Thursday, March 23, 2017

"Lawyer for Russian Whistleblower’s Family Falls Out of Window" - WSJ headline today

https://www.wsj.com/articles/lawyer-for-russian-whistleblowers-family-falls-out-of-window-1490203587?mod=djemCapitalJournalDaybreak

It seems impossible to understand Russia without referring back to The Godfather, doesn't it?  It is government by The Mob, over and out.  Don't need to think more deeply than that.

Push into Crimea, into Ukraine?  "Because we can.  It used to belong to us, anyway." 

Cyber crime?  "Why not?  It's better than drugs, isn't it, I mean, we're not taking health away from these people.  They should be grateful we're not doing that.  We could, if we wanted."

Interfering with elections in US?  "She hit us first.  Did you see what she was doing in 2011, inciting people to go into our streets?  OUR streets!  And did you hear that broad from the State Department, Victoria Nuland, manipulating the Ukrainian coup?  This is disrespect.  This cannot be ignored."

And then listen to their representative in the US, Paul Manafort, Mr. Ten Million to further their interests.  If he doesn't sound like a hood, no one does.  "Hey!  Hey!  I'm standin' here!"

Murder? 

"Michael Corleone: My father is no different than any powerful man, any man with power, like a president or senator.
Kay Adams: Do you know how naive you sound, Michael? Presidents and senators don’t have men killed!
Michael Corleone: Oh. Who’s being naive, Kay?"

Interference with elections?  "Mossadegh, Arbenz.  Who are they to talk?"

Their English speaking representatives lie, lie, lie like they believe what they are saying.  Criminal lawyers don't make any money unless they represent the very guilty, and these guys do a very good job.

One definition of sovereignty is when the state has a monopoly on violence.  The nature of the regime simply rests on how the monopoly is expressed.  The Russian example shows how the Mob acts when it has the monopoly.  The Western examples show how our traditional leaders act, bound by agreements made centuries ago, or even millennia.  Culture and history is a powerful thing.  The Russian history is much different.  I've always thought, the Russians have much to contribute in the arts and in science.  In government, not much at all.

Generally, we get angry when people don't act "the way they should."  Anger represents a reaction to violation of norms.  We can get angry at Putin, but not as angry as we get at Trump and his minions; Putin doesn't act according to international norms, but he's Russian and his own tradition is different.  Hate him, yes; angry at him, that's a little different.  With Trump, we can be both to equal degree, because he is violating both international and national norms.  And both, of course, are violating Judeo-Christian norms.

Putin can say that international norms are rigged against Russia.  The Mob suggested that they were discriminated against, and given a chance, they would welcome entry of their sons to the ranks of the passanovante, but in the meantime, they would do what they had to do.  How different are they in how they feel excluded, discriminated against?  Hard to say.

They say that cops and robbers play the same game, their just on different sides.  Down the line, at the bottom of the org chart of the CIA, ties to the Mafia are known to have existed.  Same game, different sides, but maybe some cooperation.  You keep order in your neighborhood, we don't bother you.  Can you lend us a hit man?  It's the violent nature of man.  The question is, how much is this contained to that level, and how much seeps up.  With Watergate, it seeped up pretty high.  That's the problem, too, with the Trump-Russian connection.  Seeping up pretty high.

It seems to me that Trump is a poseur.   He would like to be tough, he thinks he's tough, but at heart, he's a rich man's son who just hung out at the construction yard.  He never really made his bones, his brothers and sisters and friends weren't kidnapped and killed.  The only thing that makes him fearful to others now is his polling numbers.  If they drop, if he can't ride into town and primary a recalcitrant Republican politician, he's got nothing.  That's not such a bad thing, though, actually.  He acts like a hood, and he's playing politics like a hood, but I doubt he would get violent.  That's his shtick, that's all.  In the end, he could be seen as the pitiful specimen that he is, and damage can be undone.

That's the hope, anyway.

Budd Shenkin


Friday, March 17, 2017

Business And Government - A New Perspective


Oh, the failure of imagination! Government has been charged with many ills, and failure of imagination is just one of them. There is also failure to institute business methods, and the failure to adopt an entrepreneurial mentality. Add to that the penchant for governments to give sweetheart deals to employees and to cave to employee unions – I'm looking at you, Bay Area Rapid Transit; and at all you firefighters who, rely on you as we do, nonetheless take home up to $400,000 with overtime and then spike your final year to get sweetheart retirements – so why wouldn't the populace look askance at government unions?

So when Paul Krugman lists all the good of government and how cruel and stupid it would be to adopt anything near the Tea Party-Trump “budget,” just as those pundits overlooked the sources of dissatisfaction that led to the Trump election disaster, and just as years ago in California the pundits overlooked the likelihood of passage of Prop 13 that put a cap on property tax rates because of the “decrease in services” it would bring – just like that, even the estimable Krugman looks only at the positive of the ledger and neglects the negative. He cites the pernicious effect of Right Wing talk radio and other scourges for government's unpopularity. He would do better to visit the DMV, or talk to any state employee who is “just doing her job,” for a counterexample for good “customer service.” It's true that many big companies are the same – being “Verizoned” is a self-evident term, and talking to your health insurance company is always a treat – but nothing can really match good ol' gummint. You can switch providers and get ATT poor service instead of Verizon poor service and throw up your hands, I guess, but with government you don't even have the illusion of choice. “Off with their heads” is an understandable reaction.

Note that what Krugman cites for good government is generally simple transfer and funding programs, nothing involving actual direct services. https://www.nytimes.com/2017/03/17/opinion/conservative-fantasies-colliding-with-reality.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region&_r=0

It's understandable to think why Krugman neglects the negative. What is there to do? Few remember Al Gore's job as VP under Clinton – it was to “reinvent government.” Make it work better. I think he had some successes, actually, although they weren't very visible. But for sure the Pentagon has seen no notable successes; their expenditures are so poorly recorded that no audit is possible, believe it or not, and no upgrade is being contemplated. Throw up your hands, indeed.

We have to accept, I think, that we are a business-minded nation. For all its many weaknesses, business has triumphed in America. Even though I remember how dumbstruck I was after a year in Sweden driving back in from the first American airport I reached and seeing all the billboards, how obnoxious it was. Business, business, it's what we do.

So, if that's the way it is, government must adapt. If commercials raise money for TV shows, commercials need to raise money for government. Commercials are the unseen taxes; we need more of them.

Therefore, with that theme in mind, I have a modest proposal. If American government can't become efficient and customer friendly, which it obviously can't, it just needs to raise more money, and it needs to do it indirectly – Americans hate taxes (perhaps because we know we are funding those people who staff the DMV – “DMV,” be it noted, has become a metaphor for all direct government services.) So, my proposal – start with naming rights. No one really minds that “The Coliseum” has become “The O.Co Coliseum,” right? It's kind of fun trying to remember all the stadium names around the leagues. So, let's name cities and states! “Arkansas” – what's in a name? Some obscure historical references? Henceforth, let the name be: “Walmart Arkansas.” This naming opportunity should be worth enough to fund Medicaid in Arkansas – excuse me, Walmart Arkansas – every year.

Imagine the naming rights auctions! If you changed the name every year, it could be like draft day, or the biggest Sotheby's auction ever. The best day C-Span every had – or maybe, for the sake of expertise, we'd turn it over to ESPN. Billions, I'm talking billions here.

Now, let's talk congressional districts. Do you realize that all they have now is numbers??!! “Pennsylvania's twelfth congressional district”???? My God, what a missed opportunity! Isn't that next to the birthplace of Heinz? “Pennsylvania's Heinz Congressional District” sounds great – and that's only this year! Get a strong candidate and it grows – imagine the enhanced appeal of getting popular candidates, talk about attracting celebrities to the show – out of your TV show? Into a congressional district! Extra pay gets the Representative himself or herself named for your company. They used to call Scoop Jackson the Senator from Boeing – and it's true, he looked out for the company and all the jobs in Seattle, and probably his own campaign funds – but why not up the ante on that?

And cities. I have long wanted Oakland to be “Oakland-Clorox.” Why not?

They say that big business owns the government – certainly pharma does, and so does the NRA. But they are getting off cheap. All they pay for now is campaigns, and that's a great cost/benefit deal for the companies. Let them pay what it's really worth, and let them pay directly to the people.

OK, it would be a big change, and to some of us, it would seem a capitulation. So be it. We need change, and here it is. Just so long as San Francisco doesn't become “San Francisco 49ers.” That would really be a bridge too far.

Budd Shenkin

Monday, March 13, 2017

If Hyman Roth Could See Us Now


I usually put up long posts, or at least a page. I'm breaking the record for short here. Just one, uncomplicated thought. I'm hoping it's a clarifying one.

How to understand Putin? And Trump? Look to the movies; look to Godfather II.

Hyman Roth: … Just one small step, looking for a man who wants to be President of the United States, and having the cash to make it possible. Michael, we're bigger than U.S. Steel. … What I am saying is, we have now what we have always needed, real partnership with the government.

Tell me how this is not the way Putin and Trump are thinking? “Public interest” and “public service” – what do these terms mean, to them? You can imagine the cynical smirk, the sideways look, the knowing “are you serious?” rejoinder. It could be Coppola, it could be Tarantino, but it sure isn't Billy Wilder.

A government is something to get hold of, something to manipulate, something to shake down, something to pervert. There is only one law, the law of the jungle, the Hobbesian world. People are scum to be exploited and manipulated, to be lied to.

If you think of the men in Hyman Roth's world, if they ran Russia, and if they were trying to run the United States, what we have now is exactly what they would be doing. Putin is reportedly now the richest man in the world. Trump's scorecard has only dollar signs on it, and perhaps applause and pussies, who knows. That's where we are now. Dystopia.

All we can do is to hope it's temporary, and work for that. It's going to be hard.

Yesterday we had a small get together with our neighbors. Our street is one block long, and since we sit right on top of the Hayward Fault, it's prudent for us to be organized in case of an earthquake. We had our drill, walking up the street, divided into three sectors, checking to see that everyone was OK, as though there had been an earthquake, hanging out a white towel at each house to signal all is OK. Then we repaired to Norman and Ellie's house for a short talk running through the basics again, and then the hors d'oeuvres and soup. It was a nice day so we were on their long sloping lawn in front of the house, sitting on some wooden chairs in a couple of circles, or wandering. Sitting next to me there was a lady with two kids who was new to the block, and as the conversation turned to the Gorsuch nomination and what could be done, law professor David Levine being in attendance – my dear next door neighbor – who comments regularly on local TV stations on court proceedings, he opined that there wasn't really much the Democrats can do because the Republican's have the votes. I opined, “Resist.” Do everything possible, make a show of it, bring the message. This young lady opined that the Democrats should show the Republicans what true good governmental behavior is, and treat Gorsuch as they wish Garland had been treated.

My response was, that reminds me of my mother and what I called her Boy Scout approach. What that leads to, I said, was losing. Far from getting the respect of the country, what you show yourself to be is gutless (dare I say “a pussy?”), and you'll never win. I suppose this young lady never played sports. What do you do when the other team is stronger? You still play your hearts out.

We are a courteous and good hearted neighborhood, so the conversation then turned to reputable contractors, electricians, and plumbers. I let it lie, obviously. But why I bring this up is, with sentiment like this young lady's, it's going to be a rough time countering these friends of Hyman Roth. She's not even bringing a knife to a gun fight, she's bringing cupcakes.

Budd Shenkin

Saturday, March 11, 2017

The Political Way Forward



Okab drives a limo that acts like a taxi without a meter, seems to me. I met Okab at the Oakland airport when I needed a ride home and he accommodated. Back then I was on three different committees for the American Academy of Pediatrics and traveled to Chicago for meetings – now I've been termed out and won't be driving with him so much. But back then, I was looking for a regular carrier since my Yellow Cab company, run by Punjabi brothers, whom I enjoyed talking to, stood us up for an early morning ride for the second time. What is it about taxis that attracts the immigrants, easy entry, no need to obey a boss, entrepreneurism? I don't really know; I do know that if you want to meet an Ethiopian, try taking a taxi in DC. Anyway, when I met Okab, he became our new default ride to the airport.

Okab is in his 60's, I'd say, and is a long time immigrant from Syria – southern Syria, he says, in the mountains, where it is relatively safer. He still has a strong accent, and listens to the news stations while driving. I learned that he is divorced, or at least doesn't live with his wife, and that she is a general pain to him, although he still retains responsibility. I've heard the outrageous stories, although since my memory stores things under categories rather than details, I forget them. Although I do remember his telling me how back in Syria, what they do is visit each other in their houses, the women clear out while the men sit around and talk, which he kind of misses. His brother stayed behind in Syria and bought up some adjacent land and the war hasn't touched him, at least not much. I'm not sure where Okab's sympathies lie; he's a Druze. Maybe with the government. I guess I knew more in detail, but I've forgotten. I think he's pretty happy to be here, although like most Arab men in exile, he misses the old country. I have to apologize to you, Dear Reader, that I'm such an execrable reporter. Good thing I didn't go that route.

In my latest trip to the airport with Okab I asked him how he liked it now that his man Trump was in power. Not so good, said Okab. Okab wished that his first man, Bernie, were there instead. But there was no way he was going to vote for Hillary. What could I say? At first I thought she was a flawed candidate, now I realize it was more than that. Always calculating, in a way that you could virtually see it happening, unable to put her heart and soul and her feeling into making a case for herself. She was internally compromised and not a good enough actress to disguise the calculations. And worst of all, in this her chosen profession of electoral politics, she was electorally incompetent. She committed serial electoral malpractice, and has now lost her license to practice. She ascended to her Peter Principle level of incompetence. Never again (I'm still furious at the governmental deformity her malpractice has left us with.)

So, my friend Okab is one of those incomprehensible Bernie-Trump voters. “Incomprehensible” if you think of policy, which only a small minority of voters do. Very comprehensible if you think in terms of image. Strong person speaking his or her mind forthrightly and with feeling that is communicated to others with the same feeling. We vote for whom we want to vote and make up the reasons afterwards.

My friend Bob is tired of my berating Hillary and has essentially told me to get over it and look to the future. But I'm an historian, and I insist on understanding based on the past. What was it that has to be corrected? George Lakoff tells us one story: conservatives look to replicate a hierarchical family where obedience to authority is paramount, whereas liberals look to a family for nurturance. That makes a lot of sense to me. Makes me think we need a strong and authoritative nurturer. (Lakoff appears to be quite self-admirative, but if you want to read what he said: https://georgelakoff.com/2016/11/22/a-minority-president-why-the-polls-failed-and-what-the-majority-can-do/) I think Okab would go for that. That might be a description of Bernie.

We are at the stage now, it appears, where reasonable explanations of the election are appearing. For one thing, the age old problem of the sliding scale and boundaries of support seems still to be pervasive. If you're poor you get help; but if you're just above the line, you get very little and become resentful of those who are getting the help, because they are like the favored child. In other words: white working class resentment. As Eduardo Porter observes:

'In “White Working Class: Overcoming Class Cluelessness in America,” due out in May from Harvard Business Review Press, Joan C. Williams argues that white workers’ resentment of the safety net should not be surprising: They get next to no benefit from it' (https://www.nytimes.com/2017/03/07/business/economy/trump-budget-entitlements-working-class.html)

The Democratic strategy of banking on a generational and demographic cumulative advantage also seems to be flawed, according to Thomas Edsall: “In political terms, class, education and culture outweigh every other determinant, including age. … In “Ideological Heterogeneity and the Rise of Donald Trump,” Carmines, Ensley and Wagner make the case that in addition to the classic division of the electorate into three categories — liberal, moderate and conservative — at least two more are needed, populist and libertarian, and perhaps a sixth, nationalist: 'Trump’s support among Republican primary voters, and probably in the broader electorate, only makes sense once we recognize that the political choices offered by a conservative Republican Party and a liberal Democratic Party do not reflect the full extent of the ideological heterogeneity found in the American public.'”
https://www.nytimes.com/2017/03/09/opinion/donald-trumps-political-stew.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region&_r=0


Putting Lakoff together with these more issues-oriented articles, it's pretty clear that new leadership is necessary in the party. We see daily on MSNBC younger pretenders to the throne, as the House leadership remains in the hands of those who long ago earned their Senior's discount. There are some good ones, good on policy, and unsullied by the canny calculations of the pros who lost. Bernie's too old, and he's too monotonic, although he's got the feeling. Policies need to be adjusted – how to confront a world of robotics, how to accept a mechanized world that the Utopian Socialists (Owen, Fourier, Saint-Simon) envisioned, but instead of concentrating the resultant wealth, how to “spread it around,” an unfortunate phrase of the 2008 Obama campaign as he mistakenly told the truth. How to combine the reassuring comfort of a welfare state with the dynamism of capitalism, and how to protect the environment in the process. There's lots for the technocratic elite to do; all they need is a couple of charismatic leaders.
The Republicans have some contenders, but they have a fatal flaw, in that they are Republicans. The old time conservatives could do it – Bismarck, for instance. From John Cassidy in the New Yorker:
...the relationship between the Republican Party and Trump is based on a quid pro quo, at least tacitly: in return for dismissing concerns about his authoritarianism, self-dealing, and Russophilia, the Party gets to enact some of the soak-the-poor policies it has long been promoting. ...
Going back to late-nineteenth-century Germany, many of the most successful authoritarian populists have expanded the social safety net. Otto von Bismarck, the first Chancellor, introduced health insurance, accident insurance, and old-age pensions. 'The actual complaint of the worker is the insecurity of his existence,' he said in 1884. 'He is unsure if he will always have work, he is unsure if he will always be healthy, and he can predict that he will reach old age and be unable to work.'
During the twentieth century, Argentina’s Juan PerĂ³n, Malaysia’s Tunku Abdul Rahman, and Singapore’s Lee Kuan Yew were among the authoritarian leaders who followed Bismarck’s example. Today, if you look at the election platform of Marine Le Pen, the leader of the French National Front, you see something similar. Like Trump, Le Pen is a nativist, a protectionist, and an Islamophobe. But she is not proposing to dismantle any of the many social benefits that the French state provides. Rather, she says she will expand child-support payments and reduce the retirement age to sixty.
Trump, on the other hand, has little to offer ordinary Americans except protectionist rhetoric and anti-immigrant measures.”
http://www.newyorker.com/news/john-cassidy/exposed-donald-trumps-sham-populism?mbid=nl_TNY%20Template%20-%20With%20Photo%20(145)&CNDID=39070744&spMailingID=10597873&spUserID=MTMzMTg0NTY4MTk2S0&spJobID=1120844968&spReportId=MTEyMDg0NDk2OAS2

So, there it is. The immediate problem, of course, is resistance, and a would-be leader needs to be strong in this movement without being shrill, practical and reassuring without being passive. But at the same time, keeping the passion in reserve for the positive platform to be enunciated later, with dignified aggressiveness.

I'll be checking with Okab to see who he likes.

Budd Shenkin

Saturday, February 18, 2017

Trump Adopts Terrorism


Many have lamented the tide of decline of liberal democracy throughout the world, me among them. Clearly, the tide has moved into the United States. For a few weeks after the election I was willing to give some breathing room to Trump, to see how much was talk and how much would be action. My wife warned me that this was not a wise stance. But I found myself hoping. Denial is a primitive psychological defense, and I have long employed it. I was using it with Trump. No longer. The cabinet appointments have been horrible. And now the shock and awe of anti-immigrant terrorism has been overwhelming. I'm more than there.

Trump has a large following. Not a majority, and I'm hopeful that I am not in denial in thinking that it won't be such ever, but they sure have taken over. It's scary. I'm hopeful again not to be in denial in observing that Nazi control of Germany arose from weak governmental institutions, as opposed to strong American governmental institutions, and in observing that ours is the economics of prosperity rather than Germany's economics of Depression – although if Trumpism is to continue, the result could well be depression, it's true. I'm hopeful when I look at the world of the caudillos and observing that their traditions were less secure than ours, and that the gulf between rich and poor was wider, although understanding that ours is growing. I am cautious, but I'm hopeful.

But as Peter O'Toole defiantly declared in Lawrence of Arabia, nothing is written. They look like they are making a good try at it, riding the international wave. Executive Orders, the product of decades of executive strengthening, are providing the surfboard to ride the wave. EO's provide a narrow platform; it would take legislation to provide a motor on the board, and at this point we have to bless the tradition of the filibuster, a bulwark against tyranny of the majority. Bless you.

So what do you do if you only have a board and not a motor? Trump and the Republicans in their tolerance/support of him – I was going to say “Right Wing Republicans” but that has become a redundancy – have shown every caudillo inclination, and envy of the capacities of Putin to do what he wants with no troublesome restraints of separation of powers. Torture, victimization of minorities, bullying, suppresion of the press? Not a problem! “Do to them what they do to you,” not “do what is right,” is the mantra.

So, what you do is adopt the tactics of the enemy where you can, and get around Congress as best you can. You pick on those who are most powerless, you go for shock and awe. So, you can't deport all the 11.5 million undocumented immigrants without a lot of money and legislation – and you don't call them “undocumented immigrants,” but “illegals” – but what you can do is to terrorize them. Nothing wrong with terror, is there, if you use the standard of what “they” do to “us?” And within every society are goons who would love to do just that. ICE probably has them, they just are not wearing brown shirts yet, not yet.

Make widely visible raids, arrest random sympathetic people, mothers, saints if you can find them, put them in police vans, have children crying on TV, show the distress. Worldwide opprobrium? Bring it on – it's publicity. Defy, find people to defy. Instill fear, empower bullying. It's even better and cheaper than actual mass deportations. Terror works, it insinuates itself into the society, not just those at current risk, but those who view themselves as the next group.

Which is why I agree with everyone who says, “Resist!” Institutions and traditions are important, but in the end it takes people, specific persons, to act within those institutions and to follow those traditions. Today, even as I write this, I am at a committee meeting of the AAP, where we broke the ice by going around the table and saying what political success we had recently had, each one personally. Most people said they had been to the women's marches. Others said their kids had been there. I thought of my family's resistance, and then I noted our personal efforts to help some undocumented immigrants to get legal. Apparently all it takes in their case is money. We're happy to help. I'm thinking we should just put a sign out on our front lawn: “Resist!”

State-sponsored terrorism is a fearful thing. We're seeing the start. It's time to remember those who helped the Jews in Europe and pay back. It's time to resist. I'm still thinking that this evil wave will be meet by a far bigger counter-wave that strengthens us even more by current knowledge of how strong our democracy is. It's hard, seeing all the hatefuls in office. I just hope I'm not in denial.

Budd Shenkin

Monday, February 6, 2017

Hospitals, Health Care, Buggies, and Automobiles


I've been thinking a lot about the shape of health care, and working on a paper that is so tortured in its development, I'm beginning to think that it's a paper that will never be finished. Which is a shame, because I think the ideas are good, and naturally, because I love to see my name in print. But in a way it's not a shame, because what the paper is doing is forcing me to learn, which is I guess what a paper should actually be about.

The essence of the paper is that the shape of health care is changing, and what I see is that hospitals are trying to centralize care around themselves by buying up medical practices, and buying up skilled nursing homes and other allied facilities. You could call all this vertical integration (VI). At the same time you see lots of horizontal integration, with medical practices merging, hospitals merging, insurance companies becoming fewer and larger, etc. So there it is, lots of agglomeration, all in the service of protection of them that is and them that has. Rationalizing the industry? Somewhat, yes. But also protecting and aggrandizing themselves.

But, is centralization the best model? I think not. I think that decentralization would be better. We need lots of coordination of care, true, but VI is probably not the best way to get there, although coordination does need leadership, and that's hard to find in a decentralized system. But especially with modern IT and communication technology – if the government mandated that Electronic Medical Records (EMR) all be inter-operational, which it has to do, has to do – decentralized systems could work just fine. The decentralized system could be called the Center of Excellence (COE) system, because with all the competition for patients, each unit would have to work to become excellent. By contrast, if a unit is in a system like Kaiser, where all referrals are mandated to be intra-organizational, a mediocre unit is cushioned from competition.

Here are a couple of paragraphs in praise of COE from my paper:

The COE model envisions not VI corporations, but rather individuals and groups networked together by information and communication technology, rather than by ownership and overt direction. In this model, for instance, incorporating the model of the Patient Centered Medical Home (PCMH), the patient and the primary care provider would be choosing referrals among competing centers with varying combinations of cost and quality, be they large or small specialist practices, general or specialty hospitals or procedure centers, etc., rather then being tied into a mandatory network.

The more direct financial and personal connection to the patient may provide increased incentives for patient-centered care. Information in small units can be informal and immediately visible. Staff in smaller units specialize in only one enterprise with the skill that repetition conveys, and can focus on detail with unmatched attention. Hiring can be made appropriate to the specific need without the need to explain the job to HR. Talented and creative professionals and staff can exercise their particular abilities (e.g., computerized innovation) without corporate restraint.

The “caring function” may be easier to convey in decentralized settings, as patients may be more easily known personally by staff and professionals. Small units may have great flexibility to serve individual patient needs, whereas large companies may have relatively general and inflexible guidelines. (On the other hand, classically underserved populations might welcome general policies applicable to all, as they will not be discriminatory.) Staff and professionals can likewise benefit from enhanced non-bureaucratic personal relations.

Modern information and communication technology has given added strength to the decentralization argument. What had been a weakness – coordination and information exchange – is now easily effected by small offices as well as large, so long as the EMRs are inter-operative. If run well, a small practice can be exquisitely efficient with modern technology.

Anyway, I've got a lot more written about the details, so many details that it is probably pretty unpublishable, at least for this non-academic writer. But this is all prologue. As I lay awake this morning thinking about it, I had a thought that I liked. Unlike all the details of my paper that contrast the pros and cons of the integrated system vs. the pros and cons of the COE, this thought is succinct. And so appropriate for a blog post. Which, with no further ado, here follows.

What happens when an obsolescent institution seeks to direct an emerging institution? By this I mean:
the hospital has been the center of medical care for a very long time. It looks as though it has become very expensive, too expensive for the system as a whole. It looks also as if the locus and means of care is changing. It is becoming outpatient, with specialty units such as the outpatient surgicenter, and more and more elements of care can be lodged in outpatient settings. In addition, it seems that more and more “medical care” should really be “health care,” with attention to prevention, social determinants of disease, etc. And as we live longer and acquire more chronic diseases and we just get run down, residential facilities become merged with health care units.

So the system is changing, and the money still resides with hospitals, and they will use that money to perpetuate their predominance. But they are aware of the changes, and so they change their definition of their mission accordingly. They become not purveyors of inpatient medical care, but purveyors of health care in general. This is what organizations do. (Parenthetically, one of the reasons they do this is that the people in those organizations are loathe to give up on the organization, since the organization works, and the organization also confers onto those individuals a means of livelihood, and perks, neither of which is to be abandoned.)

So what are the consequences of this means of succession from one type of organization to another – where the obsolescent institution seeks to direct the birth of the emerging industry? One consequence is that the change is delayed by old habits that are not suitable for the new challenge. Another is that the change is wasteful, since old functions persist and are paid for. A third consequence is that the new organization has trouble being shaped into something that looks new.

What it reminds me of is the original automobiles. What preceded them was buggies, so of course the new autos looked like the old buggies, just with an engine behind instead of a horse ahead. The old stereotypes persisted and it took a couple of decades of persistent change until the Model T didn't look like a buggy at all.

I'd say that's the way we should look at the emerging health care system. It still looks like a buggy.

To really accelerate change, what's needed is a way for inventors to make gobs of money. Right now, everyone is (rightly, I guess) focussed on reducing the cost of health care. But it's hard to make money by reducing costs. When someone figures out how to make money with new institutions, that's when the buggy will come to look new and streamlined. Idealism is great and medicine has probably more of it than any other industry. But Schumpeter's fabled “animal spirits” come out when the scent of money to be made is in the air. That's what we are praying will happen with renewable energy – find a way for the animal spirits to do well by doing good. I'm thinking, same thing with health care.

Right now, the health care animal spirits are still looking around, to the on-line doctor (doomed!), to health monitoring by your smart watch (better chance here.) When the specialty hospitals take over, when money flows into primary care, when teaching is divorced from tertiary and quaternary care, when pharma is rationalized – that's when the reorganization will really take place. But while money is still with the bloated hospitals and academic centers with their gobs of money and administrators and grants and God knows where it all goes – while all that is still predominant, the future will still lie pretty far ahead.

Anyway, that's what I've been thinking.


Budd Shenkin

Saturday, January 28, 2017

A Democratic Strategy


A quick note to the Democrats on strategy. Democrats need to be wary of embodying Will Rogers' declaration that “I'm not a member of any organized political party. I'm a Democrat.” My fear is that Democrats will be over the top in resistance rhetoric by firebrands, but unsure how to use the fuel of mass protests and popular revulsion at Trumpian policies. That Democrats will be running helter-skelter, not knowing how to oppose as a group, how to find spokespeople to hold to a line of thought and rhetoric. That Democrats will be confused by the welter of targets and so hit none of them cleanly, will not be able to vote as a bloc as the Republicans could, will not be able to decry an Administration the way the Republicans did when they said Obama excluded the possibility of consultation and finding common ground. My fear is that the “reasonable” Democrats will be mamby-pamby. My fear is the “Democrat” will become a term of scorn.

It shouldn't actually be very hard. You just have to be clear on your goals. The overriding goal should be: to kill dead the Republican Party. To do to the Republicans nationally what Governor Pete Wilson was able to do in California when he committed his party to suicide by backing the anti-immigrant Proposition 187 in 1994, and thus lost California for Republicans for at least a generation, maybe more. It was as momentous as LBJ's loss of the South, which he did knowingly, and for which he should be regarded as a Profile in Courage. Now, nationally, we just need to collaborate with Trump and the Republicans as they have set out in their Death March.

The Republican Party is not your father's Republican Party, it is a body double inhabited by forces alien to the American tradition. They are basically racist – look how they treated Obama. They are against safety net programs at all. They are against the environment. They are against abortion. They are against one person one vote. On and on. As a party, they deserve to die. Trump should be regarded as a useful idiot in killing the party dead.

The mission of the Democratic Party, should they choose to accept it, then, is to tie the Republican Party as closely as they can to the Trump Administration's obnoxious, hurtful, antediluvian policies, in an effort to kill them dead. Their mission should not be to kill Trump dead – he is an abnormal transient who won't last. But the Republican Party is the real threat.

Concentrating on personalities can be helpful sometimes, but the Democrats need to find the main themes, name them and number them, and then tie every specific policy to the main themes. Gingrich did something similar in 1994 with his Contract For America, and it worked. And for every policy, don't concentrate on Trump and Bannon and their proposals – concentrate on the Republican Party – are they behind it? Will they allow it? And make sure there are 48 Democratic votes and voices opposing.

Others could construct the list better than I, but here's a vision of it. Antediluvian social policies – anti-abortion, anti-contraception, anti-feminine in every aspect. The culture war redux – it wasn't settled, apparently anymore than racism was. Antediluvian – that's theme #1.

International economics is pretty clear – Trumpian trade wars are ill-thought out, theoretically indefensible, and will fuel higher prices on goods and perhaps a recession. That's theme #2.

Combative international relations, every day another example, needless conflict, dangerous conflict, money-losing conflict, job-losing and price-increasing policies, outdated analyses, isolating steps. Paranoid – theme #3.

Anti-environment – theme #4. They want to worsen pollution.

Racist, homophobe, etc. - #5.

Anti-safety net – #6.

Inside dealers who make themselves rich - #7.

Theft of public lands - #8.

And so on. Make a list, identify each issue that comes up with that list. So to make it clear to people.

Then, the Democrats have to understand the use of the hammer. No one ever drove a nail through the plank with one blow. You have to hammer, hammer, hammer until the message is received and internalized and ready for repetition again and again. Hammer it home again and again.

As for tactics, well, there is enough stupidity around, God knows, make fun of the fools. Have Bannon impersonators walking Pennsylvania Avenue, have sandwich ads walking the streets with “Want a contract – stay in a Trump hotel!” emblazoned. Conflicts of interest are easy to understand.

And then, work with Trump on things he is for and that will embarrass the Republicans. Call the bluff. Introduce a trillion dollar infrastructure program that is paid for by taxes on the rich – paid for, paid for, paid for. Hammer it home. Paid for. Fiscally responsible. Let the Republicans try to make it profit, or not paid for, and look to the theme list. Make it understandable, and discombobulate the opposition.

The manner in which it is done is important. We need firebrands like Elizabeth Warren to hold in the Left, even if she is getting carried away with her celebrity, as I think she is. She's right, she's smart, she is useful, but she doesn't appear centered. But what we really need is the lower key leaders, smart, intense, brave, centered, persistent, believable. Leaders whom we can believe will care for us, the electorate, the citizenry. Someone who can say, “What they are proposing is just ridiculous. These people are idiots.” You don't have to be respectful, you just have to be centered. Idiots – that's got to be a major theme.

Tennis great Bill Tilden said you can beat someone by aiming at their weakness, but if you really want to humble them, attack them at their strength. My choice would be to show the electorate how intellectually bankrupt Paul Ryan really is. He thinks he is smart, but he's not. Topple him.

The Senate will be a center of resistance, and I think Shumer is up to it. We'll see. But to my mind, where we are really going to find leadership is in the states. Most states have gone over to the Republicans, but not the major ones. I can see how those governors, of California, Oregon, Washington, Minnesota, New York, Massachusetts, Virginia, and others could form an alliance and agree on model legislation, for climate and environment, for instance, and healthcare, and immigrant status, etc. They could pass legislation and invite other states to join them. The state elections could then be referenda on whether or not to go down the path of California, Oregon, etc. See which other states want to join the informal union of progressive states.

If the federal tax burden declines, the progressive states could capture the – have the wealthy and corporations pay more to the states and less to the feds, and make better use of the money in the states than the feds would. California will send less money to Alabama; well, we can use it at home. Too bad for Alabama, but maybe the underclass would rise there; one can only hope.

The agenda in the states might bring good candidates out of the woodwork. If you look at the quality of state candidates in elections, it seems abysmal to me in so many states. No wonder we lose. The political class is far from top drawer. We need a new elite to get those candidates fielded and the agenda drawn. This positive agenda could do it, while the Senate would be busy painting the Republican Party as what it is, theme by theme. Let the Senate be the killers, and the states be the builders.

Be centered, imaginative, united, and disdainful of the fools who are in momentary control. Retool the team. Make sure everyone understands that these are the bad old days of the future. Maybe that's the overall theme – the future will see this four year eruption as the bad old days that preceded the good new days, as the reaction overcame the momentary rupture of progress. But only if we prepare. And only if there are leaders to lead, and only if the feckless are labeled as such.

I believe in the moral imperative of optimism. I keep repeating that to myself. I'm hammering it home.

Budd Shenkin