dramatically from a commonly perceived rabble-rousing jailbird to a fisher of men.  King biographer David J. Garrow wrote that King had created a masterpiece on the fly like some kind of jazz musician.

King was assassinated on April 4, 1968.  I was finishing Jungle School in preparation for Vietnam on that day and I witnessed the pain and frustration.

Here is a youtube rendition of the speech. It MUST be watched and absorbed by anyone claiming to be an educated person. Take the time to watch the entire eleven minutes of this one of the most important speeches ever made by a human. Watch for the transition to extemporaneous passion.

Some thoughts on Jane Fonda and Treason



“Jane Fonda is guilty of treason and should be prosecuted to the full extent of the law:

“Forgiveness is divine, but to forget is foolish. As often stated,
” to forget the past is to repeat the same mistakes”.

“Forgetting the past is not an option for any of us
that want to maintain our liberty”.

Well, time to round out the above platitudes with a bit of an alternative view. DISCLAIMER: I am a card carrying liberal Democrat who supported Obama in 2008 and 2012, for little other reason than to avoid what the opposition offered. That said, I’m an OK guy and even my conservative Republican friends like me although they roll their eyes like Stevie Wonder when we talk politics :-). So slash away. I can take it and frequently do in “Med-Events” a forum for politics where blood runs freely.

It bears remembering that opposition to the Vietnam Conflict was extremely pervasive throughout the country in 1967 and not a function of one highly public figure who got her photo taken sitting in an NVA tank. These heterogeneous forces had reached the point where it was literally tearing the fabric of our society apart I was present at the Vietnam Vets Against The War demonstration in Washington DC in April 1971, headed incidentally by a young version of John Kerry. One of the most heart breaking scenes I ever witnessed was the lineup of vets, some in wheelchairs in turn tossing their Purple hearts, Bronze and Silver Stars over the White House wall. I wept openly and Nixon ignored them.

Jane Fonda gets singled out for the fact that she was extremely visible, but there is little evidence that she mattered other than being a good propaganda shill for Uncle Ho. Fonda has said her trip to Hanoi was primarily motivated by her desire to document the American random bombing of Hanoi that resulted in thousands of innocent civilians being killed and bombing of important dikes that, if destroyed, could devastate the lives of millions more. Fonda is unapologetic about the trip or her participation in broadcasts on radio Hanoi but regrets the pictures taken of her at the gun emplacement. She said it made it appear as though she was celebrating armaments aimed at American planes, which was not how she felt and was not the context in which the pictures were taken. She reminds readers that the U.S. investigated her trip and found no reason to bring any charges against her. Any evidence that captives at the Hanoi Hilton suffered more specifically because of Jane is not pervasive. Their captors had plenty of reasons to hassle them. If it wasn’t Jane, it would be something else.

All this is fraught with a LOT of passionate emotional overlay but the realities are extremely complex and much more difficult to fit into emotional diatribes. As it pertains to Obama, to those just to right of Genghis Kahn, it really doesn’t matter in the slightest what Obama does, it will always be wrong. In fact, there is not and never has been any convincing evidence that Obama is a Muslim or has any sympathy thereof. The supposition that Obama was born in Kenya has been refuted so many times that its laughable now except to serious loonies like The Donald.

Obama is simply a left wing liberal Chicago politician who’s trying to do the best he knows how to do while dodging bullets from all quarters. If Obama came out in support of poop scooping, his predictable opposition will argue that he’s abridging the rights of dogs to poop wherever they like undisturbed and the Constitution guarantees it. So I remain unimpressed with many of the emotional arguments against the President. The voters had alternative options in 2008 and 1012 and they didn’t accept any of them so such arguments are moot.

The problem with Vietnam is that as some of you mentioned, we didn’t learn from previous mistakes in South East Asia. Trying to fight a conflict that could never be won if for no other reason than holding up a spectacularly corrupt local government. The French found this out bitterly at Dien Bin Phu in over 170 days of fighting in 1954 in which the Viet Minh took 11,721 prisoners, of whom 4,436 were wounded.

That should have been pretty convincing evidence for the Americans to avoid this area of the world. I stood at the site in 2010 and felt the vibrations of all the suffering that occurred there. Strategically, it was apparent to even me that the French never had a chance. The Viet Minh held the high ground and that was the end of it. Read “Hell in a very small place” by Bernie Fall for a word picture of what happened there.

But at the time, the prevailing political thought was that if left alone, Communism would flow horizontally instead of vertically, so it was necessary for the forces of good to stop that progression. A disastrous mistake that left over 50,000 young Americans dead for an objective that never could have been realized ever.

And speaking of objectives that could never be realized, this argument bleeds directly into our attack on Iraq in 2003, based on non-existent evidence that a tin horn dictator in this obscure area might be a threat for the rest of the world. The rationale of the attack on Iraq remains a mystery to all but Cheney and Rumsfeld, neither of whom mention it much anymore. Presumably a manifest of the paranoia following 911. But it must also be remembered that all the conspirators of 911 were Saudis, but bombing Riyadh would not have been in the best interest of our oil consumption.

So the sum total of the invasions of Iraq amounted to nothing other than an extension of phantom menaces into Afghanistan. And speaking of not learning from history, if may have been useful for the American Federales to look how the Russians got their asses kicked in Afghanistan and unceremoniously tossed out of the country, a maneuver that directly resulted in Communism as a ruling principle collapsing in Russia.

So US troop deaths in these areas are doubly depressing. They’re depressing because they’re young, vital people that should go on to have lives, careers, children and happiness. The second tragedy is that their lives are negated in conflicts that cannot be won in any event and from which we will eventually be kicked out, resulting in a sum total of nothing. We learned nothing from Vietnam and your young people are picking up the tab.

As it pertains to Obama, I supported him not so much because he’s the cat’s ass but because some the truly frightening players of the opposition, including Palin, Bachmann and Santorum, likened to the barflies at the Star Wards Cantina. The ultimate selection of Romney, a rich guy that thought it might be cool to get ferried around in jets and helicopters, and who changed virtually ever stand on anything he held before 2012 to make the Christian Right wackos happy. They had the money. The voters got it very effectively and Romney was out before 11 pm on Nov 6, 2012.

So this has been an otherwise uneventful Friday afternoon and I have time and energy to pontificate on these issues. Enjoy for whatever interest you my have.

David Crippen, MD
Departments of Critical Care and Neurological surgery
University of Pittsburgh Medical Center

Some notes about “Obamacare”



The ACA will destroy American Healthcare as we know it. Yes, the horse is out of the barn.  The system in US is now designed to fail. Comical Crippen will worry about propofol or some other intervention turf war. It is all over.  The government is here and they are here to help :-(.


medicareThis is political in nature and ordinarily, I would scotch it immediately, but: a) there is some LIMITED medical value in clarifying some of it and, b) I can’t let you get away with it as a stand alone without an alternative view. This subject is GUARANTEED to start a prolonged argument, so I will use my prerogative as the Boss to rejoin it with a few alternative comments, then bring it to a screeching halt when the arguments start, and they will.  If you like to argue about politics, join med-events where blood runs freely.

In 1965, the medical establishment, including the AMA and my father the surgeon loudly exclaimed that Medicare and Medicaid would “destroy American health care as we know it”. In fact, those services made my father’s generation of physicians rich and created the Medical-Industrial Complex which has now grown to the point where it threatens to “destroy American health care as we know it” by it’s sheer volume and weight. The Affordable Health Care Act of 2008, is not needed to hasten that eventuality.

The bill for a typical 6-day hospital stay for childbirth in 1951 was $85—well within the out of pocket range of most families. A 6-day hospitalization for cardiac workup at a large urban hospital in 2010 has recently been calculated to be $19,254; the facility lost $2,695 of that amount after reimbursement. This cost situation arose in part because physicians in such a system have little motivation to reduce costs, given that the care is paid for by a third party relatively unable to process the value of need versus desire. Similarly, consumers of health care are not the purchasers thereof and so have little motivation to assess cost versus value. More is always better, especially when it is free.

Virtually every other civilized country in the global village has evolved to lowest common denominator of health care for ALL of their citizens, and that is single payer, government sponsored health care indemnification. the price paid for that is enforced prioritization of entry and “saying no” to expensive treatment that has a dismal benefit at great cost. It isn’t perfect, but in the end, everyone is covered and it’s more or less affordable. America runs on a consumer satisfaction mode, a situate that everyone agrees is unsustainable even if it were not for the global recession of 2008.

In 2009, the USA spent (all told) twenty five trillion dollars on health care but only indemnified about 40% of it’s population (some are underinsured). that’s US$8,000 per person, 17.3% of the GDP and increasing about 6% annually. The USA ranks below Portugal in preventable mortality. California increased it’s cost of health insurance 20% this year and there is no end in sight. As the price of health care goes up, fewer businesses can afford health care for their employees. 62% of all personal bankruptcies involve medical bills in 2010.

So, the AHCA of 2008 is not anywhere on this screen. We’re on our way to insolvency all by ourselves right now, and we’re still only covering a small portion of our population doing it, expensively and inefficiently. The AHCA of 2008 purports rectify three glaring omissions we don’t have now. It effectively ends insurance payment discrimination, adds an estimated 31 million needy potential patients to an already overloaded system and it’s portable. These are all GOOD things, and I might add GOOD things that most if not all of the other civilized countries in the global village provide for their citizens.

The argument against the AHCA of 2008 is twofold: a) Straight up political partisanship. ANYTHING that comes out of this sitting President is spawn of the devil, and: b) It will be expensive. However, complaining that the AHCA is going to break the bank implies that the bank would remain solvent without it. Nothing could be further than the truth. The bank is hemorrhaging right out into the street and is reliably headed for insolvency all on it’s own. The worst that can be said about the AHCA is it will hasten the process.

Maybe. So if you ignore the political aspects, which you definitely should, what remains is how to finance it. Of course the best way is to mandate everyone buy into it to keep the cost of participating down. If anyone is allowed to opt out, our culture mandates we still have to treat them anyway. So if opt-out is allowed, it will collapse instantly. We’ll see how that works out. Otherwise, there is an other reality that must be faced. there is NO possibility of a system that creates demand and then supplies it in a customer satisfaction mode can remain solvent. So, if the whole system is swirling around the bowl, which it is, there are several options available, two of which are painful prescriptions for providers.

1. Allocate resources toward health care and away from other previous priorities such as entitlement programs, military security, and bureaucratic priorities.

2. Pay providers less for the same (or increased) workload.

3. Reorganize health care spending so that more money is spent on some services and less or nothing is spent on others; essentially, say no more often. History suggests that it is unlikely any modern society can or will decrease support of entitlements such as social welfare, unemployment insurance, social security benefits, or retirement benefits that citizens depend on and have paid into during their working careers. Cutting military security funding is equally unlikely. Most if not all national budgets include little else that can be reallocated in any meaningful amount. That leaves options 2 and 3. It is virtually certain that providers will have to reorganize their priorities one way or the other, and accept less remuneration in the process.

So denigrating the AHCA because it will break the bank is (I think) a “straw man” argument. We’re pointing our finger at something that hasn’t even happened yet as we descend into the depths. We can continue on the path we’re on into insolvency while indemnifying only a portion of our patients at huge expense and great inefficiency, or we can continue toward insolvency indemnifying 96% of our patients more efficiently avoiding personal bankruptcies, asking our providers to work harder for less pay. Then we can just pay for it (in taxes) and get over it.

If we decide not to just pay for it and get over it, we’re going to crash, and when we do, we’ll discover the reason why most of the other civilized countries of the global village have evolved to single payer system, prioritization, saying no and standing in line. BTW, the government is here and it’s helping as MOST health care in this country is government funded. All care for Washington politicians, military, VA system, Medicare, Medicaid.

Sorry about typos and misspellings. I type once and I never proofread.

Letter to a conservative Republican friend, Nov 13, 2012


Nov 6 should be a serious wake up call for your Grand Old (soon to be extinct) Party. If you look at the demographics, you see that the Democratic candidate won in the urban areas of the country, and Romney carried most of the rural areas. I think that’s significant. I think most if not all of the rural areas in the country are where you’re more likely to find the radical fringe, especially the Christian Right. But they don’t have the population to win a National election.  The South will always go Republican even if Charley Manson was the candidate because of LBJ’s civil rights laws in 1965, but the South has never been able to carry a big election either. You put it all together and you get Florida, New England and California. If the solid Midwest chimes in, that’s it, and that’s exactly what happened on Nov 6. None of the rest mattered.

Romney was genuinely surprised that he didn’t win by a landslide.  The sanguine predictions of GOP pundits regarding the probable outcome of the 2012 election were not based on anything but their humble personal opinions. They, including Romney, wanted to believe it so strongly they simply talked themselves into it as if it were gospel.  A variation of Hitler’s “Big Lie”. The Nov 6 results also show that whiny, demeaning and mostly untrue attack ads that Romney became famous for in Pennsylvania, sponsored by big money interest groups did exactly the opposite of their intent. They were simply an irritant and were ignored by voters, the ones that weren’t actively turned off by them. So interestingly, big money doesn’t seem to work. Eight billion dollars serving only to make TV stations rich.

The reality is that Florida, New England, the Midwest and California  will never support most or any of the right wing social programs even if they did like the concept of fiscal responsibility.   If the GOP puts the specter of Bush and the continuing joke of Palin together with the last slate of the 2012 GOP candidates up again in 2016,  they will behind the same eight ball, especially if Obama manages to improve the economy significantly in the next four years.

The GOP has some good ideas regarding fiscal responsibility and but their social programs will never fly in the new demographics of voters. Home lovin’, corn fed, pussy chasin’  white boys like you and I are no longer the majority in American society. Hispanics, women, blacks now turn elections. Most if not all of the self acknowledged “only real conservative”, Rick Santorum’s platform would get him shot dead within a month if he were elected. The GOP has to figure out what works now, and what doesn’t work, which means that the likes of Bachmann, Palin and Santorum need to be shown the door. The rest of the 2012 candidates are just plain silly and need to be shunned like the Amish do it.

The GOP needs to be re-thought and re-designed from the ground up. If they’re unwilling to do this, they will become a footnote in history.