For-Profit Medicine

The U.S. healthcare system costs more than the systems in peer countries. 

Our health outcomes are no better.

Today's guest post offers hopeful news.

In some arenas, the profit motive and competition drive down costs. This doesn't work in healthcare, where consumers interact with the system out of need, not choice, and where most payments are made by third parties. Our current system leads to vertical integration and monopoly pricing at every level.

U.S. Senators Elizabeth Warren (D - MA) and Josh Hawley (R- MO) have introduced a bill to change that.

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. He allowed me to republish his post from yesterday, a welcome bit of good news amidst news of the Iran war, "unconditional surrender," inflation, job losses, and the drip from the Epstein coverup. He would welcome new subscribers:  https://bvzcvz.substack.com

Van Zee

Guest Post by Bruce Van Zee

Break up Big Medicine Act

Some Hopeful News about For-Profit Medicine

Imagine being in the market for a home. You contact a realtor who agrees to show you some homes for sale. You find a home you like and submit an offer. The offer is accepted and your realtor then refers you to a mortgage bank, home inspector, and a title company. You are a bit surprised by the steep fees of the companies, but eventually, the deal is completed. Later you learn that the only homes the realtor showed you were ones that the conglomerate that owned the realtor’s firm had listed. The same Real Estate Conglomerate also owned the title company and the mortgage bank and the home inspector’s firm. You ruefully calculate by retrospectively comparing other non-conglomerate pricing that you paid way too much.

Thankfully, this dark scenario can’t happen under U.S. law because of legislation prohibiting these incestuous and monopolistic relationships. RESPA (Real Estate Settlement Procedures Act) and other antitrust regulations prohibit such self-dealing and require disclosure and freedom to seek other services outside of the conglomerate.

Unfortunately, such is not the case with mega for-profit health insurance companies. Currently, many for-profit insurance providers (UnitedHealth, Aetna, Cigna, Humana, Elevance) operate vertically integrated companies that not only offer health insurance, but often provide a provider network of physicians, pharmaceutical company and pharmacy benefit manager, and a medical device company that they own. So, if a person purchases one of these companies’ health insurance policies, they are often referred internally for all services. One can escape the network for other physicians or pharmaceuticals, but the costs are usually higher.

The problem is that there is a host of information showing that these companies are profiting off every step of the vertical referral chain and driving up health care costs. I previously posted data showing the cost overruns of Medicare Advantage over traditional Medicare (here and here). The WSJ also has an excellent expose on the rip-off of government and taxpayers by the mega for-profit health care companies (here). Among other strategies, the vertically integrated companies subverted federal guidelines designed to limit profitability of their insurance arm by taking additional pieces of profit out of the provider and pharmaceutical entities as well.

Well, help is on the way! In a rare bipartisan partnership, Elizabeth Warren (D-MA) and Josh Hawley (R-MO) have introduced the Breakup Big Medicine Act (here). This needed legislation would prevent vertical integration of health services and, if it becomes law, would require existing companies to divest of their vertical integration services within a year or face penalties. A company could not own both an insurance company and a physician network nor could they own a pharmaceutical chain or pharmaceutical benefit manager firm or medical supply company. Hospitals would still be allowed to have employed physicians. The legislation would be analogous to the Glass-Steagall act that regulated and separated commercial and investment banking, and to the RESPA act for realty. The hoped result would be to decrease overall costs and stimulate competition. But, given our lobby-driven system of legislation that gives disproportional power to monied interests, the chance of passage is meager.

There is a humorous You-Tube video with the satirical Dr. Glaucomflecken and Elizabeth Warren that is worth the few minutes to watch. It gets the point across:

YouTube: Click here

(courtesy of Dr. M. Matthews)

My own view is the bill is a step in the right direction. But as I’ve indicated earlier, if America wants to really effect health care reform and decrease costs while improving quality, we need a well thought out National Health Plan like virtually all other western developed nations. America has twice the cost and poorer outcomes compared to these other nations. Medicare -For-All is one avenue to get us there with the safeguards and reforms previously outlined (here) and (here).

Thanks for listening!

Our troops deserve better.

I wish for the well-being of our troops in the Middle East.

They deserve a better president.

Email I received yesterday:

Peter, I agree with Trump that Iran is a danger to the world.  Should Democrats be hedging their comments on the war? Maybe our actions there will turn Iran into a friendly nation. What should Democrats be thinking or saying about this war?

Most of my readers are old enough to remember when the U.S. decided to make war on Iraq. People who were early critics, including Barack Obama, looked wise in hindsight. People like Hillary Clinton who were on record in support of the Iraq war, looked foolish. Maybe Iraq did have weapons of mass destruction. People want to be on the right side of history before the history is written. 

My response to the inquiry:

I wish for the well-being of our troops in Iran because I am an American. Those troops are an extension of me and my country, and I am vicariously responsible, even if I did not vote for Trump. My generation of Americans was put into peril in Vietnam, and I empathized with their situation then and again now. The fact that the war was flawed in its purpose, and was continued for the cynical purpose of political advantage in the 1972 election, heightens the victimhood of Vietnam veterans and the nobility of their service. I don't blame the soldiers carrying out the war against Iran. Quite the opposite. I wish them well.

This war, done this way, by this president, is a mistake. Some things --heart surgery, for example -- need to be done carefully if they are to be done at all. If you plan to do the surgery with a chain saw, it is better not to do it. Trump is carrying out this war in a way unlikely to produce a good outcome. 

--  Trump is continuing his pattern of turning our republic into a serial dictatorship by defying Congress' power to declare war. The Constitution is collateral damage.

--  Trump sprung this on our allies and the countries in the region, putting their governments, their citizens, and their economies in peril. A good outcome in Iran will require the cooperation of many nations. Trump demonstrated that we are a presumptuous, careless, untrustworthy hegemon that will ignore their interests in favor of ours.

-- Trump makes outrageous and arrogant demands on Iran. Trump first urged an organic revolution by the people of Iran to establish a new peace-seeking government without having made any provision for such a revolution. He then backtracked and said that he should shape their government, a comment so presumptuous as to make any good outcome less possible:. 

  "They are wasting their time. Khamenei's son is a lightweight. I have to be involved in the appointment, like with Delcy [Rodríguez] in Venezuela."

He later told NBC news:

“We want them to have a good leader. We have some people who I think would do a good job.

--  Trump displays shocking ignorance of the historical, ethnic, and religious factors that would be part of any successful new government in Iran. For example, Trump urged the Kurdish ethnic minority in Iraq to revolt. Shanaz Ibrahim Ahmed, Iraq's Kurdish First Lady, responded:

Sulaymaniyah, Iraq - "In 1991, the Kurds were urged to rise up against the regime of Saddam Hussein, only to be abandoned when priorities changed. No one came to our defense when the regime deployed helicopter gunships and tanks to crush the uprising. Those memories remain vivid and etched in our minds.

Today, we commemorate that chapter as “Raparin” and we do not forget what it taught us.

More recently, we saw what happened in Northeast Syria, or Rojava. After all the promises that were made, after Syria’s Kurds stood on the front lines of the war against ISIS, we witnessed how they were treated.

Today, the Kurds of Iraq have finally tasted a measure of stability and dignity in life. Because of this, it is very difficult, indeed impossible, for Kurds to accept being treated as pawns by the world’s superpowers.

The experiences are there. The empty promises are there. Too often, the Kurds are remembered only when their strength or sacrifice is needed. For that reason, I appeal to all sides involved in this conflict. Leave the Kurds alone. We are not guns for hire."

Her tone displays what a bumbling troublemaker Trump is considered to be. She openly voiced contempt.

Trump established a brand that wins him support among his MAGA base, his damn-the-torpedoes, git-'er-done man of action. He doesn't wait for permission. He doesn't care about process. He alone can do it. Trump the singular hero.

His DOGE efforts with Elon Musk's symbolic chainsaw, his ICE department with careless and rough immigration enforcement, and his slap-dash Liberation Day tariffs are all part of a pattern. The Iran war is another iteration of sloppy execution.

Things might work out in Iran. I hope so. Nevertheless, a Democrat can condemn Trump for initiating a dangerous, poorly-planned war. Our troops deserve better. The country deserves better. 

I am confident that history would be kind to that position.

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Call it what it is. (Our republic depends on it.)

“The beginning of wisdom is to call things by their proper name.”

          Confucius 

We are undergoing a silent Constitutional Convention, updating the work that took place in Philadelphia in 1787.

We are turning the U.S. from a republic into a democratic serial dictatorship. 

The Constitution is being re-written because we have a president who is governing as a single decision-maker -- a strong man -- and he isn't being stopped. There is the written Constitution, the old pro-forma rule book, and there is the real Constitution, the actual day-to-day procedure for doing things. The new rule is that the president can do anything he wants so long as at least 34 members of the U.S. Senate allow it. The Supreme Court can delay things, but as we saw with tariffs, presidents can assert a workaround and start a new clock running at the snail pace of judicial appeals. The Supreme Court needs to walk on eggshells. They, too, understand the new reality. The court, like Congress, can be ignored.

The mechanism for unitary presidential power is the power to define words. The most powerful of words is "war." It is the "elastic clause" under the new Constitution, the word that provides flexibility and open-ended power. 

By declaring that we were under invasion by immigrants,Trump said we were at war, enabling him to take control of immigration policy, the taxing power, and the power of the purse. He asserted that "war" triggered the Alien Enemies Act of 1798. Moreover, since we were at "war" with other countries due to an asymmetric balance of trade, President Trump could impose and revise tariffs -- i.e. levy taxes -- at his personal pleasure.

This week Trump joined Israel in firing missiles at and dropping bombs on Iran, killing its head of state and much of its leadership. Our bombs killed some 160 schoolgirls. We "obliterated" Iran's nuclear facilities. The U.S. Navy sunk an Iranian naval vessel on the high seas, killing 180 Iranian sailors. U.S. embassies were hit by Iranian missiles. Trump says we have a goal: a new government in Iran, forced under compulsion of violence by a foreign state. That is the very definition of war.

But for the purposes of triggering laws enacted by Congress to protect its constitutional duty to declare wars, Trump is saying this is not a war. It is a "military operation." Congressional allies are going along. Senator Lindsey Graham (R - SC) says this isn't "technically" a war.

The United States is rewriting the Constitution through practice and accretion. When words can mean whatever a president wants, laws written with words have no power. A president can define tariff, tax, regulation, invasion, war, emergency, emoluments, bribe, or any other word however it serves his interests. Trump is doing so now. It is pretense and he is shameless about it.

Congress has the power to impeach and convict a president who flouts congressional power. The writers of the original Constitution presumed that congressional members' desire to protect their institutional prerogatives would be enough for them to insist that a president share power. That is no longer true. The situation will change if and when this president becomes such a political liability that Republican senators conclude that he must be removed. That will send the message that Congress is relevant, after all, acting as a stopgap remedy. 

That action does not restore the Constitution. When Impeachment and conviction is, at long last, the tool Congress is willing to use to limit presidential power, it signifies that a new Constitution is in effect. A president is a temporary, elected dictator. Congress is a passive board of directors, an advisory panel, giving a veneer of legitimacy up until the president really screws up and needs to be fired.

We know this system of governance. It is the system in place in city and country governments, on school boards, and in nonprofit and corporate boards of directors. They hire a CEO, who runs things during his tenure. If a problem emerges and someone needs to take the fall to restore public or investor trust, the CEO is fired and replaced. The institution survives.

That system can work, but it is not the constitutional system we lived under for 245 years.

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Trrmp wants a USA-friendly autocrat in Iran

"You say you want a Revolution
Well, you know
We all wanna change the world. . . 

You'd better free your mind instead"

   The Beatles, "Revolution 1, 1968

Trump wants to leave Iran's rulers in place. Forget revolution.

Keep the police. Keep the public employees. Keep the government structure. Keep all but the very top military. Keep the autocracy.

Trump doesn't want something new and organic to rise up in Iran. That is too unpredictable.  Forget messy democracy. He wants a pro-American business partner who owes his position to Trump. He wants another Venezuela deal.

Jim Stodder put this insight together for me. Jim is a college classmate. He left school for a while amid the anti-war disturbances of the era, then returned to complete college and then get his Ph.D. in economics from Yale. He taught international economics and securities regulation at Boston University.

Guest Post by Jim Stodder

Will Trump offer Iran the same kind of deal he’s offering Venezuela and now Cuba?             

 

The deal is – “Go ahead and run your own affairs; repress your people however you want. Just stop messing with U.S. security and give us a piece of that oil and gas revenue.”  

 

He’s already made this deal explicit with Venezuela, mentioned it to Cuba, and said he’d like to discuss it with Iran.  All that democracy stuff was for his American audience.  For getting what he wants, democracy in these countries would be a bug, not a feature.

 

There are many things in such a deal that would appeal to Trump:

* It would be the easiest and quickest resolution.

* It would therefore win the most political support in the U.S.

* It offers many avenues of enrichment for his friends and family.

* Even if it’s just a ploy or falls apart, the prospect of such a deal makes it less likely Iran retaliates with serious terrorism like a dirty bomb. (It still has enough nuclear expertise to do it, and it doesn’t take an ICBM.) 

* Controlling Iran’s oil gives the U.S. leverage over China. The Economist magazine says China gets 4% of its crude from Venezuela and more than 10% from Iran.

 

There’s a counterargument to the last point, however.  It is that making Iran less secure for China makes Russia more important as its supplier. China gets about 20% of its oil from Russia, via several oil pipelines and ships from Russia’s Far East. It also gets almost 40% of its natural gas imports from Russia via the Power of Siberia 1 pipeline and LNG ships, again through Russia’s East.

 

Against this growing importance of Russia, the fact remains that 40% of China’s crude oil flows through the Strait of Hormuz, which Iran could choke off.  On balance, I’d say that controlling Iran increases Trump’s leverage over China. And giving Russia more power has never been something about which Trump seems too concerned.

 

If I were advising Trump, I'd make the case. Given the direct benefits to him, he'd give it serious thought. 

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Showdown in Texas

"Texas tough" or "Turn Texas Blue?"

Texas Democrats vote today.

Crockett

Talarico

Politics is war continued by other means. Carl von Clausewitz had it backwards.

The question is how one fights the war.

There isn't a lot of difference in the political positions of the two candidates for the U.S. senate for Texas. Jasmine Crockett isn't a member of The Squad, although her style makes it appear that she is. Talarico isn't particularly moderate or centrist, although he has a "can't we come together" tone that comes across as middle of the road.

Crockett: Media star and a tiger in Congressional hearings.

"Raping children, right or wrong?"

Democrats are making a choice about style: Crockett's in-your-face or Talarico's Mr. Nice Guy. Crockett descries herself as "tough," and willing to call out injustice. She communicates "mad as hell and not going to take it anymore." She seems fearless and ready to take on Trump, MAGA, and the Texas GOP machine. Talarico isn't conceding the ground. People with knowledge of Christianity understand the reference in Talarico's message of flipping the tables. Jesus wasn't passive in the face of abusive commerce in front of the temple. 

It is possible that a majority of Democrats prefer Crockett and her style, and in a blue state they would vote for her. Texas is a red state and the potential of electing a Democrat is central to Talarico's message. Some Democrats are likely making a strategic decision to nominate the more electable candidate, presuming that is Talarico. There is a school of thought that Crockett is more electable. She gets the "mad as hell" vote, and it is bipartisan. Trump proved that. Talarico may not be able to persuade people that he is a change agent.

Predictions markets favor Talarico. The consensus betting is for Talarico to win with a margin of 3 to 15 percent, with a small midpoint bulge expecting a 6 to 12 percent margin. Here is how Kalshi.com lays out the betting opportunities:

Few people are betting on Crockett to win, but the payoff would be high if she did. Since the betting was structured around vote margin, not just a flat win-lose, every "Yes, Tararico wins" bet is a longshot because the bettor has to predict his margin. Polls have been wildly inconsistent, some showing Crockett winning, but the prediction markets reflect the consensus of people putting money on the line. Bettors think that Talarico will win.

The win, if it happens, will launch Talarico firmly onto the national stage representing a Christian-progressive-economic populism vibe. That puts him in a space that is more overtly traditional and less technocratic than Pete Buttigieg; a space "Whiter" than Senator Raphael Warnock; and a space unburdened by the California vibe of Gavin Newsom and Kamala Harris. 

Talarico is a fresh face. Possibly the public will not want that fresh face to look like a choir boy, because the world is too vicious for choir boys. Still, Talarico will flesh out a political brand and he pushes "reset" on the Democratic brand. Even though he is thoroughly "White" in his brand, he downplays identity calling it an economic battle between the billionaires and the average American, and that the competition between ethnic and gender identities is a phony war to distract Americans from the fact that their pockets are being picked. Talarico, like Jesus, talks about economic justice.

Talarico has a lane and a story to tell. It will be disruptive to a core support group for Trump and the GOP: self-identified Christians. Trump is the champion of Christians, the one who fights in a decidedly un-Christian way on behalf of the Christian brand. Talarico conspicuously talks the language of Jesus, doing so from a position of apparent sincerity and belief, not opportunism. 

Americans will go to bed tonight having learned which direction Texas Democrats signal they want the party to turn. 

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Here is why we are at war.

"(War, huh) Lord, lord, lord, lord
(What is it good for?) Oh, absolutely nothin'"
       Edwin Starr, Motown anti-war song, 1969

People who go to war have very good reasons.

Reason: We cannot let Iran have nuclear weapons.

"They've rejected every opportunity to renounce their nuclear ambitions, and we can't take it anymore."

And more reasons:

Reason: Payback. Trump said Iran took Americans hostage in 1979, they carried out the bombing of a marine barracks in Beirut in 1983, and they might have been involved in the bombing of the USS Cole in 2000. He wrote on Truth Social that “Iran tried to interfere in 2020, 2024 elections to stop Trump." This made it personal.

Reason: Regime change. Trump sent a message to the Iranian people. Start a revolution. Create your own government amid the chaos. He said, "Now is the time to seize control of your destiny, and to unleash the prosperous and glorious future that is close within your reach. This is the moment for action. Do not let it pass."

Pundits offer other reasons.

Reason: Domestic politics, to improve his low approval rating. This one has instant credibility because it was top of mind for Trump himself when Barack Obama was president. Trump is unhappy about his bad polling. As is common with Trump, his accusations reveal a confession:

Now that Obama’s poll numbers are in tailspin – watch for him to launch a strike in Libya or Iran. He is desperate.
2:39 PM - Oct 9, 2012

and

Remember what I previously said--Obama will someday attack Iran in order to show how tough he is.
10:44 AM - Sep 25, 2013

Reason: Do what Bibi Netanyahu wants. Voices on the antisemitic, or merely anti-Israeli -- American right and left accuse the U.S. -- and Trump especially -- of having turned our Middle East foreign policy over to Israel. We are their patsy because "Jewish interests" in the U.S. control both political parties through campaign contributions. Bibi needs this war; the U.S. is dragged along.

Reason: Distract from the Epstein mess. The war pushed Epstein out of the news. The war changes the Trump news story from the lecherous playboy with teen beauty pageants into a bold military leader involved with far more important matters than unprovable sex crimes. 

Reason: Iran is a package deal with Venezuela. U.S. Gulf Coast refineries are set up to process heavy oil.

Venezuela has the world's largest reserves of that sludge-like oil. It needs to be mixed with very light oil to transport via ships and pipelines. Our new Venezuelan oil resource is incomplete without Iranian solvent. Trump is not a sentimentalist. Strong countries don't go to war for intangible democracy or human rights. They go to war for resources. 

Reason: The U.S. picked a side in the Middle East rivalry, the side that wants to do business with Trump, not the side that cares primarily about religion. This is a regional war: the Saudis and Arabic oil kingdoms versus Persian Iran. The oil kingdoms are now modern capitalists at heart.  We -- and Israel -- can do business with them. 

Burj Al Arab ultra-luxury hotel in Dubai

There is a reason that Iran lobbed a missile into this Dubai hotel.

Reason: We can. The U.S. has a big military. It isn't there to have on standby and not use. Why have it if not to use it?  The change from "Department of Defense" to "Department of War" reflects a change in policy and purpose.

Reason: Trump seeks a grand legacy. He seeks glorification. Leaders who have had their names associated with "the Great" have led successful conquests. They do big, bold things. The giant ballroom and arch projects, plus Trump's name and image on buildings, airports, currency, warships, and geographic features are not enough. Trump wants conquest. Cuba is next.

Reason: Save face. If things go poorly, there is always the fallback reason to keep on fighting even after all original reasons are gone. We cannot let the world see we did not win. That was our reason when the war dragged on in Vietnam. That is Russia's situation in Ukraine now. There is always a reason.

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Easy Sunday: Message to Iran

This isn't a new war. It is a new phase of a very old war. 

Greek City States fought the Achaemenid Empire of Cyrus the Great beginning in 499 B.C.

Design on Greek pottery: Fallen Persian soldier on left. Greek hoplite on the right.

 We are still in the honeymoon phase of this war. It is a time to imagine a happy ending: a short war; a lasting peace; Iran a  friendly neighbor in the region; and a new government in place establishing domestic tranquility among a people well-disposed toward the U.S., Israel, and the world. It isn't impossible. 

Trump carried out a sneak attack while amid supposedly-sincere negotiations with Iran. Trump did not sell this war to the American people, nor get the support of Congress, nor make this war a coalition of willing allies with a shared goal. We did this alone, with Israel. 

Sometimes process is important to the end result. This process is quick and dirty. It is swashbuckling. Heroic. It is Trump's style, especially in this second term. He doesn't wait for permission or consensus. 

Trump dismisses impediments that hobble presidents burdened by the Constitution, American laws, international laws, or norms of behavior. He is a modern-day Alexander the Great, solving Gordian Knot problems by slashing them with a sword. He is a winner and no one can stop him. Trump is consumed with hubris. He is dangerous, a dynamo in the center of our politics, the center of attention. Millions of Europeans, many of them French, died because of Napoleon's ambitions. Nevertheless, or because of it, the French have a giant memorial for him.

College classmate Chris Kellogg captured Trump's hubris in this imagined message from Trump to the people of Iran.

               TO THE PEOPLE OF IRAN

Ready or not here I come.

I have finally and successfully provoked an attack from your Ayatollah. I don’t care much if tens of thousands of you are going to be mowed down, detained or tortured by your security forces, but I don’t want your current leaders to make atomic weapons. Therefore, I personally have decided that the U.S. should bomb your country’s infrastructure even though bombing-only campaigns have only created complete chaos with few intended results elsewhere, e.g. Libia, Ukraine, etc. So now, no matter that you have no capable resistance organizations or weapons to protect you, I expect you to overthrow the regime. Then maybe I can get a long-deserved, Nobel Peace Prize - I only have a few years left to try, and the one I've got has a Venezuelan name on it.

Also, since you are not as valuable as White Christians, the casualties you suffer should not be a concern. I know I said I was going to do something to protect you, but should you consider fleeing to the U.S., just remember that although ICE is very nice, you should go to Canada instead.

Just remember there is no peace without war unless you avoid military service altogether. And good thing I did not consult Congress although it was not in response to an imminent attack.

 Despite the distration of the chaos and buildings falling around you, I thank you for your attention to this matter.

From my golf course - you should see how beautiful it is today - where I am winning too much.

DJT

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