We The People Vs. We The Maps

We the People is the way our Constitution begins.  That document describes the rules and outlines of a new nation, and it begins not with geography, or money, or descriptions of purple mountain majesties or rivers, but with the people. 

A government of the people, by the people for the people, Lincoln said, as he formulated the reasons for the second American Revolution which was the Civil War. 

But, of course, Hamilton, Jefferson and Washington and enough of the founding fathers, those 18th century men in whigs and silk stockings were afraid of "the people" so they constructed a country of states with borders and the government embodied land, borders, states as players just as important, more important than the people. 

Looking at the 2016 census, you can group the states in different ways, but there seem to be several distinct categories:

1.  States of roughly 20 million or more souls:California (39 m), Texas (27 m), Florida (20 m) New York (19m). These are the Huge States. (4 states)

2. States of 8-13 million:  Pennsylvania (13 m), Illinois(13m), Ohio (11m), Georgia (10m), North Carolina (10m), Michigan (10m), New Jersey (9m), Virginia (8m). These are the Big 8 States. (8 states)

3. States of 4-7 million: Washington (7m),Arizona (7 m),Massachusetts (7 m), Tennessee (6m), Indiana (6m), Missouri (6m), Maryland (6m), Wisconsin (6m), Colorado (6m), Minnesota (6m), South Carolina (5m), Alabama (5m), Louisiana (5m), Kentucky (4m), Oregon (4m), Oklahoma (4) Connecticut (3.5m)  These are Middleweight States.  (17 states)

4. States of roughly 3 million: Iowa(3m), Utah (3m), Mississippi (3m), Arkansas (3m), Nevada (3 m) Kansas (3m), New Mexico (2m), Nebraska (2m), West Virginia (2m) These are the Lightweight States. (9 states)

5. States of less than 2 million: Idaho, Hawaii, New Hampshire, Maine, Rhode Island, Montana, Delaware, South Dakota, North Dakota, Alaska, Vermont, Wyoming. These are the Mini States. (12 states)

2016 vote by population

All these states get about one Representative in the House per 700,000 population. But in the United States Senate, Barbara Boxer represents 18 million voters where Bernie Sanders represents 312 thousand voters. 

2016 vote by counties

Until the 2016 election, half of the biggest group (Middleweight) states were liberal, blue states, but that fell to 1/3 with the election of Trump. Of the Huge states, half are liberal, half conservative. Of the Big 8 States, only 2 are consistently liberal, the other 2/3 flip back and forth. Of the lightweight states only one (New Mexico) is liberal. Of the dozen Mini States, 1/3 are reliably liberal.

Of the 21 states in the Lightweight and Mini divisions only 4 are reliably liberal (New Mexico, Hawaii, Delaware and Vermont.) 

The End Result of Disproportionate Political Power

If the Senate were reconstructed to reflect population, then 17 states which now exert disproportionate power would enjoy only a power proportionate to their people.  These 17 states now stand in the way of a single payer/government option for health care, a Supreme Court which lives in the 21st as opposed to the 18th century, a robust environmental protection agency, the development of wind and solar power on a scale which could connect nearly every American home to the grid without increasing CO2, the resurgence of labor unions and any hope for a fair break for the middle class, free college tuition at reliable not for profit state universities, a tax code with is friendly to the middle class and which asks more from those to whom much has been given, and a huge new infrastructure program could be undertaken which would provide full employment for generations. 

If the Supreme Court were composed of 9 voting justices, the 9 most recently appointed, with 2 new justices appointed by the President with each Presidential term, then progress on a multitude of fronts would be possible.

But that is not the America we have. We are still living with the distrust of We The People which we inherited from some men who were slave owners and from some who simply distrusted the rifraff. 

Slaver

Fever Dreams

Unlike liberal Democrats, those of  the reactionary Republican persuasion have been thinking about what they want for years. 

In 2000, the platform of the Texas GOP included:
1/ A return to the gold standard
2/ Abolition of the Federal Reserve
3/ Elimination of the minimum wage
4/Abolition of Social Security
5/ Repeal of the 16th Amendment (federal income tax)
6/ Elimination of the IRS.

We are not talking about some wacko splinter group, living off the grid survivalists in Wyoming here. We are talking about a mainstream, state of Texas state Republican party.  The party of Louis Gohmert. 

Now, I ask you, while these fellow Americans have been dreaming these fever dreams, what have liberal Democrats been dreaming?

You know, the fact is, for something to happen, you must first imagine it.  Well, that's not entirely true. You can develop a disease you'd never imagine in a million years. But if you want to create something, if you want to go somewhere, build something, you have to dream first. And these people have been dreaming fervently. That is a problem for the rest of us, don't you think?

Here are members of today's "Freedom Caucus" in the United States Congress, the guys who blocked the All American Healthcare Act, because it still required insurance companies to cover hospitalization. 
I'm going to Google each one of these guys, day by day, just to see how really creepy they are. But remember, these guys are representatives of thousands of people, who think like they do.

Sweet dreams.

Andy Biggs

AZ-5

Bill Posey

FL-8

Dave Brat

VA-7

Jim Jordan

OH-4

Justin Amash

MI-3

Louie Gohmert

TX-1

Mark Meadows

NC-11

Mo Brooks

AL-5

Paul Gosar

AZ-4

Randy Weber

TX-14

Raúl R. Labrador

ID-1

Rod Blum

IA-1

Ted Budd

NC-13

Ted Yoho

FL-3

Tom Garrett

VA-5

REPEAL! Don't Let that Dog off the Leash

The Republicans in Congress are that classic brand of coward who will taunt the dog who is leashed to the front porch, dance around throwing stones at him, as long as they can see nothing will happen to them.

But once that dog is off the leash, they don't want anything to do with that beast; they won't even set foot in the front yard. They'll cross the street and run as fast as they can.

So every day for 7 years they hurled invectives at Obamacare, said what a disaster it would be/is/was and they threw stones and they voted daily to repeal it, because they knew their votes would never have any effect.

You might think they would have been thinking about what they would do to replace it, if they ever got a chance. You might think when President Trump won the election November 8, more than 4 months ago, they would have done a few retreats, listened to some invited experts about what a good health care plan would require, had some late night sessions about what they wanted to do now.

But no.

They are all talk, no action.

Action would require crunching numbers, talking about policy, thinking about what sort of world they would like to see.
But no.
They are what they've been since at least 2008, the party of No.
Mitch McConnell said his only job in 2008 was to make sure whatever President Obama wanted to do would not happen.


Apparently, he liked that job and will do the same for Mr. Trump.

Repeal and Replace Fails: Trump Claims Victory

Got to hand it to President Trump: He said he'd drain the swamp and he did it.
As he said tonight, he has said for the past 18 months Obamacare would implode and everyone would lose health care and it's in its death spiral and now the country is going to get what it deserves for allowing the Democrats to kill the Republican American Healthcare Act.
I mean how can you vote against a bill called the American Healthcare Act?
Maybe they should have called it the "All American Healthcare and Winning Act," but I quibble.

People will die! And they deserve to!  They wouldn't listen to me.

I was wrong. I could not imagine the Republicans would not pass this law after they voted every day for 7 years to repeal it. You just knew that whole time they were crafting their bill, which would provide the world's best medical care to the top 1% and pretty good health care to the top 20% and okay health care to the next 20% and the rest of the population could just die, because, well, they really are so undeserving anyway.

This is more fun than the Trojan war!

Well, it's on to tax cuts, and I got to say, I'm relieved. The tension the past few days has been close to unbearable.  I kept expecting Jim Jordan to tear off his shirt and reveal his wrestling singlet and leap up onto Speaker Ryan's podium and scream, "You want a piece of me?" 

It's his fault

It was reassuring to see Louie Gohmert on camera explaining how the Party has to just go back to fundamentals, like organizing posses to track down dark skinned Mexicans who have slipped across the border President Obama refused to defend, intent on raping white women. Well, who wouldn't want to rape white women? Mr. Gohmert is pretty obsessed about the raping of white women, something which bothers President Trump, too. He keeps bringing up that woman who was raped by a Mexican who shouldn't have been in the country.

Do Black or Hispanic women or any kind of non white women ever get raped? Are white women rape magnets? What is this thing about rape?

But about health care.  Speaker Ryan sighed and said it will be with us in its death spiral for the foreseeable future, which Mr. Trump says will be a short future because Obamacare is in its death throes. 

I want to see more of Jim Jordan. He says he's going to work tonight on another plan.  He's been working on plans for the past 7 years, but tonight he's going to get serious, right after he does 100 push ups and 200 sit ups. 

Now that's what I call preventive care. 

What Should An American Government Do?

This morning I went on the website of the Food and Drug Administration to find out what the FDA could tell me about the safety of a particular drug. If there were no FDA, I suppose I could have gone on a university medical school website for the same information, or maybe a commercial website like "The Medical Letter" but the FDA provides that service.

I also checked out the weather report on the Weather Channel and they use government weather satelittes put up in space by the National Aeronautics and Space Administration.
And I drove over the Merrimack River, which is now clean and full of fish owing to the EPA's regulations which cleaned up what was once a cesspool.
The road I drove in on is part of the Eisenhower interstate highway system.
Overhead flew airplanes guided by air controllers in the employ of the Federal Aviation Administration.
On the way in I listened to the radio story about a boat which needed a United States Coast Guard rescue.


I suppose all these things could be done by private companies, eventually.
President Trump recently submitted a budget which increased spending for the military and decreased it for everything else.
It was a very masculine budget. We spend on weapons, surveillance, border protection, armies, navies and war planes.
We don't care about soft things like healthcare, which we want to cut out of the government budget as much as possible. We don't have any use for the arts or national parks or stuff that isn't masculine and tough.


If the Marlboro man wouldn't like it, our government should not be interested, either.

Where does money and finance fall on that spectrum? All those economic and financial reports which the government churns out: employment, consumer price index, calculation of GDP.  I guess private companies could do that, the same way private companies rated the risks and value of various mortgage backed securities right before the financial crisis of 2009--if you can't recall how well that worked, just watch the movie "The Big Short."


Government is Bad, except when it's tracking down Mexicans

I don't know, maybe the Republica ns are right. Maybe we don't need no friggin government, except for defense and border control and to hunt down people who like doing abortions.

Then again, what do Republicans know about all the things government actually does?

Paul Ryan's Francis Macomber Moment: That Undeserving 3%

Paul Ryan and his friends will probably prevail today, whatever that means.
Well, I guess we do know what that means: He'll get his bill through the House of Representatives, claim victory and Mr. Trump will go to Wisconsin and claim another "Promise Kept!"

What you got is the healthy paying for the unhealthy, and the poor. Bad idea!

It all reminds me of the idea which kept coming up during the war in Vietnam: Let's just declare victory and go home.


Or that wonderful Hemingway story: "The Short Happy Life of Francis Macomber," in which a rich man on safari raises his rifle to shoot a lion but loses his nerve, drops it and turns to run when the safari guide behind him raises his gun and shoots the lion dead. The native hired hands, who carry the rich mans baggage, who are paid by the rich man, then hoist him on their shoulders and carry him back to camp, as if he has had a great victory.

So, later today, Paul Ryan will have his Francis Macomber moment. Both he and President Trump will be carried off on the shoulders of the Congressional Republicans as victors.

It's going to be so great. You'll love it.

Health care, and the legislation affecting it,  is actually more complicated than Mr. Ryan or President Trump appreciate.  I certainly do not understand it.  But as we used to say at the hospital: The most dangerous intern is not the intern who doesn't know; it's the intern who doesn't know he doesn't know.

click to enlarge

One thing I've learned through all this is by far the vast majority of our citizens are not covered by Obamacare--only about 3% are--most people are covered by employee plans, Medicare or the Veterans Administration.  The 9 million or so who use Obamacare can easily be ignored, as they had been for generations, by the Republicans and all the members of Congress. The wonder is President Obama ever got anyone to vote to help them.

But there might have been a reason Democrats were able to get  Obamacare done:  Those uninsured people, as small a portion as they were,  kept showing up at emergency rooms, and the hospitals had to pay the doctors and nurses who took care of them in the ER's, in the hospital, and  in the operating rooms, and that burden ultimately got passed down a line of hands to the government and prices for everyone's health care premiums rose.

So you had this slow leak of the tire which kept getting in the way of the functioning of the whole car.

Seven years ago,  John Boehner finally blurted out his  greatest fear about the new Obamacare bill--If you give people a taste of health care, they'll never want to live without it.  

It was a version of that droll bit of wisdom I'd hear in the South all the time from the comfortable upper class country club types:  "Don't feed a stray dog: He'll follow you home."

Which, in case you missed it, means that once you show kindness to the hungry varmits, they'll become dependent on you, so never be kind or generous, it'll be a burden. He might be your brother, but he's really too heavy.

I promised we'd kill Obamacare and we did!

Without knowing the details of Obamacare, it seemed to me when I first heard about it, if you were going to tell insurance companies they had to insure all those sick people out there with pre existing conditions, who have not been able to get health insurance because they were sick and needed health care (the customers no insurance company wants) then you have to feed the insurance company a huge new pool of customers who will never need the insurance company to pay anything, namely healthy young people. But healthy young people are invincible and don't see any benefit to health insurance so you have to intimidate them to pay money for something they don't want.  That was the "mandate."

The basic flaw in the argument is that health insurance ought to be a commercial enterprise whose raison d'etre is to make a profit for investors in insurance companies.  Any business wants to take in as much money as possible while spending as little as possible. But the purpose of a hospital, a clinic is, in fact, to spend money, or actually, to provide services, which is pretty much the same thing.  So the idea of health care as a profit center is a contradiction. You are trying to make money while not doing the thing you are being paid to do.

And then you've got those young people, from whom you are trying to make your profit. It's the young, healthy, not needy from whom you extract your profit. Of course, those healthy young people are already unwillingly paying for stuff they would never pay for unless they were forced by law to do it: Social Security and Medicare.  We have those programs because the government discovered you have to force people to plan for the times when they will no longer be young, something no young person believes will ever happen. So we said, suck it up, you don't want to and you don't like it but we are not going to support you when, so we are going to make you eat your spinach now.


But the Freedom Caucus, Paul Ryan, the Tea Party want to say, Live Free and when you get sick, Die! They don't believe in no durned gov'ment making people behave like responsible adults and when those irresponsible adults show up at the Emergency Room with their I phones and their gold necklace bling, just turn them away. Serve 'em right.


Except some kind hearted do gooder liberal Emergency Room nurses let those folks in and the whole system goes to hell in a hand basket. So what we need is a law which puts the TSI agents out in front of the ER and they don't let anyone get through the gates unless they have health insurance.

Not a dog, but you get the idea.

Don't feed them stray dogs.

Republican Realty Check

Listening to really psychotic patients on the psych ward when I was a medical student, I knew enough to keep my mouth shut.  Typically, they had their own deeply held beliefs which brooked no dispute. What was the point of questioning whether there really was a vast conspiracy of extraterrestrials  who wished this particular person harm, who sent radio waves in his direction so they could read his mind, who conspired with the ward nurses and orderlies to keep him from claiming his rightful throne as the one, true king of France? 

That's what the Republican Party has been like these past eight years--mutually validating their own beliefs, detached from reality, but really, why bother arguing with them? 

Now, they have to actually get a real, live health care bill passed and reality has a way of being very stubborn.
People don't like the idea of buying a health insurance policy which covers nothing but a week in the intensive care unit. They want their diabetes care covered, the visits to their cardiologist.

Even Ross Douthat (Doubt that?) has become desperate enough to offer a plan of his own, which he bases on solid conservative principles, "a coherent vision" as he calls it:
1/ "Health insurance should be, like other forms of insurance, something that protects you against serious illnesses and pays unexpected bills but doesn't cover more every day expenses. People need catastrophic coverage, but otherwise they should spend their own money whenever possible."
2/ "Because that's the best way to bring normal market pressures to bear on health care services, driving down costs."
3/ "Without strangling medical innovation."

So here's what's wrong with this:  The short answer is Mr. Douthat has not the faintest idea what he's talking about. (He's been listening to that famous lady in the parking lot who told Donald Trump vaccines cause autism, or maybe Ted Cruz or Paul Ryan or really, any Republican.)

But here's the long answer, if you are interested.

Health insurance for less traumatic and the less dramatic things prevents the catastrophes from developing.  
Even non catastrophic things, medically speaking, can be financially catastrophic. Take a single case which springs to mind. A 24 year old piano teacher in Brooklyn, bicycles to give his lessons to his students. One day he hits a curb, falls of his bicycle and strikes his wrist on cement. He has only catastrophic insurance. He considers going to the ER for $800, with another $200 for the X Ray and another $200 for the ER physician. He is not sure this is what the bill for his care will be, because, well, how do you ever know what such a medical bill will actually be? But that's what he can get from Professor Google, which is not so easy when you are trying to type with one hand. That bill will be close to a month's income for him.  Even if the hospital allows him to pay it off over time, there might be interest and he has rent and food to consider. 

On the other hand, if he does not go to the ER, he might be able to get an appointment with an orthopedist, if he could get a referral from an internist, but he doesn't have an internist because he's only 24 and has no other medical problems. The orthopedist office visit might be cheaper,  but his wrist is now the size of a grapefruit and he's got to give piano lessons the next day. If he needs a cast, it would seem prudent to act sooner rather than later. 

The 800 pound gorilla in the room

That is just one of a thousand examples.  The middle age hypertensive man who doesn't feel bad because of his hypertension,  but the $120 bill at the internist's office for his visit and his lab and his medications is painful.  Mr. Ryan would tell him that's money well spent, better than the new smart phone, but that new smart phone might help him in his night job as an Uber driver. That smart phone is a tangible benefit; treating his hypertension is only an abstract good. On the other hand, his catastrophic insurance will cover his ICU care when he has a stroke from his untreated hypertension. 

Then there is that great Republican mantra: Let "normal market forces drive costs down."
 This simply does not, never has and never will pertain to medicine. 
Medicine is not driven by "normal market forces."  Decades ago, Senator Ted Kennedy was bothered by complaints from his constituents about long waiting times for new appointments with doctors and about high office visit costs. So he said, well now the reason all this is happening is supply and demand, classic normal  market forces. So he got a law passed doubling the size of medical school classes, and within a few years the supply of doctors did in fact increase, nation wide, but waiting times for new appointments in fact quadrupled and costs quintupled. 

Why? 
For several reasons:  All those new doctors did not flood into communities, opening up offices with lots of space in their schedules. They became specialists and rather than competing with each other, doctors cooperated and they started referring Mr. Kennedy's constituents to each other and now the citizen had four appointments with specialists where he had only one before and he  spent four times the hours waiting in four new waiting rooms. Normal market forces: supply and demand. Simple minded people with simple solutions don't work in the macroeconomics of medical care.

And, oh, "medical innovation." What exactly does Mr. Doubt that have in mind? Does he mean new drugs? As if reducing the health insurance coverage of the average citizen will somehow stimulate the drug company to spend money on research for a new cancer cure or a new drug for diabetes?  Or is he talking about say, laparoscopic surgery? Now there is a medical innovation which is actually a revolution. 

Healthy people paying for sick people: Who woulda thunk? What a scandal!

How did that big innovation occur? Was it driven by market forces?  
No, actually, it was driven by curiosity. Gynecologists had been using laparoscopy for decades, pointing their scopes south, ward the ovaries and uterus,  and over a few beers they told their general surgeon colleagues they might want to point that instrument north, toward the gall bladder and some surgeons in private practice thought: why not?  
They got some CEO's at local community hospitals to invest $10,000 on new equipment, which for those hospitals was not much more than they were spending on coffee and sandwiches for the doctors' lounge and presto:  A whole new world of surgery blossomed. 
Not driven by big business. 
Not driven by government. 
Not driven by normal market forces or even abnormal market forces.
Not driven by academic university hospitals. 
Just a bunch of open minded, scientifically trained humble local surgeons, with the souls of engineers. 

Go figure.

Do Paul Ryan, Mitch McConnell, Louie Gohmert, Jim Jordan or any of the "Freedom Caucus" know any of this?

What do you think?