Charles D. Hayes: People Before Profit in Healthcare


If we play our cards right, the GOP’s killing of the Affordable Care Act, may be the very impetus, we need to get a single-payer system enacted. As I have pointed out elsewhere, after the war ended in 1945, Harry Truman tried to get legislative approval for universal healthcare and because of the goodwill from the war effort, most people were for it.

But law makers from the South blocked the measure, because their constituents were afraid they would have to share doctors and medical facilities with racial minorities. Obamacare, however, is fashioned after a conservative plan, hatched by the Heritage Foundation, that put an emphasis on personal responsibility by making insurance mandatory.

President Obama thought he was meeting the GOP halfway by using their model, instead they turned against their own idea and flip-flopped from an issue of personal responsibility to an attack on personal freedom, rather than give President Obama a victory.

If the GOP were to replace the ACA with something better, that would be great, but we know, it’s not going to happen. That’s not the way they roll, they are big talkers about freedom of choice, but they are betrothed to big-money.

The GOP will cut deals that favor Big Pharma and the insurance companies, over the interests of their constituents, this is what they do, they can’t help themselves, it’s who they are, it’s what they believe is just, it’s a trace of the ethos of their deep-seated ideology of the survival of the fittest and their visceral, but seldom publicly acknowledged assumption, that people who can’t afford private health insurance, don’t really deserve it.

Once the full painful effects from the GOP’s botched special-interest rigging are felt by the public, there is going to be a backlash from people in dire straits without available medical treatment and we need to catch the winds of their justified anger in our sails and force a hurricane of dissent.

We are the only developed country in the world that can’t seem to generate enough goodwill to see to the that all our citizens have affordable healthcare without emotional angst and constant whining. Our dilemma is embarrassing, but worse, it’s an egregious insult to the memory of real patriots.

That we have lost members of the armed services on the battlefield who have had relatives die from a lack of medical care, because they couldn’t afford health insurance, is a national disgrace. This doesn’t happen in a good country, let alone one that incessantly claims to be great.

That we can spend trillions of dollars for potential military threats without blinking, but cry budget deficit, when it comes to our citizens facing actual harm, life and death threats, is a moral blasphemy that flies in the face of any ideal of what it means to be an American.

There is no room for profit in health insurance, because it comes at the expense of medical treatment, period. We need to keep making the case that not only is single-payer the only ethical system of handling our health insurance, it’s the only method that is proven to be economical and this is easy to prove.

Fortunately, the number of people in favor of single-payer is growing and when the GOP bungles the ACA, which they are honor bound to do, we need to make a BIG DEAL about SINGLE-PAYER as a slam dunk election issue in 2018, and 2020.

Naked Capitalism on TrumpCare


TrumpCare: ObamaCare, Medicaid, Medicare, and the Veterans Administration

By Lambert Strether of Corrente.

Assuming that Trump takes office on January 20, we can expect health care policy to shift from the left side of the Overton Window to the right, even as the only solutions that remain “on the table” are neoliberal and markets-first non-solutions. Let’s begin by setting the baseline for a rational and humane health care policy — i.e., not neoliberalism — as a universal benefit.[1] From Richard D. Lamm and Vince Markovchic in the Denver Post:

U.S. is on fast track to health care train wreck

In 2015 we spent $3.2 trillion on health care, which was $10,000 per person in the U.S., ($25,000 for a typical American family). This is 17.5 percent of the U.S. Gross Domestic Product (GDP). To put this in perspective, this is more than twice what most other developed nations spend on health care while insuring all of their residents. This year we are on track to exceed that amount with it being 18 percent of GDP.

Even with the implementation of the Affordable Care Act, we still have 28 million people with no health insurance, and many more are under-insured due to rising co-pays and deductibles….

Of the $3.2 trillion health spending, 70 percent goes directly to fund the cost of our healthcare. The remaining 30 percent is spent on administration and profit, which is more than twice that of any other nation. In 2014, studies published by the Institute of Medicine, Rand Corporation, and the Center for Medicare/Medicaid Services estimated that out of total health care spending, as much as $900 billion, or about one third of our total spending, can be attributed to waste, fraud and abuse.

This current system is unsustainable, but who will tell the American public? We suggest that the solutions to the real problems of health care are hardly being talked or written about.

The ideal health insurance system is one that: provides free choice of hospitals and doctors; provides insurance coverage to all at all times (i.e., not tied to an employer); is affordable and will remove all risk of medical bankruptcy. This system should have an administrative cost of less than 5 percent and have everyone in the risk pool, thus making premiums affordable. We have such a system now: Medicare covers all persons over 65, those on total disability, and all renal dialysis patients.

Medicare, with all the fraud and other issues, still operates with about 3 percent to 4 percent overhead. That is much less than the profit and overhead added by U.S. health insurers, which is instead 15 percent to 20 percent. In addition, Obamacare, Veterans Affairs and Medicaid each add another entire layer of expensive bureaucracies. All these, along with the government being unable to bid for drugs purchased under Medicare, add up to unnecessary cost and waste in our system.

Similarly, there would be tremendous cost savings if under Medicare as a single payer, it is authorized to negotiate for hospital care on a more cost-efficient and more comparable basis across the nation.

So, the health insurance companies are parasites who should be removed. Now, I don’t know why Lamm and Markovchic don’t just lower the age for Medicare eligibility from 65 to zero, like Teddy Kennedy proposed. And I also don’t know why Democrats (including Sanders) aren’t prefacing every statement they make on heatlh care with “Of course, Americans deserve Medicare for All. Until then….” Instead, they’re digging in to defend a flawed system that hasn’t covered 28 million people, instead of going on the offense for the universal benefit. (That’s the difference between “resistance” and “revolution,” I guess. The one is reactionary; the other is, er, progressive.)

Anyhow, it is what it is and we are where we are. Absent a universal benefit[1], we get health care silos: ObamaCare, Medicare, Medicaid, and the Veterans Administration, among others. In this post, I’m going to take a very quick look at the current news in each silo. All the silos are in decay and disrepair — except from the standpoint of those who profit from them, of course — and all suffer from neoliberal infestations, but the forms of decay and the degrees of infestation differ. So the post will be a bit of a patchwork, but then the health care system itself if a patchwork. As always, I welcome comments from readers with informed experience interacting with these systems, for good or ill.

ObamaCare: Repeal and Replace, But How, When, and with What?

On ObamaCare repeal, Chuck Schumer suggests: “It’s a political nightmare for them. They’ll be like the dog that caught the bus.” Heaven forfend Schumer should defend a universal benefit, but on this he could be right. Throwing 30 million people off the rolls[2] is a heavy lift, even for Republicans. That’s because there’s really no popular consensus for doing it:

But the euphoria of finally acting on a long-sought goal will quickly give way to the reality that Republicans — and President-elect Donald Trump — have no agreement thus far on how to replace coverage for about 20 [or 30] million people who gained insurance under the health-care law.

Obamacare continues to be viewed unfavorably by Americans, but the politics of undoing the law are complicated. A Kaiser Family Foundation poll after the election showed 26 percent want to repeal it, while 17 percent want to scale it back. Nineteen percent want to move forward with implementation and 30 percent want to expand it.

It’s also not clear what would happen to Republican border states like Tennessee and Kentucky, that benefited signifacantly from Medicaid expansion under ObamaCare.

So the Republicans want Democrats to hold hands with them as they jump off the cliff. Let me know how that works out:

Some Republican aides say they may pursue a replacement through a series of small bills as opposed to one big measure. Leading Republicans such as Senate Majority Whip John Cornyn of Texas have said they want Democratic buy-in on a replacement plan. Breaking a filibuster would require the support of at least eight Democrats.

(Of course, reconciliation requires a bare majority, and the filibuster can be altered or abolished when the Senate adopts its rules at the start of a session.)

So the Republicans are toying with various ideas, some of which involve kicking the can down the road (“three year delay”), or even off the road entirely:

Now comes the American Enterprise Institute’s conservative health wonk James Capretta with an idea that cuts to the chase: Why not just “grandfather” all the people currently receiving benefits via the ACA and make whatever the new “replacement” system turns out to be prospective for new people seeking assistance?

It is also worth noting that Republicans have not had much luck in the past convincing people to accept radical policy changes by grandfathering those most immediately affected. George W. Bush’s proposed partial privatization of Social Security was supposedly only going to affect people aged 55 or younger. The same was true of Paul Ryan’s original Medicare voucher proposal.

(ObamaCare enrollment hit a record high this year, so I wonder if people were acting on rational expectations of a grandfathering solution. I know I thought of it.) So the 115th Congress should be interesting. However, if the 21st Century has taught us anything, it’s that it’s always possible to make a bad situation worse. Remember the ObamaCare rollout debacle? Does anybody believe the Republicans will do any better at a rollback?

Medicare: Balance Billing

Naked Capitalism covered ObamaCare’s balance billing problems back in 2013:

One of the proofs that Obamacare is really about helping insurers and Big Pharma rather than ordinary Americans is its failure to do much about the seamy practice known as balance billing.

Say you have a scheduled procedure, like getting a stent. Like most Americans who have health insurance, you are in an HMO or a PPO. Your doctor, who is in your network, schedules you for the operation at a hospital in your network. You assume the only thing you need to worry about is a fairly minor co-pay and recovery.

But weeks later, you find that the anesthesiologist wasn’t in your network, and you are hit with a $12,000 bill for his services. And this sort of scamming (hospitals knowingly putting people on a surgical team that they can bill at huge premiums to negotiated rates) is routine. And of course, if the ambulance takes you to an emergency room that is not in your network, the outcome can be catastrophic.

And now, the Trump administration is considering expanding this pleasant practice to Medicare:

“[B]alance billing” [is] why the American Medical Association is strongly supporting Donald Trump’s pick of [the aptronymic] Rep. Tom Price (R-Ga.) to lead the Department of Health and Human Services, which oversees Medicare. … In 2011, Price (an orthopedic surgeon himself) introduced a Medicare “reform” bill in Congress that, among other things, would have brought balance billing to the program. This

Balance billing is basically illegal for Medicare patients…

Permanently obliterating the financial security of helpless families with no or bad insurance as a loved one dies slowly and painfully of a chronic illness is a nice little profit center for providers. But it pales in comparison to the gravy train they might get if they can bring balance billing to Medicare. Seniors use far more care than the younger exchange population, and there are a lot more of them — 55.5 million, versus 12.7 million people on the exchanges. Perhaps most importantly, they’re quite a bit richer on average. Many seniors have been scrimping their whole lives to save for retirement, in keeping with decades of agitprop from conservatives and Wall Street, and the more sociopathic among the health-care population are licking their chops at the prospect of being able to devour those nest eggs.

(I like Ryan Cooper. The man can write.) So, like I said, it’s always possible to make things worse…

Medicaid: Privatization in Iowa

Let’s start out by noting that Medicaid has a serious neoliberal infestation problem:

More than two-thirds of states contract out some or all of their Medicaid program to private companies. The benefits of the practice and its impact on quality and cost of care have been unclear, however.

The Des Moines Register:

HHS believes 57% of Medicaid beneficiaries were enrolled in Medicaid managed-care organizations as of July 1, 2011, compared with 10% in 1991. The consulting firm Avalere Health projects that 75% of Medicaid beneficiaries will be covered by managed-care organizations starting in 2015. A recent U.S. Government Accountability Office report, using fiscal 2011 data, found Medicaid managed-care plans received about 27%, or $74.7 billion, of federal Medicaid expenditures.

The rush into Medicaid managed care came despite limited evidence that the plans save money for states and the federal government.

Iowa’s Republican governor Terry Branstad controversially privatized Iowa Medicaid services, on the (ostensible) premise that the state would save money (see Lamm and Markovchic, supra). Oops:

Iowa Medicaid payment shortages are ‘catastrophic,’ private managers tell state

In a Nov. 18 letter to Iowa Medicaid Director Mikki Stier, a UnitedHealthcare executive also warned of financial problems. Kimberly Foltz, chief executive officer of the company’s Iowa branch, wrote to Stier that she appreciated the state’s efforts to address some of the issues, “but overall the program remains drastically underfunded.”

Foltz wrote that experts from the Milliman firm, who were hired by the state, underestimated by 40 percent how much it would cost to cover the tens of thousands of poor Iowans who were allowed to sign up for Medicaid under the federal Affordable Care Act.


The mistake “suggests there were material flaws in the rating projection,” [Foltz] wrote.

Oops. (Had UnitedHealthcare no data to check Milliman’s figures?)

Foltz wrote that one way to help make up for the shortfall would be to allow the managed care companies to negotiate down how much they pay pharmacies to fill prescriptions. She suggested her company could cut those rates by nearly 90 percent. Hill said the contracts are written in a way that would make it difficult for the managed care companies to opt out unilaterally. But she said the companies could argue that the state and its actuarial firm, Milliman, did not properly estimate the costs of covering care for Iowa’s poor and disabled residents. “Conceivably, that could be a material breach of the contract,” which could allow the companies to bail out of the project, she said.

A nice Christmas gift for Terry Branstad. (The 90% figure seems to me remarkable.)

Of course, the real solution to cost problems is to abolish the insurance companies altogether, and use the power of single payer to beat back Big Pharma. But then you knew that.

Veterans Administration: Creeping Privatization

Finally, let’s take a look at the Veterans Administration. (I’m by no means an expert in the VA, and so readers will correct me, but my general impression is that the VA rations by queuing but can’t admit it, which has caused them political problems. But once you’re in, the care is good, which presumably explains why veterans themselves don’t want to “privatize” it. However, I think privatization as a frame is slightly deceptive, as we shall see (even if Sanders adopts that frame).

So, here’s Trump doing the Trump thing, which is — and do not underestimate him! — translating policy into vivid phrases voters can grasp immediately:

TRUMP: “We think we have to have kind of a public-private option, because some vets love the VA. Definitely an option on the table to have a system where potentially vets can choose either/or or all private.”

Brilliant of Trump to hijack the virulently memetic phrase “public option” — the bait and switch vaporware “progressives” used to suppress single payer advocacy in 2009 — with the conservative-sounding “public-privateoption.” And here Trump explains how such an option would work from the user’s perspective. Poltico:

Trump has insisted that what he wants is not to hand the veterans’ support mission entirely to the private sector. “No, it doesn’t have to be privatization,” he said in May. “What it has to be is when somebody is on line and they say it’s a seven-day wait, that person’s going to walk across the street to a private doctor, be taken care of, we’re gonna pay the bill.”

He has also proposed that all veterans be able to use their veterans’ IDs to get care at any hospital or doctor’s office that accepts Medicare.

Vets could use their ID cards! It’s brilliantly simple![3] It’s also a bridge too far for veterans:

But veterans’ groups see that as a major step toward privatization because it would allow veterans to opt out of the VA health care system. That is different from the recommendations of a recent federal Commission on Care, which pushed for the VA to oversee a network of qualified private health care providers to supplement VA-run hospitals and clinics.

But there’s less to this distinction than there seems to be at first sight. Trump proposes “walk[ing] across the street to a private doctor”; and the Federal Commission proposes “walk[ing] across the street to a certified private doctor.” Since the VA actually delivers health care, both solutions “allow veterans to opt out of the VA health care system,” and so both destroy the universality of the benefit. The Commission on Care (PDF) explains certification:

VHA credential community providers. To qualify for participation in community networks, providers must be fully credential ed with appropriate education, training, and experience, provide veteran access that meets VHA standards, demonstrate high-quality clinical and utilization outcomes, demonstrate military cultural competency, and have capability for interoperable data exchange.

Oh. Credentials. Not that I don’t want medical personnel to have them, but isn’t this rather a dog-whistle for liberals? And:

[A]ddressing veterans’ needs requires a new model of care: rather than remaining primarily a direct care provider, the VA should become an integrated payer and provider.

So, from being the American equivalent of the UK’s National Health Service, a “direct care provider” (even if the vile Tories are gutting it), the Commission proposes that the VA become more like Canadian Medicare for All, a single payer system. I told you it was a patchwork!

Now, let’s step back for a minute. The Commission was set up in 2014 under Veterans Access, Choice, and Accountability Act (VACAA), which was designed to solve a queueing crisis through “choice,” i.e., by allowing veterans who are unable to get an appointment in a reasonable time to seek care outside the VA. Now, a suspicious mind would put this under the heading of a neoliberal pattern for destroying a universal public benefit: 1) Underfund the service; 2) Wait for the inevitable problems; 3) Publicize them; 4) Push through a privatizing solution; 5) Rinse and repeat until the public service is destroyed. The VACAA was quite small. The Commission’s proposals are not so small. And in a decade or so, if the neoliberals get their way, the VA will be where Iowa is today, even if it does pass through a single payer phase on the way.

That’s why I think the privatization frame is a little deceptive. Yes, the ultimate goal, as with all neoliberal programs, is privatization. But it can take place a little at a time. For example, from Stars and Stripes:

Concerned Veterans for America, or CVA, is a veterans advocacy group in the Koch brothers’ political network and has been one of the most vocal critics of VA since the 2014 wait-time scandal.

The CVA is poised to become more influential under the new administration, as President-elect Donald Trump has tapped the group to help overhaul the veterans health-care system. The most controversial proposal by the group is an expansion of veterans’ health-care options in the private marketplace – which critics, including traditional veterans advocacy groups and Democratic lawmakers, say could lead to the dismantling of the current VA..

But CVA has not proposed a wholesale transfer of VA’s services over to the private sector – which is what “privatization” usually describes.

No, there is no “wholesale transfer.” Now. That’s for later, as with the Tories and the NHS.


So, what we have is a number of different battles on different fronts: ObamaCare, Medicaid, Medicare, and the Veterans Administration. It would be nice, and politically useful, if all these battles could be seen as a single theatre of war: Are we to have a humane and rational health care system — a universal benefit — or are we to have TrumpCare: An expensive and lethal mess?


[1] In of the earlier stories on Trump administration health care policy, the Times suggested that the Republicans seek a universal benefit. See FAIR, “Media Legitimizing GOP’s ‘Universal’ Health Plan That Doesn’t Exist.” I’ll believe it when I see it. The Democrats didn’t do it, so why would the Republicans?

[2] The 30 million figure comes from the Democrat nomenklatura at Think Progress, who helpfully calculate the number of deaths that will result. Ironically, they never calculate the lives saved with Medicare for All.

[3] Heaven forfend that any adult could use, say, their Social Security card for the same purpose.

The Price of Greed

Follow the Money: Nominee for Secretary of Health and Human Services Traded Health Care Stocks and Owned Tobacco Stocks While in Congress

By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine.  Originally published at Health Care Renewal

At least the US president-elect seems to be making the problems of conflict of interests and health care corruptionless anechoic.

Dr Price’s Stock Portfolio

The latest relevant big story was first picked up by Sheila Kaplan writing in Stat. It seems that Dr Tom Price, once a practicing orthopedic surgeon, then a Congressman, and now Mr Trump’s pick for Secretary of DHHS, owned and owns lots of health care related stocks:

his stock portfolio includes investments in pharmaceutical, medical device, and health insurance companies, the heart of the industries he would be overseeing as secretary.

In particular,

Among Price’s holdings are some in Innate Immunotherapeutics, Ltd., a biomedical company in which another lawmaker is a major shareholder. According to his financial disclosure statements, on Aug. 31 he bought between $50,001 and $100,000 worth of stock the firm.

Representative Chris Collins, a New York Republican, is a director of the company, which develops drugs to treat multiple sclerosis. He lists assets in the firm worth between $5,000,001 and $25 million. Price also purchased a smaller amount of stock in Innate Immunotherapeutics in 2015.

Collins is also a member of Trump’s transition team.

In March, Price invested between $1,001 and $15,000 in AmgenEli Lilly and Co.; PfizerBiogenBristol-Myers SquibbZimmer Biomet, a medical device company; Aetna; and Athenahealth. Also that month, Price sold the same amounts in GileadAbbott Laboratories, and Thermo Fisher Scientific.

So for readers of Health Care Renewal, this is very familiar. We have discussed ad infinitum the conflicts of interest that may affect physicians, particularly due to financial relationships with big health care corporations. The issue is that physicians swear oathes to put the health of their individual patients first, and to support the public health in general. Yet the interests of, for example, drug, biotechnology, device companies may be at odds with this primary mission. Such companies in this age of promoting “stock holder value” may primarily be about increasing revenue by selling as much of their products as they can, and let the Devil take the hindmost. Yet physicians ought to use drugs and devices judiciously, and only when their benefits for individual patients outweigh their harms. The concern is that physicians who have financial interests in such and other health care related companies may consciously or unconsciously allow their professional decisions to be influenced by their personal financial advantage.

Dr Price appears to be a member of the US House of Representatives full time, and no longer a practicing physician. But he has not relinquished his Georgia medical license (look here). So he should still be bound by his oath as a physician.

Dr Price’s Active Stock Trading

But wait, there’s more. Last week, the Wall Street Journal noted that Dr Price was not simply a long-term owner of stocks, he was an active trader.

President-elect Donald Trump’s pick to run the Health and Human Services Department traded more than $300,000 in shares of health-related companies over the past four years while sponsoring and advocating legislation that potentially could affect those companies’ stocks.

Rep. Tom Price, a Georgia Republican, bought and sold stock in about 40 health-care, pharmaceutical and biomedical companies since 2012, including a dozen in the current congressional session, according to a Wall Street Journal review of hundreds of pages of stock trades he filed with Congress.

In the same two-year period, he has sponsored nine and co-sponsored 35 health-related bills in the House.

His stock trades included Amgen Inc., Bristol Myers Squibb Co., Eli Lilly & Co., Pfizer Inc. and Aetna Inc.

This raises more issues. First, that Dr Price was actively trading these stocks suggests that his financial holdings might have been more salient to him than, say, a long-term investor who just buys stocks and puts them away in a retirement portfolio. This increases the likelihood that his stock holdings, and their recent performance, may well have influenced his decision making.

Moreover, this emphasizes that we should be concerned not so much about the effect of financial relationships on Dr Price’s clinical decisions – in fact, it appears that he is a full time Congressman, and hence is not practicing – but on his decision making as a national legislator with considerable influence on health policy and the public health. As a congressman, Dr Price also took an oath to “support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion, and that I will well and faithfully discharge the duties of the office on which I am about to enter.” So the concern is that the immediate profitablity of his actively traded stock portfolio might influence how Dr Price legislates.

As the WSJ article noted,

Mr. Price, an orthopedic surgeon who chairs the House Budget Committee, has played an influential role in shaping health legislation. He sits on the Ways and Means Committee’s health panel, which oversees Medicare. He also is a member of the Republicans’ Congressional Health Care Caucus that has called for repeal of the Obama administration’s landmark health overhaul.

Beyond just the issue of conflict of interest is that of Dr Price’s apparent comfort with the ethical and sometimes criminal track records of the companies from whose stocks he appears to have profited. We on Health Care Renewal have been documenting the ethical misadventures, and sometimes crimes committed by large health care organizations which claim they operate for the good of patients and the public, but seem more to operate for the benefit of their insiders, particularly top management. Many of the companies held by Dr Price have lengthy lists of such bad behavior. See the links above to some individual companues for many more, sometimes sordid details.

If Dr Price, who is not only a physician but a legislator with significant influence on health policy, is unaware of these companies’ track records shame on him. If he owned these stocks with full knowledge of the companies’ track records, more shame on him.

Dr Price’s Tobacco Stocks

But wait, there’s more.

The WSJ article also noted:

Mr. Price also has traded in shares of … tobacco stocks, including Altria Group Inc., whose products are regulated under the Food and Drug Administration, a part of HHS.

An article in Wired implied that Dr Price’s tobacco holdings may have affected his legislative decision making. Price voted against

a law that now requires the FDA to regulate tobacco as a drug.

That now goes beyond just a relatively simple set of conflict of interest issues. At least drug, biotechnology, and device companies make products meant to benefit patients and the public’s health, if used properly and judiciously. For that matter, insurance companies, like Aetna, are supposed to help patients afford needed medical care.

But tobacco companies are different. Although they are legal in the US, there is overwhelming evidence that their products are harmful to health, and this harm is not outweighed by any health benefits, nor any benefits to society other than the money tobacco companies can make from them. Most doctors now would recommend their patients stop smoking and, if they are not smoking, never start to smoke. It is extremely hard to reconcile Dr Price’s professional status and his ownership of tobacco stocks.

A physician legislator with a powerful role in health policy owning tobacco stocks may appear to be abusing his entrusted power for private gain. That is the ethical definition of corruption used by Transparency International(although it is not a legal definition.) No wonder that in a commentary in New York Magazine on Dr Price’s stock holdings suggested that they mean in Dr Price’s eyes

The appearance of corruption is totally fine.


Mr Trump’s ongoing behavior does have some silver linings. It is making the public more aware of the dangers of conflicts of interest and corruption, not just in health policy or health care. And it is also making the public aware how we have to follow the money, all the money that flows around our new plutocrat-in-chief to be, and his rich and well connected cronies.

If we cannot restrain the increasing pile of conflicted and possibly corrupt political appointments, we will be in for much worse than the health care dysfunction Health Care Renewal has been lamenting for more than 10 years.

Judge Steve Russell: Netanyahu Is Not Israel



It never fails. A U.S. administration spends the last months or weeks trying to cut the Gordian Knot of Palestine.

Bush 43 ridiculed Bill Clinton for even trying….and then he did the same.

I hesitate to tell other nations how to run their business, but Israel cannot take so much from our treasury and our political capital and then say we have no right—I would say duty–to insert our point of view.

Israel is a hard problem but Jerusalem is easy. We install a nuclear bomb smack on top of the Dome of the Rock. Distribute three triggers to the three highest mucky-mucks—Christian, Jewish, Muslum. Pressing a trigger sets off a signal, so the world knows if anybody presses one, but the bomb will only detonate when two of the three are pressed. Remove the bomb when all three parties sign an agreement to share Jerusalem.


As we speak, Israel is sabotaging the Two State Solution by building more settlements on the West Bank, changing the facts on the ground.

Israel wants Palestine to be a non-militarized state like Costa Rica or Japan immediately post-bellum.

The Palestinians claim that would reduce them to a client state.

That would be so if the only source of power in the neighborhood were military force, but the whole objective is to change that.

A Palestinian state would start out as a client state of Israel because trade would be its lifeblood and there is no Arab state that can hold up both ends of a trade route that starts in Palestine. The reasons why are internal governance and waste of assets on military power.

The remedy for Palestinians is not an army. It’s an economy.

Why two states?

There are more Muslims than Jews on the real estate if you draw state borders around Israel plus all the disputed lands. Within those lines, there can be no equal protection of the law, no formal equality.

Democracy and apartheid cannot coexist.

The Two State solution is the only way to have both a Jewish state and a democratic state.

Netanyahu is not pitching Jewish under the bus, but rather democracy.

I do hope somebody can convince Mr. Trump that Netanyahu is not Israel.

I wonder if there’s a point at which the two states idea is dead and cannot be revived?

 *  *  *  *

And this:

There’s a rumble among my generally smart and well informed FB friends that the Two State Solution is dead.

If that is so, whither US policy?

My fascination with democracy means I enter the discussion with one hand tied behind my back. I am unwilling to adopt an apartheid state.

I do firmly believe that a state encompassing all the disputed territory cannot be both Jewish and democratic. After the civilized world sat on its hands during the Shoah, we all ill equipped to veto a Jewish state if casting that veto were doable in terms of domestic US politics. Since it’s not doable, sane people either look for a way to have a Jewish state or a way to break the AIPAC death grip on Congress.

I’m OK with breaking the AIPAC grip because I think it’s counterproductive. It destroys any hope for a US role as honest broker.

There’s no future in supporting an apartheid state.

Here’s what I’m thinking. There is already a substantial Arab/Muslim minority living in Israel.

We should regard the Arab Israelis as hostages to Israeli democracy. At the same time, we should regard the West Bank settlers as offering themselves as hostages to Palestinian democracy.

It is an objective fact that no Arab state has successfully navigated the challenges of democratic government for any length of time. If that means they can’t, then this entire effort is folly. Eventually some Arab state will develop nuclear weapons and the entire region will be laid waste.

The Grim Reaper is the only winner if the Middle East becomes nothing but a tale of three theocracies: Iran as the tip of the Shi’a spear, Saudi Arabia as the tip of the Sunni spear, and Israel as the militarized Jewish state living out the battle cry, “Never again!”

If we must pick a rogue out of that gallery to befriend, Israel is the obvious choice.

The Saudis are the source of “radical Islamic terrorism.” The unholy alliance of the House of Saud with Wahhabi Islam is based on domestic politics, not religion. The Saudi royals have used their wealth to create a social bubble in which they do not have to comply with the austere lifestyle required by the flavor of Islam that same money promotes worldwide.

The Iranian mullahs are the least transparent, and as best I can tell the most sincerely religious. Their aggressive moves are more conventional. They rely on young men from the endless pool of ambitious and unemployed who have no other prospects.

One tide of history running against global jihad is world response to global warming, if we bring it off. The drive to erase Israel from the map is funded by oil money. Should there come a time when oil goes the way of coal, Iran may still have an economy but Saudi Arabia will not.

The Shi’a minority might appear to be economically better off for the long run that the Sunni majority in world Islam, but that’s only so as to Sunni Arabs. And the Saudis still control access to the Hajj, the pilgrimage to Mecca required of every observant Muslim who is able.

Israel is the only one of the three with a 21st century, knowledge-based service economy.

The nations with oil riches could use those riches to leap frog directly to a service economy without ever having had an industrial or consumer economy. So far, they have conducted themselves in the way dictatorships normally do: promise butter and deliver guns.

Another reason to back the Israeli horse is that they have the only economy that can generate internal democratic legitimacy without an outside threat. But if that legitimacy entails second class status for Israeli Arabs, how does that square with our professed values?

Charles D. Hayes: The Trickle-Down Shakedown



One of the most change resistant views in America is the claim that we can’t afford living wages for all full-time employment. Few beliefs are so deeply ingrained in our culture.

People wedded to this idea believe it with a religious fervor equal to their faith in gravity and when challenged they will pull out text books authored by people who qualify as high priests of scarcity.

The religiosity of this acceptance is why geneticist David Suzuki has characterized conventional economics as a form of brain disease. To my thinking, it is simply a case in which the means have become more important than the ends.

We created an exchange system to thrive that metastasized beyond its purpose because of the power of a few to exploit the many. Bottom line examples all over the world show clearly that you can rig an economy for any purpose, it can be to sustain a middle class or mostly benefit the rich and once the rich have legally bribed most of the politicians the latter example is hard to control.

I internalized the trickledown ideology growing up and I used to believe it as they say with every fiber of my being. But after many years of study, in my view, the assumption that living wages for all fulltime employment are not possible in a country where our citizens often claim to be the greatest country on earth is pure unadulterated bullshit.

Three hundred years of global economic history shows decidedly that over time the growth of capital outpaces labor, unless there are safeguards to prevent it.

Competition in the production of goods and services leads to lower prices, competition among businesses for employees leads to higher wages. And this must be considered constantly in a robotic and digital app economy. There are lots of jobs being created that are tasks that need to be done, but they lack the political power needed to demand fair compensation.

Some of our most successful companies pay wages so low that taxpayers must subsidize their employees, and yet, when they announce their executive salaries, bonuses and stock options in the millions and millions of dollars we don’t hear complaints about them having to raise prices for their goods and services. Why is that?

But when employees at the low end ask for livable wages, well connected and well compensated economists will leap out of the woodwork screaming about how the country just can’t afford it.

The reality is that in America, public corporations are openly looted by executives and quid pro quo boards of directors. Even upon going bankrupt executives often bailout with multimillion dollar golden parachutes.

What makes living wages impossible is an echelon of wealthy individuals and corporations with the political power to gain a legislated freeride and escape paying their fair share of taxes.

Unfortunately, all they need to do is send their free market lobbyist missionaries out with messages that some poor fools somewhere are going to benefit at public expense and the distraction is complete, along with the notion that trickledown Kool-Aid is the only drink in town.

Charles D. Hayes: The Myth of Exceptionalism



The Cold War was as effective in conditioning American citizens to genuflect angst upon hearing the word socialist, as Ivan Pavlov was at conditioning dogs to salivate upon hearing a bell. This acclimatization works like a Star Trek deflector shield, upon hearing the word socialism, it closes the door, nothing further to discuss.

This reflex is an aspect of us vs them identity politics and because it works so effectively, we Americans are less free than we would be, if we simply started thinking and cooperating instead of genuflecting ire. We need to apply the best of socialism and capitalism because no ism alone, is adequate for an equitable society.

People who have internalized an aversion to anything socialistic believe that all they must do to win an argument is to identify their opposition as being socialists (or liberals) and they win without need of an explanation. That they do this with this assumption is proof that they don’t understand the genealogy of freedom and the essence of deliberative cooperation.

Socialism is advanced cooperation, our military is our best example, and it is seldom acknowledged, but at the high end of our financialized economy, the folks near the top look after one another’s interests in ways that could make the most avid socialists envious.

Our growing inequality is proof that our capitalistic system is failing and it’s only going to get worse as we become ever more dependent on an economy driven by robotics and apps.

A score of countries in the world have adopted socialistic programs that enable their citizens to enjoy freedom instead of just talking about it. People stuck in lowing paying jobs with medical bills, even when they have insurance can be forced into bankruptcy by the copay. These people aren’t free.

Students who must indenture themselves to a financial institution to get a college education to qualify for a job in which the salary will be inadequate to repay the loan are not free.

A country that doesn’t have enough goodwill to see that all its citizens have quality healthcare without whining is not good, let alone great.

America as the land of the free is more apparent than real, and when people from other nations point this out, we often respond with a stance of exceptionalism. I agree, we are exceptional.

We are exceptionally arrogant, narcissistic, and boastful and now after the 2016 election, the whole world knows that politically, we are exceptionally ignorant.

Mother Jones Charts on Inequality

11 Charts That Show Income Inequality Isn’t Getting Better Anytime Soon

It’s no secret: More and more wealth is trickling up.


It’s no secret that the United States has a glaring—and growing—problem with inequality. The Great Recession made things worse, and the recent economic recovery remains uneven, and unevenly distributed. Families in the bottom 99 percent of households have recovered just 60 percent of their income losses from the economic slump, according to a recent analysis of tax data by University of California-Berkeley economist Emmanuel Saez.

Meanwhile, the superrich keep getting richer: The average family in the top 1 percent of earners makes 40 times more than the average family in the bottom 90 percent of households. Families in the top 0.01 percent—the 1 percent of the 1 percent—make, on average, a whopping 198 times more than those in the bottom 90 percent, according to Saez and fellow economist Thomas Piketty’s data.

It’s no wonder, then, that despite millions of jobs being added under President Barack Obama and an economy that looks good on paper, many voters who felt left out of the recovery turned out for Donald Trump. “An economy that fails to deliver growth for half of its people for an entire generation is bound to generate discontent with the status quo and a rejection of establishment politics,” Saez, Piketty, and fellow economist Gabriel Zucman recently wrote in a post for the Washington Center for Equitable Growth. Trump tapped into that discontent—now we’ll see if he and his billionaire-packed Cabinet can recover those decades of lost prosperity for most Americans.

Here’s a closer look at the current state of income and wealth inequality:

The middle class is still struggling

First, some good news: Last year, middle-class households reaped an income gain of 5.2 percent, the highest level since 2007. Now the bad news: Despite such overdue gains, average American households are barely making more than they did in 1980. Median household incomes have risen just 17 percent (in real dollars) during the past 35 years, lagging far behind GDP growth. Meanwhile, the corporate profits and the average income of the top 1 percent of earners has skyrocketed.



The superrich are still thriving

The average income for the top 0.01 percent of households grew an astounding 322 percent, to $6.7 million, between 1980 and 2015. Despite seeing 3.9 percent growth in the last year, the highest rate since 1998, the average income of the bottom 90 percent has effectively flatlined, increasing just 0.03 percent since 1980.



Half of all income goes to the top

As of 2015, half of all US income was going to the top 10 percent of earners. Piketty, an economist at the Paris School of Economics, predicts that if the current trend holds, their share will eventually reach 60 percent.

Most post-recession gains went to the top

Like millions of Americans, top earners took a hit during the Great Recession. But when the slump officially ended, they bounced back much faster and further than most. In fact, more than half of all income gain during the six years following the downturn went to the top 1 percent.



Minimum wage can’t keep up

The situation for workers earning minimum wage remains bleak. In real dollars, the current federal minimum wage is worth 26 percent less than it was in 1970. Compare that to the increase in top incomes (like those of Trump’s pick for labor secretary, fast-food CEO Andy Puzder, a staunch opponent of minimum-wage hikes).



It’s not just about income, but wealth

The richest households have not only seen an upsurge in incomes, but also an accumulation of wealth in the form of property and assets. The recession tanked many Americans’ net worth: The median household net worth dropped 45 percent between 2007 and 2010.



More wealth is trickling up

Here, too, the superrich are capturing the lion’s share of gains. Since 1983, the 1 percent’s share of total net worth has jumped to 37 percent, while the share of net worth held by the bottom 90 percent has slumped to 23 percent. “Income inequality has a snowballing effect on wealth distribution,” Saez and Zucman wrote in a May paper in the Quarterly Journal of Economics. “[T]his snowballing effect has been sufficiently powerful to dramatically affect the shape of the US wealth distribution over the last 30 years.”



Race and inequality are linked

Not all families benefited equally from the economic recovery. The median wealth of white households remains 13 times more than that of black households and 10 times more than Latino households’.



Education also matters

Education levels also affect income disparities. David Autor, an economist at the Massachusetts Institute of Technology, found that between 1979 and 2012, the gap in median earnings between high school-educated and college-educated households grew by $28,000. If these households benefited from the same income gain as the top 1 percent, they would have seen an increase of $7,000 each.



Location, location, location

Economic inequality also isn’t distributed evenly geographically. Children growing up poor in Baltimore, Maryland, will make 17 percent less than the average low-income American by the time they becomes 26. But children family who live just 46 miles west in Montgomery County could earn 10 percent more than average low-income adults.



Upward mobility is slipping

For decades, Americans have assumed they might be more prosperous than their parents. But that dream of upward mobility is becoming harder to realize. As research from the Equality of Opportunity Project shows, a child born in 1980 is half as likely to make more money than their parents by the time they reach adulthood, while a person born in 1940 had a 92 percent chance of doing so. And as more income has become concentrated at the very top, even children born into wealthy homes are seeing their prospects decline.

Added from another source for posterity:

“[T]here isn’t much evidence that what has been holding back corporate investment is high corporate taxes. Because the U.S. tax code is riddled with loopholes, the tax rate that big businesses actually pay isn’t anything like thirty-five per cent. Between 2008 and 2012, according to a recent study by the nonpartisan Government Accountability Office, they paid a tax rate of about fourteen per cent, on average. Small corporations tend to pay even less. From 2006 to 2012, two-thirds of all incorporated businesses didn’t pay anything, the study found.

“Surveys by the Federal Reserve Board and other organizations indicate that the main factor depressing corporate investment has been weak demand.”

Charles D. Hayes: The Arrogance of Power



Watching snippets of Trump on his Thank You Tour, I keep wondering why someone doesn’t tell the con man he won. He is still in campaign mode. He is like a dog who has finally caught the car he was chasing and doesn’t know what the hell to do now. He is about to get slammed into the pavement by a job he is unfit and totally unprepared for, although, it is the country that will suffer the impact.

People keep attributing Trump with having a high IQ and this is total bullshit. They are projecting their hopes on Trump with the assumption that if he’s rich he must be smart. Trump speaks at a third to fifth grade level at best and his biographer claims his vocabulary is around 200 words, but it appears that 75 of them are taken up by “great.”

The troubling thing though, is that medical professionals have pointed out that Trump clearly shows he has all nine symptoms of NPD, Narcissistic Personality Disorder.

NPD must be why Trump is engaged in serial gloating and trolling for adoration instead of trying to bring the country together, which any sane President-elect would be doing now.

But then, getting attention is what makes him tick. The only thing I can come up with that might be positive providing we survive Trump’s presidency is that we are in for one hell of a civics lesson.

*  *  *  *

The great irony that I can never get my mind around is that the GOP’s policies undermine the very things in life they claim to value most. That conservatism is unconcerned about clean air and water and global warming makes no sense.

An ethos that glorifies obedience, and yet, is not adamant that people who work hard should be afforded a living wage and that this should takes precedence over an entrepreneur’s right to exploit people, undermines itself. Hard work as a virtue is the bedrock of conservatism, at least it used to be.

A political ideology built around reifying families, and yet, whose policies are overtly oppressive to families, is an anathema to the notion of being a “family values party.”

Both of our political parties need to reexamine their reasons for being. Liberals need to cut to the bone of what liberalism stands for and conservatives need to rethink what’s worth conserving.

I’m old enough to recall a time when Democrats were all about being for the working class and Republicans used to do the right things for the right reasons.

But, continuously cutting taxes while our deficit soars, our infrastructure crumbles, and digital app technology threatens employment, is not conservativism, it is instead, an expression of contempt, arrogance, political immaturity and greed.

The strangest thing of all, however, is the decision of working class America to reward the political party that is most responsible for today’s growing inequality with the expectation that these people, led by Donald Trump will fix the problem.

This is neither liberal, or conservative, this is naiveté bordering on lunacy. The sad reality, though, that I keep pointing out is that every time people start getting close to figuring out that they have been conned, someone is going to burn a flag.


Judge Steve Russell: You Bought It, We Own It (So STFU)





I hope you third party voters are having more fun at Hogwarts than we are back here.

Last time you turned an election, the difference was:

1. Gore would have gotten us into the climate change fight back when there was still a chance to avoid the worst of it.

2. Gore would have used the Clinton surplus to take the Social Security trust fund out of the budget calculations as a current asset–what he meant in the debate when he said “put Social Security in a lock box.” Of course, the Bush tax cuts would not have happened and so the national debt would be a lot less.

3. Gore was VP when Clinton turned down the neocon plan to go “finish the job” in Iraq, so he probably would have demurred. If he did go, he would not have gone off-budget. Another reason the national debt would be a lot less.

So, earlier in the week Trump put a climate change denier in charge of the EPA.

Today, he picked a guy to head the Labor Department who opposes any federal minimum wage and so opposes raising the one we have and who was on a jihad against Obama’s revision of the overtime rules to expand the number of employees who qualify for overtime when they work over 40 hours a week.

So, the push to raise the minimum wage is history and the argument between Clinton and Sanders about how much the raise should be is moot. And non-union workers can kiss their overtime goodbye.

And he is stacking his national security bureaucracy with people who want to expand the war on terror to make it a war on all of Islam—the Islamic State’s wet dream.

I quit the Democrats and I do not regret it because they are bought and I’m tired of the ambient sleaze. However, as an Independent I’ll vote for the best candidate who has a chance of winning.

If you don’t have the juice to take over the Democratic Party like the Tea Party did the Republican Party, then you don’t have the juice to take over the country.

This year has been even worse for pissing away your vote on a third party, because at least Ralph Nader was qualified to be POTUS. Stein is not. I thought Johnson was until I heard him try to discuss foreign affairs. He made Sarah Palin sound like Secretary of State material.

So we had a choice between two corrupt candidates. One was the most qualified candidate I’ve ever seen nominated by either party and one was the least qualified.

I’m not talking about policy disagreements. I’m talking about whether they have the skills to drive the goddam bus, not whether I agree with the destination.

But, as I set out at the beginning of this rant, Trump is pushing every policy choice in the wrong direction. He’s also promised that all of his SCOTUS nominees will be “pro-life,” which creates better than even odds that in his first term the votes will be there to reverse Roe v. Wade and the gay rights revolution will be stopped in its tracks.

And just in case you were going to just tune out of politics and light a joint, I forgot to mention that Trump has nominated an Attorney General who has been harshly critical of the failure of the Justice Department to use federal power against the states that have been decriminalizing and legalizing marijuana.

Weed is now legal for some purposes in over half the states but the federal law controls and Trump is putting somebody in charge who will use federal law to keep up the fiction that marijuana is as dangerous as methamphetamine.

That we’ve come to this pass is not the fault of third party voters alone and that’s not what I’m claiming.

I’m just saying that I don’t what to hear you telling me that there are not policy differences between the two corrupt major parties and therefore it’s OK to vote third party or stay home on election day because that choice of cancer or polio means nothing to the average person.

To that argument, I want to say STFU.

How to Really Make America Great Again


Don the Con wheedled his way into the presidency with his brand of sloganeering and snake oil, sticking his opponents with his snide names and claiming he would “make America great again.” His administration appointments in the past several weeks provide a clue to what exactly that means: more trickle down, less regulation, and a heapin’ helpin’ of radical right. He has awakened the beast and now he has to feed it. Of course, he’s already backing off some of his signature bluster he used to rouse the rabble—maybe not a wall but a nice fence. Maybe he wouldn’t throw Hillary into jail.

But if he sincerely (and I use the term loosely) wanted to make America great again, statistics provide a wealth of information on how the United States has slipped relative to the rest of the developed world. What follows is just a portion of the categories we’ve fallen behind in, followed by extensive excerpts on some of these failings from the recent book American Amnesia: How the War on Government Led Us to Forget What Made America Prosper, by Jacob S. Hacker and Paul Pierson. As a New York Times book review remarked on the book’s thesis:

The country has been brainwashed by a powerful alliance of forces hostile to government: big business, especially Wall Street, spending unparalleled lobbying dollars to advance its narrow self-interest; a new wealthy elite propagating wrongheaded Ayn Randian notions that free markets are always good and government always bad; and a Republican Party using a strategy of attacking and weakening government as a way to win more power for itself.

In 2013, the Huffington Post ( published the following figures of our ranking in the world on these various categories:

“Child Well-Being in Rich Countries” ranks 29 developed countries, according to the well-being of their children, on numerous factors.

The U.S. ranks #26 overall for “Child Well-Being.” This overall rank includes: #26 for “Material Well-Being”; #28 for “Child Poverty Rates”; #25 for “Health and Safety”; #26 for “Infant Mortality Rates”; #26 for “Low Birthweight”; #22 for “Immunization Rates”; #27 for “Educational Well-Being”; #27 for “Preschool Enrollment Rates”; #25 for “Participation in Further Education”; #16 for “Educational Achievement by Age 15”; #29 for “Overweight”; #2 for “Exercise”; #29 for teen-pregnancy rates; #1 for “Alcohol” (U.S. receives the top rank for absence of drunkenness); #4 for “Smoking” (again, absence); #11 for “Fighting”; #12 for “Being Bullied”; #23 for “Housing”; #27 for “Homicide”; #3 for (lack of) “Air Pollution”; #23 for children’s self-reported “Life Satisfaction”; and #28 for “Relationships with Parents and Peers.”

A much broader ranking-system, from the World Economic Forum, is “The Global Competitiveness Report 2012-2013,” which ranks 144 countries, on a wide range of factors related to global economic competitiveness.

These include the following:

  • #34 on “Life Expectancy”
  • #41 on “Infant Mortality” (unlike the “Infant Mortality” rankings from UNICEF, this ranking is among 144 countries—thus some underdeveloped countries actually have higher life-expectancy than does the U.S.)
  • #38 on “Quality of Primary Education”
  • #58 on “Primary Education Enrollment Rate”
  • #28 on “Quality of the Educational System”
  • #47 on “Quality of Math and Science Education”
  • #12 on “PCT [Patent Cooperation Treaty] Patent Applications [per-capita]”
  • #14 on “Firm-Level Technology Absorption” (which is an indicator of business-acceptance of inventions), we are #14.

Trust is likewise only moderately high in the U.S.:

  • #10 on “Willingness to Delegate Authority”
  • #42 on “Cooperation in Labor-Employer Relations”
  • #18 in “Degree of Customer Orientation”

Corruption seems to be a rather pervasive problem in the U.S.:

  • #34 on “Diversion of Public Funds [due to corruption]”
  • #42 on “Irregular Payments and Bribes” (which is perhaps an even better measure of lack of corruption)
  • #54 on “Public Trust in Politicians”
  • #38 on “Judicial Independence”
  • #59 on “Favoritism in Decisions of Government Officials” (otherwise known as governmental “cronyism”)
  • #87 on “Organized Crime”
  • #29 on “Ethical Behavior of Firms”
  • #30 on “Reliability of Police Services”
  • #56 on “Transparency of Governmental Policymaking”
  • #37 on “Efficiency of Legal Framework in Challenging Regulations”
  • #35 on “Efficiency of Legal Framework in Settling Disputes”

Investors evidently find somewhat shaky ground in the U.S.

  • #33 on “Protection of Minority Shareholders’ Interests”
  • #23 on “Efficacy of Corporate Boards”
  • #19 on “Reliance on Professional Management”
  • #37 on “Strength of Auditing and Reporting Standards”
  • #80 on “Soundness of Banks”
  • #39 on “Regulation of Securities Exchanges”

* * * *

In American Amnesia, a well-annotated book for someone interested in their research, Hacker and Pierson write that the evidence of our drift downwards towards the Third World is evident in many ways:

Americans are no longer the tallest people in the world. Not even close: Once three inches taller than residents of the Old World, on average, Americans are now about three inches shorter. The average Dutch height for men is six foot one, and for women, five foot eight—versus five foot nine for American men and five foot five for American women. . . .

Because height is a powerful indicator of social and individual health, America’s relative decline should ring alarms. Our young are coming up short, relative not just to gains in stature of the past but also to gains in stature in other rich nations. . . .

So it is more than a little disconcerting that health is also where the United States does most poorly compared with other rich nations. In 2013, the prestigious National Academy of Sciences released a mammoth report with a self-explanatory title: U.S. Health in International Perspective: Shorter Lives, Poorer Health. “The United States is among the wealthiest nations in the world,” the report began, “but it is far from the healthiest. . . . Americans live shorter lives and experience more injuries and illnesses than people in other high-income countries.”

On virtually all measures, according to the report, the United States is losing ground rapidly to other rich nations. At midcentury, Americans were generally healthier than citizens of other rich nations, and as late as 1980, they were still not far from the middle of the pack. Since then, however other rich countries have seen rapid health gains. The United States has not.

Take life expectancy at birth—the easiest statistic to track, since death records are generally reliable and consistent across nations. The National Academies study looked at seventeen rich nations. Among these, the United States ranked seventeenth for men in 2011 (life expectancy: 76.3 years, a full 4.2 years shorter than the top-ranking nation). It ranked an equally dismal seventeenth for women (81.1 years, 4.8 years shorter than the top-ranking nation. . . .

The relative decline has been particularly steep for an unlikely group: middle-aged white adults. In a groundbreaking 2015 study, the Princeton University economists Anne Case and Angus Deaton (the latter the recipient of the Nobel Prize in Economics that same year) dug into the mortality statistics to examine how and why the American experience departed so starkly from the international norm. Their startling result: Whites ages forty-five to fifty-four were dying at higher rates in 2013 than they had been in 1999, even as every other rich country had seen dramatic drops in mortality in this age group. . . . The only other example of such a shocking loss of life in recent decades is the AIDS epidemic.

The authors noted that this is particularly true among those citizens who might have been Trump’s biggest supporters:

The trend was most devastating for whites with a high school diploma or less. In 2013 there were 736 deaths per 100,000 people within this group, up from 601 per 100,000 in 1999. (By comparison, the death rate for people in this age group in Canada fell from around 300 per 100,000 in 1999 to just under 249 per 100,000 in 2011.) But those who had gone to college but not received a degree saw no distinguishable improvement in death rates either—even as, again, such rates plummeted abroad. Only among whites with a college degree did death rates fall substantially over this period. In 2013, white adults in the forty-five- to fifty-four-year-old age group with no more than a high school diploma were more than four times as likely to die as those with a college degree.

To be clear, many measures of health are improving in the United States. But they are improving much more slowly than in other countries. One grim statistic commonly used by demographers is the chance that a fifteen-year-old will die before age fifty. For American women, it’s 4 percent: four in a hundred women die between fifteen and fifty. The average for other rich nations is around 2 percent, and, on average, death rates in these nations fell below 4 percent almost forty years ago. We are more than a generation behind.

A similar story can be told about infant mortality, or deaths of children before their first birthday. In 1960 infant mortality in the United States was lower than in the majority of other rich nations. In recent decades, however, America has seen limited improvement, while death rates for infants have continued to plummet abroad. In 2011 the average rate of infant death in other rich nations was 1 child for every 300 or so births. In the United States, it was roughly twice that—1 child for every 164 births. That year, the only countries in the Organization for Economic Cooperation and Development (OECD) with higher rates of infant mortality were Chile, Mexico, and Turkey.

This unimpressive performance is particularly striking because the United States spends so much more on health care than other rich nations do—roughly twice as much per person. Of course, medical care is not the only or even the most important determinant of health. But the United States does poorly even where health care matters most. For almost every cause—from injuries to diseases—death rates are the highest or nearly the highest in the United States. And we have the highest rate of what health experts call “amenable mortality”: deaths that could have been prevented with the provision of timely and effective care. Despite high spending, we are falling behind other rich nations in reducing such preventable deaths. We don’t see our relative decline because we are getting better at preventing death. But we’re getting better far too slowly for a rich nation.

This problem in our healthcare system—a lack of universal insurance, the stranglehold Big Pharm has on pricing, and so forth—is well documented elsewhere, but the authors don’t stop there. They touch next on education, where we once led the pack:

As the Harvard economists Lawrence Katz and Claudia Goldin show in their revelatory The Race Between Education and Technology, we bolted decades ahead of other Western nations in the spread of elementary and then high schools during the twentieth century, and we were the world leader in college education in the immediate decades after World War II. No more. The United States is now a mediocre performer in international education rankings. . . . The United States now ranks twentieth out of twenty-seven OECD nations in the share of young people expected to finish high school.

A measure of that, of course, is attributable to the school-to-prison pipeline, duly noted:

Another reason is that young adults behind bars disappear from the statistics. In most rich nations, this distinction makes little difference because incarceration is so rare. In the United States—which incarcerates roughly ten times as high a share of the population (eight in a thousand versus fewer than one in a thousand in most other advanced industrial democracies)—it makes a real difference, especially for demographic groups with the highest rates of incarceration. Indeed, the high school dropout rate for young black men is more than 40 percent higher when we include in our count the incarcerated, wiping out all the apparent gains in their high school completion since the late 1980s. Here again, conventional indicators present an overly sunny picture of our relative performance.

The big story, however, is our relative decline in higher education. The United States has many of the finest institutions of higher education in the world. The problem is that the share of young people getting a degree is rising much more slowly in the United States than in other OECD nations. One reason is the erosion of public support through federal grants and state universities, leaving students and their families much more reliant on loans. Once without peer, the United States has fallen to nineteenth in college completion in the OECD, and the gap in completion between higher-income and lower-income students has widened. Older Americans are the most educated in the world. Younger Americans, not even close.

Much of the discrepancy can be laid on the inequality of educational opportunity. The push now—among people like Trump’s choice of Betsy DeVos to lead the Education Department—is for public funding of charter schools, in the form of vouchers. These schools have shown to be no better (and often worse) than their public counterparts. They not only siphon funds from public education; the money is also used to pay CEO salaries and the like. And as some reports have noted, the net effect in some states is that the schools are now more segregated than they were in the Fifties.

And if the United States as a whole is in the breakdown lane, some Americans are barely getting on the road. At least as striking as our poor performance among the young is how unequal educational opportunities in the United States are. Decades after de jure integration of schools and the famous 1966 Coleman Report on the subpar schooling of the poor, we remain a nation with gaps in educational quality, funding, and outcomes that are far greater than the norm for developed democracies. These gaps not only thwart the upward progress of tens of millions of Americans but hold back our economy overall.

Since the 1960s, the divide in test scores between children from high-income families and those from low-income families has grown by more than a third; it is now twice as large as the gap between blacks and whites. Yet the United States is one of the few nations that finances schools primarily through local property taxes, which magnifies unequal opportunity. As one OECD researcher puts it, “The vast majority of OECD countries either invest equally in every student or disproportionately more in disadvantaged students. The US is one of the few countries doing the opposite.”

Inequality of opportunity begins early, and it costs everyone. Good pre-K education, for example, more than pays off in higher growth and tax receipts and lower public costs, from social assistance to incarceration. Yet the United States ranks twenty-fifth in the OECD in the share of three-year-olds in early childhood education, and even lower, twenty-eighth, when it comes to four-year-olds.

And, of course, the big one: income. Here, the trends of trickle-down economics are most apparent:

Historically, economists have considered national income per capita the best single measure of the standard of living of middle-class citizens. For much of the twentieth century, it was. Since the early 1970s, however, the link has broken. The American economy is more and more productive, and national income has continued to grow smartly (if more slowly than before). But these gains have not translated into substantially higher wages for most Americans. The typical hourly earnings of American workers—adjusting for inflation and including the escalating cost of medical benefits—rose only 10 percent between 1973 and 2011. That works out to an annual raise of 0.27 percent.

But American families have grown significantly richer, right? Yes and no. Between the early 1970s and the late 1990s, the typical household’s income increased from around $49,000 to almost $57,000 (after adjusting for inflation). Yet the wage stagnation of the 2000s and the financial crisis that closed out the decade wiped out all of the gains created by the strong economy of the 1990s, leaving typical households about where typical households were in 1989. . . .

Just as important, the overriding reason the typical family earns a little more today is not more pay per hour but more paychecks per household, as women have moved into the paid workforce. This change isn’t because the United States has led the world in female employment. (In 2010 America was seventeenth in the OECD in the share of women in paid employment, down from sixth in 1990. It’s because US workers, both male and female, work many more hours than workers in other countries do—and the gap is growing. . . .

Where did all the growth go? The answer, it turns out, is simple: It went to the top, especially the very top. When it comes to inequality, the United States once looked relatively similar to other rich countries. Today it’s the most unequal rich nation in the world by a large margin. However else that matters, the increasing concentration of income at the top drives a wedge between overall economic growth and the income gains of most households. When a rising tide lifts all boats, economic growth is a better measure of ordinary Americans’ living standards than when a rising tide lifts only yachts.

You can see the disparity even more clearly when you look at wealth: housing, stocks, bonds, and all the other assets that people hold to weather economic shocks and build their future. Americans’ average net wealth is an impressive $301,000, the fourth highest in the world, behind only Switzerland, Australia, and Norway. Median net wealth—the amount held by someone exactly in the middle of the distribution—is another story. The typical American adult has just $45,000, which places the United States nineteenth in the world, behind every rich country but Israel (including such “economic heavyweights” as Spain and Taiwan). The obvious reason for the difference is that wealth is so unequal across American households. The richest 1 percent own more than a third of the nation’s wealth; the top 10 percent, more than three-quarters. No other rich country comes close to this level of concentration at the top.

Beginning with the Reagan years and its huge tax cuts for the upper crust, wealth disparity has skyrocketed. And the vaunted notion of the Horatio Alger success story—going from rags to riches—has been laid bare.

Today, however, the frontier is gone, and so is America’s mobility advantage. Indeed, the United States now has close to the lowest level of upward mobility in the advanced industrial world: lower than in Tocqueville’s France, lower than in Sombart’s Germany, and lower—much lower—than in our northern neighbor, Canada. Roughly two in three Americans born in the bottom fifth of incomes either stay there (42 percent) or rise just into the next fifth (23 percent). An American boy whose dad is in the bottom fifth has only a 30 percent chance of climbing into the top half. A Canadian boy has a 38 percent chance. This 8-point difference might seem small, but it’s not. With 138 million American men, 8 percentage points represent 2 million boys escaping the bottom fifth into the top half.

Again it’s the youngest of the young who are most disadvantaged. The United Nations Children’s Fund (UNICEF) has compiled a composite index of the “material well-being” of children in developed countries, which takes into account various measures of childhood poverty and material deprivation (lack of access to regular meals, for example). In the most recent report, the United States ranked twenty-sixth out of twenty-nine developed nations. First in the standings was the Netherlands, where soon-to-be-giants are born. UNICEF has produced its index since the early 2000s. The United States was one of only five nations that were ‘below average at that time yet failed to improve kids’ material well-being in the following decade. The other four were Greece, Hungary, Italy, and Spain.

The government role in research and development of new science and technology, once a hallmark of American exceptionalism, has shrunk to the extent that it could, as the zealots suggest, be drowned in a bathtub:

Though government promotion and funding of science has a long history, it expanded dramatically during World War II and continued afterward with the National Science Foundation (NSF), National Institutes of Health (NIH), and other public agencies that supported training in science and engineering and financed research in the private sector and academia. In the quarter century after World War II; the United States didn’t just lead the world in R&D funding. It owned the field. Well into the 1960s, the federal government spent more than the combined total of all R&D spending by governments and businesses outside the United States. The fruits of these investments ranged from radar and GPS, to advanced medical technology, to robotics and the computer systems that figure in nearly every modern technology. Far from crowding out private R&D, moreover, these public investments spurred additional private innovation. The computer pioneers who developed better and smaller systems not only relied on publicly fostered breakthroughs in technology; they also would have found little market for their most-profitable products if not for the internet, GPS, and other government-sponsored platforms for the digital revolution.

That was then. Over the last half century, R&D spending by the federal government has plummeted as a share of the economy, falling from a peak of nearly 2 percent of GDP in the mid-1960s to around 0.7 percent in the late 1990s, before rebounding slightly in recent years. Between 1987 and 2008, federal expenditures were essentially flat once inflation is taken into account (rising 0.3 percent a year). The United States now ranks ninth in the world in government R&D expenditures as a share of the economy. The majority of this spending, however, is for defense-related projects, which have fewer positive spillovers than nondefense R&D does. Take out defense, and the United States ranks thirty-ninth in government R&D spending as a share of the economy. . . .

We are not talking just about dollars and cents. We are talking about lives. Consider one chilling example: drug-resistant infections. As America’s breakthroughs in antibiotics recede into the past, bacteria are evolving to defeat current antibiotics. For more and more infections, we are plunging back into the pre-antibiotic era. In the United States alone, two million people are sickened and tens of thousands die each year from drug-resistant infections—mostly because private companies see little incentive to invest in the necessary research, and the federal government has failed to step in. . . .

And health research has fared better than most areas. Public investment of all sorts and by all tiers of government has reached the lowest level since demobilization after the Second World War. Until the 1970s, gross investment by the public sector—R&D plus investment in physical capital—averaged around 7 percent of GDP. It fell below 6 percent in the 1970s and 1980s, and below 4 percent in the 1990s and 2000s. It is now at 3.6 percent and falling. The biggest crunch is in infrastructure: roads, bridges, water supplies, communications networks, public buildings, and the like. These are among the most productive investments governments make, with average rates of return that are probably several times higher than those of typical private investments. And American infrastructure was once the envy of the world: The interstate highway system started under President Eisenhower—a Republican—eventually stretched over forty-two thousand miles, at a cost (in present dollars) of $493 billion. But the investment paid off, accounting for almost a third of the increase in the nation’s economic productivity in the late 1950s and around a quarter in the 1960s.

American infrastructure is no longer the envy of the world. The World Economic Forum, the Davos-based center of business-oriented thinking, ranks the United States fifteenth in the quality of railway structures, sixteenth in the quality of roads, and ninth in transportation infrastructure. The American Society of Civil Engineers estimates that the United States would have to spend $3.6 trillion more than currently budgeted just to bring our infrastructure up to acceptable levels by 2020. China and India are spending almost 10 percent of GDP on infrastructure; Europe, around 5 percent. Even Mexico spends just over 3 percent. The United States has not broken 3 percent once since the mid-1970s.

And this doesn’t begin to address the problems of pollution so blithely ignored by the powers that be as well as the ecological risks—i.e., global warming—facing the nation.

[T]he United States, once the unquestioned leader in addressing pollution and other ecological risks, lags behind the rich world on most measures of environmental performance. It emits more carbon dioxide per person than any affluent country besides tiny Luxembourg—roughly twice as much as Germany and Japan, and more than threetimes as much as France and Sweden. The widely respected Yale Environmental Performance Index, which assesses air and water pollution and other key environmental outcomes as well as measures relevant to climate change, ranked the United States thirty-third in the world in 2014—two spots down from its similarly uninspiring ranking of thirty-first a decade earlier.

We have seen how far we have to go in tackling the dangerous warming of our planet—a challenge that cannot be addressed without the leadership of the world’s sole superpower and second-largest carbon emitter. But consider a very different emerging challenge where lack of an effective response is literally weighing down America’s future.

A larger share of Americans are obese than in any other rich country. Defined as having a body mass index of 30 or higher (roughly two hundred-plus pounds for a five-foot-eight person), obesity now afflicts more than one in three adults and one in six children, compared with around one in seven people or fewer in most European countries. Individual medical costs associated with obesity are on par with those of smoking. In the aggregate, obesity accounts for a tenth of health spending in the United States, generating $270 billion in total economic cost due to medical bills, mortality, and disability. When additional consequences of obesity are factored in—lower earnings, lost work time, reduced productivity—the costs are even more staggering.

The basic causes are no mystery: Americans have become more sedentary, and they consume more calories than they once did. Even small differences in activity and diet can add up: One soda a day—a twelve-ounce can, not the megacups that are served at fast-food restaurants (KFC’s “Mega Jug” is sixty-four ounces)—adds up to 55,000 additional calories and fifteen extra pounds a year. And once again, adding up all these individual changes across the population leads to enormous effects (no pun intended), such as $270 billion in higher health spending a year. It’s often said that obesity is a personal problem. But people’s basic biological desire for fat and sugar hasn’t changed in the last few decades; their environment has. And American food policy—including federal subsidies for sugar and high-fructose corn syrup—has played a major role in shaping that environment.

Want a vivid image of how American bodies have changed? The average American woman now weighs around 165 pounds. According to the US Centers for Disease Control and Prevention (CDC), that’s essentially what the average American man weighed in 1960. (Today’s average man is around 195 pounds.) Americans were once the tallest people in the advanced industrial world. We are now not just among the shortest but also far and away the heaviest. Where once we towered over others when standing, now we only do so when everyone is lying down.

So you want to make America great again, Mr. President-elect? These are just some of the ways we’ve been found lacking, and it’s not because we don’t give free rein to the banksters or Wall Street CEOs, or a bigger share of the pie to those one-percenters. And the cure isn’t cutting regulations for our long-suffering corporate overlords or letting them park even more money offshore. The facts are there for all to see, though in your fact-free administration this may be a problem.