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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 an overall premium price for healthcare, Americans use the healthcare system less than foreigners in other industrialized countries.

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 this time. 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 that frustrate change and then address some potential steps that could be taken to better manage costs.

Underlying Cultural and Structural Influencers within the American System

Price Inelasticity

First, 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. Moreover, the cost structure within the healthcare system produces a disconnect between billed charges and services rendered.  Charges are somewhat arbitrarily set by Medicare and other insurance carriers and reflect the International Classification of Disease (ICD-10) 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 or the duration of empathetic counseling given by the physician. ABC (Activity Based Costing) accounting methods that are standard in industry are not a part of the vernacular of the Chief Financial Officer and accounting departments in hospitals.

I have always been flummoxed 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 with few competitive forces on the supply side as new 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 when a medical service center is underutilized and unprofitable, there is a tendency at that facility to perform more testing and treatments and schedule return visits at shorter intervals on their smaller patient census.

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 answered by either the consumer or the supplier.

Misplaced Pay Incentives

Another fundamental cultural and 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. This guideline 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 forming a trusting doctor/patient collaborative relationship and increases stress. Indeed, a recent survey of primary care physicians showed that 50 percent of physicians acknowledged burn-out attributable in some measure to this productivity mode 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 money sloshing around in the 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 that espouse supportive views. Each major player and even the smaller ones have sizeable cadres of lobbyists that badger, monetarily incentivize, threaten and cajole political candidates. Their web of influence extends to all levels of government, trade unions and organizations, 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

Physicians and patients have become powerless bystanders to crafting public policy due to the high stakes and influence peddling. Often, they 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.

Other Miscellaneous Factors

 

At one time, religious orders ran and staffed many of our hospitals with unpaid nuns. Likewise, in those times 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. Hospitals are staffed with paid 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, and medical advertisements 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 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.

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 health 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 physicians and other healthcare workers.

How has this happened? The one statistic covering the 36 years between 1970 and 2006 may give us some insight. During that time frame, the number of physicians practicing medicine in the United State increased by 300 percent. In comparison there was a 3000 percent increase in the number of healthcare administrative personnel. Indeed, the organizational charts of hospitals, insurance companies and other healthcare providers have expanded to accommodate new functions such as added services, quality evaluation, coding and compliance. Each new department introduces new transactional expense that increases the demand on Information Systems. Throughout this period of automation I have never overheard administrator brag or even mention how it has decreased the amount of ‘paper’ and storage space for paper records.

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 proper coding. 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 meticulous documentation, many primary care physicians could see 50 or more patients comfortably during office hours. But, Medicare guidelines insist upon comprehensive documentation because “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 keep up with changing requirements and regulations. The medical codes to receive payment from hundreds of the insurance carriers are complicated and subject to their rules. And submitting insurance claims introduces many transactional steps with huge variation in plan requirements, copays, multiple coverages, uncovered services and balance billing. And insurance claims are often denied due to minor errors and must be revised, resubmitted and appealed. To manage this challenge, doctor’s offices now need business managers, coding and billing specialists and Physician Assistants to administer efficient quality care. All of these job descriptions require specialized training and none represent minimum wage jobs.

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

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 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 become more efficient, eliminate duplication, limit marginal therapies and focus on wellness.

Rationalizing 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 doctors plus decrease unnecessary testing 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 75 percent of your healthcare premium is paid to healthcare providers and the remainder is ‘non-value-added’ to our system of healthcare. In comparison to private health insurance companies, the administrative expense for Medicare runs about three percent versus private insurance that averages 20 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 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 a 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 and 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 Appropriate Health Care

About 44 million Americans have no health insurance, and another 38 million have inadequate health insurance coverage. And 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 health 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 increasing collaborate approach to medical care by measuring readmission rates, hospital acquired infections, mortality rates, falls and patient satisfaction. These parameters are being linked to hospital reimbursements and statistical grades that 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 such as 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 juries usually side with the defendants. Indeed, few actually go to trial and usually valid cases 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 and personal preferences. 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 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 and 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 system.

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. These resources are liberally used to build expensive new facilities that afford complete geographical coverage. Often many similar clinics cluster in one area and offer identical services. Moreover, each hospital system boasts of leading edge equipment and a superior/best multispecialty group of employed physicians.

According to the plethora of marketing materials, 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 Children’s Hospital is like a vacuum sweeper for charitable dollars in 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.

 

 

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:

  1. Reinstate the ACA or Obamacare in its original form to include:
  2. The Federal Mandate.
  3. Coverage of preexisting conditions
  4. 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:

  1. First, after appointing a healthcare Czar, 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 jobs 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 to 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, however, 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 cure 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 Democracy moves at a snail’s pace, some observers might conjecture that a benevolent dictator could more expeditiously get things done 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 unleashed the creativity and ingenuity of its citizens and brought with it prosperity and some measure of equality. Granted, there are social problems that remain to be resolved, but in our free society the forces of change to rectify structural inequalities and injustices have a platform upon which to operate and progress to meet the needs and wants of the electorate.

My greatest intrinsic concern 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 relatively small number of big donors and lobbying groups undue influence over the democratic process. This has caused a disruptive polarization of our politics in which candidates must strictly adhere to the party line or else lose financial and grass roots support in the primary elections. Money rather than mission has become the opioid addiction for elected officials.

Before 1987, America’s Federal Communications Commission enforced the “Fairness Doctrine”, which required broadcasters to give equal time to opposing sides on controversial issues. Even though media outlets today often claim to provide “fair and balanced” news coverage, this ‘equal time’ stance has become a rarity in broadcasting. Today with 24 hour news coverage from radio, TV, emails and social media the reporting is quite slanted and laced with alternate facts, untruths and fake news that appeal to the opposite ends of the political spectrum. In my inbox I receive emails from UnfilteredPatriot and Total Conservative that are two ultra conservative organizations. The content of their messages are pure fiction and spin with no objective discussion of the complexity of the issues. They are Rush Limbaugh on steroids. The National Review magazine, however, has excellent articles and I feel sorry for their editors as the new polarized media marketplace has given them an identity crisis.

And once this political sorting takes place with daily reinforcement via FOX or CNN it causes resistance to any rethinking of viewpoints based upon the facts. Illogical as it may seem, the distortions of alternate facts can rationalized or justify most any stance. And within social groups, Group Think is a much easier pathway to take than putting the time and effort into becoming informed plus taking pushback from your friends and even family. Moreover, this media divergence seems to result in a feeding frenzy that enhances the shifts to either the right or the left leaving the middle vacant. Realistically this polarization must put the skids 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, fake news and slanted commentary can emanate from any online user or, for that matter ‘bots’ of fake accounts that do not represent an individual. E-mails are likewise tailored to liberal or conservative causes and sent selectively to constituents with similar beliefs. And talk radio and TV news have followed this polarizing evolution to attract and build loyal followings.

In summary, big money and Information Technology has introduced a degree of dysfunction into our Democratic processes and this has resulted in the muffling of moderation, compromise and tolerance as avenues for consensus building and dealing with the complexity of governance. Moreover, this turmoil acts as a barrier to recruiting and retaining highly qualified men and women for elected office. The drift toward the Alt-Right and Alt-Left promotes and institutionalizes distrust, conspiracy and confrontation as the new normal.

China, The Real Threat

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.

Chinese Communism came under this umbrella of thought. 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 economically but failed to redirect its 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. It also leverages trade to punish its enemies. With an expanding military and claims to artificial islands in the South China Sea and Western Pacific it is clearly trying to displace American power in the Pacific and across the Globe.

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 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. They do not represent an imminent threat to the Communist dictatorship.

Our trade deficit with China in 2017 was $375.2 billion and China owns about 1.19 trillion in official US debt. As a result the West’s commerce and debt burden is so heavily invested in and indebted to China that we are in the straightjacket of financial partnership with China. This leaves us little leverage to sell or impose American values and lead China down the path to improved human rights. A genuine tug of war between the totalitarianism dictatorship of China and the free democratic societies will only get worse and in my view represents a serious threat to the representative governments in the world and perhaps the values at the heart of Democracy.

In view of this asymmetry in trade and debt that adds fuel to Chinese expansionism with such projects as the Belt and Road initiative, it would seem appropriate for our government to recognize this grave threat and craft ways to reverse these two asymmetries that bind our economy to China. The first and simplest is to better protect our intellectual properties by using legal means to restrain the sharing 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 and putting curbs on what American firms China can acquire. Second would be the adoption of multilateral trade agreements and collaborative arrangements with the full range of Pacific Rim and South Asia countries that surround China. Lastly and most controversial would be imposing tariffs on imported Chinese products with a goal for imports to equal exports to China. This would probably start a trade war. However, because we import much more from China than we export to China, we have buyer’s power and this does give us a strategic advantage.

These measures would create major pushback from many vested interested parties. Because short term objective generally trump longer-term objective in American politics, the politics might be unpalatable unless there was a well-orchestrated marketing program. The ripple effects would be huge and there would be a few winners but probably more short-term losers. Many would suffer including the American consumer, Iowa farmers, the supply chain and some manufacturers. In all probability the growth of the American GDP would decline for a few quarters and push the economy into a recession.

However, our other trading partners are well position to take up the slack and benefit from focused trade barriers aimed at decreasing 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 an 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 the flow of information, this abrogation of rights 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 in reverse in China as it is fully controlled by the government.

In periodicals, ads and propaganda, 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 in these articles, individual freedoms, rights, liberty, justice and rule of law are never once mentioned.

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. 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.

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 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.

North Korea is a prime case study in dictatorship 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.

Other regimes such as Russia, Venezuela and Turkey also may be headed down similar pathways. In these countries, populism and nativism have surfaced to enshrine oppressive governments that maintain control through 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 we are to prevail, our brand of democracy needs to be more functional, cohesive and moderate.

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 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 why it is so critical that America retains 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.

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 this electronic revolution remains the privacy issue but also a threat to human rights. 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 appropriation 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 Democratic 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 need for 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 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 it does not measure up and this malignant status quo in China is rooted and supported using modern IT for information control.

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 all of our communications 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 pure science fiction that robots, clones and drones with learning algorithms could perform the usual tasks that comprise the majority of job descriptions for ordinary human beings. Unfortunately, if that were the case, 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.

Full Legalization of Addicting Drugs: A New Direction for the ‘War on Drugs’

According to a recent article in the Enquirer over 13,000 heroin users spent time in Greater Cincinnati’s jails last year and 300 ended up in the morgue.

Introduction

There are six compelling arguments for decriminalizing and legalizing the sale of all banned addictive drugs.

  1. Legalization would decrease the crime to support drug habits and homicides related to drug trafficking.
  2. Producing inexpensive standardized doses of addictive drugs under government supervision could put the drug cartels out of business and decrease the incidence of fatal drug overdosing.
  3. The border problems of interdiction of illegal drugs would be nullified and the drug fueled gang warfare suppressed.
  4. Drug addiction could be treated openly as a medical disorder and the punitive ‘war on drugs’ could refocus on rehabilitation, education, housing and job training.
  5. The cost savings to law enforcement would be huge enabling a shift of resources toward improving community relationships
  6. Finally, taxing of currently banned substances could stimulate job creation and become a rich source of tax revenues.

During the past 40 years, the ‘War on Drugs’ has cost more than $1 trillion for the American tax payer. In 2014, according to the FBI there were 620,000 people arrested for simple marijuana possession and of all the drug arrests in 2013, 82.3 percent were for the simple possession of a controlled substance. In Cincinnati, about 85 percent of criminal arrests that are processed through the Hamilton County Justice Center relate in some way to drugs. Even in the affluent suburbs a large share of police activity focuses on the nonviolent possession of illegal drugs and drug paraphernalia.

There are 2.3 million Americans in prison or about one in every 100 American adults. Over 48 percent of these inmates are there due to drug offenses and it is estimated that the annual cost to warehouse these offenders is about $80 billion per year.

According to the American Bar Association, a single misdemeanor conviction for marijuana possession can be ruinous. In many jurisdictions, a drug indictment cannot be expunged and is discoverable. As a result, this black mark may make finding a job very difficult and preclude access to public housing and college loans plus risk the suspension or revocation of a driver’s license.

The Federal Drug Enforcement Agency (DEA) employs about 10,000 agents and support staff. At the local level, policemen and law enforcement spend millions of hours arresting, processing and prosecuting nonviolent drug offenses. Additionally, attorneys interview, defend, appeal and plea bargain for those that have been arrested and this produces a mountain of paper work and expensive transactions that clog the court system.

William F. Buckley Jr, the conservative pundit who founded the National Review magazine, and Milton Friedman, an economist focusing on free markets, were some of the first to advocate legalizing illegal drugs. Buckley’s basic premise was that nothing had worked to address any of the many facets of the drug problem and Friedman believed that individuals had the right to choose without government interference.

Of course, most advocates for decriminalization draw upon the analogy to the prohibition of alcohol from 1920 to 1933 that filled the prisons with bootleggers and mobsters. The 18th Amendment that imposed prohibition was repealed by the 21st Amendment to the Constitution. Government regulation of the booze industry has succeeded even as alcoholism continues to be a pervasive medical and social problem that dwarfs illegal and prescription drug abuse.

In the United States, the ‘drug problem’ surfaced as a major issue in the early 1900s, a time when cocaine and heroin were unregulated and widely prescribed by physicians.  In 1922, the Federal Government restricted the importation of raw opium and the Bureau of Narcotics was created in 1930.

In the early 20th century, the menace to society from opium addiction was greatly exaggerated. The threat of a drug epidemic conjured up the image of the Chinese opium den. A quote from Harry J. Anslinger, the first commissioner of the Bureau of Narcotics was “How many murders, suicides, robberies, criminal assaults, holdups, burglaries and deeds of maniacal insanity it causes each year, especially among the young, can only be conjectured”.  There was a cultural hysteria that developed about drugs. For instance, in 1948, Robert Mitchum was arrested for the possession of marijuana. This was abhorrent and unimaginable at the time and it hijacked his acting career.

The Supply of Illegal Drugs

On the supply side, addictive illegal mind altering drugs have always been readily available. The opium poppy is widely grown throughout Asia and the Middle East. Afghanistan is a major supplier and attempts to switch Afghan farmers from growing this lucrative crop to other crops had only temporary success.

The leaf of the coco plants from which cocaine is extracted is native to large areas of South America. Cocaine powder can easily be converted to crack cocaine, the free base form of cocaine that can be smoked. In the past fifteen years American contractors have sprayed an area the size of New Jersey with weed killer to wipe out the coco crop in Columbia. In response, some of the production just shifted to adjoining countries, especially Peru. In Columbia, the drug trade is so lucrative that it has fomented a guerrilla war that has lasted decades and the drug barons of Columbia are allegedly some of the wealthiest individuals in the world.

The three species of the marijuana plant are indigenous to Central and South Asia. Of course, marijuana can be grown most anywhere such as your neighbor’s back yard or using grow lights in your basement or attic. A Google search for marijuana seeds turned up hundreds of suppliers in the US.

Methamphetamine and its purified derivatives such as ICE are relatively simple compounds. Although Meth labs explode periodically, Meth can be manufactured using a few basic chemicals in an improvised laboratory. Many other illegal psychoactive drugs exist. These include MDMA or ecstasy that is similar to Methamphetamine; Mescaline or Peyote derived from several species of cacti; PCP an intravenous anesthetic agent; psilocybin a hallucinogen found in certain types of mushrooms; bath salts or synthetic cathinone; and LSD or lysergic acid.

New psychoactive boutique drugs surface frequently. Jil Head, a forensic chemist at a DEA research lab in Dulles, Va., estimates that in the past five or six years over 350 new derivative drugs have emerged that are unstudied and usually synthesized in modern laboratories that, in some cases, receive state support from countries such as China, India and North Korea.

The Trend toward Decriminalization

The advocates for decriminalization of drug possession of small quantities of marijuana are legion. The principle arguments for decriminalization are that it would decrease the prison population of nonviolent offenders, unclog our court system and open the door for drug dependent individuals to seek treatment without the threat of recriminations and incarceration. The fairness issue of social justice reflecting the disproportionate number of minorities that are incarcerated also drives this debate.

The decriminalization initiative seems to be gaining traction. In 2002, a non-profit organization called Law Enforcement Against Prohibition (LEAP) was formed to speak out about our existing drug policies. This group of law enforcement and criminal justice representatives contend that the war on drugs pursued by the US government has worsened the problem instead of alleviating it.

In this author’s opinion, partial decriminalization of drug possession without legalization is only a Band-Aid approach to the problem and may carry with it unintended consequences. Decriminalization alone does little to eliminate the suppliers and dealers that profit from the illegal drug trade. Thus while the jailhouse population decreases, the lucrative drug trade remains intact.

If addicting drugs were legal, profits from the sale of these drugs would plummet. Certainly, one or more pharmaceutical companies under the auspices of the Federal Government could inexpensively produce them in bulk to quickly deflate street prices and displace the drug dealers.

The purity and standardization of prescription painkillers and other Schedule II medications support premium street prices for drugs like OxyContin and Percocet. In contrast, inexpensive street heroin is often watered down or modified with unsafe additives such as fentanyl. Especially in the Midwest, a heroin epidemic has spread and in some areas fatal overdosing is so common that naloxone, a lifesaving pure opioid antagonist that directly counteracts the effects of heroin, is now available in pre-filled syringes without a prescription.

Sealing the Borders: the Problems with Interdiction

Interdiction and policing our borders and coastlines to prevent importation is a daunting task as illegal drugs come in easily portable small packages. Drug sniffing dogs, drones and border patrols may lead to the confiscation of caches of illegal drugs but it is only a small sampling of the amounts crossing the borders. Likewise the air traffic controllers and the coast guard have similar challenges in intercepting smugglers. The drug cartels have proven to be very creative in transport with their use of submersibles, aircraft, vast network of tunnels and concealment by ingestion of sealed packets of drugs. Often those transporting the drugs are only couriers or runners taking the risk for a quick buck without even knowing the dangerous contents of their cargo.  About 80 percent of the illegal drugs imported into the United States come through Mexico.

Meanwhile, ‘drug money’ and drug trafficking has bred gangs and gang warfare in many countries and across borders. The high homicide rates in New York, Chicago and even Cincinnati largely reflect the activities within the drug trade. In Mexico, since former President Felipe Calderon declared war on the cartels nine years ago, 160,000 people have been killed and 26,000 have gone missing. The American thirst for illegal drugs has largely contributed to this chaos while straining American’s diplomatic relations with Mexico and other South American countries.

Money: the root of the Problem

Money and money laundering are the heart and soul of the illegal drug trade. The cash-and-carry incentives filter through the entire supply chain from growers, processors, laboratories, mules and distributors to street vendors. At the bottom rung of the food chain are usually disadvantaged youths looking for a quick buck. Once recruited into the drug trade and gangs, they enter the downward spiral of school dropout, addiction, crime and incarceration. Moreover, this subterranean drug culture comes with a high price tag for our communities where the violence and corruption causes the flight to safety of legitimate business and responsible families. This leaves behind urban blight and decay.

The ‘war on drugs’ provides employment for thousands of law enforcement workers and consumes a significant percentage of public funds to build and maintain lock-up facilities. The cultural shift from search, seizure and arrest to a stance of help, education and rehabilitation would transform police work, ripple across the social landscape and involve a sizeable investment.

Any viable solution to the drug problem must first nullify money within the illicit drug trade. Only by deflating drug prices to the point where the drug trade is no longer profitable for dealers can you contain this blight on society in the longer term. Illegal drug dealing must be replaced with inexpensive, readily available and regulated substitutions. Then the war on drugs can refocus on education, treatment and rehabilitation. It is the primary premise of this paper that education can decrease the rate of experimentation and addiction. Moreover, better rehabilitation for the addicted populations can stabilize this group of addicts realizing that just like alcoholics they are ‘addicted for life.’

New Approaches

According to several surveys, the majority of heroin addicts claim they became hooked after taking prescription painkillers supplied by their physicians, family or acquaintances. These disturbing responses may in part relate to the tendency for addicts to shift the blame for their addiction to the system, but are nevertheless significant. In the realm of addiction you must also add cigarettes and alcohol as threshold or gateway drugs to addiction.

This road to addiction confirms the need to shut down the prescription pill mills and indiscriminate dispensing of addicting pain medications. There is a pressing need for better guidelines and tracking of the prescribing practices of physicians and allied health workers. In the State of Ohio, the Ohio Automate Rx Reporting System (OAARS) tracks the dispensing of all controlled medications by physicians and pharmacies. If implemented in all states, programs like OAARS could share information to make the control more seamless. If illegal drugs were legalized under government auspices, a similar type program could track these substances nationwide. This would provide data to shape public policy and help in directing educational, treatment and rehabilitation services.

Medical studies support the fact that certain personality types are more susceptible to addiction than others with genetic, epigenetic and environmental factors all playing a role. Research has shown that the various types of addictive behaviors follow a common pathway in the brain with the euphoric effects related to a surge in the release of the neurotransmitters dopamine and GABA in the nucleus accumbuns. This region of the brain has been labelled the brain’s pleasure center that triggers motivation, pleasure and reinforced learning. Unfortunately, current brain science is still in its infancy but the large research projects now underway may give better insight into how to more effectively prevent and treat drug addiction in the future.

Due to the abject failure of the punitive war on drugs, it is time for law enforcement to ‘call in the dogs’ and change direction. It is quite apparent that you cannot arrest your way out of the drug problem. There has been no change in drug policy in the past 40 years. Richard Nixon’s “war on drugs” and Ronald Reagan’s “zero tolerance” moralistic viewpoint have failed with the end result that America has gotten the reputation of being the jailhouse nation that costs taxpayers a fortune.

Marijuana: A Special Case and Outlier

Marijuana as a habit forming drug has properties that are much different from opoids, cocaine and methamphetamines. The psychoactive cannabinoids in Marijuana are remarkably safe and there are virtually no deaths directly linked to overdosing. Users may develop dependence upon the drug but marijuana is not highly addictive like many of the other major banned substances. Moreover, withdrawal does not produce physical signs and symptoms but may be associated with mood disturbances. This contrasts sharply with the serious withdrawal effects for addicts that ‘cold turkey’ from opoids, cocaine, methamphetamine and alcohol. When the health risks from Marijuana are compared to those of cigarette smoking and alcohol, they are miniscule. The long term effects of marijuana on the developing brain remain to be adequately studied.

The movement to legalize the medical and recreational use of marijuana has evolved state-by-state into a tug of war between politicians, law enforcement, medical experts, users, home growers, farmers, retailers, ethicists, concerned citizens and tax collectors to name just a few interested parties. Cultural, ethnic and generational differences also muddy any objective approach to addressing the complexity of the marijuana issue and the Federal laws remain proscriptive of legalization. Even the medical benefits of marijuana to combat the side effects of chemotherapy for cancer are controversial and unproven.

In Colorado and other states the economics of legalization have produced a rush of entrepreneurship. It is projected that in Colorado legalization of marijuana will create over 20,000 jobs and billions in tax revenues and license fees from the cultivation, processing, distribution and retail sales. Additionally, it seems to have provided a windfall of commerce to Colorado’s treatment centers, tourist industry, college enrollments and new business development.  But the picture is not all rosy. In Colorado, even as the rate of robberies and burglaries has fallen, there has been an increase in DUI/OVI. In 2014, 12.2 percent of these violations were linked to marijuana. Traffic deaths are also on the rise as is some petty crime due to teenagers doing stupid things while under the influence.

In Ohio, the ResponsibleOhio ballot initiative to legalize marijuana failed but was projected to produce $554 million in tax revenue and 35,000 new jobs. Across the nation, polling shows that over 50 percent of Americans favor legalization suggesting that in addition to the four states in which marijuana is currently legal, more states will pass similar legislation. Indeed, the receipts from the taxation of marijuana and job creation are too tempting to ignore.

As with cigarettes and alcoholic beverages, regulation and legalization of marijuana will fall within the province and jurisdiction of state governments. This is assuming that the Federal government repeals its current prohibition statutes that force the trade in marijuana to appear as a money laundering and subterranean cash business.

A New Model

Historically, prohibition did not work to ameliorate alcoholism and it will not work to solve the hard drug problem. A better approach is to decriminalize and legalize addictive drug as you implement a strategic plan based upon objective sound management principles and medical studies. The Federal Government must take a leadership role in this major initiative. Logically, the ownership of drug policy would reside with The Bureau of Alcohol Tobacco, Firearms and Explosives (ATF) and Health and Human Services (HHS).  A ‘drug czar’ appointed by the President and approved by Congress would be in charge of the new mandate. The new power structure would take into consideration the ‘lessons learned’ from prohibition and the legalization of marijuana. It would also seek the imputes from a broad range of experts and scientists working in law enforcement, the pharmaceutical industry and mental health. The privacy and legal issues are beyond the scope of this paper, but in all probabilities, the congress would have to draft a Constitutional Amendment to legalize.

At present, there are many overlapping agencies within federal and state governments that are involved in the regulation of illegal drugs. At the federal level you have The National Institute for Drug Abuse (NIDA), the National Institutes of Health (NIH), Federal Drug Administration (FDA), Department of Justice (DOA), Department of Labor (DOL), National Institutes of Mental Health (NIMH), Department of Homeland Security, Bureau of Alcohol Tobacco, Firearms and Explosives and many more with some regulatory responsibility. Each state and municipality has multiple agencies that are entrusted with the regulation and control of banned substances.  This highlights the need for a single agency on the federal level to have ownership of drug policy with a number of task forces to centrally coordinate and bring together the host of agencies to achieve a consensus for implementation. Rolling out a new ‘drug czar’ framework may be critical to the success of this major cultural and policy shift.

Drug Safety

Drug safety is a major issue in legalization. Overdosing, bad trips, crack babies and HIV are costly to society. Today, most drug users are putting their faith in the street vendors that represent the lowest tier of the drug supply chain. These street dealers are often addicts that are interested in taking your money to support their habit and life style and quickly disappear if complications occur. Thus, the user trusts these street-wise dregs of society who are generally marginally informed about the potency and additives of the products they are selling.

An addict develops drug tolerance and often needs progressively higher doses to achieve the same effect. These dosages might be fatal to the first time user or even those addicts that have stayed ‘clean’ for a period of time. Drug tolerances also relates to age, gender, weight, general health and interactions with prescription medicines taken for medical problems.

The euphoria and highs produced by addictive drugs are generally of short duration and followed by the lows that reinforce the drive for the next fix. At the end of the day, depression, fatigue, personality change and even suicide may result.  You might think that the rigors of withdrawal and social disruption caused by drugs would cause addicted individuals to seek treatment. However, the criminality and social mores intercede to prevent follow-through in drug rehabilitation programs for this desperate population.

Lack of Scientific Study

The process to legalize would be a gradual one. As a first step, the scale, scope and chemistry of the problem would need to be studied. Often naturally occurring drugs have many synthetic imitations and the introduction of one radical into a chemical structure can profoundly alter the physiologic effects on humans. Many of the laboratories producing contraband drugs use different manufacturing processes that produce wide variation in composition, concentration and effects. Add to this the adulteration of addicting drugs sold by street dealers and the complexity of research challenge becomes apparent.

The dosing and medical side effects of standardized doses of opioids, cocaine, LSD and methamphetamine are fairly well established. But there are a number of boutique substitutes and other hallucinogens that lack scientific study. This poses a real challenge for the FDA that has limited resources.

Academic centers and pharmaceutical companies are not prone to conduct controlled trials on humans to study these drugs because of liability, funding, supply and purity issues as well as the need for animal studies and Phase I and Phase II clinical trials. And where is a legitimate market for an illegal drug? As a consequence, a lack of drug trials also precludes finding out if some of these compounds might have therapeutic value to treat mental illness or other medical disorders.

More resources need to be directed toward controlled studies of these compounds with more direct involvement by the FDA. Perhaps a new division of the FDA could be formed to focus on these banned substances.

Many questions need to be answered about each drug:

  1. Safety features and what is the minimum lethal dose (MLD) of each drug and its variants?
  2. What are the potentials for addiction?
  3. What long and short term side effects might the drug have?
  4. Does the drug have any therapeutic value?
  5. How does the drug interact with other medications?
  6. What are the blood levels at which the drug impairs performance?
  7. How do you screen for drug use and test blood levels?

Education: ‘An ounce of prevention is worth a pound of cure’

No one denies that addictive drugs disrupt lives, families and industry while having a terrible ripple effect across the global community. No reasonable or responsible educator, guardian, parent or even drug addict would encourage their sons and daughters to experiment with drugs or become involved in any way in the drug trade.

Unquestionably, the best way to reduce the prevalence of drug usage is to reduce the incidence of individuals taking drugs for the first time. A preventative medical approach to the war on drugs is more effective than building elaborate rehabilitation centers.

Yet, there is no powerful lobby or poster child for drug policy that draws the public into the debate even as drug addiction affects all socioeconomic strata of our society and festers under a mask of stigmatization and immorality. The punitive ‘war on drugs’ mentality remains largely unchanged.

As a medical student on a field trip to the Federal drug treatment center in Lexington, Kentucky I interviewed a number of recovering heroin addicts. All conceded that drugs had ruined their lives as their addiction took hold and became their sole reason for living. Most were young robust African American men. I came away thinking; what a waste and why would anyone self-destruct in this way? If these individuals had known the consequences of addiction, would they have made the same choices?

For most addicts, the withdrawal process from their addiction is a horrific experience. Just like the DTs when alcoholics dry out, going ‘cold turkey’ from heroin after incarceration or forced withdrawal produces a week or more of agony and life threatening medical issues. The fear of the withdrawal, of course, is one of the drivers to get the next fix. Rehab centers generally use a gradual withdrawal process that decreases the acute suffering and medical risks.

Education about the dangers of addicting drugs should begin in the home at an early age. Parents need to learn the key essentials about the dangers of drug addiction and openly discuss this threat with their children. They should be poised to counter any misinformation and confront any temptations to experiment that may pervade a neighborhood culture. The churches, preschools and nonprofit agencies can also play a role in directly confronting the problem with accurate information.

Often the gateway to addiction begins with tobacco and alcohol. Any educational program designed to curb addiction should also include an added focus on these legal substances that cost the society dearly.

In many public and private school systems health and sex education are a part of the curriculum. Information about the dangers and consequences of addictive drugs should be added to these courses. Video interviews with drug addicts can detail the dangers of addiction and experimenting with drugs. Have school assembly programs for both students and parents dedicated to inform and combat drugs in the local communities. Encourage school student councils and other school organizations such as honor societies, Key Clubs, athletic teams and band members to take a drug free oath and submit to urine testing. Mobilize peer pressures against students that deal or use drugs and encourage students to report incidents of drug abuse to their superiors anonymously. Offer instructive programs to parents that provide a guide as to how to suspect drug usage among their children. Just because drugs are legal does not mean they need to be tolerated in our schools. Expulsion and disciplinary action would still be an enforcement measure. Drug education should be extended to the college campuses as well.

Drug Testing

As with performance enhancing drugs, testing for illegal drug abuse offers many challenges. No simple inexpensive quick urine or blood test currently exists that broadly screens and quantifies the majority of illegal drugs. Recent studies suggest that saliva testing looks promising to check for heroin, amphetamines and cocaine. Adequate funding should enable modern bioscience to produce cost/effective and speedy testing solutions.

Drug testing would involve two steps; one qualitative and the other quantitative.  The first would broadly screen and, if this were strongly positive, lead to a more precise test to quantify blood levels. Newer standards for safe blood levels consistent with acceptable performance and judgement would need to be developed.

Legalization would in no way interfere and probably enhance the appropriate use of drug testing in the work place, schools, athletics and law enforcement.

In the workplace, corporations could continue to have random drug testing as a condition for employment. Driving under the influence of drugs would remain in place and a policy of a drug free school environment would not change. Prenatal clinics would have to provide a routine drug screen with those testing positive encouraged to enter drug rehab programs.

Drug Rehabilitation: Once an addict, always an addict.

To accommodate the surge of drug dependent individuals seeking treatment after legalization, a marked expansion of drug rehab programs and facilities would be necessary. A no-questions-asked approach would help to remove the stigma of drug addiction and deal with the problem as a medical disorder.  Compassionate medication assisted treatment (MAT) rather than ‘cold turkey’ withdrawal would become the standard as newer approaches to addiction became available. Rehabilitation programs in prisons would need to integrate with community programs to insure continuity of care as drug addiction becomes a coded psychiatric medical disorder. Taxes on drug sales would finance the increase in capacity necessary for public, nonprofit and for-profit funded rehabilitation centers to expand and prisons programs to take root. Clinical and scientific research into the causes of addiction would be carried out in these centers and results of this research shared and molded into better prevention and treatment models

An improved curriculum for mental health workers specializing in addiction would be developed. Pharmaceutical companies would receive tax incentives and financial aid to develop new drugs to treat addiction. This would add to the assortment of drugs that are currently employed such as methadone and suboxone.

Downsizing the Judicial System

          No other groups of public servants would be impacted more than law enforcement officers. Because drugs consume a large proportion of law enforcement work and half of all prison inmates are warehoused due to drug offenses, the cost savings secondary to drug legalization would be huge. Additionally, legalization should decrease the rate of violent crime, robberies and burglaries.

The actual cost savings in ‘right sizing’ law enforcement is hard to quantify. There are many vested players in this ‘war on drugs’. Even as legalization would create public and private sector jobs, it would also put many law enforcement jobs at risk.

Especially among minorities, the punitive war on drugs fuels the perception that the policeman is the adversary. Models like New York City’s stop-question-and-frisk concept do little to improve the relationship between the police and the community. With legalization the number of outstanding warrants for parole violations and arrests for drug offenses would diminish and the police officer could have the time to become a mentor and coach for risky behaviors and not just the ‘got you’ enforcer.

The Role of the Federal Government

The Federal Government must take the lead if legalization is to become a reality. Such a dramatic cultural shift, by necessity, would need to be instituted in measured steps that took into consideration all parties. In the author’s opinion, if the federal government offloaded the process to state governments it would devolve into a mishmash of 50 plans tainted with personal agendas and moralistic stances.

A task force of experts representing the major disciplines involved could be convened to assess the barriers to smooth implementation and come up with the outlines of a strategic plan. A master congressional subcommittee would be involved in the planning process and a federal agency would be responsible for crafting the final comprehensive plan in consultation with the FDA, NIH, pharmaceutical industry, state governments, law enforcement and other interested parties. If a consensus is achieved, a legal decision would be necessary to decide if congress alone could approve the legislation to legalize or whether it would require a constitutional amendment.

Replicating the Supply Chain

In general, marijuana, opioids, cocaine and methamphetamine are the four major psychoactive drug classifications that are sold illegally on the street. If legalized, the American pharmaceutical industry under the auspices and control of the federal government could fairly easily, economically and expeditiously produce an abundant supply of these drugs and their various derivatives. If these new legal drugs were supplied at very low prices, it is reasonable to assume that the drug cartel supply chain would implode.

The production and distribution of alcoholic beverages and cigarettes is carefully regulated by states and the federal government. With the regulation of illegal drugs, the division of responsibilities between the federal and state governments would need to be defined. Who would be the suppliers and how would they be regulated? How would the costs and tax revenues be divided? How would law enforcement deal with the residual supply of alternative or designer drugs that remained on the street?

At the state level, the local pharmacies or government licensed outlets would probably be the distribution points. How would the retail outlets track sales and usage? Would they have an integrated and coordinated program that could compile data similar to the way the OAARS program works in Ohio? How would the revenues be directed toward new services for education and rehabilitation?

At first glance, the abundant supply of cheap legalized drugs suggests that it would encourage drug abuse and cause a meteoric rise in the number of lethargic pot heads and euphoric thrill seekers in our society. There is some scientific evidence to suggest otherwise. In 2000, Portugal decriminalized the possession of limited quantities of addictive drugs. This resulted in no rise in drug usage rates and a marked decrease in the rates of drug overdose, HIV and other sexually transmitted diseases.

Most addicts are aware of the dire consequences of drug abuse and are familiar with the terms poverty, homelessness, destroyed families, gun violence and crime that are indicative of drug addiction. Most articles in the media describe the addicting highs from mind altering drugs, but infrequently discuss the soon to follow aftereffects and devastating lows that are compelling reasons not to experiment or become regular users of addicting drugs. Most addicts are highly motivated to quit but ‘the war on drugs’ and traditional norms create barriers to rehabilitation. The penal system remains geared to arresting and warehousing addicts and not medically assisted treatment (MAT) and drug rehabilitation.

In America, legalization might usher in an initial spike in drug experimentation and even addiction. But nothing has worked in the past 40 years to curb illegal drug usage or suppress the illegal drug industry. Cocaine, heroin, methamphetamine and a whole range of deadly illegal drugs destroy lives and undermine our societies. An informed individual is not powerless to ‘just say no’ or quit, and if already addicted seek no-questions-asked help from good rehabilitation centers.

The experience in more than 25 or more countries supports the removal of criminal penalties for drug use.

At the very least, it is time to have a serious conversation about new approaches toward solving the drug problem as the current ‘war on drugs’ is too wasteful of lives and resources. In a more perfect world there should be better solutions, but all else has failed dismally and it may be time to throw in the towel and search for less punitive solutions. One thing is certain, you must be able to nullify ‘drug money’ and illegal drug trafficking, if you are going to make inroads in solving the drug problem.

 

The Arguments for Legalization of Drugs

  • Smaller percentage of Americans incarcerated for nonviolent offenses
  • Decrease in the number of drug related homicides and crime
  • Decrease in the number of deaths from overdosing (43,982 in 2013)
  • Improved access to appropriate treatment for addicts
  • Increased number of addicts and drug abusers rehabilitated back into the mainstream of society
  • Fewer cases of HIV and Hepatitis C due to contaminated syringes
  • Improved tracking of addictive drugs and prescription medications
  • Greater research to find treatments for drug addiction, mental illness and medical disease
  • Elimination of a contentious international political issue
  • Cost savings in law enforcement and improved police/community relations
  • New jobs, tax revenues and entrepreneurial innovation in a new industry
  • A safer world
  • Improved drug screening tests
  • Greater emphasis on rehabilitation, education and drug screening

 

The Arguments against Legalization

  • The potential for an increased rate of addiction
  • Economic and social disruption to the legal system
  • The complexities of regulating and supplying currently illegal substance and Scheduled prescription medications
  • Constitutional and jurisdictional challenges that include privacy and drug testing
  • The moral and ethical dilemmas of legalization
  • Crime syndicates that turn to other types of crime

Richard G. Wendel MD, MBA

 

 

Things to Consider for the Future of Mariemont

Things to Consider for the Future of Mariemont

If you are progressive in your views about the future of Mariemont, I believe that you would support many of the following initiatives during the next four years.

  1. Cooperative agreements with adjoining communities to share police and fire services to reduce redundancy and cut taxes.
  2. Development of the South 80 into a more complete recreational destination.
  3. A long term solution to the chronic parking shortage in Mariemont.
  4. See new agencies emerge like 3CDC in OTR in Cincinnati to spur economic development and the rejuvenation of Old Town.
  5. Electric aggregation for Village residents.
  6. The hiring of a City Manager/ Village Administrator.
  7. New Village Ordinances that imposes term limits, reinstitutes the elected position of Village Treasurer, and increases the number of Council Members.
  8. A balanced budget without erosion of the Capital Improvement fund.
  9. Renovation of the Municipal Building
  10. A comprehensive tree management program
  11. Continued trash collection in the back.
  12. Revision of the Murray Intersection and support for Columbia Township to improve the Southern gateway to Mariemont.
  13. A revisiting of Mariemont Preservation’s Vision 2021 plan.
  14. The demolition of the Steam Plant with condo development. (Work in progress?)
  15. A better rating for Mariemont in Cincy Magazines’ Best Burbs.
  16. Measures to decrease the polarization of the electorate in Mariemont with a more democratic and participatory Village Government.

Best Regards.

Dick Wendel MD, MBA

The new Mariemont Firetruck

The new fire truck is a firefighter’s dream. This type of fire truck is called a ‘quint’ reflecting four capabilities that include an aerial ladder, pumping capabilities, a tank for water and storage of ground ladders and tools.

The span of the aerial ladder is 107 feet with a 750 pound tip load that easily accommodates the weight of both the firefighters and rescued victims. The truck has a 400 gallon water tank and can pump 1500 gallons of water per minute.

The vehicle accommodates six firefighters and a 1000 foot large diameter supply hose and many smaller hoses. Its state of the art toolbox includes the extricating ‘jaws of life’ that can cut through metal and other barriers to remove trapped accident victims.

Notably, Mariemont’s old fire truck was sold for $8,000 and the purchaser refurbished it for $2,500 and it was placed back into service. I wonder why another community could repair the truck and use it when Mariemont could not?

Thus it begs the question, did Mariemont really need a $750,000 fire truck that ate into the reserves of the Permanent Improvement Fund (one final installment of about $250,000 due this year) as opposed to a standard fire truck? It is also noteworthy that there are two fire departments with ladder trucks within a radius of 3.2 miles and most structures within the Village of Mariemont are just two stories tall. Those that are over two stories have sprinkler systems that meet code.

I know it is comforting to have a fire department with a superior ISO rating of 2, but is this really necessary, and when did we last have a significant fire? Most insurance companies do not base their rates on ISO ratings. Moreover,  Terrace Park residents feel quite safe with an all volunteer fire department (24 volunteers) that annually costs between $130,000 and $150,000 per year to maintain versus Mariemont’s cost of $821,187 in 2013 (exclusive of the $254,000 installment for the fire truck).

– Dick Wendel, MD, MBA

The South 80 in Mariemont: history, transformation and future

The South 80 in Mariemont: history, transformation and future

The South 75+ acreage was bequeathed to Mariemont in 1976. Historically the acreage was used to grow corn and beans although, at one time in the early 20th Century, it was a nine hole golf course with a club house, the remnants of which still exist. During recent years H. Hafner & Sons have cultivated the acreage without land rent in exchange for disposing of the yard waste and leaves in the Fall. Few Villagers even knew that this acreage was a part of Mariemont until small garden plots were offered to Mariemont residents in recent years and the Eastern Corridor project resurfaced.

During most of my 52 years as a Mariemont resident, the ‘South 80’ was considered just farm acreage in the flood plain adjacent to the train tracks at Clare Junction. In the days when Clare Junction was an active switching yard, the din from the steam engines and coupling of railroad cars was fairly continuous. Plus the smell of smoke or diesel fuel often settled like an early morning fog over the community. There was also an artesian well with a water tap at Clare Junction where anyone could fill containers with the pure Silver Springs water.

When my children were small, the ‘bottoms’ as we called the South 80 was a great place to shoot off bottle rockets, fly model airplanes and skip stones in Whiskey Creek. At that time, unbeknownst to most parents, the kids used to climb through the large pipes running to Whiskey Creek as well as climb up to the top floor of the abandoned steam-power plant along the railroad tracks.

Now let’s fast forward.  Almost overnight, this fertile farm land has become a remarkably prized piece of real-estate. It has morphed into the site of an ancient Indian Village and has allegedly become a lynch pin for Mariemont’s designation as a National Historic Landmark. Most now refer to the South 80 as a Park. Indeed, it has a nice hiking trail for a pleasant walk in the out-of-doors and numerous small garden plots for residents to grow vegetable and flowers. Additionally, a well with a hand pump has been dug for clean but non-potable water for the gardens.

Three major public work projects have catapulted the South 80 into prominence in the media and conscience of Mariemont. These include the Eastern Corridor Project for Route 32, the Oasis Trail Transit for light passenger rail and the Wasson Line Bicycle Trail. The foremost project creating the most pushback from the residents of Mariemont, Newtown, and Madisonville is the Eastern Corridor Project that entails building a “boulevard” extension of Red Bank Road to act as a connector to Route 32 in Newtown. The argument for building this extender is to relieve traffic congestion on Route 50 and the Beechmont Levee and provide a more direct route to Eastgate, Clermont County and beyond. ODOT contends that this boulevard would stimulate economic growth in the region even as the proposed route would bypass the business district in Newtown.

One of the Routes under consideration by ODOT for building a part of the Eastern Corridor carries the Route 32 connector through the South 80. Supposedly, this route is being considered because a more direct extension of Red Bank Road to Route 32 across the Horseshoe Bend in the Little Miami River would be more costly and challenging from an engineering standpoint.

At this juncture, this segment of the Eastern Corridor Project is unfunded even as it has been on the drawing board for over three decades. Furthermore, where is the $100 billion coming from with so many other competing infrastructure needs such as the Bent Spence Bridge? At the end of the day, I think it will be the no build option that wins out and, if the Ohio State Route 32 project ever moves forward, it will not be in our lifetimes.

The following objections were expressed in the Mayor’s Bulletin in early 2013 concerning the rerouting of Route 32 through the South 80.

  1. Destabilization of the Miami Bluff hillside and further loss of the Indian serpent mound earthwork at the top of the Bluff from landslides caused by major excavation at the base of a volatile hillside
  2. Possible loss of National Historic Landmark Designation
  3. Destruction of Native American Archeological Site (Prehistoric village just discovered by University of Cincinnati)
  4. Negative environmental impact on our park and nature trails
  5. Significant reduction in Village of Mariemont parklands
  6. Increases in the amount of air pollution in the Village
  7. Terrible noise pollution
  8. Water pollution to the Little Miami River, which is listed as a National Scenic River and must be protected
  9. Loss of wildlife habitat (In what other Hamilton County community can a short walk from your home lead you to a natural wildlife area and scenic river? Do we want to lose this unique characteristic of our Village?)
  10. Destruction of the track used by our high school Cross-Country Track team
  11. Impact on Concourse resulting in loss of one of the most beautiful valley views in Hamilton County
  12. Major impact on the nearby Prevey Bird Sanctuary
  13. ODOT’s flawed analysis of alternative routes

In the 2013 Mayor’s October Bulletin, he showed how the Eastern Corridor opposition was gaining momentum. The Mayor was appealing to the court of public opinion and listed the groups showing support to preempt any ODOT plans. This opposition list included the Village of Newtown, the Madisonville Community Council, the Village of Terrace Park, Little Miami Incorporated, Sierra Club, the National Trust in Washington, D.C., John Ruthven, Dr. Ken Tankersley of the University of Cincinnati, the Cincinnati Preservation Association, the Mariemont Preservation Foundation, Hamilton County Commissioners Chris Monzel, Greg Hartman and Todd Portune, Laure Quinilvan, Dr. Stanley Hedeen, the National Trust of Historic Places, the Hillside Trust, the Ohio River Way, Heritage Ohio, the Ohio Ornithological Society, the Cincinnati Bird Club, the Cultural Landscape Foundation, State Representative Peter Stautberg, Brad Wenstrup, and the Piqua Shawnee Native American Tribe. To obtain the endorsements from this mind-boggling array of individuals and agencies must have consumed a huge amount of the Mayor’s time. In general, it seems like overkill and an invitation to make ODOT a hostile advisory to the interests of the Village.

In another Bulletin, the Mayor disclosed that he had enlisted the services of an attorney, Matt Fellerhoff and Bob Newman, to represent the Village in this matter and initiated a program to raise money for legal defense and appeals.

To further muddy the waters, ODOT sponsored community poster sessions for the Oasis Trail Transit Project and the Eastern Corridor Project. Even though the whole engineering crews was present at these meetings, the presenters shed little light on the specifics concerning the rerouting of State Route 32 and Light Passenger Rail.

At a recent scheduled ODOT meeting in Fairfax to explain the programs, I attempted to get some answers from Andy Fleugemann, the 8th District Deputy Director of ODOT. Despite intense probing, he provided no specifics and seemed indifferent to the rising tide of negative public opinion. At that meeting there were no less than 6 engineer representatives from ODOT and I came away with the impression that these Projects were insuring long term employment for this cadre of engineers.

There are many questions to answer if the State Route 32 extender were to go through the South 80.

  1. How wide an easement or swath would the road occupy and how many lanes would it have. What assurances do the residents of Mariemont have that this would not be an expressway or Interstate Highway?
  2. Would the highway or boulevard be separate or run parallel to the railroad tracks?
  3. Assuming the Oasis Rail Line and Watson Road bike path became a reality; how would they integrate with the Ohio 32 extender?
  4. How many of the South 80 acres would be consumed and what would be the configuration of those left for development?
  5. How would you insure improved access to the residual acreage for recreational activities?
  6. How much and to what height would the connector need to be elevated to address the flood plain issue and to what degree would this obstruct the view from the Mariemont Concourse?
  7. Would the high tension wire towers need to be moved, relocated or would these utilities be buried?
  8. The traffic would cause what decibel level of background noise and what steps would be taken for noise abatement?
  9. Would the project cause any instability to the Miami Bluff or cause rerouting of the Little Miami River?
  10. How would you safeguard or preserve any antiquities that might be uncovered during construction?
  11. How much money as ‘sweeteners’ to the deal would ODOT give to the Village of Mariemont to build access to the South 80 and create recreational facilities such as ball fields, picnic areas, parking lots, camp grounds, gardening sheds, electric outlets, city water and a fishing dock?
  12. How will ODOT deal with the Mariemont Historic Village issue and manage all the concerns expressed by the residents of Mariemont as well as other effected communities?

None of these questions have been answered to the satisfaction of the vast majority of Mariemont Residents.

When I hike the trail, I see additional opportunities for the Village to consider in the utilization of the South 80 such as:

  1. A couple of baseball diamonds or soccer fields with a parking lot and portable toilets. This would alleviate some of the congestion and improve safety around Dogwood Park in the heat of baseball and soccer season and provide practice fields for the Mariemont School System.
  2. An elevated open air shelter house that can be easily cleaned if flooding occurs and provide shelter for campers, hikers and picnickers.
  3. Make the garden plots more appealing by offering rentable sheds to house farming equipment and provide electric
  4. Improved access and parking

This is just brainstorming to produce food-for-thought for the council committee that oversees the South 80. The minutes of their meetings have been posted on this blog in the past. As the first step the 1.4 mile scenic trail around the South 80 acres below Miami Bluff is a great addition. The community is indebted to the volunteers for the hard work that brought this about.

Missed Opportunities come home to roost

Missed Opportunities come home to roost

Village Residents that follow the political landscape in Mariemont are dismayed that Mariemont was ranked 28th among the suburbs in Greater Cincinnati by Cincy Magazine. Let’s try to sort out why Cincy Magazine might make this assessment. It certainly does not relate to our school system or safety services. Indeed, Mariemont is a safe, walk able community with many amenities that make it an outstanding place in which to live and raise a family.

Perhaps, our high comfort level with the way things are may breed complacency that fosters an acceptance of the status quo. In business school parlance, the residents of Mariemont might be “dumb, fat and happy” so why change or become circumspect as to why Cincy Magazine does not rate us amongst the very best suburbs? Maybe it may relate to the management of Village finances and strategic planning during recent years.

In 2014, the Village posted a General Fund budgetary loss for the first time in many years of $28,652. Also, the Permanent Improvement Fund or Capital Fund notably decreased by $183,272.  Taken by themselves, these losses are fairly modest but they do suggest a downward trend in Village finances.

The financial position of the Village has been and will be impacted by the following factors.

  1. The loss of Ohio State estate taxes and subsidy that historically produced about $250,000 in annual revenues. Indeed, Governor Kasich has balanced the Ohio State budget by cutting back on the funds that the local communities receive from the State.
  2. The missed opportunity to form a JEDZ with Columbia Township which probably would have produced over $200,000 in unfettered annual revenues. This directly led to the formation of a JEDZ between Columbia Township and Fairfax.
  3. The possible winding down of Kellogg operations in the business district that would put $600,000 in revenues at risk (about 18 percent of the total budget).
  4. The continued maintenance of a fully-equipped independent Police, Fire and EMS service without sharing these services with surrounding communities.

With these threats to Village income, what is left to cut to balance the budget? At this time, it appears that the Village is poorly positioned to meet the coming financial crunch without higher taxes.

In retrospect, when the Village was flush with revenues during the past ten years, many strategic initiatives could have been undertaken to enhance the standing of the Village amongst the suburbs in Hamilton County. These might have included:

  1. Give financial support and incentives to rejuvenate the Historic District
  2. Plan and build a parking garage to alleviate the shortage of parking
  3. Renovate the Municipal Building
  4. Develop the South 80 into a recreational destination
  5. Hire a Village Administrator
  6. Work with surrounding communities to save money by sharing services
  7. Put in place a plan for a community center
  8. Use creative financing to foster business development

When I first heard that Mariemont was ranked 28th among the suburbs in Hamilton County, I was incredulous. However, this ranking does point to the fact that the status quo may not be good enough.

Does Village Government cede too much power to the Mayor?

Does the current structure of Village Government cede too much power and control to the Mayor?

Mariemont has always had a strong mayor or mayor-centric form of government which is the norm for small communities. In Mariemont the Mayor is elected for four years without term limits.

Six Village Council members with four year terms are the only counterbalance to the authority of the Mayor.  In January 2014, the two elected official positions of Village Clerk and Village Treasurer were eliminated and replaced with a Mayor appointed ‘Fiscal Officer.’

Typically, two or four Council candidates are nominated at an annual Village Town Meeting in March or April every other year and generally run unopposed. Many prominent residents believe the Village Town Meeting construct is an outmoded and antiquated system that as a ‘default result’ produces weak candidates due to a lack of resident participation. Moreover, councilmen receive nominal compensation of about $1000 per year for their volunteer time and efforts that includes many meetings that deal with mundane matters. It is easy to see why so few Villagers wish to become involved in local government and at the present time, most new recruits for Council are ‘persuaded’ as ‘friends of the Mayor’ to run for Council. It is not surprising that the turnover rate for Village Council members is quite high due to term expiration, resignations and relocation.

Unlike corporate America and larger nonprofit boards, the members of the Village Council are not selected based upon their competitive range of skills, knowledge and abilities and, as a consequence, there is limited diversity and narrow skill sets in council membership. Additionally, there is no formal Village Administrator to handle operations and provide input and feedback to the Mayor and Council.

To understand the dominant power and control equation enjoyed by the Mayor consider the following:

  1. All Departments report directly to the Mayor
  2. The Mayor crafts the agenda for Council Meetings
  3. The Mayor controls council committee appointments
  4. The Mayor restricts committee activities to those he personally assigns
  5. The Mayor unilaterally, without review or approval by Council, produces a monthly Mayor’s Bulletin for distribution to each household in the community
  6. The Mayor is a voting member on the Architectural Review Board
  7. The Mayor is the Chair of the Planning Commission and a voting member
  8. The Mayor maintains an official Village website that gives little transparency to Village Government
  9. The Mayor presides over very perfunctory bi-monthly Council Meetings that last an average of 18 minutes, in which real issues are seldom discussed
  10. The Mayor has a three minute time limit for any Village resident coming before Council.

My suggestions to improve the make-up of Mariemont Village Government include:

  1. Form a Membership or Governance Committee of Council to recruit qualified candidates for Council. The committee could be chaired by the Vice Mayor and comprised of an additional Council member, a Village resident appointed by MPF and a representative from the School Board for a total of 4 members.
  2. Modestly increase the compensation for the Mayor and Council members
  3. Hire an empowered Village administrator that has more than just clerical duties
  4. Reinstate the elected Office of Village Treasurer to act as an independent voice
  5. Increase the number of elected Councilmen to eight with the addition of two at-large-members identified by the Governance Committee
  6. The Mayor should be only an ex-officio member of the Planning and Architectural Review Boards
  7. Term limits: two successive terms for both the Mayor and Council members

 

Responses to this post from Mariemont Residents:

  1. “Agree with your assessment. There are likely 20 more examples of the lopsided nature of government in Mariemont.”
  2. “The problem stems from the mayor being too power hungry compounded by voter apathy and fear of reprisal. Without new faces, nothing will change.”
  3. “I think we would be better off pursuing term limits and would further support the hiring of a Village Administrator as the remedy for the over control of the Mayor.”
  4. “It should be emphasized that the Code of Ordinances governs the Village, and it specifically states that the Mayor reports to Council, not vice versa.”