The U.S. healthcare system is broken.

Healthcare in America: Pay more. Get less.

Americans are sicker, die earlier, risk medical bankruptcy, waste time and money, distort labor markets, burden employers, and people hate it.

Let's fix this.

Alexander the Great cuts through the Gordian Knot

We spend more than enough money. We need to spend it better.

Most expensive by far

Worse outcomes by far

In 1996, when my college classmates and I were about 46 years old, I attended a class reunion. Graduates are mid-career. The lawyers, professors, writers, and finance people told me they loved their work. But doctors grumbled. They had regrets. They told me they spend too much time dealing with insurance gatekeepers and billing documentation, not patient care. The system was broken, they said.  

Everything that was broken then has gotten far worse. Everyone knows this: Democrats, Republicans, providers, employers, healthcare analysts, and anyone who has gotten sick in Europe and experienced healthcare there. We had a government shutdown over this consensus. Everyone agrees that we are patching a broken system.

Ten years ago, when presidential candidate Bernie Sanders campaigned on Medicare-for-all, the consensus for change did not exist except among a minority of Democratic voters. People who had private health insurance didn't want to give it up. They had "business class" tickets in the healthcare airplane and feared a downgrade to "coach." Labor unions opposed Medicare-for-all because a health plan was a hard-fought union benefit. Medicare-for-all seemed like loss and people hate losing what they have, even if something better is offered. Insurance companies lobbied against it. Republicans could have seen this as a business-benefit issue. After all, why should healthcare be the burden of employers? It made them less competitive than developed-country competitors where healthcare a public benefit. But Republicans stuck with their insurance company patrons, who called Medicare-for-all "socialism." 

Plus there is the free-rider morality problem that bothered Americans. Even if everybody would be better off, Medicare-for-all would mean that less-deserving people would get healthcare -- how unfair! Of course, public schools mean education-for-all, and parks and streets and national defense are socialized for the benefit of all, but not health care. It is different somehow. Institutions that benefit from the medical industrial complex have the resources to keep a majority in Congress in opposition and people thinking that health care is a consumer good, but schools, streets, parks, and the military are not.

I think the political mood has changed. The drip of rising costs changed what is possible. I don't think a president or presidential candidate would claim that the current American system deserves the A-plus-plus-plus-plus grade that Trump gave our economy. People know better.

My presumption is that change toward Medicare-for-all would come from the political left, and that partisanship would solidify Republicans to be in opposition. But they would be defending a weak hand, rather like trying to tell people in California, New York, Massachusetts, and Austin that homes are cheap and affordable. At some point people cannot be sold what they know not to be true.

Oddly enough, Trump might be the change agent here. Trump is impulsive and he doesn't care who he offends. Trump is willing to make abrupt change, to our trade agreements, to our foreign policy, to our relations with Russia, to our sensibilities regarding pardons and grift, to public ownership of private businesses, and to immigration. Americans have become accustomed to bold enlargements of executive power and Trump likes having the power. It is a new era in American politics. Trump could sell it to MAGA. I expect Republican legislators would go along as dutifully as they go along with Trump on everything else. It would be "Trumpcare."

Heads up to Democrats: Don't be knee-jerk opponents if Trump does something good. Let him score the "win." When Medicare-for-all gets branded "Trumpcare," don't protest. Trump and Republicans will take better care of it if it is named after Trump.

But the notion of Trump doing something bold and dramatic, and then aggressively selling it, can be a point of inspiration for Democrats. Trump changed the political environment. Now the American public is accustomed to bold, disruptive executive action. Trump would not pussy-foot with half-hearted, tentative, incremental change. Trump would know he had a great issue, because people are ready for change and they like seeing Trump smash through a stuck status quo.

If Trump could do it, so could a Democrat. The public is ready for this.

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Do Americans care who controls eastern Ukraine?

Fear, Honor, and Self-interest: The three reasons countries go to war, as identified by Greek historian Thucydides.

Peace negotiations between Russia and Ukraine are underway. The U.S. is in the center of it.

Trump understands an important thing about the American public: Few Americans know much about this part of the world.

Could Americans locate NATO countries on an unmarked map? Test yourself: Where is Latvia? Where is Estonia? Where is Lithuania? Which is which?

Belarus is tucked between Russia and Poland. Do you know where? Does it change anything for Americans if Belarus is independent, but aligned with Russia, as opposed to being part of Russia? Would it matter if it were independent of Russia but aligned with the West, like Poland? And Kaliningrad, that part of Russia off on its own; where is it? 

Unmarked map

Here is a marked map, but with the countries unlabeled. Does this help? Which one is Latvia? Where is Kaliningrad?

Trump won some support in 2016 as the no-foreign-wars candidate. Americans feel self-sufficient. The electorate truly cares about foreign policy only if it is a matter of fear or honor. We don't want to go to war for oil; that is the charge opponents of a war make against people who support the war. Trump says that the primary threat to the personal safety and national identity of people in the U.S. and Europe is invasion by immigrants from the global south: Latin America, Muslim countries, and Africa. Not Russia. Whether something is Russian or Russia-adjacent or Russia-aligned in Eastern Europe doesn't affect us. Muslims are the enemy, not Russians.

And since Russia isn't dangerous, then no honor is lost by letting them consolidate their own region. This is a Slavic civil war. There could be glory in it for Trump. He might be known as a better peacemaker than Barack Obama, who got the Nobel Peace Prize. Trump wants that.

All this makes sense in light of the new world order under Trump. Trump doesn't think that the rule-based order, exemplified by the United Nations has ever been anything but hypocritical window dressing. The post-WWII world order was always leadership by the powerful. Russia did not concede power in Eastern Europe because they loved democracy. They gave it up because they lost the economic and military power to continue their domination.

Trump is a peacemaker in the sense that he thinks that great regional powers ought to mind their own business. The Western Hemisphere is ours. Mexico and Canada are ours to bully. Venezuela is in our neighborhood, so we are going to stop pretending we respect the sovereignty of pip-squeak countries. We don't want to own them -- they are too much trouble to own. Look at Puerto Rico. But we are entitled to manage them.

And all this makes sense of what China is doing right now. China is displaying possession while Trump is demonstrating his position on regional power.

Huffington Post landing page

They understand Trump, and they think Trump understands the American public. We are willing to pound our chests and make threat displays, but we don't want actual conflict, not over something half a world away. Taiwan is Chinese. They speak Chinese there. They were part of China. They are in China's neighborhood. 

Which one is Taiwan? Which is Hainan? Which is part of the Philippines?

Maybe Americans care if Taiwan is fully independent. Americans can be made to care if our leaders tell us it is essential to our security, Maybe, if we get to keep getting the advanced computer chips we need from them or somewhere else, we can let it go. Maybe leaders can persuade Americans that it is a matter of honor. We continued a war in Vietnam for years chasing "Peace with Honor." But I suspect all we really want is their chips.

I expect some sort of resolution in Ukraine. Trump has refocused the threat to European security from Russia to Muslim immigrants. The rise in blood-and-soil rightist parties in Europe shows that Western leaders need to adjust to stay in sync with their publics. The Brexit vote was the early warning. Trump's election was the second notice. The real enemy isn't another aggressive consolidator of ethnic groups. It is foreign ethnicities. I expect Europe to go along with carving up of Ukraine. 

None of this is what I want, but I think it is what is happening, and I expect the American public will be OK with it if Trump leads it. Eastern Europe is so far away. So is Taiwan.

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Easy Sunday: Year-end reverie.

Be of good cheer. 

"We are stardust, we are golden
We are billion-year-old carbon
And we got to get ourselves
Back to the garden."
     Joni MItchell, Woodstock, 1970

We are a speck in the universe and everything ends.

The odd thing about existential nihilism is that it doesn't necessarily destroy meaning and purpose for our lives. It focuses it. It doesn't lead me to despair. It leads me to try to live well. 

Red giant 

The Sun appears constant and dependable. That steadiness tempts us to imagine permanence in an eternal story with good guys and bad guys: conflicts that must be resolved now or never; a present moment that decides if things are going to plan; an arc leaning toward justice. 

We read the news today, oh boy. 

Astronomy reminds us to lengthen our perspective from the crowded today. In deep time, the Sun will swell into a red giant and erase Earth and everyone on it. Nothing in the news changes that. It ends, and everything is erased.

I have reconciled to understanding that we have a brief window of coherence in a vast, indifferent universe. We are all aboard the Titanic, and we know its fate. Meaning must be local: in kindness offered and the care we take with one another. I can live with that. Wasn't that Jesus' message, the one I grew up hearing? 

I don't need the magic parts of the big stories that religions posit to make us feel better about the reality of an indifferent universe. I am OK with the here and now, because that is what there is, and it is on us. 

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Be careful out there

"I get the willies when I see closed doors."
     Joseph Heller, opening line from the novel, Something Happened, 1974 

 

There is always something to worry about. Most of it won't come true. Some will, though.

Don't mind me. I am an old man with too much experience.

Americans who watch financial markets know the warnings about a tech stock bubble. People with money or careers at risk during the internet boom and bust understand the risk. The potential is that artificial intelligence will unlock giant gains in productivity. The worry is AI companies won't earn monopoly profits from AI anytime soon, therefore the stock prices of companies spending money to create AI platforms are running ahead of their current value.  

Deutsche Bank asked its customers to list the biggest risks to market stability in 2026. Fifty-seven percent listed a tech bubble. The second was the fear that the new Fed chair would try to please the president who had just appointed him by lowering interest rates too far and too fast. Well down the list are other things readers have heard about: a crypto crisis, a China attack of Taiwan. Russia-Ukraine escalation, energy infrastructure failure, and a global trade war. Here is a chart, oriented in two directions for readabilty.

 

 

The best evidence that there is no AI bubble is that people worry about a bubble. If prices reflect nervous, skeptical investors, it is less likely to be a bubble. Bubble prices come from unchecked optimism.

Impending disasters are obvious -- in hindsight. Anybody can see that making mortgage loans to people without assets, income, or jobs is foolish, but from 2004 to 2007 bankers imagined that as long as they packaged bad loans with other bad loans, the resulting sausage was perfectly safe and AAA-rated and could be sold to pension funds or held on their own books. People were making great money creating those loans; it is hard to knock success. Nobody likes a naysayer. Same with people worried about the Magnificent Seven stocks. So far, so good on them.

There is no shortage of hazards and warnings. Many people distrust the U.S. dollar as a storehouse of wealth -- a reasonable fear. Readers who have scrolled social media this week are learning about a new reason for worry: a short squeeze on silver. An ounce of silver has gone from $30 to $80 in a year, and from $40 to $80 since September. Silver prices aren't reflecting industrial and jewelry supply and demand. They reflect stress in the financial markets.

Bank trading desks with short futures positions on silver must deliver silver. Funds that contracted to match ounce-for-ounce in physical silver their investors' deposits in their funds also need physical silver. It isn't available. What could go wrong?

I worry about the optimistic people holding crypto "assets." Crypto money is the equivalent of electronic baseball cards, but without the nostalgia. Crypto assets are valuable as long as people think the price of fairy-dust will go up. The prices reflect a social consensus that if there is a price there must be value, at least one that can be captured if sold to someone else. Banks go where the opportunities are and where federal regulators permit risk-taking. Banks are loaning money collateralized by crypto. What could go wrong?

There is a mismatch between incomes and home prices. President Trump's solution is more leverage and debt, now in the form of 50-year mortgages. What could go wrong?

There could be a geopolitical crisis. The U.S. has had 24 years where we are  doing the bombing: Iraq: Afghanistan: Iran: this month Venezuela; this week Nigeria. We dish it out; we feel both invincible and entitled. No one has bigger aircraft carriers. What will go wrong will likely be a surprise. It probably wont be an airliner crashing into a building. It will be something new. The U.S. does not have a monopoly on shock and awe. 

I am glad there are young people with optimistic entrepreneurial spirit starting new enterprises in garages and dorm rooms. I am glad there is competition among the companies creating AI platforms. I am glad Americans see opportunity and are racing to take advantage of it. 

I reflect a different perspective. I am OK with my age and situation. I hedge my bets. My goal is to survive bad times. I don't consider that pessimistic. I think it is realistic and good. If bad times come, the U.S. will need survivors. 

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Christmas wishes from Steve Martiin

So many serious things to consider.

Let's not today.

It feels self-indulgent to post something short and funny when there are so many serious things happening.  But it isn't self-indulgent. It is staying sane. Enjoying our families. Enjoying a holiday. Laughing, because that is what humans do, even in serious times. Maybe especially then.

In the heart of World War II, in March of 1943, Winston Churchill said, 

"There is no finer investment for any community than putting milk into babies."

So, on the advice from Winston Churchill not to neglect simple acts that sustain our humanity, here are three minutes of Christmas wishes from Steve Martin on YouTube from an old Saturday Night Live sketch. 

https://youtu.be/_uVUSBi3u0E?si=CC0NO9x2y4rEJTDb

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Be happy.

"Happy Holidays."

I say it with a smile. I intend a "Happy Holidays" greeting to be neutral, pleasant, and inclusive. 

But "Happy Holidays" isn't neutral because neutral isn't really neutral. 

L. A. Times

Fox News still talks about the "War on Christmas" because many Americans feel that Christmas traditions are under attack. They say "Merry Christmas" on Fox. When used as the universal greeting,"Merry Christmas" affirms Christianity's status as first and default. Who could object? Aren't we all Christians here in America?

"Feliz Navidad" is a complication. It is Christian, celebrating Jesus' nativity, but in Spanish, therefore recognizing the presence of the other: brown-skinned, presumably "not their best," criminal, and probably in the U.S. illegally. But Christian. Depending on the context, Hispanics are either an ally against secularism or a defilement of American blood, language, and heritage.

"Happy Holidays" is inclusive of everyone who celebrates any of the many holidays of this season. I am comfortable with the greeting, but should not be. Some Americans consider it an implied insult and aggressive secularism. Either Christianity is the common denominator religion, and therefore unique, or it is just one of many. Equal respect is implied disrespect, when neutral equality is a demotion. 

Tucker Carlson, back when he had a very popular show on Fox, explained the situation to Democrats. 

  "If you are wondering why so many Christians are willing to support this president, despite his personal life, this is why: because whatever his flaws he has made it clear he is not the enemy of Christians. In fact, under certain circumstances, he will protect Christians. For people whose values are under assault every day by powerful forces in America, and that’s not overstating it, and if you are one of them, you know that means everything. . . .Christians don’t feel they have a duty to be destroyed by people who hate them."

I don't consider diversity and equality to be an attack on White Christians, but Tucker Carlson does, and he speaks for a great many people. They feel "powerful forces" are eroding their status, and they are right. The country is becoming more ethnically and culturally diverse. Polite respect in the modern era leads us to avoid voicing presumptions about others. Don't presume religion, ethnicity, gender, marital status, nationality, or politics. But I recognize that this comes across to some as stripping them of an important part of their identity, and is therefore disrespectful, indeed hateful. How dare I not presume they are Christian?

It can be a minefield out there. 

I don't presume that people are Christian. I presume they could be any religion or no religion, and that is OK with me. 

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Memorable Christmas Gifts

There is a theme to Christmas memories. 

Bittersweet. 

"So we beat on, boats against the current, borne back ceaselessly into the past."

           Final lines of The Great Gatsby.

"Nostalgia isn't what it used to be."

           Classic joke.

"You can't go home again."

           Title of a book by Thomas Wolfe

I thought I would have an easy-to-write, holiday-themed blog post reporting readers' descriptions of favorite gifts. It turned out to be hard. People reported long-held memories. They are moments of joy, a moment that is past and gone. 

Bittersweet mixes joy and loss. A bittersweet memory persists as an ache-y spot. Edgar Allen Poe wrote about this in "The Raven:" "Nevermore" is the saddest word in English, he said. 

One reader, a neighbor of my farm, got a toy tractor of his own, with heavy metal construction and thick-treaded rear tires. 

A few readers got Lionel brand electric trains in young boyhood. They set them up with their fathers. One reader begged his parents to help him buy a Lionel train to give to his grandfather -- just what grandad wanted.

A few readers got bicycles. Bicycles are liberation. You could go places on your own. One reader still had his at college, when it was stolen from where it was chained to a fence in front of his Harvard dorm.

One reader got a transistor radio. It was an introduction to electronic communication. Sixty years later he builds data centers for a mobile-phone company.

A young reader (yes, I have one Gen Z reader) said her favorite gift was something she got a few years ago, a mini-Segway.

She is still creating childhood memories and the Segway and the parent who gave it to her are still around. Too early for bittersweet. The nostalgia comes later.

One reader reported wanting dolls designed around a theme of bug-eyes babies in poverty. She said she just had to have it, and her parents came through.

People who were poor in their childhoods remember Christmas as a standout moment, a tiny exception to the rule of not-having, or as a moment when felt what they didn't have. However small, a treat was memorable: a salvaged tree repaired and decorated with little lights or a story of Santa Claus having eaten the cookie, proof that he came and left, even if all he brought was an orange for the stocking.

A reader well into his 80s, now in end-of-life care and on oxygen, told me his favorite gift was a winter jacket his late wife gave in 1964. He still has it and wears it.

One reader mentioned disappointment at age seven. He wanted a blackboard and chalk, and got the gift. The disappointment was that "Merry Christmas from Santa" was written on the blackboard in his mother's handwriting. What? Santa is really just Mom??!! 

The best stories were stories of gifts given. A reader gave her husband, then in the end-stage of hospice, a copy of a book he had owned then lost in a move, the National Lampoon 1964 Yearbook parody. He received it in time to read it again in his last two weeks.

Grandparents enjoyed passing down a happy family keepsake, a rocking chair for toddlers in the form of a boat.

My own best memory is the long Christmas Eve evening of frustration while I tried to figure out how to assemble a sit-in-it pedal car for my four-year old. It looked about like this, except mine was yellow: 

The box said it was easy to assemble. Ha! Perhaps if one has assembled three of them, then the fourth would be easy, but the first one was confusing and there were lots of parts. The joy of the memory was that I managed to complete the job about midnight, a deadline met. Whew. Santa could go to bed. It would be five hours before Dillon would wake up and go downstairs to see what was under the tree. 

That was 30 years ago. A good memory of a time here and gone.

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