Health care reform: A better idea

      "On our current track, health care is anticipated to consume 20 percent of our GDP at about $7 trillion annually. Cost containment is key to making the system affordable, and many options would provide relief while at same time enhancing the quality of health care delivery."

                      Bruce Van Zee, M.D. 

I requested guest posts from people with knowledge and experience in healthcare delivery. 

Yesterday I posted the first response. Today I post another.

Bruce Van Zee is a retired nephrologist. He lives in Medford, Oregon and calls himself a "Never Trumper." He began sharing his thoughts during this second Trump term in his new blog on Substack.

Guest Post by Bruce Van Zee, M.D.

I read the yesterday's guest post by Mark Knudsen, and dashed off a comment. I wanted to add to the discussion of what we might do to fix health care in the USA. Other developed countries have worked out a way to have access to healthcare for citizens. We know it can be done because it is being done. 

Rather than reiterate what I have posted on health care in the past, I will leave links to several of the posts at the end of this comment. I agree with Peter that the system Mark described could well improve the chaos and dysfunction that now permeates our system, but it is complicated and still has too many moving parts, I think. Currently, our providers ---hospitals and physicians -- are inundated with regulations, forms, requests, and criteria from a host of payers. They must hire large numbers of clerical people to deal with all the players, each taking a bite out of the health care dollar that ideally would be going to care. It is no wonder the American hodgepodge system is twice as expensive than all other Western developed countries and delivers worse population-level outcomes. To add insult to injury, it still doesn't provide universal access, even in Oregon, which has a robust Medicaid system, the Oregon Health Plan. 

Imagine if our federal highway interstate system had been built by individual entrepreneurs to their own specifications for signage, asphalt, maintenance, and so forth. And with a toll booth every 25 miles or so. I'm a believer in free enterprise and capitalism; government should not be involved in selling cars or TV's. But neither should for-profit businesses, private equity, and publicly held companies be major players in health care. Shareholder goals are not the same as what patients need. When Obamacare was being debated, we almost got a Medicare option for all. If that had happened, our problem might be considerably improved. Medicare runs with a 4 percent overhead. Private insurance and for profit companies are above 20 percent. Denials and prior authorization are not significant issues with traditional Medicare because they are only based on scientific evidence of benefit, not the conflict of interest in profit vs. care that for-profit companies face. Former Governor John Kitzhaber's program more than a decade ago for Oregon Medicaid was rational. Care was ranked: A special health commission ranked hundreds of medical conditions and treatments based on clinical effectiveness and public values. That is a much more appropriate way to manage costs than denial of care based on profitability. 

Bottom line: my vote is for a Medicare-for-all option. The obstacle in doing this is, of course, the monied interests that are immense, all taking a bite of the $15.5 trillion being spent on our dysfunctional health care system. And those players give enormous amounts of money to the lawmaker's campaigns to make sure the system doesn't change. It will take a grassroots effort to convince legislators to offer a Medicare-for-all option. The beauty of the option is that you don't have to do anything with the for-profit companies; they will be unable to profit as they have been as folks begin to realize the hassle-free value of traditional Medicare. The costs of the increased Medicare system will require higher corporate and high-income taxes, but businesses would be relieved of the burden of employee health insurance.  

I have been posting my own thoughts on healthcare at my Substack site: https://bvzcvz.substack.com. 

Here are links to specific articles:  

Can we afford medicare for all?

Traditional Medicare vs Medicare Advantage?

U.S. healthcare costs and outcomes: a primer

The dangers of for-profit healthcare

Mega-corporations are a threat to American values 

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Health Care Reform: Here's an idea.

"Medicare for all" is easy to communicate. 

People are familiar with it, and most people getting Medicare like it. It has political viability as an idea because it sounds like such a simple, clear solution.

Just do it.

But there are questions and problems. How to pay for it? How to transition to it? What about current institutions, including insurance carriers? What about people who like what they have now, and consider Medicare a downgrade? And what about people who want less government, not more government?

I asked people who work in health care for their best suggestion on how to structure a reformed health care system. The first person to respond in writing is Mark Knudsen, a near-classmate in college, graduating a year after me. Knudsen went to business school and then had a long career in administration of health care for providers and insurers. He administered hospital and clinical services at the Shriners Hospital for Children and Cascade Health Solutions. He also negotiated health care contracts with employers.  He is retired and lives in the Portland, Oregon area.

He doesn't describe a simple solution, nor a government-run one. He says to get employers out of the system. His idea is hard to describe and it would be a much harder one to build a political movement around. (Hillary Clinton's 1994 solution was mocked and dismissed as too complicated -- its fatal flaw.)  I don't dismiss this idea as wrong; only as politically impossible. But I pay attention to it because Knudsen had a career dealing with the issues and problems of providing and paying for health care, and I don't dismiss the thoughts of people with knowledge and experience in complicated matters. 

Guest Post by Mark Knudsen

Proposal for Health Care Reform

Advocates of health care reform face two problems. First, it is too easy to opt out of paying for services and secondly, there are too many unaligned interests in the health care market unlike other commercial markets. The proposal below defines the health care market as medical, dental, mental and drug services and providers.

The first step is to require all people in the United States to enroll in a healthcare payment program or demonstrate that one has sufficient liquid assets to pay for services that can be attachable by a healthcare provider.

Employers, state and federal governments, providers, patients, drug companies, and insurance companies are currently involved in the marketplace. Each has different and conflicting interests. Of those involved, the employer has the no legitimate interest in health care. Eliminating the deductibility of health care expenses and rewarding companies who increase employee pay for the loss of this benefit would be the next step.

The third step would be to create independent consumer consortiums which would negotiate directly with insurance companies for benefit packages and premiums. Costs would become more apparent to potential patients, and patient needs more apparent to insurance companies.

Insurance companies would retain their care delivery contracts with providers. By being in direct conversation with subscribers, the insurance companies can more effectively pressure hospitals, physicians, drug companies, and other providers to meet changing consumer demands and to minimize expenses. Insurance companies who fail will become less competitive and lose subscribers. Providers would be more effective in negotiating their reimbursement levels given their knowledge of their patients and their needs.

State and federal governments would be the primary payer for indigent and special needs populations. They could enter into agreements with insurance companies to administer these programs or contract directly with delivery systems or specialty clinics. State and Federal government certification and licensure programs would be the only quality assurance standards for delivery providers. The federal government would be the reinsurer for extraordinarily expensive cases and for experimental efforts that show promise for a wide swath the American public. For example, the Federal Government would have reimbursed providers for Tommy John’s surgery in 1974, not the Los Angeles Dodgers.

Medical expenses incurred by a taxpayer are now an itemized deduction on Schedule A. Under this proposal, medical expenses would be an adjustment to adjusted gross income on a personal 1040.

Like any proposal, the devil is in the details. The transition period would be complicated and involved but removing the employer from direct involvement in the health care marketplace should make reform easier.

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Melons, grapes, and puncture vine

It isn't all politics, all the time, everywhere.

Part Two: grapes

(I wrote about melons on Saturday, and I will get to my noxious puncture vine weed problem soon. If reading about the vineyard bores you, skip this post.)

I am putting up netting to protect my crop from birds.

Last year I got my first harvest in the new vineyard. The Pinot Noir grapes are the first of my three varieties to blossom and the first to be ripe enough for harvest. We picked on October 6 last year. There was no bird loss.

The Malbecs were next to pick, scheduled about 10 days later. There was a huge crop waiting, so huge I had to "drop fruit," in preparation for the harvest, which is to say remove about 40 percent of the grape clusters to try to concentrate the vines' energy onto fewer grapes. I had a valuable crop on deck. I posted a photo of the grape clusters remaining to be picked, along with the dropped fruit lying on the ground below.

Then, three days before the planned harvest on October 17, when the Malbecs would have been at peak, birds wiped me out. I headlined the blog post of October 16  reporting the loss with lyrics from "Monday, Monday" by the Mamas and the Papas: "Monday morning couldn't guarantee that Monday evening you would still be here with me." Starlings swooped in and ate the entire crop in two days. Every grape.

Heartbreaking.

I am busy this week putting up netting to try to make sure that doesn't happen this year. I am using a black plastic mesh netting, with 3/4-inch holes, on rolls shaped three feet by 3,000 feet. My nephew and I unroll the spool of netting on each side of the row, surrounding the hanging grapes. The unspooling goes quickly. The problem comes from the need to close up the net by clipping the two sides together at the top and bottom. If there are big gaps, birds will find their way to the ripe fruit. This part is slow.

The black plastic does not photograph well, but it is visible.

I am doing it with these clips to make the connection, the same kind we see for closing bags of food:

Like a lot of farm field work, the job isn't complicated, but it is tedious and repetitive, which turns it into hard work. My nephew and I reach in, grab the net from the other side of the row, pull the two sides together, and clip them. We place a clip about every three or four feet, top and bottom. The top is an easier job because the farm worker (me) stands upright. Clipping the bottom requires the worker (my nephew) to crouch down. Crouching is not hard. Repeatedly getting up from the crouch is hard, at least for me, so I assign that job to him.

My theory and hope is that my pumice soil will produce unusually good wine grapes. In the extraordinarily fine-grained pumice, the capillary roots of the grape plant access elements of the soil not available in heavier soils. There are rare deposits of pumice soil at Mt. Etna in Italy and the volcanic island of Santorini in the Mediterranean. Wines from those two places are considered excellent and unusual by the people who taste and evaluate wines. Mount Mazama blew a small deposit of pumice soil into about a square mile at the base of the Table Rocks, a deposit that is just out of reach of the floods of the Rogue River, so the deep deposit is still there after 7,200 years. 

The grapes are worth protecting, and that is my task for this week. Southern Oregon's pioneer vineyard and winery, Valley View Vineyards, provided the bird netting. They are monitoring my grapes, and the owners tell me the grapes look good and are very marketable, and therefore worth this effort. The grape canopy is vigorous — too good, if anything — because the soil readily pulls up moisture and grape nutrients. I have done only perfunctory irrigation. All three of my varieties survived an April frost that hurt most vineyards around the region. That was unfortunate timing since Southern Oregon just got rated the country's best wine-growing region. We are that niche, undiscovered place that wine aficionados seek out in the effort to find hidden gems.

Valley View Vineyards' nets saved me about $8,000 in new net purchases. I have 39,000 linear feet of grape rows, with netting required on both sides, almost 80,000 feet of net. 

Starlings in November on a nearby tree. Famous for their swooping flock murmurations. Infamous for their damage to crops.

Apparently distressed bird recordings on loudspeakers work to keep Valley View Vineyard's own Applegate vineyard free of bird predation. I had such an infestation of starlings last year that I decided I needed to use nets, the gold standard of crop protection.

The premise in the wine-grape industry is that the money one spends to make great grapes is an investment in great grapes. Through art, science, and expertise, those grapes get made into very high-quality wine, which then readily sells at a premium price because people notice the higher quality. 

That's the intention. Lots could go wrong. It is farming. 

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Canada says no.

"These boots are made for walkin'
And that's just what they'll do"
     Lee Hazlewood, "These Boots are Made for Walkin'", made popular by Nancy Sinatra, 1965

President Trump is picking a fight with Canada. He taunts them. He says that Canada wants the advantages of being the 51st state without actually being one.

Canada's Prime Minister Mark Carney said,"No deal is better than a bad deal."

He had his negotiators walk out of the negotiations.

Click: YouTube

Then, in clear, mature, reasonable language he explained to Canadians and the world why the tariff negotiations ended. The contrast between Mark Carney and Donald Trump is profound. What is happening in America that we would pick a Donald Trump in a world that produces leaders like Mark Carney?

Sandford Borins is a college classmate. He is Canadian. Borins is Professor of Public Management Emeritus at the University of Toronto. In retirement he and his wife Beth Herst wrote Public Representations: Screen Stories, Narrative, and the Public Sphere, 

Guest Post by Sanford Borins

Resisting Trump’s Imperialism

While the U.S. and Canada accuse each other of making last-minute demands that led to the collapse of their recent trade negotiations, I want to step back to consider the Trump administration's actions in an historical context.

Canada evolved slowly from being a group of British colonies to nationhood. An act of the British Parliament, the British North America Act, united four eastern provinces (New Brunswick, Nova Scotia, Quebec, and Ontario) to establish Canada in 1867. Other British colonies joined later, most recently Newfoundland and Labrador in 1949. Initially, Canada didn’t have its own foreign policy and its highest court was in London. Canadian sovereignty developed gradually, and Canadians retain the distasteful memory of having been a colony.

 
Following the signing of NAFTA in 1994, the U.S., Canada, and Mexico became what then Prime Minister Jean Chretien called “the three amigos.” This was a period of free trade and increased economic integration, most notably in automobile production. Each partner respected the others’sovereignty. Canada participated wholeheartedly and suffered many casualties in the war in Afghanistan but took a pass on Iraq. Unlike the U.S., Canada and Mexico have always maintained warm diplomatic and economic relations with Cuba.

Been There, Done That

Canadians see the second Trump administration’s approach to its relationship with Canada as a desire to return Canada to the status of a colony and a negation of “the three amigos” era. President Trump’s juvenile “51st state” rhetoric and gaslighting and taunting of Canadian leaders poison the atmosphere but are not the essential problem. Our critical concern is the Trump administration's attempt to thwart Canada’s economic development and sovereignty, in effect to turn it into a vassal state. This is of a piece with other Trump administration initiatives to dominate the western hemisphere, such as the attempt to seize Greenland, the takeover of the Venezuelan Government, and the blockade of Cuba.

Why Canada Walked

There are several components of this imperialist approach, and they all appear to have come together in the recent negotiations. The Trump administration wants to weaken or destroy some Canadian industries, most notably automobile assembly, auto parts, and steel, all of which currently sell much of their output to the U.S., by implementing prohibitive tariffs. It hopes that dismantling Canadian manufacturing will increase manufacturing jobs in the U.S.

In resources such as oil, gas, potash, and critical minerals the Trump administration wants the U.S. to be the sole purchaser of Canadian output – the introductory economics term is “monopsony.” Hence the willingness of the Trump administration not to tariff Canadian energy producers, its desire to build the Keystone XL oil pipeline, and its demand that Canada not make agreements to sell these products to other countries. Clearly the Trump administration wants cheap, guaranteed supply.

 
These two approaches represent classic imperialism, in which the colony produces raw materials for the metropole and the metropole sells finished goods back to the colony. Late in the negotiations, the Trump administration introduced demands that Canada drop requirements that U.S. streaming platforms such as Netflix and Amazon Prime promote Canadian (including French-language) content to users in Canada and requirements for bilingual packaging of products sold in Canada. These demands represent an attack on Canadian cultural sovereignty and are particularly tone-deaf on the eve of an election in Quebec.

Defense is a third aspect of the would-be imperialist relationship. The U.S. wants substantial Canadian participation in its vision of North American defense and also wants to make sure that Canada buys American weaponry. Increasingly, Canada sees the Trump administration as an unreliable military partner. The flashpoint now is whether Canada will complete a major order of F35 fighter aircraft, which the Trump administration has been demanding. In his statement the morning after Canada walked away from the trade negotiations, Prime Minister Carney made it clear that the concessions the Trump administration was asking for amount to an unacceptable incursion on Canadian sovereignty, in effect an attempt to establish a new imperial relationship.

The Empire Strikes Back?

Carney has announced that Canada will put in place a program of support for Canadian producers who will be hurt by the additional U.S. tariffs that just went into effect and will also impose counter-tariffs on September 8, the day after Labor Day. In some instances, the counter-tariffs are a logical response to the U.S. tariffs. For example, both the U.S. and Canada produce steel. If U.S. tariffs make it impossible for Canadian steel producers to sell in the U.S., not imposing counter-tariffs would allow U.S. steel producers to continue to sell in Canada. The counter-tariffs level the playing field for Canadian steel producers selling in Canada. The slight delay in implementing counter-tariffs permits additional negotiation, if both sides are so inclined.

Trump’s typical response to opposition is social media taunts and escalating threats. The taunts have already started. The threats are likely to come soon.



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Chris Beck Meet and Greet in Grants Psss

Josephine County voters: 

      Chris Beck wants to hear from you.

Chris Beck is the Democratic candidate for U.S. Congress in Oregon's second district. 

It is a good invitation, but it isn't the one I suggested to the event organizers. Read the invitation. Attend if you live somewhere close to the event. 

The event organizers sent me a draft of this invitation. It emphasized the point that Chris Beck wanted to hear from you. He is there to listen, it said. 

I suggested a different emphasis. That invitation was too passive. Instead, position Beck's election as a message of protest against an unsatisfactory status quo. Urge people to show up to see the guy who will be their "no" vote on Trump and our Trump-enabling GOP congressman, Cliff Bentz.

They tweaked the invitation to add that we can send a message that we want a change in leadership. 

But maybe this invitation was exactly right in its original form: Beck will be there to listen and learn. The point of an invitation is to get people to show up. Maybe the best draw was their first instinct, the chance for voters to tell Beck what they think. 

I probably overthink this.  

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Easy Sunday: Scenes from Washington, D.C.

     "Ask not what your country can do for you. Ask what you can do for your country."
         JFK inauguration speech, January, 1961

I felt the same feeling of national pride as did Jack Mullen, today's guest post author, back in 1976. 

President Kennedy's words were still fresh. Moreover, the country had just decided that a president who lied about a burglary, then obstructed justice to cover up the lie, was not fit to be president. Republicans agreed. America was better than that, the country's leaders decided, so we cleaned house.

That era seems so remote. President Trump openly and proudly enriches himself, demands he be exempted from IRS audits, sells pardons, robs gullible investors, obstructs justice, and is corrupt at a level unimaginable 50 years ago. It is a take, take, take world for Trump, and the country is ripe for the taking. Republican voters seem OK with it. 

Trump has put his stamp on America. He has also put his stamp on the 250th celebration of the country's founding. Jack Mullen grew up in Medford, worked with me in local orchards, attended the U. of O., served in the Peace Corp, had a long career in publishishing, and is now retired and living in the District of Columbia, where he is an eyewitness to our capital city in this era of Trump.

Guest Post by Jack Mullen

I remember the pride felt at the 1976 bicentennial parade in Ashland, Oregon. Locals cheered bands and local officials as they marched down Siskiyou Boulevard to Lithia Plaza. I live in our nation's capital, and hoped to rekindle that feeling when America's 250th birthday occurred. I have watched in disgust as President Trump pushed aside long-planned events, and decided to do things his way.

The America250 celebration spans the entire summer. The kick-off event, a UFC cage fighting event on the South Lawn of the White House, occurred June 14th, Trump's 80th birthday. I had no interest in attending the fight. However, my curiosity got the better of me, and I set out to catch a glimpse of the massive overhead steel structure of the fighting arena, nicknamed by locals "The Claw."

My trip to grab a glimpse of "The Claw" led me to unforeseen obstacles. A fortress of security roadblocks forced me in circles, which eventually led me across Memorial Bridge and into Arlington, Virginia. Since I was already in Arlington, I decided to contemplate and, in a way, celebrate America's 250-year history by revisiting the resting place of generations of American soldiers at Arlington Cemetery.

The Memorial Bridge, which led me to the cemetery, was designed to connect the Virginia side of the Potomac River and Arlington Cemetery to the Lincoln Memorial. The bridge was built to symbolize the reconciliation of the North and South after the Civil War. This visual connection of Civil War soldiers to President Lincoln will soon be lost if Trump is allowed to build a 250-foot granite "Arc de Trump" (officially the United States Triumphal Arch).

The "Arc" is meant to commemorate America's 250th birthday and has nothing to do with Lincoln or the cemetery. A Trump-appointed commission gave preliminary approval to the design in July. The National Park Service dutifully requested public comments on the structure, which were overwhelmingly negative, 99% against. The comments will be ignored, and another commission vote may occur on September 3. But there is hope that ongoing litigation and Congressional opposition will at least slow the construction down or reduce the arch's massive size.

A week later, my wife and I decided to take advantage of a balmy Saturday and re-visit the newsworthy Reflecting Pool at the base of the Lincoln Memorial. Members of the National Guard patrolling the area never bothered us as we took a few photos to pass on to friends. The pool was coated with green, and workers were standing in waders skimming it off. There was no evidence of the “American Flag blue” coating. Shortly after our visit, Park Police, at Trump’s urging, arrested several people for supposedly vandalizing the pool by removing small pieces of the coating that were floating to the surface. Bet on it – there will be no convictions. Soon after, Trump erected dark covered fences around the pool, just one more pockmark in our nation’s capital. Meanwhile, the Justice Department just renewed its investigation of possible vandalism.

Mercifully, the “America 250” celebration officially ends this weekend when the 2026 Indy Car race takes place on the streets of Washington. 

 

Billed as “America Speed, America Greatness for One Week” by the White House, the race will consist of 147 laps around the 1.7-mile course down Pennsylvania Avenue (but not in front of the White House) and around the National Mall at speeds up to 175 mph. The National Gallery of Art has braced some of its more fragile works for the vibrations from the race.

I’m not sure where the pit area exists where drivers refuel and change tires, or stop if they encounter mechanical problems. My curiosity will be rewarded if I tune into Fox’s complete race coverage this Sunday morning.

When we Washingtonians return to our normal lives on Monday, August 24, half of the 5,000 National Guard personnel used to patrol American 250 celebration will return home and the District of Columbia will be left, until January 2029, with the regular 2,500 Guard personnel patrolling streets and picking up litter. Total cost to taxpayers $1.4 billion.

 

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Melons, Grapes, and Puncture Vine

It isn't all politics, all the time, everywhere.

Part One: Melons.

(I will catch you up on grapes and the noxious puncture vine in subsequent posts. If posts about melons bore you, skip reading now.)

I still grow a few melons in a small patch next to the vineyard. I grow them out of habit and inertia. 

Jerry Evans, with a sample of the melons we picked Tuesday morning

Southern Oregon residents will recognize Jerry Evans, the owner-operator-host of the fine-dining restaurant The Jacksonville Inn, now retired. It was a great restaurant. It served presidents, senators, celebrities of all kinds, billionaires, poor people, and teens on prom dates. He came out to the farm to look over my grapes and melons.

My father, brother, and I started growing melons in about 1961, when I was 11 years old. We sold them to local produce markets and to Sherm's Thunderbird, who made the effort to buy local produce. My brother and I each banked $1,000 every summer. That amount was over half of the tuition at Harvard; it was $1,760 my freshman year. Melons got me though college debt free.

My farm roots may have allowed me to win election to the county commission as a Democrat, notwithstanding the Reagan landslide election of 1980. My election opponents described me as a fish out of water, a local boy ruined by an east-coast education. But I was authentically poor. I drove an old truck. I got dirty working. I was proud to call myself a truck farmer. And people saw my melons, rubber stamped "SAGE" in stores. 

When I was freshly retired from my career as a financial advisor in 2015, I experimented with growing a large field again and I invited people out to see the melon field.

I had fun watching parents and kids eating watermelon.

Roy and Barbara Saigo

There was a problem. I had aged out of doing field work. Carrying multiple loads of 60-pound buckets of melons became more than my back could handle. 

I still host people at the melon patch, but do so a much smaller scale. My niece and nephew got a small taste of the farm six years ago.

My nephew, now age 18, is a huge help with the vineyard as we put up bird netting. More about that shortly.

There is an art to picking a ripe watermelon and there is some guesswork. The proof is when one cuts it or drops it.

But most of the other varieties of melons that I grow have an unmistakable look when they are ripe. Cantaloupes turn color, from greenish-buff to tan. The field is best picked every day to catch them at that first day when they will "slip." Refrigerated, they may last a week. On a kitchen counter they are still perfect for about three days.

The best way to have a melon that looks great on the shelf in the mass-market supply chain is for the grower to pick it a few days before that moment of perfect ripeness. The result is an OK melon. That is changing, though. Plant hybridizers have created a melon variety, the Tuscan-style melon, which is rather forgiving of being picked early. I am a melon snob, but admit that even when picked a bit green, they are pretty good. The ribbed melons being held by Roy and Barbara Saigo and the melons in the grey bin are Tuscan style melons. 

The yellow and green melons in the Saigo's hands are a Spanish melon called Piel de Sapo, sometimes called "Santa Claus" melons. In the U.S. at this latitude you would see them starting now. Look for this and try them:

They are astonishingly sweet and "melon-ish" in flavor.  They are my favorite. 

Melons are in season now. Ten months of the year you are doomed to eat, at best, pretty-good melons. Now is the time to eat a very, very good melon, especially if you buy them in a place that sources local fruit.

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