Author Archive for Rich

My Take on Human Sexuality and Marriage at Age 82

Richard G. Wendel MD. MBA.

Just like all living organisms, mammals must be able to grow and reproduce. And in most species the reproductive function is a fairly strait forward core competency complicated only by male or female competitive behaviors. But humans are quite different from other mammals and to conform to our cultural norms, human sexual fulfillment is a capricious maze of competing biologic, sociologic and psychologic forces. Humans talk more about sex than almost any other topic aside from maybe sports and the weather and yet they are quite clumsy and often confused when it comes to the implementation of the mating ritual. Each society introduces unique standards and morality to mold this purely basic instinct and sex is saddled with infinite inhibitions relevant to political, religious, tribal and social restraints.

One explanation for the paucity of rigorous studies about human sexuality is that it is very difficult to define what is normal and what is abnormal. It is difficult to apply objectivity and rational thought to sexual expression and if you try to launch a double-blind scientific study of sexuality, the controls are often just as variable and screwed up as the group being studied. To put a statistical frame around sex is like trying to produce a formula for a forced drill of goldfish.

The somatic or voluntary nervous system in humans provides precise control over physical movements, and the involuntary nervous system efficiently maintains a steady state or homeostasis without much coaching. The frontal cortex of the brain which is conveniently called the ‘executive center’ contains the control center for rational behavior. It obviously maintains some control over sexual behavior, but the nuclei within the brain where reproductive instincts reside and sexual performance is initiated and sustained are located further down in the lower centers of the brain and brain stem. It is easy to see how these two control centers might have different goals and objectives or at least a different slant in how to go about it.

The neural network and pathways that conduct the electrical impulses for the physical performance of sexual intercourse reside in the involuntary parasympathetic and sympathetic nervous systems. Unlike the motor cortex of the brain that enables one to move a skeletal muscle at will, the involuntary nervous systems, although in a constant state of readiness, doesn’t usually follow voluntary sexual commands unless they are in sync with one’s emotional milieu and readiness. And emotions, libido and sexual programming are thought to each emanate from differing locations within the brain. Add to this the fact that sex is a highly conditioned and reinforced type behavior and you soon realize that sex does not simply have a start and stop button. Put crudely, from a male and female perspective “Peter rarely lies” and “Fake orgasms are rarely convincing”.

In the human species, there are many erogenous zones that have a plethora of nerve endings. The foremost of these is the entire perineum that includes the external genitalia and perianal areas. Young children quickly come to recognize these sensitive areas; stimulation of which is pleasurable. Perhaps, a parent will tell a child not to play with themselves ‘down there’ or explore the orifices, but with these innate erogenous zones the child learns more through exploration as opposed to parental guidance. Immature males experience penile erections with or without touching of these sensitive areas. And stimulation from contact with parents or relatives can be arousing even if it falls in the realm of routine toilet training and changing clothing. The taking of a rectal temperature, an enema, medical examinations or stroking of the genitalia can cause sensations that produce sexual fantasies that later may influence adult behavior.

A number of studies suggest that sexual orientation is determined during intrauterine life and occurs early during the development of the fetus. One commonly held theory is that it relates to poorly defined hormonal factors that embryological influence the genital ridge during intrauterine life. Homosexual orientations seem to occur randomly without linkage to any familial factors. And many scientific studies fail to show any consistent relationship to the genome, epigenome and anatomic changes in the brain. In the DSM 5 classification of mental disorders homosexuality is not listed as a medical disease and anthropological studies show that homosexuality has been recognized in all cultures regardless of any cultural proscription.

My conversations with several gay young men revealed that all were aware of their attraction to the same sex very early in their lives. With heterosexual orientation the same holds true. Play behaviors emerge early in childhood consistent with male or female sexual orientation. Speaking for myself, I avidly looked at the nude pictures of women in my father’s medical textbooks and when I first danced with a girl in the fifth grade, I knew there was something very special about girls.

I believe that many adults do not appreciate the extent to which our young children are sexual beings. This is certainly not a subject that is easily discussed with a child that basically lives in a sensory world with no frame of reference other than dependency. Thus, infantile sexual ‘make-believe’ or even ‘playing doctor’ evolves unrestrained by moral considerations and parental impute. Even as childhood fantasies may be irrational like dreams; nevertheless their effect can carry over into normal and even unusual sexual preferences in adult life. Reproduction is a primal instinct where desire and fantasy may partially live in the subconscious world and yet highly influence conscious behavior. And for parents this dream world is locked out of sight and control.

In young adult life, there are many inhibitory social factors that impact the natural feel of sexuality. Starting in middle school and high school a girl’s reputation could be hurt if she ‘acted out’ sexually even if it involved just kissing and petting. In my high school years, no girl wanted to be labelled a ‘make-out’ especially since boys of similar age rarely could keep a secret and often bragged. Recently, the dire effect of social media sexting has made headlines and this has been linked to some teen suicides especially in young girls.

Religious proscriptions about premarital sex remain to some degree as do parental wishes that their daughters remain inviolate until marriage. Plus most all parents wish for their sons to associate with a ‘good crowd’ and date nice girls from good families that can be brought home to meet the family. For teenagers, privacy and fear of discovery causes sexual relationships to be more impulsive than well-reasoned due to these barriers. Indeed, male hormonal surges and persistence often short circuit the usual intimacy and courtship that typically precedes a healthy consensual coupling. Regret and even blame are added to the fear of pregnancy and venereal disease. Moreover inexperience and ineptitude often makes the encounter unsatisfactory and may have lifelong psychological consequences. And unsatisfactory sex may contribute to performance anxiety and avoidance of sex even as sexual expression is an instinctual drive that comes fully equipped.

The Adult Condition   

Even as sex is instinctual and hard-wired, the mating ritual is highly susceptible to positive and negative reinforcements. Privacy, safety, mood, transferences, beliefs, expectations, cleanliness, odors and health often complicate this very natural activity and, moreover, can directly impact performance. Indeed, the male and female ego is highly intertwined with sex and self-esteem, and one or more bad experiences can have a long term dampening effect on sexual expression. Additionally, speaking as a Urologist, few individuals are completely satisfied with the size or configuration of their sexual anatomy. Moreover, when they read beauty and muscle building magazines their body contours and perceived beauty often fall short as well. This causes a heightened self-consciousness and sensitivity to any critical or derisive comment during love making. Just one insult or any expression of dissatisfaction can severely damage a relationship and instill self-doubt.

Many other factors may influence sex. Each partner has a unique set of fantasies, idiosyncrasies and turn-ons/turn-offs. Women especially want a romantic setting as a prelude to love making and some desire lengthy foreplay and teasing. More men are inclined to want to swiftly get down to business. Some couples act passively, while others are more emotive with passion, body movements, throaty sounds and verbal exchanges. There are some men and to a lesser extent woman that wish to bypass the emotional underpinnings and think that sexual pleasure begins and ends with ejaculation or climax.

One statistic that causes disbelief (and denial among men) is found in Master and Johnson’s studies on Human Sexuality. Their data showed that male ejaculation on average occurred 55 seconds after penetration. Obviously, this short time frame is designed for procreation, but is not very reassuring for those that consider their mating ritual a form of physical endurance and intimacy plus a type of contemporary artistry. It does explain why couples rarely experience ejaculation and orgasm simultaneously.

Today, the ubiquitous exposure to pornographic videos have influenced sexual expectations and commoditized sexual expression. It has added new twists to love making that may be contrary to Victorian ways of thinking. It certainly has made a market for vibrators, dildos and sex toys, and explicitly exposed couples to sexual practices such as oral and anal sex that at one time were considered to be aberrant and kinky sexual practices.

If you manage to successfully navigate these sexual concerns and have a gratifying sexual relationship; sexual activity tends to gain a special momentum. The repetitive reinforcement gets imprinted into a ‘sexual map’ we create in our brains that is very similar to the common pathway followed by addiction to other pleasurable experiences. The early ‘sexual maps’ leave a trail to follow for both permanent and less permanent sexual relationships. In my experience as a urologist, libido may fade with age but some old folks are still quite motivated with hard-wired sexual maps.

A satisfactory sex life is an important ingredient in enduring relationships. There is an old adage about marriage that ‘if sex is good it is responsible for 20 percent of marital bliss, but if it is poor, it is 80 percent of marital dissatisfaction.’ Over time the frequency of sexual intercourse in a long term relationship declines and a humorous take on this is that ‘if you put a jelly bean in a jar for each time you had sex during the first six months of marriage, you could take one out each time from that time forward and still have some left over.’ I doubt that this holds true today as premarital sex and cohabitation before wedlock are quite common and increasingly acceptable arrangements.

Recently the #MeToo woman’s movement has surfaced to encourage women victims of sexual abuse and misconduct to speak out and come forward to tell their stories. The response to this initiative has finally gained traction and seems to be influencing corporate cultures. Certainly the casualties from sexual misconduct that include elected politicians, actors and executives attest to the effectiveness of new guidelines for engagement with subordinates and the opposite sex.

For many years, the EEOC, a Federal agency, has had the authority to investigate hostile work environment claims about 45 percent of which are relate to sexual misconduct. Often sexual improprieties went unnoticed. But due to the #MeToo movement many more businesses are adding clauses to their HR manuals that include anti-harassment training, anonymous reporting and protection for the sexual whistle blowers. The recent women’s march in all of the major cities across America suggests that this issue will not fade in the conscience of the nation. I have often wondered why with so many consensual opportunities would a business executive try to inappropriately steal a kiss, fondle a butt or bodice, demand sexual favors through threats, make unwanted physical contact and expose themselves?

Prostitution is alleged to be the oldest profession in the world. In many countries it is legal and regulated. In others it is illegal, unregulated and part of the criminal underworld. In Japan there are sex tours to visit places like Thailand to partake of their brothels. Paid sex separates sex from relationships and I often wonder how many men are impotent or have premature ejaculation when faced with paid ‘sex on demand’ with no emotional underpinnings.  I would think masturbation would be a more cost effective mature alternative that does not bring with it the threat of blackmail, STD and possibly remorse.

Philandering

If a man or woman wishes to have an affair, it is a fairly straight forward process. Consensually, men and women don’t just fall into bed together and even under the influence of alcohol or just being ‘horny,’ there is conscious intent. The devil made me do it is not a legitimate excuse. Moreover, smutty jokes and crude ‘locker talk’ and a ‘hostile work environment’ are rarely the initial stimulus for an illicit affair. The serial philanderer always has their ‘mating antennae up’ looking for provocative or receptive body language and eye contact from an attractive partner. By virtue of proximity and opportunity these suggestive signals often emanate from coworkers or friends. The affair often begins with an excuse to meet for a cup of coffee or maybe lunch or a drink after work. Office parties, especially during the winter Christmas season are a breeding ground for casual encounters. These meetings permit the private assessment of the risks, convenience, motivations and ability to conceal the affair. If the opportunity costs are not too great, the pair exchange contact information and the affair begins. In this type of relationship in which both parties are heavily invested right at the start sexual intercourse occurs at the first meeting. Outcomes from philandering are unpredictable. Here are some scenarios.

  1. Over time one or both parties back pedal because of guilt or conflict
  2. One or a few intimate encounters take place and the pair evolve into being just friends
  3. A single encounter with sexual intercourse followed by regret, anger and avoidance
  4. A satisfactory relationship that leads to a typical affair lasting about one year after which the curiosity wears off, circumstances change or one partner’s expectations become greater than the other’s
  5. On again and off again casual affair with no permanence or commitment (may span many years)
  6. A lengthy arrangement with varying degrees of intimacy, commitment, sex and financial subsidy
  7. An affair that turns serious and explodes the status quo and reshuffles relationships. This scenario occurs with some regularity and is a serious generator of divorce and family breakup

Without exception, having any type of affair carries risks with the threat of wide ripple effects and often unanticipated consequences. In general, the ego gratification and adventurism of an affair does not exceed the heartache, recriminations and guilt that it causes at its termination. Men and women that are philanderers cheat because they enjoy it regardless of how they rationalize the dalliance and justify it on the basis of unmet wants and needs.

The motivating factors for entering into illicit relationships between single or married individuals are quite varied. Psychoanalysists often attribute it to the male’s search for a surrogate mother and narcissism.  The expression Men are from Mars (the Roman god of war) and women are from Venus (the goddess of love and beauty)” or “men are hunters and women gathers” probably captures some of the instinctual and aggressive elements. Certainly, sexual gratification, libido and attraction may be the fuel that kindles the flame, but there are most always some additional motivations such as conquest, revenge, depression, loneliness, dependency needs, promotion and so on.

In traditional courting, men have always been more fixated on physical attractiveness and sexual attributes than women who certainly like handsome men but are also attracted to men with position, affluence and warmth. In marriage today in which both women and men are bread winners other factors also play a more prominent role than heretofore. For instance, women executives tend to marry men executives, and male physicians tend to marry female physicians rather than their office personnel and nurses. This, of course, has augmented the economic and social gap between rich and poor in our society. Philandering, however, does not adhere to this differential.

The propelling reasons for affairs between married and single individuals are extremely variable. Some single women naively date married men and only later question their involvement realizing that the relationship is going nowhere. Some married women and men feel cheated by an unhappy marriage and more susceptible to acting out. Many men and women have emotional problems that are palliated by the aphrodisiac of intimate relationships. Some fall into relationships due to inexperience or because they misinterpret the advance (the innocent virgin) while others want to have an adventure. Many are on the rebound from a failed relationship or marriage or in a transition period in life when they move to a new city or job. And there are some that have personality disorders and are very gifted as sexual partners, an asset that they use to manipulate the world around them. And there are some men and women that have few options to land a mate and are looking for some form of social life, perhaps financial support and feeling of self-worth even with the slim hope of stealing a mate.

Plus, there are some women that love to sleep around with many partners. And a few even have fantasies about being raped, abducted or going to bed with someone of a different race. In fact, one study on sexual behavior found that the rape fantasy is fairly common and that these women had better sex lives. Promiscuous women generally have more sexual partners than roaming men (professional athletes and entertainers with entourages excluded).

At the end of the day, there are a myriad of reasons to cheat and break the customary rules. The overriding truth is that most philanderers both men and women enjoy the intimacy, sex and the adventure of these trysts. Many talk about a midlife crisis or seven year itch in marriage in which the individual feels short-changed in the competition and acts out. I am not convinced that this is a common precipitating factor.

Male Erectile Dysfunction

About 40 percent of my urologic practice was treating male erectile dysfunction (ED). Most of these men had multifactorial performance anxiety rather than any underlying medical reason such as advanced vascular disease or anatomical problems. Indeed, the male anatomic and physiologic mating mechanism is very durable and one of the last to go with aging.  Reassurance was the primary therapy for performance anxiety. To alleviate the pressure these men felt, I often gave this a medical explanation for their problem and gave them supplements such as Vitamin E or testosterone shots. We also used vacuum erectile devices with limited success because they were cumbersome to use. Penile implants were an option but again with limited success. Today we have Viagra and Cialis that are quite effective in producing erections and successful if the couple is motivated.

In general, I found male sexual dysfunction to be mainly psychological and related to a host of feelings such as anger, rejection, inadequacy, resistance, availability and lack of a suitable partner. A few just had low libido with lack of interest. Many were encouraged by their female partners to seek urologic consultation. A psychological test, the Millon, that I administered was not found to differentiate or be predictive of organic versus a psychological basis for ED.  A satisfactory sex life highly reinforces itself. And when sex is good, it gains momentum, but when there are complicating factors it can also quickly lead to a dampening of the passion and thrill that makes it a ho-hum experience that is increased by fear of failure.

Marriage versus cohabitation and affairs are different animals. With living together or cohabitation for an extended period of time the relationship is put under the magnifying glass and the relationship probed for the entire range of issues such as finance, social networks, skills, knowledge and abilities. And this occurs without the bonds of a formalized commitment. Thus cohabitation takes away the discovery process of marriage and may replace some of the excitement that goes with marriage with greater realism and objectivity. This can be either good or bad but can result in uncovering frictions and uneven ‘power relationships’ that would probably be glossed over or mediated by the bonds of a marriage certificate and would not result in dissolution.

Marriage that is not attended by a lengthy courtship is quite different from living together. In reality, sexual needs and wants can, in most instances, be met with multiple partners better outside of a marriage. And marriage is carried out with the expectation of permanence, fidelity, financial sharing, children, blending of lives and maintaining a residence. And with this range of new responsibilities come a need for greater tolerance of your spouse and in-laws plus more respect and sensitivity to their needs and personal space. Marriage invariably brings some good and not so good surprises. Few newlywed couples are totally prepared for the transition and mature enough to cope without a major dose of forbearance, perspective and tenacity. Truthfully, why would an independent, autonomous man or woman that enjoys freedom ever want to get married? After all, the all-consuming infatuation and romance of marriage are generally fleeting and child rearing is not a barrel of laughs either.

Having been married 59 years, I understand why folks get married and I vote for marriage. For starters, there are obvious cultural reasons. Marriage puts a frame around financial and family matters. It is the ideal mode for child rearing and supporting your parents as they grow old. Most importantly marriage provides the warmth and security of having someone there for you through thick and through thin that meets your inherent dependency needs. Plus, from a medical standpoint, marriage is therapeutic and increases longevity. The survival advantages of marriage, children and grandchildren are huge. Few do well with being alone with no one that truly cares or has an obligation to care. Most all marriages have some degree of dysfunction but as the years pass it generally lessens and having a mate in the autumn of your life, especially for men, is a strategic imperative for happiness. That is why men remarry at a higher rate than women when they are widowers.

The Changing State of Marriage Today

When I was growing up one of Frank Sinatra’s most popular songs had the following lyrics; Love and Marriage, Love and Marriage; They go together like a horse and carriage; this I tell you, brother; You can’t have one without the other. In the 1940s and 50s this resonated as the cultural norm, and then came the 1960s with the hippie counter-culture and Flower Power. In the late 1950s Playboy magazine made the scene with a nude Marylyn Monroe featured in the centerfold. Many smutty tabloids followed and in 1972, the sexually graphic XXX movie Deep Throat hit the cinemas. This opened the door to a growing range of pornographic material that populated print and visual media. Today internet porn is viewed by the majority of our youngsters long before they have even entered, much less gone through puberty. This permissiveness has caused a cultural dichotomy in which sex and marriage are no longer viewed as culturally inseparable and exclusive. The Ward Cleaver-esque idealized American family model with the dutiful stay at home mom, a bunch of well-behaved children and meals together is still a part of the solid marriage, but few unions consistently achieve this high standard today.

Statistics confirm that the desire to get married and the attendant commitment to be married is not as compelling and universal as it once was. In fact, a 2010 survey of Americans between the ages of 18 and 29 found that half thought that marriage was becoming obsolete. Their views are supported by the fact that 50% percent of first marriages, 67% of second marriages, and 73% of third marriages end in divorce.

In my lifetime the greatest cultural change in America has been the ascent of women into the workplace. In 1961, in my graduating medical school class there were only three female graduates out of 83 students and the surgical residency programs nationwide had virtually no women residents. Today there are more women graduates from our medical colleges than men and this type of shift has occurred in law and many other professions as well. Thus, the stay at home dad to care for the kids may reshuffle the roles that men and women play in the family. Moreover, the younger generations are more focused on ‘lifestyle balance’ where social life, leisure time, parenting and hobbies are given equal importance when compared to work than in the past. Role reversal and income parity can create a competition that stresses the identities of the couple in a broad range of activities including sex.

Many societal trends have undercut or at least complicated the traditional heterosexual marriage that was/is punctuated as a legal and moral covenant that was permanent “until death do us part”.

  1. Increasing numbers of young and, most notably, older couples are cohabitating without any formal arrangement
  2. Same sex marriage is legalized and greater numbers of gay individuals are ‘coming out’.
  3. Increasing numbers of multi-racial and multi-ethnic unions are occurring
  4. Marriage and child bearing is increasingly taking the back seat to postgraduate education and aspiring career pathways (older marital and child bearing ages)
  5. Gender identification (LGBT) has become a political issue
  6. Fewer high-paying jobs have been created to support a family on one or even two incomes leading to increasing age at the time of marriage
  7. An increasing number of ‘boomerang’ children live with their parents
  8. Increasing numbers, mainly women, enjoy the independence and freedom of living free from the constraints of marriage
  9. Rising earning power of women that make them less dependent on a male bread winner
  10. A more liberal and tolerant attitude toward multiple sexual partners
  11. Decreasing numbers of extended families and multigenerational family businesses
  12. High educational costs and a creeping apocalypse mentality about the future of the human race
  13. Job mobility

Perhaps not all of these trends are destructive of marriage. For some couples a cohabitated trial period might be predictive of marital compatibility. And ‘sleeping around’ with a number of partners might mold expectations and avoid nuptial surprises. But sociologically, the best predictor of marital success remains the determination of the two partners to make it work. A quote that is pertinent to marital bliss is “marriage is the epitome of tolerance.” Of course, children, financial obligations, inheritance, social networks, medical problems and outside opportunities impact marriage and form the glue that may or may not motivate a couple to stay together. Certainly, the pressures and social stigma to remain in a bad marriage are less today than in earlier times. But despite the claims of divorce lawyers that divorce can be an amicable and a simple mediation process, most all divorces are ugly affairs and this is especially true if the very same divorce lawyers get involved.

 

The Good Old Days of Courtship

I have no idea if humans are genetically monogamous or polygamous. Is variety the spice of life or is a strong relationship with one intimate partner the optimal epigenetic trait? I am certain of one thing; with all of the uncertainties of aging and the future; it is very reassuring to have someone there for you through thick and through thin. Unquestionably, this need steadily increases as your grow old. The wonder and joy in having grandchildren, family reunions and compatible companionship far outweighs the independent luxury of living it up alone. Often being single becomes permanent as you find yourself alone with no one that cares. If there is a good sexual accord in a marriage, it is a bonus.

The new sexual freedom does detract from the compelling experience of the traditional courting ritual. There was a time before online match-ups, pervasive pornography, multiple sexual partners and new sexual practices and expectations when kids primarily dated those in their social group, school classmates and family circle of acquaintances. They fell in with the social norms and it was unusual to kiss on the first date. Multiple dates resulted in a relationship based upon familiarity and social intimacy, before sexual intimacy. During this routine there was time to nurture and magnify infatuation and dreams about your girlfriend or boyfriend. This lead to a framework of fantasies, desire and respect for the partner. It was not uncommon for a boy to place his girlfriend on a pedestal on par with his mother or for a girl to view the boyfriend as a comparison figure to their fathers. Stated differently, in the good old days generally you did not put the sexual cart before the horse of personal and psychological harmony. These measured steps, however, were exhilarating and thrilling as they enveloped your partner in a shroud of mystery, expectations and idealization. Today this may seem outdated, but I think the new approach to mating has lost something quite special.

I am sure that this characterization does not capture the journey for the majority of young couples. There is great variation. Furthermore, there are both pluses and minuses to the new sexual roadmap. Maybe multiple sexual partners make marital expectations more realistic and avoid some mismatches that could deteriorate into unhappy marriages and divorce.

 

The Main Message

I am certain of one thing; with all of the uncertainties of aging and the future; it is very reassuring to have someone there for you through thick and through thin. Unquestionably, this need steadily increases as your grow old. The wonder and joy in having grandchildren, family reunions and compatible companionship far outweighs the independent luxury of living it up alone. Often being single becomes permanent as you find yourself alone with no one that cares. If there is a good sexual accord in a marriage, it is a bonus.

 

 

 

 

 

 

Managing Healthcare Costs

Managing Healthcare Costs

Dick Wendel MD, MBA

Everyone in America belly aches about healthcare costs. Indeed, the US spends about twice the amount on healthcare as other developed countries and yet our healthcare statistics do not reflect superior quality of care and better health outcomes. And even as we pay a premium price for healthcare, Americans use healthcare services on a less regular basis than foreigners with fewer doctor’s visits and hospitalizations.

The annual costs for healthcare have risen much faster than the consumer price index (CPI) by one or two percentage points per year. In 1950, healthcare consumed 4.4 percent of GDP; in 2000, it consumed 14 percent, and in 2016, it consumed 17.2 percent. Most forecasters predict it will continue to gobble up increasing amounts of the American pocketbook.

The growth in Healthcare services has been a windfall for the American economy and a true engine of economic growth. If you subtracted the growth in the number of jobs created in healthcare services during the past 25 years, you would have had overall negative job growth during that time frame. In recent years over 11 percent of American workers are employed in just the private sector of health services.

To identify the fat and slack within our healthcare system is not rocket science. However, remedies for this bloated system have been elusive for as long as I can remember. To start my analysis for potential palliation, I will first identify some of the underlying structural and cultural factors that underpin our healthcare system and then address some specific steps that could be taken to better manage costs.

 

The Underlying Cultural and Structural Influencers within the American System

Price Inelasticity

Our system of healthcare lacks price elasticity. In a capitalistic system competitive forces usually act to deter overpricing and economic profit. But in our system, healthcare does not abide by this ‘perfect market’ model. Individuals with pressing health problems do not shop around for the lowest cost healthcare provider. They are more interested in access, perceived quality of care and reputation than whether that physician’s office charges 120 dollars or 85 dollars for an office visit. This lack of price elasticity is also aggravated by comprehensive health insurance coverage in which the enrollee pays little or nothing and often does not see the invoices for billed charges so as to better understand healthcare costs.

Moreover, the accounting methods within the healthcare system produce a disconnect between billed charges and services rendered.  Charges are somewhat arbitrarily set by Medicare and other insurance carriers to reflect the International Classification of Disease (ICD-10 codes) and Current Procedural Terminology (Cpt codes) entered on the charge slips. Most medical bills do not clearly factor in severity of disease, quality of care, outcomes of treatment, counseling provided, socioeconomic factors and resources consumed in rendering care. ABC (Activity Based Costing) accounting methods that are standard in industry are not a part of the vernacular of a hospital’s CFO or the accounting department.

I have always been perplexes as to why the patient healthcare consumer is not more cost conscious. In my 35 years of urologic practice, less than a dozen patients sitting across from me as I discussed surgical procedures asked me “Doc, what is it going to cost?” Moreover, physicians who direct about 80 percent of all healthcare dollars likewise have a very limited appreciation of costs. Even at scientific seminars and hospital grand rounds it is rare for cost issues to surface. And with costly new therapies a parallel cost message to the other consequences of treatments is usually glossed over.

In addition to the price inelasticity on this demand side, there is minimal price competition on the supply side as new healthcare facilities and services come on line. Health care abides by Parkinson’s Law that, for our purposes, is that if you have capacity it tends to be utilized. When you build duplicate facilities or offer competing services such as new specialty clinics, imaging centers and outpatient surgi-centers you draw patients not only from existing facilities but also generate new demand and referrals. And unfortunately, when a medical service center is underutilized and unprofitable, there is a tendency for the doctors and administrators to encourage the performance of more testing, treatments and return visits on their smaller patient census to pad revenues.

And when you try to place a dollar value on what a quality-adjusted life-year (QALY) of good health is worth in dollar terms, everyone just scratches their heads. Thus, with no price elasticity or constraints on the expenditure of healthcare dollars, this question does not need to be addressed by the consumer or the provider. Indeed, public policy and American culture avoids this moral issue and any healthcare proposal that even hints at “killing grandma” or accepting of “mercy killing”, makes it an extremely toxic political issue.

Misplaced Pay Incentives

Another structural problem that escalates healthcare costs is the current payment system that rewards production in numbers that incentivizes the healthcare provider to ‘do more rather than less.’  Due to this assembly line model, medical care becomes more of a commodity. To illustrate, the hospital systems in Greater Cincinnati that own about 80 percent of all physician practices mandate or, at least, strongly encourage their doctors to stay within the limits of 15 minutes for an established-patient visit. Physician incomes and incentive pay is linked to this metric and guideline that probably causes physicians to have their healthy patients return more often for follow up than their sicker ones, because it takes less time to hustle well patients through an encounter and stay within the 15 minute time limit.

Physicians dislike these time restraints, and doctors and patients alike complain that it detracts from the doctor/patient relationship. It also imposes added stress on the physician and, not surprisingly, a recent survey of primary care physicians showed that 50 percent of physicians acknowledged burn-out attributable in some measure to this productivity model of office practice.

Emergency rooms, imaging centers, testing labs and treatment facilities are all wedded to this production model that encourages more rather than less. And some patients are complicit in overutilization and insist that ‘everything to be done’.

Interest Group Money

Another cultural/structural barrier to real healthcare reform is the money sloshing around in the deep pockets of special interests. Each of the major players in the healthcare market have amassed war chests that open the political doors to the hearts of elected officials. Each has a sizeable cadre of lobbyists that badger, monetarily incentivize, threaten and cajole political candidates. Their web of influence and marketing extends to all levels of government, trade unions, public agencies, nonprofits and the electorate. Their mission is to shield their interests from burdensome regulations, budgetary cutbacks, antitrust, unfavorable publicity and the potential threats from healthcare reform.

Few politicians can hold out against these powerful forces. Prime examples are in Obamacare or ACA where the pharmaceutical industry blocked the ability of Medicare to directly negotiate with the drug industry to lower prices; and the healthcare insurance carriers thwarted competition from the Public Option of Medicare in the State Exchanges. Obamacare probably would not have passed without these compromises that have seriously flawed the legislation.

Lack of Physician and Patient Advocacy

In the current system, physicians and patients have become powerless bystanders in crafting public policy. Often, doctors complain that “they have lost the franchise” and indeed, they have. Organized medicine and medical specialty societies have been rendered impotent and have neither the means nor unified purpose to help transform the system. And as an unintended consequence, the patient has lost their physician advocate. The ballot box gives the consuming public a voice, but healthcare public policy does not closely reflect the wishes of the electorate. About 70 percent of Americans support universal access to healthcare through Medicare, yet the Republican Congress voted innumerable times to repeal the ACA even as it was a major step toward universal coverage.

Other Miscellaneous Factors

In the good old days, religious orders ran and staffed many of our hospitals with unpaid nuns and volunteers. Likewise, most medical school and residency teaching was provided by volunteer physicians practicing in the community. Moreover, interns and residents were paid a paltry wage and medical school tuitions and textbooks were quite affordable. There was little medical practice specialization, advertising was unethical and end of life supportive care was usually provided by the extended family in the home setting.

This has all changed. Today, hospitals are staffed with highly paid specialized personnel, the medical schools have large permanent faculties, medical school tuitions and books are expensive and the average medical school graduate shoulders $150,000 in student debt. There are now over 125 medical subspecialties each with their own professional organization. Marketing ads for drugs and medical services clutter all types of media. Today, women have joined the workforce and there are fewer extended families to care for aging seniors in the home, and as a consequence, more seniors in decline go to nursing homes where the care is very expensive.

In summary, these underlying structural and cultural obstacles severely hamper initiatives for real transformational change. Indeed, lack of price elasticity, misplaced pay incentives, interest group money, loss of physician control and the natural transformation of the healthcare system have created formable barriers to change. And the intrinsic paradigms of the current system create loud background noise whenever we address specific measures that might help to contain costs and improve the healthcare system.

Now, let’s objectively discuss some specific measure that might help to contain costs.

 

Process of Managing Healthcare Cost

Controlling Drug Prices

A prominent abuser of the system is the pharmaceutical industry. These publically held companies focus primarily on shareholder value and executive compensation rather than the wellness of Americans. With patent protection and reformulations of drugs to extend patents plus tacit price fixing they charge the highest price they can or whatever the market will allow. There has been a rapid rise in drug costs and they consume 10-11 percent of healthcare dollars. In inflation adjusted dollars the cost per person over the 16 years between 2000 and 2016 was $572 versus $1019. This acceleration in costs are projected to continue as newer biological medications and customized therapies for cancer and inflammatory diseases exit the drug pipeline of new remedies.

Drug companies do not disclose how they price their drugs and they enjoy profit margins of about 20 percent. These margins are far above the group of companies in the S&P 500. They also spend more money on direct to the consumer advertising than they do on research and development.

Pharmaceutical Benefit Managers (PBM) are intermediaries to the system and negotiate drug prices for health insurance carriers. The oligarchy of PBMs (Caremark, Express Scripts, and OptumRx) control 80 percent of the market. Their activities also lack transparency and their revenue streams rely on a complex formula of discounts, rebates and offsets that suggest that they are in bed with their suppliers rather than being advocates for lower drug prices and the patient consumer.

And comparing prices charged by retail pharmacies is challenging if not virtually impossible. The local pharmacist and even the large pharmacy chains are besieged by a host of drug plans that yearly change formularies, categorized individual drugs according to levels of coverage, switch the list of preferred pharmacies and modify prices. Moreover, drug plans encourage the use of mail order pharmacies to cut costs. Unfortunately, the small local pharmacies with their personalized service are rapidly disappearing,

Of course, it is general knowledge that Mexicans, Canadians, Australians and the entire world pay much less for the same medications than Americans. On the surface it looks as if the US consumer is subsidizing the drug costs for other nations. But the explanation for this disparity hinges on a number of factors. First, foreign healthcare systems competitively bid drug prices as a single purchasing unit from multiple drug companies. Secondly, they buy more generics and are more accepting of outside suppliers of equivalent medications and generics made in India, China and so on.

Some observers suggest that a partial solution to drug costs is to tighten the patent laws and push generics drugs. However, in the American marketplace it is curious that generics are often as expensive as named brands. And in many major classes of drugs such as antibiotics and statins the prices for generics cluster very closely around a single price point. Those drug companies that can capture a sole supplier status on an orphan drug or even an old remedy usually, in an obscene fashion, jack up the price.

The solution to the high cost of drugs is fairly strait forward. You need someone with the ‘buyer power’ and agency to achieve ‘most favored nation’ status when purchasing drugs. The ‘most favored nation’ objective would be for the buyer to receive the same price discounts, rebates and negotiated lowest prices that foreigners, the VA system and Medicaid receive. In this way, the American consumer would be guaranteed the lowest price. In this new framework it would be necessary to develop a ‘competitive’ drug formulary that reflected cost, quality and efficacy.

Today, there is only one medical insurance agency in America that is the 1100 pound gorilla with that kind of buyer power to control drug prices. That obviously is Medicare. Medicare must be allowed to negotiate price with drug companies. The drug companies and PBMs will balk but with average profit margins for pharmaceutical companies of 20-21 percent and a healthy bottom line for PBMs, adequate return on investment would remain in place. Additionally, the drug companies might want to trim their budgets for direct to the consumer advertising and limit their quiver of boring television ads and spend more on R&D.

Solving the Transactional Maze in Healthcare

When the digital age arrived it was forecast to streamline medical processes, enhance the efficiency of the healthcare system and decrease healthcare costs. Indeed, IT has a great future in transforming medicine with artificial intelligence, big data, improved digital interconnectivity, Telemedicine, efficient medical record keeping and so on.

But, since the introduction of the Electronic Medical Record (EMR) and an elaborate coding system of DRGs and CPT codes, Information Technology has not lived up to its promise and the ‘paperless’ office remains a distant dream. And quite to the contrary, Information Technology has increased the transactional costs of healthcare and, at the same time, made life miserable for the physician and other healthcare workers.

How can you explain this development? I can cite one statistic that is telling. During the 36 years between 1970 and 2006 the number of physicians practicing medicine in the United State increased by 300 percent. At the same time there was a 3000 percent increase in the number of healthcare administrative personnel. Today, running a healthcare business is complicated and requires more qualified staff to handle new services, new facilities, quality oversight, coding, risk management, compliance and documentation. Each of these introduces a tier of transactional expense. As a result I have never heard an administrator mention how IT has decreased the burden of ‘paper’ work and paper storage.

Record keeping and documentation of the medical encounters has become a nightmare for the medical practitioner. Studies show that about 40 percent of a typical physician’s time is spent entering patient data into the EMR and assigning proper codes. This dramatically impacts a physician’s productivity to the point where few practitioners can see more than 20 patients a day in the office. Before the electronic era and mandated thorough documentation for reimbursement, many primary care physicians could see 50 or more patients comfortably during office hours. But, Medicare guidelines state that “if it is not documented, it was not done” and the claim will not be paid.

Record keeping software systems such as Epic (used in all Hospital systems in Cincinnati) are very costly to purchase, maintain, secure, update and tweak to implement and modify to keep up with changing requirements and regulations. Mastering the medical coding system is complicated and the submission of insurance claims requires many transactional steps to cope with significant variations in individual insurance plan coverages including copays, uncovered services, balance billing, plan maximums and multiple coverages. And insurance claims are often denied due to minor errors in submission and often must be revised, resubmitted and appealed. To manage this challenge, doctor’s offices and clinics need business managers, coding and billing specialists and Physician Assistants. All of these jobs require specialized training and none are minimum wage positions.

Some of the problems with IT in implementing and streamlining healthcare processes will be resolved with time. First, the younger generation is more computer literate and quite handy with their thumbs in accessing information, keyboarding and intuitively understanding software programs and platforms. Vocal recognition software is also improving. Second, information transfer and automation is speeding up and should decrease the number of transactional steps in receiving payment. Third, integrated software systems should help to mitigate the duplications of paper work in history taking, authorization and HIPPA compliance. Sarcastically speaking, this evolution should enable the hospital departments and administrators to hold more boring meetings to fill their days.

From a practical standpoint it is population base medicine with capitation and bundled fees for services that will help to solve the transactional maze that characterizes medicine today. In this optimal model a horizontally integrated system (probably hospital based) would receive a fixed amount per patient per month using cost averaging derived from a representative patient population. This approach would eliminate a mountain of paperwork and, not surprisingly, realign the incentive system to curb unnecessary or marginal medical care and focus on wellness.

Making Sense of Health Insurance and Managed Care Organizations

In the 1980s, health insurance companies began to flourish and the major insurers morphed into Managed Care Organizations with HMOs and PPOs. The insurance agencies touted Managed Care as a solution to the high cost of healthcare. Allegedly, manage care could put together quality parameters and weed out the over utilizing or bad doctors and put the skids on inappropriate medical care. Unfortunately, managed care companies did not have the tools to define quality of care. But their arrival did decrease costs by cutting the reimbursements to physicians by about 12 percent. Beyond that cost savings, it had no effect but did succeed in introducing new transactional expenses.

Managed Care Organizations have increased the cost of healthcare. On average, when a private health insurance company takes your premium dollar, 20 percent is applied to administrative expense and five percent to profit. Another way of stating this is that just 75 percent of your healthcare premium is paid for the provision of healthcare to patients and the remainder is ‘non-value-added’ to the system. In comparison to the 20 percent administrative expense of private health insurance companies, the administrative expense for Medicare runs about three percent.

There are several steps that can be taken to mitigate this ‘non-value added’ expense. The simplest, of course, is a single payer system. Also, if the state exchanges offered the ‘public option’ of Medicare in competition with MCOs, I feel confident that to remain competitive the administrative expenses and profit margins of MCOs would decrease as a result. Another possibility is to permit insurance companies to transition into agencies that run the back office systems of large vertically and horizontally integrated hospital systems that have the size to directly contract with employers and private individuals.

Reasons for Encouraging Healthy Life Styles

One argument that explains some of the higher costs of healthcare relate to an aging population with more chronic degenerative conditions. Indeed, age and, I should add smoking, are risks factors for most all ailments. Certainly, smoking, drug abuse, crack babies and the fetal alcohol syndrome all impact healthcare costs as has the epidemic of the Metabolic Syndrome consisting of obesity, HPT, high cholesterol and adult onset of Diabetes. In response, more and more physicians are focusing on the survival benefits of a healthy lifestyle with a holistic and integrative medical approach to healthcare.

It costs a lot to die in our society as some 28 percent of medical expenditures for those over age 65 are spent in the last year of life. Of note is the fact that over 70 percent of people express a desire to die at home in the presence of their loved ones and yet about 75 percent die in an institution under the care of strangers.

The healthcare system is geared to the ethics of preserving life at all costs and, for many healthcare providers and families it is difficult to turn off the life support machines, enter Do Not Resuscitate (DNR) orders, and even follow advanced directives scripted by the patient that usually state that he or she does not want heroic measures carried out should they become terminal and totally incapacitated with no prospect for quality of life.

Medicine is starting to adopt and promote the benefits of palliative care and hospice with the goal of eliminating futile care and providing a maximum degree of comfort and quality of life. Death with dignity is superior to living with severe pain and misery with little or no hope.

I am a believer that a healthy lifestyle extends life, and, remarkably, also shorten the period of decline and disability prior to death. It is a cost saving strategy.

Providing Universal Access to Health Care

Before the Affordable Care Act, about 44 million Americans have no health insurance, and another 38 million have inadequate health insurance coverage. And today medical bills remain the number one cause of U.S. bankruptcies. It is troubling, even disgraceful, that the United States is the only developed country without a universal healthcare program for its citizens. Granted, the uninsured or underinsured 25 percent of our population is generally young and healthy, but due to cost they often delay seeking medical advice and rely on Emergency Rooms as their primary care provider. This delay causes disorders to be more costly to treat because they are detected at a more advanced stage.

Moreover, Emergency Rooms are very high cost providers and notorious for excessive testing and charges. The solution, of course, is a Federal mandate for universal coverage. This would lower healthcare premiums, offer long term savings to the healthcare system and improve our nation’s health.

In America, many individuals are confused about the term socialized medicine. In a true socialized medical system the government owns everything including the hospitals and clinics, whereas in a single payor system that is being considered in America, it is a socialized insurance system where the instruments of care are still privately owned.

Reducing Medical Mistakes

According to a recent study by the researchers at Johns Hopkins more than 250,000 Americans die each year because of medical mistakes. I believe the system is safer than what this statistic implies. But mistakes do occur and in most cases they represent ‘process errors’ rather than lack of the physician’s skills, knowledge and abilities. The hospital systems are increasingly focused on continuous process and quality improvement with special emphasis on team based patient care and seamless exchange of information. Medicare has been influential in this increasingly collaborative approach to medical care by linking hospital reimbursements to readmission rates, hospital acquired infections, mortality rates, falls and patient satisfaction. These statistical grades are also used to compare hospital systems. Medical mistakes are costly and with improved fail-safe IT systems and integration of processes, the number of medical mistakes should steadily decline.

Historically, medical malpractice premiums have been a big line item for the practicing physician especially in the specialties of obstetrics, orthopedics and neurosurgery. In the past, medical malpractice litigation consumed about one percent of total healthcare costs. However, today most states have implemented medical malpractice reforms and capped awards and punitive damages and malpractice insurance premiums have declined. This has decreased the use of defensive medicine by physicians to quiet their fears of being sued. Moreover, medical malpractice cases are difficult for lawyers to litigate and malpractice juries usually side with the defendants. Indeed, few malpractice cases actually go to trial and most valid cases with clear negligence are settled through arbitration.

Maintaining and Improving the Standards of Care

In the past, physician’s ‘patterns of practice’ and standards of care varied considerably and physician decision making often linked to where they were trained, personal preferences and intuition. A few physician outliers could consume two to three times as much in medical resources treating the same patient population as the average practitioner and there were also some physicians that underutilized medical resources. Also some physicians over utilized hospital inpatient facilities with excessive lengths of stay, and the use of general anesthesia and the operating room for minor procedures that could have been carried out in the office using local anesthesia. There was a lack of standards of care, and Evidence Based Medicine was a newly coined concept.

Today the standards of care are more precise and this variance in patterns of practice is not as pervasive. Still, some disease entities such as prostate cancer are over treated and some screening and imaging and laboratory testing for minor complaints are still over utilized. Today, the hospital systems are increasingly putting physician practice patterns under the magnifying glass of performance and comparison with other providers. Moreover, standardized algorithms of care for common disease entities are being developed that physicians are encouraged and even required to follow. This is a positive trend because of the burgeoning amount of medical information that exceeds the capacity of the human brain to remember. This improvement in standards of care may be the entry point for Artificial Intelligence to gain a footing in medical diagnosis and treatment.

Integrating New Technology and Treatments

Almost daily new pharmaceuticals, tests, techniques and surgical instruments arrive on the scene and are approved by the FDA for clinical use. Unfortunately, new arrivals usually increase medical costs because most innovative products or even ‘new and improved’ modifications of existing technologies are very pricey. The suppliers rationalize these exorbitant prices on the basis of Research and Development expenses; not to mention patent protection and lack of competing products. New discoveries in genetics, inflammatory disease and cancer head the list of transformational technologies. Collectively these advanced technologies are adding terms to the medical lexicon such as precision, tailored and customized medical care for each individual patient.

One overriding problem, of course, is that most innovations are not curative and add just a few months to an often compromised existence. As more of these innovations come online, the society will need to address cost/benefit ratios and how much a year of quality life is worth and still sustainable within the current healthcare budget.

Looking into the future, Information Technology will make medical care safer, more efficient and cost effective. But I do worry about the future. If robotics and artificial intelligence and the ‘machines’ comes into their own; will it eliminate healthcare jobs and create a real surplus of physicians and will the MD degree still guarantee life-long employment?

Reducing Duplication in the Hospital Systems

The hospitals are a major part of the problem. Each hospital system in Greater Cincinnati has aggressive capital campaigns and amazingly deep pockets to expand and build new facilities that afford complete geographical coverage for each hospital system. Often many similar clinics cluster in one area and offer identical services. Moreover, each hospital system boasts of state of the art equipment and a superior group of employed physicians.

According to the flood of marketing materials in the media, the five adult hospital systems in Cincinnati have five of the very best cardiac and orthopedic units in the nation and each claim to be the best in Greater Cincinnati. And how many times have you heard on the radio and TV ads that the Cincinnati Children’s hospital is ranked number two in the nation by U.S. News and World Report. The range of marketing hype and promotional hyperbole is astounding coming from a not-for-profit sector of the economy. Advertising budgets are primarily directed at retaining and growing market share and not cost/effective health care.

Obviously, not-for-profit hospitals are very profitable and objectively are the epitome of social enterprises with revenues and assets in the many billions of dollars. Despite their healthy revenue streams, hospitals milk millions in donations from foundations, corporations, estates, individuals and drug companies that could better be applied to other nonprofits that help the needy and disadvantaged. The Cincinnati Children’s Hospital is like a vacuum sweeper for charitable dollars in the City of Cincinnati.

Hospitals are run just like big businesses in corporate America. I even have difficulty understanding why hospitals qualify as 501-C-3 or charitable entities by the IRS. The redundancy and duplications in the hospital systems across Southwestern Ohio is troubling. And the entire hospital healthcare system within the United States lacks any semblance of central or regional planning. In our region the Certificates of Need (CON) that used to be featured as a constraint on the duplication of facilities has faded into history.

Competition between hospitals is fierce but this does not boil down to lower costs. Insurance carrier pay standardized fees to hospitals and this could be considered price fixing as it does not relate uniformly to quality or quantity of care.

Moreover, payroll expense for hospitals equals 80 percent of revenues and when a hospital is encountering financial difficulties; they can respond by decreasing staffing. They are immune to economic forces that cause most businesses to go out of business.

Having discussed structural problems and more specific cost items in our healthcare system, I will give a brief history of Federal legislation during recent years and then list possible reform solutions.

 

A Brief History of Healthcare Initiatives at the Federal Level

Across the Westernized world universal health care is almost universal with thirty-two of the thirty-three developed nations providing it; the sole exception being the United States. In recent decades, public opinion has evolved to where the majority of citizens now consider access to quality healthcare to be a right reflecting social justice and morality rather than a privilege. Universal health insurance has become a popular political and party platform issue.

As early as 1945, President Truman called for the creation of a national health insurance fund to be run by the federal government. This fund would be open to all Americans, but would remain optional. In 1965, during the presidency of Lyndon B. Johnson Medicare and Medicaid were enacted. In 1971, President Richard Nixon proposed more limited health insurance reform—an employer mandate to offer private health insurance if employees volunteered to pay 25 percent of premiums, plus federalization of Medicaid for the poor with dependent minor children, and support for health maintenance organizations(HMOs). In 1972, this was followed with a Social Security Amendment extending Medicare to those under 65 who have been severely disabled for over two years or had end stage renal disease (ESRD). In 1974, COBRA was passed to give some employees the ability to continue health insurance coverage after leaving employment.

In 1993, the proposed Clinton health care plan included mandatory enrollment in a health insurance plan, subsidies to guarantee affordability across all income ranges, and the establishment of health alliances in each state.

In 2003, President Bush signed into law the Medicare Prescription Drug benefit plan that offered prescription benefits for elderly and disabled Americans.

Finally, on March 23, 2010, President Obama signed into law the Affordable Care Act (ACA) that drove the healthcare markets toward a universal health insurance coverage system. It included many provisions including a Federal Mandate and State Exchanges. Unfortunately, the following day, Republicans introduced legislation to repeal the ACA.

 

My Opinion about the Solutions

The First Steps in Healthcare Reform:

Reinstate the ACA or Obamacare in its original form to include:

  1. The Federal Mandate.
  2. Coverage of preexisting conditions.
  3. Reconfirm a standardized package of healthcare benefits.

Additional Provisions would be drafted by the Congress to include:

  1. Permitting Medicare to negotiate drug prices directly with the pharmaceutical companies
  2. Strengthen the State Health Insurance Exchanges and offer the Public Option (Medicare) as a competitive offering
  3. Mandate Federally subsidized State Medicaid programs

The Longer Term Approach:

  1. First, after appointing a healthcare Czar who would convene multiple panels and committees of experts with broad nonpartisan representation to piece together the ultimate goals and objectives of an optimal healthcare plan for Americans that would guarantee universal coverage, manage costs and ensure quality of healthcare.

Salient questions for their consideration would be:

  1. How do you transition to a single payer system with the least amount of disruption to the economy and job market?
  2. How do you make rational cost projections for the implementation of new initiatives and cushion or phase in the stress placed upon existing institutions and vested interests?
  3. How do you integrate ‘big data’ and population based/capitation models into the healthcare system?
  4. How do you incorporate ‘what works and what doesn’t work’ when you draw ideas from the single payer systems currently used in other countries?
  5. How do you address the ethical issues of rationing of medical care, cost/benefit ratios, and end of life futile care?
  6. Finally, do you have a ‘one size fits all’ system or a two or three tiered system of healthcare?

Most everything in transforming healthcare is fraught with political risk and nothing would be easy. You would need to get some consensus from both political parties and specials interests as to the viability of the changes and then sell it to the preponderance of the electorate. In the current environment this is like an ice cube surviving in hell.

However, I predict that at some point in the near or distant future we will have a single payer system. It will be a long slog probably characterized by a thousand Band-Aids to palliate the system of waste and inefficiency along the way.

You Must Lose Yourself to Find Yourself?

Social Commentary by: Richard G. Wendel MD. MBA

In High School English the students read Ivanhoe a book written by Sir Walter Scott. This lead to a discussion of King Arthur’s Court and the Round Table that King Arthur had designed as ‘round’ to signify equality. To be a knight in King Arthur’s Court you had to accept the Code of Chivalry that included honor, honesty, valor and loyalty. The book Ivanhoe also stimulated a discussion about the Search for the Holy Grail from which Christ drank wine at the Last Supper. The Holy Grail was a symbol of Christian salvation and eternal life. It was associated with spiritual purity, the second coming of Christ and the ‘rapture’ at some later date when the saved righteous would be carried away to heaven.

The teacher also raised the question “what does it means to “lose yourself, to find yourself”. I was a bit young to understand this phrase but as an impressionable teenager, eager to comprehend the meaning of life, I gave the question considerable thought. My Christian upbringing and the idealism of youth also fueled my interest, especially since losing yourself in the search for the Holy Grail bestowed eternal life.

But what does ‘losing yourself to find yourself’ really mean? It sounds noble and pure enough. Since I was raised in an advantaged home I had a broad range of opportunities in which ‘to find myself’. That is, assuming I was of good moral character and willing to work hard. But it also made me wonder, what if I were disadvantaged and raised in poverty without opportunity? If that were the case you might literally be lost and might even be faced with the sole option of finding yourself within a culture of poverty, drug addiction and at best a minimum wage menial job. And for that matter, didn’t Hitler, Mussolini and Tojo find themselves by losing themselves in the spoils of war and dictatorship?

Over time I began to question this notion about “losing yourself to find yourself.” Looking at the issue critically, I began to believe that ‘losing yourself’ might prevent you from enjoying the great intellectual diversity and abundance of this life. A number of my friends have been swept up by a crusade or special set of beliefs that seem extreme and that they steer into all discussions. Often these dogmatic views stifle the conversation and preclude information exchange in a civil manner. For instance, when you are at the bridge table discussing the current events of the day and one of your bridge partners open the discussion with “President Obama is a communistic Muslin who was not born in the USA” or “the Republicans are all misogynistic and racist,” you quickly realize that the conversation is going nowhere; at least not in a tolerant and conciliatory frame if you plan to have a pleasant afternoon of bridge.

In general, individuals that are total disciples of this or that cause are a pretty dull lot and trying to meet them half way with thoughtful conversation usually deteriorates into an outburst that amplifies their viewpoints. It is the old story; don’t bother me with the facts and statistics because they probably are alternate facts and made up statistics.  It is quite obvious that there are no simplistic solutions to the complex problems facing contemporary societies. We live in confusing times where tolerance is in short supply and the issues are made difficult due to the myriad of variables.

In 1964 Barry Goldwater in his campaign for President made the statement that “extremism in the defense of liberty is no vice.” I voted for Goldwater and thought this quote as insightful at the time. Now I think extremism is a vice as it leaves little wiggle room to be a compassionate human that sees issues from all sides and works for the common good as opposed to the objectives of the hardcore believers.

Certainly some moral and social issues are straight forward and no caring or ethical person would promote slavery, drug trafficking, rape, homicide, lynching and so on. Fortunately, our social and moral fabric have recognized the lesser but still egregious abuses and taken proscriptive action over time as is exemplified by the recent ‘Black Lives Matter’ and the #Me Too ‘Silence Breaker’s’ movements. Although some issues with discrimination, abusive behaviors and social justice remain, the nation has come a long ways since I was a teenager in the 1950s.

In that speech Barry Goldwater went on to say “moderation in the pursuit of justice is no virtue”. Today, that quote seems to be the overriding idea behind many movements and belief systems such as Prolife, ProChoice, NRA, Alt Right, Alt Left and sadly both major political parties in Washington. Indeed, moderates are fading as a species and centrist viewpoint no longer seem a viable political option.  That is because you must follow the money from special interests or power brokers if you wish to win the primary against a fellow politician, then plug into the party’s coffers and be reelected. Our politicians can be compared to alcoholics that attend AA programs to stay dry and know that drinking in moderation will cause a total relapse. Alcoholism is like political polarity and the party line; there is nothing in between being either on the wagon or a drunk.

From the perspective of social change, adamantine views frustrate solutions to social problems. How do you address teenage pregnancy, major birth defects and unwanted children when you are a devout advocate against abortion and hold the belief that a fertilized human egg has all of the rights of a newborn viable baby? How do you reconcile the ethical dilemma of late-term abortion performed on a normal viable fetus when you are prochoice? How do you legislate a rational gun policy and mitigate the number of suicides, murders and terrorist attacks when you adhere to the dogma of the NRA and vote against legislations that would permit research on gun ownership? How do you address the issues with Dreamers, illegal aliens, Muslims and refugees when you are a member of the Alt Right that wish to seal the borders and American society? How do you negotiate capitalistic values versus socialism and communism when you are a member of the Alt Left? And how do you just instill a small sense of civility, bipartisanship and cooperation into the operations of the Federal Government when moderates are an endangered species?

The media does not help with this extremism. Sensationalism and the dramatic spin applied to the news make better material for talk radio and social media than the bland commentary of good deeds, the common good and community benefit. Fake news, issue spin and slanted media coverage rules the airwaves and 15 second sound bites or 280 character tweets mold the opinions of the electorate that in most cases is not very discerning of the true picture behind these snapshots. I greatly respect our elected officials and feel quite certain that there are many moderate voices in Washington that become corrupted by extremism due to campaign finance, cronyism and the heavy burden of uncertainty and unadulterated group think.

President Donald Trump is hard to categorize on the spectrum of losing and finding yourself. I think it is fair to say he has ‘lost himself and found himself’ in his self-absorption and self-enrichment. He is a pawn to his narcissistic instincts and although his tweets are designed to hold his Populist base together, his real interests lie in hobnobbing with the rich and famous and showing off his power and “good brain” by undoing the policies of his predecessors. From a psychiatrist’s point of view his diagnosis could fall under many headings such as narcissistic, sociopathic, hypomanic and ADD disorder. His callousness and unapologetic nature suggests that like the Tin Man in The Wizard of Oz he needs to go to the Wizard for a heart.

In many cases, positions of power and control are held by sociopathic individuals who lack a moral compass. This attribute if it has an added degree of paranoia makes for a formidable politician that can take either side of an issue with equal aplomb.  This injects some uncertainty in the legislative process and without a beacon of consistency in your superior’s position, the subordinates or in this case the two political parties is hampered in behaving in a cooperative or bipartisan manner. How do you mediate or negotiate when you are uncertain of the position of your leader? To survive and maintain a semblance of integrity, you remain silent and accept the unrelenting gridlock and dysfunction that flows across the organization or political entitie.

As Lincoln said “God must have loved poor people because he made so many of them” and, at present, Washington is maintaining this status quo even as we are the wealthiest nation on earth. The American dream achieved through industry and ingenuity must be kept alive but how does this reconcile with a childhood poverty rate of 21%, miserable healthcare statistics and the fact that the richest 1 percent in the United States now own more wealth than the bottom 90 percent. Adam Smith is quoted as saying “The real tragedy of the poor is the poverty of their aspirations.” In my opinion, I don’t believe the poor lack motivation; I think they lack opportunity. Isn’t Government entrusted with the responsibility to provide the ‘greatest good for the greatest number of its citizens?’ How does the wealth of a few who have ‘lost themselves to find themselves’ in their economic prowess trickle down to the disadvantaged and how does this represent our national best interests. Furthermore, how do you ‘find yourself’ or achieve your greatest potential when you are raised in poverty

All management and leadership programs stress activities such as teamwork, sensitivity, incremental change and continuous process improvement. And in family affairs tolerance, caring and compromise is the glue that leads to a warm and cohesive family. And diversity training is featured in all leadership programs, board retreats, religious services and public education. Tolerance, understanding and win-win negotiations are preached in every bloody pulpit throughout our great land. But how does this translate to public good?

Our children are raised to succeed, but at what cost? The competition to score well on the SAT and ACT and to get into an elite university is fierce. Increasingly, the advantaged kids with conscientious parents, good school systems, safe neighborhoods and high aspirations are harnessed to the power structure of money, enterprise and control. To compete, they must lose themselves to find themselves in career pathways determined by our universities that have transitioned away from the Liberal or liberating arts into a myriad of specialized departments with focused curriculums that are foisted on even freshman students. Even as today’s youth are more into community service and a balance between career, family and pleasure, for many the competitive forces positively magnetize their orientation toward success at any cost without much regard for values and other kids on the block.

Unlike when I was a kid, aspiring student athletes today need to lose themselves in a single sport to find themselves on the team. This allows no time for gifted athletes to letter in multiple sports. For instance, in tennis to be ranked you must play in USTA sanctioned tournaments and, as strange as this seems, this often preempts playing high school tennis for the best players. To get a tennis scholarship to a Level I or II college you must be willing to play tennis year around for 3-4 hours per day. This begs the question, isn’t university’s primarily role to educate our young people? Moreover, the costs to achieve a high USTA ranking as a rising tennis star are considerable and, on average, about $15,000 per year when you include racquets, restringing, new tennis shoes every 3-4 weeks, entrance fees, travel expense and professional coaches. And, in general, the parents must become helicopter bystanders in the tennis program and do the signups for tournaments, carpooling and live the consuming thrill of victories and agonies of defeat. Less than a hundred male tennis stars on the professional tour make a comfortable living. And at the end of the day, many if not most student athletes really do ‘lose themselves’ as they burn out, sustain injuries that linger and fruitlessly pursue blind ending career pathways in the sports sectors.

The entertainment value and marketing of sports attracts big dollars. Extensive news coverage is given to sports even on the middle and high school level. But, all of this commercialization corrupts and detracts from the pure fun that the student athlete might enjoy in a more social and less competitive environment. In the good old days, we learned sports by just participating, enjoying and competing. We didn’t take a bunch of lessons and follow a rigorous training schedule. Leisurely riding you bikes in the neighborhood was great fun.

Brain function is very complicated. We do know that the amygdala which is an almond shaped nucleus in the temporal lobe is primarily responsible for the fight or flight reflex that regulates emotions and survival instincts and that the hippocampus is the memory unit.  In addition the prefrontal cortex and frontal lobe houses the control panel of our personality that exerts the chief executive function and is the final pathway in how we behave.

Our scientific knowledge about how the brain works is quite rudimentary but, biologically there is a tug of war between the lower centers of our animal brains where survival instincts reside and the higher centers where socialization and civility occur. Despite most human’s mask of calm and stability, most men and women live a life of quiet desperation. This internal emotional turmoil is one reason why, as humans, we like certainty, and structure and predictability in our lives. Ambiguity is threatening and a common strategy to avoid ambiguity is to adopt a simplistic uncluttered perspective unconditionally. Just as the individual cells in our bodies are engineered to maintain homeostasis; our minds are also oriented to stability, certainty and reassurance. All generations fondly look back at the so called good old days when life seemed so secure and uncomplicated and we try to duplicate this tranquility in the present tense.

Whether we like it or not, as human we all must accept the fact that we are mortal beings just like other animals. And as rational human beings, this reality instills a constant uneasiness about the insecurities of living and the frailty of our physical bodies. For this reason, most all world religions have crafted a metaphysical explanation about the universe that gives reassurances about life after death and provides a more permanent meaning to our existence. Additionally, for these beliefs to satisfy the deep seated needs of the faithful followers they must be absolute and plausible. To achieve this threshold, the religious philosophy must produce a value system that sorts out the deserving versus the undeserving and the winners and losers in the claim for heavenly real-estate. This creates a dilemma because there are many different religious philosophies that have differing ways of meeting these same expectations. How do you reconcile these differences while still maintaining the cardinal beliefs within each religion? What seems to be the common solution to these differences is ongoing tribal warfare and mayhem. And the Infallibility of religious beliefs is a major source of extremism and true believers lose themselves and find themselves in their beliefs.

Today with globalization and migration a major challenge for societies is how to bridge the cultural divides and mitigate the upheaval when societies try to integrate competing values and belief systems. Unfortunately, each cultural need to have a lock on special metaphysical knowledge that is usually exclusive rather than inclusive with the scriptures defining the good guys and the bad guys or the winners and the losers. Thus, from a human perspective even though all of us are made from the same ‘dust’ and are in this same boat together with similar emotions and problems, unyielding moral codes  take over that trump acceptance of competing viewpoints. Thus religion becomes a zero sum game with the polarization of good and evil.  And with life after death and Heaven, Hell or Nirvana on the line, it hard to ignore the end game and lose yourself in fixed belief systems.

When you discuss religion with Christian creationists and those that interpret the bible literally it is apparent that they have ‘found themselves’ and do not wish to be sidetracked with a discussion about science. And to many Christians, the ascent with the ‘rapture’ will chose the winners and losers. And if you go to an Islamic Madrasa School that uses the Koran as the textbook that divides humanity into believers and infidels, you see an irreconcilable divide that is difficult to combat with reason.  Even many atheist and agnostics try to impose their beliefs on others. Finding the Holy Grail of certainty may be ‘losing yourself to find yourself’ but it does not justify the plethora of atrocities of the past to cleanse society of nonbelievers. It is amazing how religion can be both good and evil at the same time. Today, in Islam the Sunnis and the Shia are battling each other over what seems to us Judeo-Christian’s to be a pretty minor technicality in their interpretation of the Koran.

Addiction is another way of ‘losing yourself to find yourself’. When in medical school a field trip took the class to the Lexington Hospital for Drug Addiction. The typical inmate was a young mainliners or IV drug abusers that openly discussed how heroin had become the sole purpose in life on the road to finding themselves by losing themselves. Our current heroin epidemic that causes more overdose fatalities than traffic accidents each year attests to this deep seated need for humans to willingly and intentionally lose themselves; often through addictions. And this occurs even as these anti-social behaviors may be totally self-destructive with a devastating ripple effect on society and families. And the high recidivism rates of drug addiction attest to the strong attraction of temporary fixes that are totally consuming of their freedom and free will.

Of course, there are many addictions and compulsions that are a form of extremism and losing oneself. Sex is a perfectly normal and healthy activity but it epitomizes pleasure and when it becomes an addiction with compulsive masturbation, sexual perversion or the indiscriminate selection of sexual partners its can cause one to lose themselves as well as their marriages and significant relationships. Gambling for affordable stakes can make gaming interesting and intense, but some individuals with susceptible psychological profiles get hooked and extreme in their betting. And gambling loses can and often do bankrupt families and foster criminal activity. Many fitness nuts of course are addicted to extreme diets and manic exercise that may or may not have survival advantage but certainly do not grant immortality. Sadly and tragically, many mental disorders take over the personality and cause loss of self with a limited chance to find oneself including schizophrenia (1% of the population), Bipolar disorder (2 %), Autism (1.5 %), Personality Disorders (.6-9.4 %) and Major Depressive Disorder (1.5%) .

There are innumerable social and ethical causes to capture your focused mind, body and soul on your way to losing yourself. The environmentalist movement to save the planet is very appealing and logical and incorporates real science into a movement. But beliefs about climate change and endangered species are not uniform and the special interests of coal miners, energy producers, fisherman and others push back with a minority viewpoint. Where is the compromise as the environmentalists become adamant and disruptive?  Animal activists are also adamant about animal rights and supportive of legal remedies that would lead you to believe that horses, dogs, cats and so on have the same rights as human beings and that we should all become vegetarians and vegans. The devout alt-right comes to blows with the alleged alt-left, and black lives matter advocates are pitted against the police and law enforcement policies. The list of missionary causes is endless in which individuals lose themselves to find themselves. Where does moderation and compromise fit in with extreme viewpoints when there are valid arguments on both sides of the issues?

Extremism has always been and will continue to be pervasive across the globe. There are dozens of countries with authoritarian governments that monopolize power, control the media and suppress dissent. And there is no doubt that power corrupts and absolute power corrupts absolutely. Who would challenge the observation that Kim Jong-un of Korea, Xi Jinping of China, Nicolás Maduro of Venezuela or Recep Tayyip Erdo?an of Turkey have found themselves by losing themselves in their quest for power and hegemony. These are blatant examples where “cream like bastards rise to the top” as it pertains to the levers of power.

There is a more insidious type of manipulative extremism that mixes charisma, money and promises that bypasses morality, fairness, truth and integrity in successfully campaigning for political office. A prime example is the deft harnessing by Trump of the anger of Populism in our most recent election. This, of course, was facilitated by Roger Ailes with Fox News, Bannon with Breitbart, perhaps the Russians that broadcast extreme views sprinkled with alternate facts and fake news via social media. Plus, less than half of the American electorate votes. And many of those that do have only a marginal grasp of the facts and how their vote has the potential to impact their lives. Many voters are extremists in that they lose the scale of their political voice by voting on single issues, party loyalty and subjective and often disleading impressions of the candidates.

In my professional life, I would like to think that I lost myself in the mission of practicing medicine. In terms of Maslow’s hierarchy of needs, medicine has provided me the opportunity for self-actualization which might be considered a synonym for ‘finding oneself’ and being all you can be. Certainly, losing yourself to find yourself in the challenge of a productive career, a fruitful marriage and successful child rearing is glorious and a gift that keeps giving of the bounty that this life offers. But this paper is not about the life well lived but rather the dysfunction that occurs when you ‘find yourself’ in the purity paradox of unflinching orthodoxy and competition.

The world community needs greater flexibility and tolerance in public policy making and international relationships. Nations should not need to ‘lose themselves’ or become isolationist to find themselves. Democratic values are more resistant to nativism and dictatorship but they require an engaged electorate that are involved with the political process and who are seekers of truth and moderation.

All of us are on a quest for certainty, structure and emotional reassurance and survival.  In an ideal world it would be comforting for everything to be either black or white and not grey. But, most issues are infected with diametrically opposing viewpoints just like a criminal trial where attorneys proffer opposite conclusions from the same body of evidence. And it is far too easy to take an extreme view without having to confront the ambiguities of reality and truth and the universality of being mortal.

In closing, I would contend that extremism is a vice and moderation is a virtue and make a plea for individuals to become lost in moderation and balanced views.

Will ‘Big Brother’ supplant Democratic Principles?

Electronic Surveillance in the Information Age; Will ‘Big Brother’ supplant Democratic Principles?

Written by – Richard G. Wendel MD, MBA

 

It has often been said that Democracy is not a great system of governance but it is better than all the rest. Because most all Democracies, even within Parliamentary Systems, move at a snail’s pace, some observers might conjecture that a benevolent dictator or authoritarian regime could get things done in a more expeditious fashion to serve the common good. Unfortunately authoritarian power always corrupts and encroaches upon the rights of the people while at the same time morphing into a scheme to perpetuate that power. Over the millenniums, absolute power has always corrupted absolutely.

American liberty and freedom anchored in separation of powers, equality under the law and a strong Bill of Rights has enabled a mixture of immigrant cultures to blend into a melting pot and produce the greatest civilization the world has ever known. American Democracy has unleased the creativity and ingenuity of its citizens and brought with it prosperity and a high degree of equality.

One of my greatest concerns for American’s future is that massive campaign contributions are eroding democratic principles and social values within a representative system. Supreme Court rulings such as the Citizen’s United case plus the use of 501 © 4 nonprofit Civic Associations to conceal the origins of contributions has distorted the electoral process. As a result, it has given a small numbers of big donors and lobbyists excessive influence over the democratic process and forces politicians to strictly adhere to party lines and follow the money into the narrows of political polarization to get elected.

Before 1987, America’s Federal Communications Commission enforced the “Fairness Doctrine”, which required broadcasters to give equal time to opposing viewpoints on controversial issues. Even though media outlets today often claim to provide “fair and balanced” news coverage, this ‘equal time’ stance has become a relic of bygone eras. Today with 24 hour news coverage from radio, TV, emails, texting and social media the message is often slanted and laced with alternate facts, untruths and fake news that appeal to the opposite ends of the political spectrum. This makes it quite difficult to be an informed moderate. This ‘Group Think’ puts the kibosh on true bipartisanship and compromise that might oil the wheels of government to get something done.

Computer science has contributed to the polarizing tribalism between left and right as well. Some studies show that the majority of news is received from social media rather than traditional media sources. And social media tends to exacerbate the divergence of opinion into separate liberal and conservative camps in which your ‘friends’ and ‘connections’ are segregated to reinforce your particular viewpoints. Moreover, because social media is populated with open source posts, slanted and false commentary can emanate from any online user or, for that matter ‘bots’ from fake accounts. And talk radio and TV exaggerates this split in order to build loyalty within their viewing audience.

In summary, big money and Information Technology has introduced a degree of dysfunction into our Democratic processes that has muffled moderation, compromise and tolerance. Moreover, this turmoil acts as a barrier to recruiting highly qualified men and women to run for elected office, as this drift toward the Alt-Right and Alt-Left institutionalizes distrust and confrontation as the new normal. And this, in turn, produces the unrest and conspiracy approach that can be an enabler and facilitator of authoritarian regimes. This we will discuss later in the paper.

Communist China;The Real Threat to American Democracy

Commercial Ties

When I was a boy, my father often mentioned the ‘yellow tide’ that referred to the masses of Chinese people that would one day sweep west, much the same way that Gengus Khan and the Mongolian hordes did during the 13th Century. It seemed strange at the time because China was a 3rd world backwater country noteworthy only for its rich history. (It did invent gun powder) Later, between 1958 and 1962 with Mao Zedong’s disastrous Great Leap Forward additional skepticism arose about China’s ability to even be a member of the nation of civilized societies. And then when the Berlin Wall Came down and Russian Communism succumbed to the notions of perestroika and glasnost scripted by Mikhail Gorbachev in the late 1990s, it seemed as if Communism would fade and democratic free societies prevail. The Communist ‘Domino Theory’ was discredited and it was postulated that the world’s other authoritarian societies would likewise evolve in the direction of more representative governments.

Communist China came under this umbrella of thoughtful optimism. It was widely held that China could not resist the appeal of Western culture and would evolve into a more Westernized country with an open market economy and a society with greater democratic rights. This assumption and the promise of unlimited cheap labor caused the West to open the door for China to integrate into the Global economic order.

Unfortunately, that expectation proved to be a Trojan horse that has given China equal footing with the West politically and economically but failed to redirect its authoritarian trajectory toward a free and open society. Confirmatory of this observation, Xi Jinping, General Secretary of the Chinese Community Party, recently had the Chinese constitution changed to allow him to be President for life or as long as he chooses. And during his rule he has steered politics and economics towards repression, state control and confrontation. The Chinese government has evolved from just an authoritarian capitalistic country into a dictatorship with total state control.

In his ascent Xi has purged potential rivals, imprisoned free-thinking lawyers, and initiated an elaborate surveillance system to monitor and prevent deviance from state orthodoxy. The Chinese Government controls businesses as an arm of state power, encourages Intellectual property theft and subsidizes and protects numerous strategic industries that account for 40 percent of its foreign trade. China also leverages trade to punish its enemies and in 2018, it extended its outreach by providing 13 percent of total funds supplied to venture-capital–backed-companies in America. This amount of funding was only second to Europe’s contribution.

China is rapidly increasing its full range of defensive and offensive military capabilities with a published military budget in 2016 of $146 billion. It has aggressively pursued its territorial claims to artificially dredged islands in the South China Sea and Western Pacific and widened its claim to these alleged territorial waters. This aggressive action flew in the face of a July 2016, Permanent Court of Arbitration at The Hague ruling against the Chinese annexation. It is clear that China is blatantly trying to displace American power in the Pacific and across the Globe.

Then there is China’s ‘economic’ Belt and ‘silk’ Road initiative to develop economic inroads and infrastructure projects across the region into other parts of Africa and Asia. Hundreds of billions of dollars are appropriated for this initiative that comes with a high price tag and indebtedness for the countries that agree to play ball and take the investment by China. Invariably, as a part of the deal the recipient country is burdened with a stifling debt burden. And being in debt to the Chines feeds Chinese influence and graft. It is clear that China’s long range vision is to displace the influence of the Western powers across Asia and Africa as well as South America.

When economists analyze the Chinese financial system they draw a variety of conclusions. Some predict impending trouble with their unsustainable debt burden, a glut of government subsidized housing, excess manufacturing capacity, currency manipulation, fraud and the excesses of central planning. But with absolute Government control and a range of financial advisors trained in the West and homebred as well these seem to me to be manageable structural and economic problems. Indeed, some economists argue that the most efficient system may be a centralized one because of the emergence of ‘Big Data’ that allows tech firms and governments to “see” the entire economy and coordinate its management in a more logical systematic fashion. Thus, the commonly held notion that a centrally planned economy such as that you had in the Soviet Union will always fail due to misallocation of resources may not hold true today.

Our trade deficit with China in 2017 was $375.2 billion and China owns about 1.19 trillion in official US debt. Moreover, most all major world supply chains run through China. One troubling sector is electronics where 85 percent of the world’s supply is either assembled or manufactured in China. As a result the West’s commerce and debt burden is so heavily entwined with China that we find our economy in a straightjacket of financial and commercial partnership with China. The recent major disruptions in world markets when minor tariffs were imposed on a small portion of Chinese imports and higher tariffs are discussed attest to the strong interconnected relationship between American and Chinese commerce. At a minimum, this leaves us little leverage to peacefully insist on the adoption of American values, human rights and representative Democracy in China. And at the very least a trade war will precipitate a global recession and, quite possibly, a world crisis. Indeed, this clash of China’s totalitarianism dictatorship and the free democratic societies seems to be on a collision course.

Despite the profound disruption inherent in proactively dealing with the China problem, our government must move decisively on a bipartisan basis to recognize the threat and take definitive measures to contain and restrain China. It is no longer a matter of kicking the can down the road as we have for too long. As starters, we need to better protect our intellectual properties by using legal means to mitigate the sharing and theft of leading edge technology when our businesses wish to operate in China. This should include an initiative to encourage American firms to bring their advanced manufacturing facilities home plus regulating in the national interest the American firms that China can invest in and acquire. Secondly we need to negotiate multilateral trade agreements, defense treaties, collaborative arrangements and an enhanced supply chain with the full range of Pacific Rim and South Asia countries that surround China. Lastly, we need to leverage our foremost strategic advantage which is our buyer power and impose tariffs on imported Chinese products with a goal for imports to equal exports to China. This will unleash a costly trade war; the disruption and pain from which is a necessary price to pay for the defense of American liberty and freedom.

  Any impulsive all out trade war would have serious ramifications. Thus, an incremental approach to readjust trade deficits, protect intellectual properties and form new alliances would be the imperative. There will be few winners and many vociferous short term losers. The American consumer will pay higher prices, supply chains will need to be reconfigured and some exporters such as the Midwestern farmer will suffer. In all probability the economy would shrink for a period of time.

However, our other trading partners are well position to step forward and benefit from focused trade barriers against China that aim to decrease the indebtedness and trade deficit with China. In fact, I am confident they would welcome it because many nations especially in South East Asia have a strong anti-Chinese bias. At the end of the day, an ounce of proactive prevention may be worth a pound of reactive cure in the years to come.

The Clash of the Two Systems:

The Chinese form of centralized control has some strategic advantages over our free system of government. Controlling the media with digital technology has been the game changer that enables continuous surveillance and control of the Chinese population. The Chinese ‘Big Brother’ just like a supercharged George Orwell’s dystopian ‘1984’, has perfected new tools to regulate the flow of information and introduce total asymmetry in information exchange at all levels of Chinese society.

In America, social issues are vigorously debated. But in China, how do you think the issues of gun control, abortion, privacy, discrimination, capital punishment, enhanced interrogation and immigration would be handled? Without the possibility for significant pushback, these controversial issues are and would be resolved by simple decree from the small ruling circle. Those dissenting would be punished, discredited or suppressed. As an example, look at the way the Chinese government implemented the one child policy to combat overpopulation. They used mandatory abortion, sterilization and withdrawal of rights and privileges for the families that did not comply. The Tiananmen Square Massacre in 1989 is a glaring example of how Chinese Communism deals with dissent.

Strict authoritarianism has some advantages that exploit the human psyche as well. In general, human beings do not like ambiguity and uncertainty. The Chinese brand of Communism and dictatorship sets forth dogma that requires fealty and offers a singularity of purpose that borders on a religion. In Chairman Mao’s perspective it might be the new “opiate of the people” that displaces the needs for religious beliefs and values.

Thirty years ago without modern Information Technology to manage and censor the flow of information, this abrogation of human free speech would not have been as troubling as it is today. In fact, in the early days of the IT revolution as with the Arab Spring in 2010 in which the uprising spread via social media, cell phones and emails, it was conjectured that the Internet would promote free exchange of information and foster representative government. But today the Internet works and social media in reverse in China as it is fully controlled and monitored by the government.

In sponsored Chines ads and advertising in periodicals and all media outlets, the Chinese boast of putting their citizen’s ‘livelihoods first’, ‘addressing poverty’ and ‘seeking truths in the facts.’ They also brag about their rapid economic ascent and development. In the text and verbiage in this propaganda, individual freedoms, rights, liberty, justice and rule of law are never, never mentioned.

Since 1970, some two million Chinese have been educated in the United States and large numbers stayed to become American citizens. This trend seems to be reversing. According to The Economist, in 2016 more than 430,000 people went back to China after finishing their studies, nearly 60 percent more than in 2011. In the same period, the number leaving China rose by less than 40 percent. The opportunities offered by the robust Chinese economic expansion seems to override the importance of freedom and free speech.

To a Western observer it is difficult to fully appreciate the social and political ramifications of having limited access to divergent opinions and objective news reporting. In China, the Internet is controlled and vetted to insure that there is little variance from state orthodoxy. In China, Internet censors employ more foot-soldier than some armies.  Also it is rumored that a new plan is in the works to impose a ‘social’ rating system that grades the compliance and worthiness of each of its citizens and links these ratings to a range of privileges including education and jobs.

America must wake up and confront this reality that in the Chinese controlled society; liberty, freedom and justice is being subverted to the enduring monotheism of a Communist Dictator. In China, limited freedom of expression is bestowed upon just the few spheres of economic and social life that do not challenge the authority of the Communist party. Unfortunately, the Information Superhighway is a major enabler of this state of institutionalized dictatorship. Indeed, the sustainability of tyrants is assured when all of the vestiges of a free society are cast aside by information control.

 

Positive Steps

American exceptionalism is real but it is time to nurture this across the planet while there is time for our form of government to beat the competition. Isolationism, tariffs, sanctions, unilateralism, military saber rattling, unwelcoming walls plus skeletonizing the State Department, defunding the United Nations and WTO and withdrawing from the TPP and Paris Global Warming Accord are strategies that are self-defeating and drive other nations into the Chinese and opposing camps. We certainly need more soft power, accommodation and multilateralism to win the hearts and minds of our allies if we are to succeed. If Democracy and representative government is to prevail, our way of life must be salable and sustainable so that freedom and justice can outdistance authoritarian communism.

Increasing resources should be directed at maintaining America’s technological supremacy in the information age. There are many facets to this initiative that include a focus on STEM education, more money for scientific R&D and immigration policies that bring the best minds to our shores. Moreover we need to improve our policies that protect our intellectual properties.

Information and electronic technology is entering new realms of advanced robotics, artificial intelligence, drone and military drone swarms, 3D printing and quantum computing. These technologies were the grist for science fiction works twenty years ago. Despite Steven Hawkins admonition before his death about AI when he stated “I fear that AI may replace humans altogether,” I am not concerned that robots will develop ambitions and turn on the human race. However, I am concerned that robots with artificial intelligence will become the agents for the hegemony of tyrants. Robots may be the “big brother’ enforcers for an aspiring despot and this is just one more reason why America needs to retain its technological edge.

Pervasive Surveillance

In earlier times before the digital revolution the private lives of Americans were just that, private. Photographs and family movies were special and filled scrap books and film reels depicting special occasions and watching children grow and mature. Meetings were private affairs and security cameras did not dot the entire landscape. The grapevine and hearsay were significant information sources and the inner sanctum of the home was not transparent to outsiders. When you took a trip you had to carefully follow the maps and detours were not uncommon due to navigational mistakes. Even public figures had private lives in which past indiscretions and skeletons remained in the closet for the most part.

The past twenty-five years has seen the sun rise on a new electronic era of surveillance. Today virtually nothing enjoys the sanctity of privacy and most everything we do is a part of a searchable database. The routs I travel in my car are traceable via GPS and the police have license plate scanners to access my public records and body cameras to document my movements should I be pulled over. The Internet shopping platforms track and aggregate my shopping habits and catalog my surfing to capture my preferences to offer me deals that match my tastes. Social media tracks my posts that give clues to my political beliefs and earmark them for political and governmental scrutiny. The NSA through cellular providers has a log of my cell phone calls and the Internet providers register my clicking around on the web and accordingly sell ad space to other platforms that post materials tailored to my interests. TV viewership is also tracked. Even with HIPPA regulations, my medical history can be accessed by many parties and an insurance company has only a modicum of difficulty in checking up to make certain I did not fabricate any medical condition when applying for insurance. Your Social Security number is contained in many documents. A cold Google search and social media usually provides the inquisitive person a snapshot of your education, employment, volunteer work and achievements. Moreover, your online banking history, credit card transactions and loans are electronically stored and pop up when your credit score is accessed to check for financial worthiness. And many permits, business registrations, media posting and death notices are just a few clicks away from being exposed to any party’s wondering eyeballs. And the government has much more information such as income tax forms and recorded business transactions.

Added to this feeling that your lack privacy is the dire reports of Internet hacking, scams and phishing that has caused a plethora of security firms to raise the alarm bells and enter the market to provide electronic internet security. Put it all together and one has a tendency to get alarmed, worried and even paranoid about their use of the Internet.

Then you have the new range of personal identifiers. Mug shots, blood types and fingerprints used to be the benchmarks for identification. Now we must add to that DNA analysis, iris scans and most importantly sophisticated and accurate facial and body recognition software programs.

Another privacy invasion is the ubiquitous security cameras in the home, on the streets and in public spaces. It is fair to say that we are being protected but at the same time spied upon most every minute of the day. In my opinion, the decline in the crime rates in major cities relates to this surveillance rather than a decrease in the criminal element and better policing. We are being watched and this causes the deck to be stacked against the shop lifter, mugger or rapist.

On the flip side, I greatly appreciate all of the benefits from the electronic revolution. When I was in school I would have grooved on a Siri or Cortana that provides instant answers to most any question you ask. I like the ease of shopping on line, electronic bill paying, emailing, and posting on social media and to web sites. The how to do this or that on YouTube and other sites helps in making home projects a breeze and the ease of travel provided by GPS and Google Maps insures that you never get lost. I like the personal security afforded by surveillance cameras and the ease of access to streaming entertainment videos and news sources. Plus simple and usually free apps enable you to store information and access the whole world of information to support your hobbies, collections and special interests. Indeed, the Internet is almost too good and has raised concerns that it is too addicting and impairs social interaction especially amongst our younger generation.

The Scary Part   

The worrisome part of the electronic revolution is the privacy issue and its threat to freedom and independent actions. We have discussed the facilitating role that information control wields in the Chinese model. However, military coups or rebellions occur on a fairly regular basis in both the underdeveloped and developed countries. In these circumstances, Marshall Law is usually declared as the first action to rid the country of a corrupt government or as a simple power grab. To enshrine this take-over censorship, imprisonment of opposition leaders and journalists usually follows along with the expropriation of the broadcasting media outlets. Once in control, the Internet and social media are usually scrubbed of dissenters and then leveraged for propaganda purposes. The next step usually involves the assault or purge of the judicial system so as to make changes in the country’s Constitution to accept deviation from historic guidance and principles. During this process an external or internal enemy’s list is created and their threats to societal norms and the nation’s sovereignty exaggerated to justify the continued or increasing need for military law and the police state. A failing economy, terrorism, religious and ethnic differences may be the justification for heavy handed suppression. Once in power, this is generally followed by a rigged election to put the stamp of legitimacy on the new regime. Throughout this process the existing institutions are weakened or replaced and the security forces brought under strict control of the ruling junta. The steps along the road to dictatorship are remarkable similar in most cases.

Usually this chain of events toward authoritarian rule occurs in failed states. But in particular, China is not a failed state in terms of a stable society both economically and politically. By Western standards that include freedom and human rights but in China it equates to insuring a malignant status quo and sustainability supported by modern IT for total information control.

North Korea is another prime example where dictatorship is perpetuated by strict control of all media and constant surveillance of information exchange between its citizens. As a brutal oppressive state it ranks 180th out of 180 nations by Human Rights Watch. Internet access is prohibited to outside sources and all news is broadcast and filtered by state media. Despite the severe hardships imposed on the North Korean people, Kim Jong-un, the Supreme Leader, allegedly enjoys a high degree of popular support. The IT propaganda machine is the engine of this strange contradiction between reality and perception.

Heretofore, this usurpation of power would be less durable than it is today because the tools to control the information flow and instigate surveillance were not as perfected or sophisticated before the IT era. Then lives were more private and opposition groups could better remain hidden or protected. But today once a coup is stabilized the mastery of the electronic media ensures greater sustainability of a tyrannical power grab. The dictatorship in North Korea, the theocracy in Iran and the budding sectarian government in Turkey are good examples. Moreover, when there is a coup or internal conflict in a sovereign state, outside nations are usually reluctant to get involved and risk getting mired in the intrigue of regime change or even civil war. At the end of the day, the inherent societal forces that have historically evolved toward representative government and universal suffrage may fall victim to the instruments and platforms of the information revolution.

Does this road to dictatorship pose an increasingly threat to our American Democracy? Possibly, even as it seems unlikely or even impossible in our great land. But what if an unforeseen catastrophic event occurred? What if a cyber-attack disrupted our entire communications and power grid or military conflict came to American soil? What if the social discontent due to a rising disparity between rich and poor boiled over into the streets? What if climate warming accelerated with rising oceans and drought? Or the all-volunteer army revolted and displaced our democratically elected government? I am not a doomsayer but I guess it could happen and having a bunch of AR-15 or Mini-14 assault rifles in civilian hands would not prevent it.

I certainly hope it remains to some degree pure science fiction that robots, clones and drones with learning algorithms can displace humans altogether and perform both the usual and complicated tasks that comprise the majority of job descriptions for us ordinary human beings. Unfortunately, if robots take over, humans would be relegated to volunteer status or underemployment with serious psychological effects. In this grim scenario a totalitarian state could use information control and a system of guaranteed base pay incentives and disincentives to totally control the lives of their subjects. Freedom would be relegated to the history books.

I do not lose sleep worrying about the lives my grandchildren and great grandchildren. It is impossible to predict the future. Some young people are pessimists and forego or give excuses for not having children thinking that the future is too uncertain. I think the future is bright but society must deal with the longer term problems that the digital cyber world poses. Privacy and freedom of information exchange need protection to ward off ‘big brother’.

The Mini-14 Assault Weapon: is civilian ownership justified?

 

assault-weapons-v2

Comparing the AR-15 to the Mini-14

During my year in Vietnam as a medical officer I occasionally did target shooting with my M-16 on both fully automatic and semi-automatic settings. I also debrided horrendous wounds from AK-47 or M-16 guns that had muzzle velocities of 2800 and 3200 feet per second respectively.

Today I shot a Ruger Mini-14 semi-automatic Military style rifle. This assault rifle that takes the same ammunition as an AR-15 has a 30 round clip that can be exchanged with a new clip in a matter of seconds. The Mini-14 weights about 6 pounds, is small in size, has amazingly little recoil and is remarkable accurate. It can be fired at the rate of over 100 rounds per minute with ease. The devastation to our targets that included concrete blocks, water container and cans was awesome. This macho weapon conveys a real sense of power and devastation.

The Mini-14 assault weapon is every bit as deadly as an M-16 military style rifle. In my opinion, it has no place in civilian hands. It is not in general use for hunting, competitive rifle meets, or even self-defense. It is a killing machine that enables some kook to kill in short order large numbers of people.

It is beyond comprehension why the NRA and gun lobby support allowing these weapons to fall into civilian hands with no universal background checks and weapon registration. To outlaw bump fire stocks, oversize magazines, automatic rifles and waiting periods are no brainers but this limited approach is just a band aide if you want to address mass indiscriminate shootings that are occurring at a seemingly increasing rate.

I have a carry conceal permit but believe that all gun sales should include a background check and gun registration and this includes dealers that appear at gun shows without Federal licenses. I realize that there are well 200 million+ unregistered fire arms floating around our country and to call them in to be registered is out of the question, but, at least, universal registration with new gun sales is a start at beginning to track gun ownership. It is no magic bullet but I believe that this initiative does not conflict with the 2nd Amendment rights.

I feel that public opinion is trending toward greater gun control and the NRA will have to adjust if it is to survive.

Written By: Dick Wendel MD, MBA.

Mariemont Students Among Top Business Students in the Country

Ten students in the Mariemont High School/ Great Oaks High School of Business™ satellite program scored among the top business students nationwide on rigorous exams to test their business knowledge.

The exams are part of the High School of Business program, a national accelerated business administration program. Sarah Morgan placed first in Marketing; Wilson Compton placed third and Alexander Wilson placed fourth in Business Economics; Emily Ferguson tied eighth in Finance; Will Hobart and Katie Newman tied sixth, Morgan Rowe placed seventh and Anthony Dimichele tied eighth in Management; Will Hobart placed third in Business Strategies (Entrepreneurship); and Jacob Crabtree and Parker Gilmore tied eighth in Wealth Management.

“Once again, we at Mariemont High School are very proud of how well our High School of Business students have competed locally as well as nationally,” said Dr. James Renner, principal at Mariemont High School. “This is a testament to their strong work ethic, the rigorous and enriching curriculum, and diligence on the part of their teacher.”

The school ranks in the top nine nationally in the number of students scoring in the top 20. Nationally there were only 30 schools with at least one student in the top 20 nationwide and only nine with at least six students in the top 20.

Students participating in High School of Business™ complete hands-on business projects. The program includes observational internships, opportunities to earn college credit and local oversight via a steering team of business professionals, school personnel, parents and former students.

This accelerated program is designed for college-bound students with interest in business administration careers, such as marketing, finance, entrepreneurship and management. Click here for more information about the national organization or contact Debra Baas, business instructor, for more information about the program offered at Mariemont High School.

From left to right: Jacob Crabtree, Anthony DiMichele, Parker Gilmore, Alexander Wilson, Emily Ferguson.

From left to right: Jacob Crabtree, Anthony DiMichele, Parker Gilmore, Alexander Wilson, Emily Ferguson.

Two Local Student Athletes Sign Letters of Intent

Two Mariemont High School seniors recently signed national letters of intent to participate in athletics at the collegiate level. Corinne Fanta signed with the University of Tampa for cross country and Rebekah Justice signed with Iona College for basketball.

Rebekah is a four-year varsity starter at Mariemont High School, two time 2nd team CHL and two time second team all city. She was 1st team CHL and all city and honorable mention all southwest Ohio as a junior.

“Rebekah has been the inside scoring attack for the past three years and the team has had great success,” said Tom Nerl, district athletic director. “She has been a great asset to her team, as a leader both on and off the court.”

Corinne was a regional finalist in cross country and has been named a CHL champion. Nerl said she “took off her sophomore year, following Coach Thomas’s lead, and never looked back. She’s an incredible athlete.”

Corinne said she knew she wanted to run at the collegiate level before she knew anything else. She plans on studying allied health at the University of Tampa, where she said she fell in love with the school and everything else clicked.

“Corinne is probably the most self-motivated student athlete I have worked with in all of my years of coaching,” said Terri Thomas, coach of the Mariemont High School cross country team. “She does her best to make her team better, and she is incredibly driven and well rounded. I have never seen anything like it, and I mean that from my heart.”

Corinne Fanta, her mom, Amie, her brother, Chad, and Coach Terri Thomas enjoy the moment with the entire girls cross country team.

Corinne Fanta, her mom, Amie, her brother, Chad, and Coach Terri Thomas enjoy the moment with the entire girls cross country team.

From left to right (front): Carson Fields, Rebekah Justice, Audrey Theye. From left to right (back): Coach Spreen, Coach Weilbacher, Amanda Lewis, Danielle Bryant, Ashley Rothert, Coach Franklin

From left to right (front): Carson Fields, Rebekah Justice, Audrey Theye. From left to right (back): Coach Spreen, Coach Weilbacher, Amanda Lewis, Danielle Bryant, Ashley Rothert, Coach Franklin

The Barn: Art Roadshow & Showcase of Arts

Cowan's Art RoadshowCowan’s @ The Barn: “Art Roadshow”

Friday Dec. 2 from 9 am – 12 noon

Have you always wondered about that painting, vase, or quilt that was handed down to you, discovered in an attic, or bought at a yard sale? Bring that piece of art or decorative art to the Barn on Friday, Dec. 2 from 9am to noon, where professionals from Cowan’s Auction House evaluate your item and give you an estimate of how much they would expect it to sell for at auction if it were put up for sale today. Fee is $25 per item, all proceeds to benefit the The Barn (Woman’s Art Club of Cincinnati Foundation).

Complete information and registration here.

 

 


Finish your Holiday Shopping at Our Annual Showcase of Arts

Saturday, Dec. 3rd, 10 – 5 pm, and Sunday 12 – 5 pm

Grab lunch at the “Fire on High” food truck!
Click here for list of participating Artists & Artisans 

showcase_of_arts

Opportunities to lower your Village taxes

Indian Hill and Madiera are considering sharing police and public works. Isn’t it time for Mariemont and Fairfax to do the same?

To understand the opportunities, we must first review the budgetary cost structure for the Village of Mariemont. In 2015, total disbursements were $3,243,322 and income was $3,139,322 making a deficit of $104,000. The largest item in the budget was for police services costing $1,108,066 with fire services adding $467,138. The two taken together equated to 49% of the entire operating budget.

The Village of Mariemont has about 3400 residents living in a land area of .89 square miles. Area wise, Fairfax is even smaller with .82 square miles. And yet both communities have a police force of 10 officers and independent, fully equipped fire departments. Surely, there must be some cost savings to sharing or even combining services.

My estimate (that is reinforced by opinions of other Village leaders) is that a savings of 40 percent in police and fire services could be achieved. With the combined police and fire costing $1,575,204 in 2015 that equates to cost savings of $630,000 per year.

What could be done with annual savings of $630,000?

How about:

  1. Eliminate garbage collection fees for residents of the Village (cost $282,527 in 2015)
  2. Hire a Village Administrator ($70,000)
  3. Eliminate the Tennis Association fees for all Mariemont residents (cost $4,612 in 2015)
  4. Eliminate the Swim Club fees for all Mariemont residents (cost $81,161 in 2015)

Longer Range Strategic Initiatives:

  1. The construction of a 200 car parking garage behind the theatre (cost $4 million or $20,000 per space)
  2. A formal tree management program for the aging maple tree stock in Mariemont
  3. Evaluate additional ways to evolve the South 80 into a recreation park and relieve the pressures on Dogwood Park
  4. A million dollar renovation of the Municipal Building to make it into a Municipal Center with better meeting rooms and bring it up to code for the disabled. (This would be in addition to the $400,000 for the Indian Artifacts Museum)

Taking major steps like this to reduce taxes is never easy and requires strategic leadership. I suggest we raise this issue in public discourse and with Council.

Important articles posted on Mariemont.com

Links to the more important articles posted on the Mariemont.com blog during the past 12 months.

 

Mariemont Rankings fall in Cincy Magazine in May

The new Mariemont Firetruck

The South 80 in Mariemont: history, transformation and future April

Missed Opportunities come home to roost April

Does Village Government cede too much power to the Mayor? April

Can Mariemont’s chronic shortages of parking be solved?

Should the Village of Mariemont have a Village Administrator? March

How can local governments cut expenses? January

What if the Village had a budget surplus? January

Is the old Mariemont Steam Plant finally coming down? Nov 2014

A further look at Electric aggregation Oct 2014

A Vision Statement for Mariemont: All Parts July 2014