How Does US Healthcare Compare?

US Healthcare Spending Infographic:Title is U.S. Healthcare Spending; lower left chart titled Healthcare spending does not equal long life; the chart shows that we spend $7,960 oer oerson  which is the highest in the world, but we are 50th on thelist of life expectency; Upper right pie chart shows that we spend  3 to 5 times more on heatlcare that ifrastructure, military, or education totaling 16% (now 118%) of our GDP; lower right show that $.75 of every healthcare dollar goes to chronic diseases, listed as obesity, Type 2 diabestes, heart disease, and lung disease

How Do We Compare?

Commonwealth Overview of US and other Healthcare Systems

It is well worth reviewing the Commonwealth article on the actual state of US healthcare to grasp the totality of the unsustainable health system that we must use right now.

While there are many problems with the US healthcare system, the most profound problem of the current one is the unsustainable cost, 30-60% higher than any other developed society. While we tend to think of this cost as related to individual high-cost parts of the system (say, prescription drugs), it is truly a system problem. At 18% of the GDP, it is approaching $1 in $5 of our national economy. When you combine that with entertainment, our economy is more than one-third in these 2 categories.

The next time you see an article on the stagnant American economy and the future of work, remember that we are rapidly becoming a society of entertainment and healthcare.

Also, ask yourself about reducing our costs to equal, say, the next highest cost healthcare system, which is, like all the other systems in major countries, single payer in one form or another.  We do a worse job of health support than other developed countries, and we need to understand that reducing costs to any real extent in our current system will worsen our healthcare significantly.

Since a major cost in our system is wage and benefits costs, we will also be reducing both jobs and the spending power of the replacement jobs, if there are any. This wouldn’t mean all that much in most areas of employment, but because healthcare is so large, any significant decrease in jobs is a big deal for the whole economy.

Remember that for the most part, those individuals working in healthcare have invested a lot of money, time, and a good bit of their personal and family future in the health system. If they end up failing to contribute this substantial investment to the national economy, we will all suffer, and not just in our health.

This creeping system failure is the definition of a Catch-22. All the approaches that might reduce the cost of the system compete poorly right now with the existing system in resources, institutional infrastructure, and political power.

There is no obvious system level solution to this. Single payer would help, but it wouldn’t magically eliminate all the system effects in our health behemoth. But there are trends we can support and ones we can fight.

More in future posts.


What Does Health Integration Mean?

Title is 360 degree Care with arrow pointing to phrase, The Power of Whole-Person Care; Circle of sections that describe impact of coordinated care, including: 38% Increase in consumer engagement; 16% decrease in use of healthcare services; 148% more successful addictions treatment; 74% reduction in symptoms of major depression; 23% increase in primary care services; 80% decrease cost of total care; 30% reduced hospital admissions. A side bar says;In any given year, there are approximately 34 million American adults with co-morbid mental and medical conditions. Coordinating care can improve clinical outcomes, incease care quality while reducing costs, and boost customer satisfaction.

What Coordination Could Mean

Michigan has been pursuing integration of behavioral and physical health for several decades now, primarily using various changes in Medicaid payment systems as the driver. Even though almost everyone sees integration as a positive improvement, our health care system is so complex that actually producing effective integration remains an outcome for our future. It doesn’t exist except on small scale in a few places now.

In addition, the money involved motivates actors in the larger systems of physical and behavioral health to view integration primarily as a financial support for whatever part of the health system the actors occupy. The essence of capturing all that money is largely seen as a political task, not a health care task.

This struggle between who will control the money and how effective integration actually happens is driving the current fight between Michigan Managed Medicaid health care (the responsibility of various Medicaid Health Plans) and Michigan’s managed behavioral health system (managed by what are called PIHP’s through their relationships with local community mental health agencies).

But, what does integration actually mean? Why does it seem to be so difficult to choose a path of integration?

It is easy enough to say what the outcome of integration should be:

All your behavioral and physical health supports should be coordinated with one another through a person centered plan and everyone who provides services to you should understand all the supports you are getting through that PCP.

Although most of what you hear about integration is about who will control the money, that outcome is supposed to be the end result. But control of the money doesn’t in any way guarantee that your services and supports will be truly coordinated by a person-centered plan. The arguments about who controls the money are really about the “most efficient” and “least costly” way to providing the services and supports.

These terms don’t really mean what you might think. They don’t mean that services and supports will be provided at the highest quality for the lowest cost. They mean that the services and supports will be provided at the lowest cost regardless of the impact on quality.

So, when you hear someone talking about integrated care and how it should be provided, always ask whether that means anything other than the least possible services and supports that the system can provide on the cheap.



Choices in Our Strategic Defense

three intertwining paths meet in the woods by williams cairns photography llc

                                                   Paths Meeting in the Future                                                          See

In my last post, I tried to give the flavor of how the Strategic Defense plays out in military conflicts. Of the three examples, the one that has the most lessons for our resistance is the third, the American Civil War.

In fact, I would argue that the current effort by the GOP to remake America as it was in the 1950’s draws on the arrogance and self-delusion of the Confederate example of the Strategic Defense, which believed that there was no possible way they could lose against the Union, so obvious was their moral, personal, and economic superiority. The South was seen by white southerners at the time as the Betamax to the North’s VHS.

(One of these days, I’m going to do an overview of Thucydides work, “The History of the Peloponnesian War”, which covered the 27-year long military engagement between Athens and Sparta and all their allies that destroyed Greece 2500 years ago. There are many lessons for modern “realpolitik” foreign policy and “endless war” pundits, as well as political establishments).

The lessons of studying the actual reality of the American Civil War include the role that stupidity, personal venality, and incompetence played in the conflict, and how ironically robust insurgent tactics are, even in the face of the long-term overwhelming advantages that the Union had. These advantages ultimately destroyed the antebellum South and the residue of that collapse (stretched out by southern insurgent tactics) continues to stigmatize and undermine both African-American communities and white southerners to this day.

Phase 1 of the Strategic Defense is a long way from being concluded. Even if the entire Congress were to shift into the hands of the Democratic Party in 2018, and the Presidency in 2020, don’t kid yourself into thinking that nothing else needs to change.

Phase 2 in the Strategic Defense is the proof in the pudding and the only reason we should tolerate the chaos and randomness of Phase 1. And the essence of a successful Phase 2 lies in how much, of what led you to end up on the Strategic Defense, you are willing to rebuild from scratch.

In this case, ALL the decisions that have lead us to the thoughtless, mind-numbingly automatic efforts to restore what existed before the 2016 election will undermine the success of Phase 2 for exactly the same reasons that the refusal of the Confederacy to give up any part of their ideology and societal structure led to their social destruction.

While people with disabilities would do better under almost anyone other than those in power now, that won’t change the larger trends that are driving the short-term thinking in both our economy and our republic, and the long-term degradation of our society.

As a minor but telling and ongoing example of this, the Democratic establishment is now building lists of people and organizations that they will punish when they get back into power, the same way that the Republicans are now implementing their revenge on those who were put on their lists over the last couple of decades.

For reasons that I don’t grasp, this endless cycle of recrimination seems acceptable to an alarming number of otherwise compassionate and intelligent people.

It is not enough to win back the seats of power. If we are not building something that hasn’t existed to this point, we will keep running through the same rhetorical cycles over the generations until we collapse enough to become irrelevant.

I’m not talking about some kind of top-down, professional, radical, or political plan based on some top-down, elitist silver bullet for revolution. I am talking about building from scratch, not a new society, but the basic practical way in which we hold each other dear, and mutually support our common growth toward an actual lived experience of both liberty and choice.

I’ll try to be more specific in the next post.

Living in the Flow of A Strategic Defense

Complex flow of liquid in many colors

Flows Are Complex

As I discussed last time, we are in the first phase of a Strategic Defense against the Administration’s effort to dismantle supports for people with disabilities and eliminate us as a cultural and political force. The flow of change in a Strategic Defense follows a general framework, though every example is unique.

I’ll go over three examples from military history at a very high level to build a feel for how the dynamic of a strategic defense plays out:

  • The Eastern Front in World War II
  • The US War in Viet Nam
  • The US Civil War

The Eastern Front

When the Nazi regime invaded the Soviet Union in June of 1941, they did so with what was arguably the strongest military organization up to that point in human history. They had carefully planned, staffed, and supplied the largest invasion force in history. They invaded a land with many soldiers but little military ability.

The invasion was entirely successful by every standard until the final defense of Moscow in December of 1941 and the beginning of 1942. Persistent, if spectacularly inept Soviet defense, the gradual erosion of the ability of the Nazi army to maintain it’s fighting quality, supplies, and leadership, and the onset of winter ground them to a halt.

In the Spring of 1942, the Nazis began an apparently successful offensive again, until Hitler decided that the proper end to his invasion would be to take Stalingrad, the city named after his Soviet opponent. This was a strategic error, but this kind of arrogance and strategic slippage is common among those who start wars and is one of the hallmarks of a successful Strategic Defense.

The Battle of Stalingrad was in many ways the largest in history. A million people died, and another million were wounded or captured. In mid-November 1942, the Soviet army counterattacked at the margins of the Nazi offensive, surrounding and eventually destroying the entire Nazi 6th Army. Though it took another two years, the Nazi “experiment” was over.

The Soviets tracked the two-phase framework described earlier. They tried to blunt the invasion and cost the Nazi Army what they could without being able to achieve any standard notion of military success. Nonetheless the blunting cost the Nazi Army through very gradual degradation and provided time for the creation of the second phase effort. The Soviet Army gradually built a well-equipped, well trained, fresh force in the far eastern part of the Soviet Union. Only when the Nazi Army was stretched to its practical limit at Stalingrad, only when the offensive had ground to a halt, and only when the fresh force was sufficiently prepared, did the counteroffensive begin.

The US War in Viet Nam

The War in Viet Nam that the US conducted from 1965 to 1975 is a complex example of how to conduct the Strategic Defense, as demonstrated by the approach that North Viet Nam took to responding to the US defense of the South Viet Nam government and Army (RVN).

It wasn’t remotely feasible for the North Vietnamese Army (NVA) to have a militarily strategic success against American forces. While not entirely true, the American argument, “We won every battle” was close enough to true that it, like the early offensive successes of the Nazi Army, shows the strategic shallowness of operational military success as a measure of strategic success when facing a competently conducted Strategic Defense.

The NVA settled on a very costly insurgency approach of continuing to engage the American military, in order to force expanded involvement and commitment of the US across South Viet Nam. This was the functional equivalent of phase one in the Strategic Defense.

It was very costly. Three million Vietnamese died over the time of the American involvement, and nearly 60,000 Americans died as well. When the United States stopped its military involvement, never to come back, the NVA began the process of the second phase, and eventually defeated the RVN using standard military operations.

An insurgency, however it is built and used, is functionally the first phase of a Strategic Defense, and there are many examples of such a use globally right now. The NVA developed a particularly sophisticated use of phase one, blunting the US military effort psychologically and politically rather than militarily. The military aspect of the NVA strategy was to ensure continued engagement over a protracted period of time so that when the US effort faltered psychologically, it would be politically impossible for it to begin again. This would leave the South open to military conquest by the North.

The American Civil War

I chose the Civil War as my third example because of its complexity and the fact that it is still being fought.  The initial invasion wasn’t a military one, but the secession of what became the Confederacy. The “invasion” was the attack on the idea of the union of the United States. After that initial action, the Confederacy settled into a Strategic Defense, based on the notion that the North would militarily invade the south and bring out the insurgency of the entire South fighting to the last.

Initially, this proved problematic. The North fumbled around for so long, that the South was having difficulty keeping the energy for the fight in their troops and communities. There was even some effort by the South to provoke the North into invading.

The delusions of the Strategic Defense of the South included:

  • Their initial superiority in individual fighting ability and operational competence would make up for their long-term deficits in numbers, manufacturing ability and their rigid and inflexible economy.
  • Europe, particularly England and France, would side with the South even though this would require Europeans to renounce their moral objections to slavery, the long-term economic and social consequences of mounting a war against the United States, and the very large surplus of cotton in Europe that had built up before the secession.
  • The arrogant delusion that the South’s economic system, social culture, and values were so superior to everyone else that they would somehow overcome the extraordinary barriers of the actual reality.

The Confederate notion of fighting to the last resulted in the complete destruction of their economic base, and the Reconstruction cemented the polarization which continues to this day. In the end, the Confederacy was unable to mount a competent second phase in their Strategic Defense, and the reason for this failure was economic. But the delusions that led to this debacle and the enormous human cost of the Civil War are still an important driver of the modern US economic and social system.

Next Post: Lessons for Our Current Strategic Defense

More We Can Be Doing

Salmon background color with the phrase, The more we do the more we can do, by William Hazlitt published by

Expanding the Wave of Impact

While we are blunting the destruction of supports for our friends and families, we also have to learn from the experiences we have in resisting, and begin the arduous process of preparing our eventual counteroffensive. It is still very early in this second phase of the Strategic Defense, but it isn’t too early to start organizing it.

Right now, the public hope of resistance is focused on somehow ending the presidency of Donald Trump.

This hope is a little like the story of the drunk crawling around under a street light obviously looking for something. A guy comes over and asks him what he is looking for. The drunk says he lost his car keys.  The guy asks him where he thinks he dropped them, and the drunk points out into a field next to the road and says, “Somewhere out there.” The guy asks him why he isn’t looking out in the field, and the drunk says, “Because it’s too dark out there to see my keys.”

Like a flare set off in the wrong place during an attack on the perimeter of a combat base, the President attracts all the attention but creates none of the value in dealing with the threat. Attacks on the President are proxies for attacks on those who voted for him. While it is gratifying to express contempt for those who cause your current pain, no one ever changed their vote because they were treated as vermin. And, every ounce of effort to pin where we are now on one person is effort taken away from preparation for the second phase of the Strategic Defense.

Clicks in social media have no impact on the long-range turnaround of political values in our country.

There is no comprehensive solution to the current situation because of the systemic forces that led us to this juncture. Any viable strategy has to be for the long term. While effective change can improve our situation, no change in the short term will alter those systemic forces.

Our first operational boundary as we go about building resistance is the 2018 election cycle.  A small change in the Senate, say three seats changed from Republican to Democrat or to what used to be core Republican values would put a halt to the legislative destruction of support to our friends and family members.

For this to happen, there has to be a very large turnout of those most affected by the destruction of the support system, including members of minority and poor communities, older citizens, and people with disabilities and chronic health conditions. That means that simply asking people to vote or scaring them into voting won’t be enough. We need to take a lesson from the resistance to voting barriers in the early sixties and assure our community’s participation by accompanying voters, transporting voters and intervening at polling places when eligible voters are harassed or prevented from voting.

The British have begun to turn back the forces that led to Brexit only by increasing the turnout of young voters by 70%. 45% of eligible voters in the US 2016 election, clearly the most important in several decades,  did not vote. It isn’t at all clear to me that we are willing to make the relatively small sacrifices necessary for a large turnout.

If we are willing, we need to start now.

Another operational arena that has a lot of potential impact on the values of our society is to begin organizing locally so that we can do what the right has done for a half century-organizing from the bottom up. There is probably no better place to start this organizing that supporting our community members in running for school board positions. There is an overview of how to run for school boards in Michigan and there is a site called Vote Run Lead that has much information on running for a lot of offices and a section on school boards.

If you are not an experienced politician, you need to pull together a support network that can help you learn and succeed. This network can be the beginning of larger networks that will keep us in the resistance over the long term.

Next Post: The Flow of Effort in a Successful Strategic Defense

Fighting on Two Fronts

Game Graphic that says, Fight on Two Fronts! Fight in air and on land! with cartoon depictions of the two strategies

Parallel Strategies

We are approaching the end of the Administration’s first 6 months and the overall strategy of their effort to change the structure of American society is clear:

  • Reduce all non-defense spending, and most particularly those parts that support anyone who is vulnerable, poor,  and has no robust political power. The proposed reductions in social security disability payments are a perfect proxy for all of the social services and healthcare cuts.
  • Increase defense spending, with particular emphasis on the part of defense spending that provides money to defense contractors (corporations) of all kinds.
  • Eliminate those parts of the Federal government that were created to support disenfranchised communities.
  • Defang civil rights and any media that resist the offensive.
  • Finally, shift the political burden for the blowback from these changes to the states, so that they absorb the long term anger that will result from success in this strategy.

For people with chronic medical conditions, disability characteristics of all sorts, and older people, these changes if successful will result in early death, increased disability, the elimination of local support networks, increasing isolation, and even less political power than exists now.

We have to fight as hard as we can to reduce the impact of the Federal government’s strategy, and I imagine that we will be partially successful. I believe that most people hope we will blunt the offensive and that we will be able to replace the current crop of politicians with others who understand the impact of such change on our lives.

I think there is an underlying naivety in this view that doesn’t see how the condition we are now in was an outgrowth of the large-scale evolution of the US and global economy, making a return to what was (pick your decade for the social situation you want to return to) very difficult. It is far, far easier to create complexity than it is to dismantle it.

Restoration would require enormous political and personal effort and would not alter those underlying forces that are driving the relentless increase in complexity that we variously interpret as political polarization, the growth of inequality, the dominance of social, political, and financial elites, the growth of corporate power, and the systematic disenfranchising of all communities viewed by elites as “takers”, as less than human.

In military theory, there is a concept called the Strategic Defensive. Typically, it becomes the strategy of a party to a conflict when they are surprised by the power of their enemy’s offensive strength. Basically, they fall into Strategic Defense because they have no other choice. We are now in the midst of a Strategic Defensive.

All Strategic Defensive responses consist of two parts:

  • An initial counter to blunt the impact of the offensive
  • A second strategy that builds during the course of the hopefully slowing offensive to eventually provide a basis for a counter-attack.

The value and ultimate impact of the Strategic Defensive does not usually depend on the first response of trying to blunt the offensive, but on the sophistication, depth, and patient focused preparation of the second strategy.

So, although I called this post, “Fighting on Two Fronts”, I don’t mean the traditional idea of two geographic areas of counteroffensive. I mean the two fronts as the very different strategies of blunting the current offensive and building a long-term response.

The first response is always chaotic and energy/resource wasting and its core is to counter every initiative of the offensive, in order to force enemy investment of time, resources, and money in furthering the goals of the assault, thus slowing it.

As far as I can tell, there is no way around the waste involved in the effort to blunt the offensive. Because the offensive was a surprise, there is no realistic contingency plan for the specific nature of the offensive and everybody falls back on abstract counters that are organized around the entirely unrealistic framework of getting things back to where they were before the offensive. That restoration never happens. Sometimes you end up in a worse place, and sometimes you end up in a better one, but you never return to what was once upon a time.

While we are fighting to preserve resources to support people in the first phase of our Strategic Defensive, there are also other ways of blunting we must consider in addition to the obvious ones, and we need to start thinking more about the second phase, the long-term response.

Next Post: More We Could Be Doing

Deep Impact: The Administration’s Budget

Image of Asteroid impacting the earth from the film Deep Impact

The Final Countdown

Well, the 2018 budget for the Federal Government is out, and it is a pip. Devastating cuts of $2.5 trillion in programs that support poor and moderate income folks and families, and a total of $4.3 trillion nondefense totals.

Some highlights:

  • A total of $1.9 trillion in healthcare cuts, focused on Medicaid and subsidies and resulting in a Medicaid program that is half the size of the one we have now by 2027.
  • Steady cuts over the decade in job training, housing (a loss of 250,000 housing subsidy vouchers), the end of the energy assistance program that helps people pay their heating bills, etc., etc. resulting in $400 billion in cuts over the decade.
  • $193 billion in cuts in the SNAP program which helps poor people (and many military families) to avoid hunger.
  • A total of $72 billion in cuts from SSI ($9 billion) and SSDI (the rest).
  • $40 billion in cuts to the student loan program
  • $28 billion in cuts to the child tax credit and Earned Income Tax program
  • And much, much more.

While the budget as written will not pass, compromises that get it passed will be devastating as well, since the increases in defense industry sweetheart deals ($54 billion in 2018) will prevent future increases in nondefense programs as effectively as if defense contracts were protected by the weapons those contracts build.

Republican defense hawks are already whining about the weakness of the defense increases.

Winter is coming…….

Center on Budget and Policy Priorities