Why I’m a small government guy. October 2020

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Political power is a zero-sum game

Part I

Is “radical conservative” an oxymoron? By the plain meaning of the words, perhaps so, but functionally, it may make sense. Read on.

If my source of news were broadcast television and newspapers, or if I were voting for a good example of language, manners and behavior, I would likely be voting this year for Joe Biden. If my choice for president were dependent on who appears to have high moral character, then I’m not sure I should vote this year, and may not have voted four years ago, either.

However, I voted for Donald Trump four years ago and again a few days ago.  Both times I ignored my negative emotional reaction to his public persona with its rancor, egoism and exaggerations, since emotions are an unreliable guide to good decisions.

My vote for presidents, senators and representatives usually rests on who will grow the federal government least. I’m a small government guy. I see power as a zero-sum entity. As individuals cede power, they retain less. Politically, the extremes of this paradigm are anarchy, where people retain all their power, and communism, where the individual-everyone owns nothing, the collective-everyone owns everything and decisions are made by government committees and officials.

Everyone recognizes that money is power but some may fail to realize that the more that we supply to the federal  treasury, the less power we have individually.  People sometimes prefer more collective power, so this is not a good-bad issue. Indeed, collective power versus personal freedom has animated American politics since the eighteenth century and the conflict is in a growth phase again.

One corollary to my small central government theorem is that governments seldom do anything well.  Scandinavian governments seem to be an exception to this rule.

Another corollary is that one size does not fit all, and that individuals, regions, cultures, cities, counties and states have inherent variabilities that cannot be addressed specifically on a national level when the nation contains hundreds of millions of very different people. Government close to the people is more responsive and more responsible in a democratic society. It is delusional to believe that all constraints imposed by a government in a dense inner city are needed and effective in a rural agrarian county and visa versa. Democrats dominate in densely populated areas and Republicans the less dense as shown by the majority of citizens in over eighty percent of counties voting for Republican presidential candidates for decades.

The US may be the most diverse country in the modern world. I see it as a quilt of innumerable colors, hues, patterns, fabrics and threads. Rather than show off the beauty of our diversity, ruling from a central locale turns it into a plain, gray thin blanket. It makes no sense to me to try to rule this multifaceted nation of ours as one would a city, which is what moving deeper into socialism would attempt. I prefer having government closer to the people and embracing the regional varieties we still have.

In the classic definition, conservatives oppose change while liberals advocate for it. Do liberals advocate for changing Michelangelo’s David or DaVinci’s Mona Lisa? (No, but the current crop of activists might want these pieces of art to reflect Wokeness. Paint David in every shade of brown? Make Mona a transgender? Visa versa?)

Human nature does not change. The U.S. constitution may be the best document ever devised for accommodating differences in opinions, standards and preferences, providing liberty for the state and freedom for the individual, while maintaining reasonable cohesion as a society and country. I am liberal by a number of measures but in this respect I am conservative. 

I have been surprised to learn of the extent and depth of dissatisfaction with our constitution as expressed by Democratic politicians and thought leaders. If we have widespread disagreement about the basic foundation of our country, which falls generally along party lines, then it’s going to be quite challenging to agree on much that is substantial. Indeed, through the fickle ebb and flow of fashion characteristic of a democracy, our central government has grown in power at the expense of states and individuals during the twentieth century through amendments to the constitution as well as signature legislative actions.

Another corollary of smaller central government is that it limits the impact of corruption. Politics is and has ever been about power. The phrase, power corrupts, was perhaps first seen in a letter from a Lord Acton to an Archbishop in 1887. While the sentence in bold print is the one often quoted, the context of that statement is illustrative in light of current propensities.

I cannot accept your canon that we are to judge Pope and King unlike other men, with a favourable presumption that they did no wrong. If there is any presumption it is the other way against holders of power, increasing as the power increases. Historic responsibility [that is, the later judgment of historians] has to make up for the want of legal responsibility [that is, legal consequences during the rulers’ lifetimes]. Power tends to corrupt and absolute power corrupts absolutely. Great men are almost always bad men, even when they exercise influence and not authority: still more when you superadd the tendency or the certainty of corruption by authority. There is no worse heresy than that the office sanctifies the holder of it. That is the point at which . . . the end learns to justify the means. You would hang a man of no position, . . . but if what one hears is true, then Elizabeth asked the gaoler to murder Mary, and William III ordered his Scots minister to extirpate a clan. Here are the greater names coupled with the greater crimes. You would spare these criminals, for some mysterious reason. I would hang them, higher than Haman, for reasons of quite obvious justice; still more, still higher, for the sake of historical science.

My final corollary is the larger the country and the greater the government’s power, the greater is the potential for good but the propensity for corruption rises even more. Concentrated power has historically resulted in subjugation whereas distributed and balanced power lends to peace. A hundred million deaths in the twentieth century resulted from powerful socialist or communist governments.

These are some of the proofs of my theorem of superiority of small central government and its several corollaries. Part II, to follow, outlines how we no longer have a union of states but an amalgam and proposes changes for consideration to return to the original form of governance.

Radical Conservatism

Part II 

Until the US constitution was amended in 1913 to permit personal taxation of citizens based on income, no ordinary citizen had any direct financial connection to the federal government. The congressmen elected by and to represent the people sat in body in parallel with a smaller body of people appointed by states to represent them. The people’s representatives were in essence equal to the state’s representatives. States elected the president via the Electoral College. All direct relationships were between citizens and their congressmen and their states, counties or cities. 

Since the 1930s the federal government began providing funding to individuals for retirement, healthcare and disaster recovery, among other things despite wording in the preamble which says, “promote the general welfare.” It does not say provide it, as it says with, “provide for the common defense.” I am certain that these specific verbs were used with intent. Regardless, due to incremental progressivism, spending on such social programs now equals about 70% of the tax revenue received (or 55% of the total budget, since we borrow $27 for each $100 received in taxes—except last fiscal year, when we borrowed about $90 for each $100 received). With a large number of direct financial obligations to citizens from Washington, the nature of our country shifted from a union of states to—what metaphor to use here?—an alloy, high in the elements of California and New York. (Should we consider a name change? America Amalgated?)

The impetus for social programs is the ethic that we need, as a society, to take care of the herd. I agree, but a “herd” of 300 million extremely diverse humans is not manageable. (I hesitate to point out that herds have negligible diversity and are made more healthy when predators eat the infirm in it.) Social programs are vital to a healthy society but, to run optimally, must be the responsibility of a smaller entity and managed by even smaller entities. Washington should promote, not provide, programs that improve the general welfare. 

If Americans want to embrace real diversity and have social programs that are more efficient effective and accountable, we should perhaps consider returning to a union form of governance. The following bullet points describe some thoughts about how to do that. 

  • We should transition all such social support services to the states. Legislation would be needed to create templates of federal priorities for all within our borders within which states and counties can operate to meet the specific needs of their citizens. At the federal level, an office would be needed to coordinate between states, notably for people who reside in more than one.
  • Collection of and accountability for federal income tax should be transitioned to states, abolishing the IRS. States would retain revenue for the social programs they provide and remit to Washington the funds needed there for defense, administration, law enforcement, commerce, and other federal core functions. There would need to be either some provisions that create significant incentives to the states to remit funds or an account that is jointly held or an alternate balance of power mechanism. States can determine whether they have a flat tax, one based on a differential equation or anything in between.
  • The federal tax code should be discarded, root and branch.  Income subject to federal tax should be modified by nothing except certain basic deductions in order to avoid market distortions. These include a standard deduction, a high deduction for health plans/insurance, and a 110% deduction of the amount contributed to a retirement plan up to a limit. Retirement contribution shall be mandatory as Social Security would transition over twenty years to approved retirement plans, either a government retirement bond (essentially similar to social security as it is now) or a financial vehicle that meets certain safety and performance criteria. The glut of retirement investment funds, providing capital for investment, may lead to some unintended economic consequences so this aspect of replacing social security will require expert analysis and adjustment. I’m not an economist, or an absolutist and I don’t want to be king, so this paragraph is here to promote discussion.
  • State citizens, governors and legislators may want to rethink Amendment XVII, popular election of U.S. Senators in this realignment of power and allocation of funds. Changes as outlined will require greater communication and negotiation between states and the federal government. Additionally, in the Senate and House, seniority should be eliminated as a determinant of committee leadership. In lieu of term limits, people with twenty years of service should be barred from chair positions and should have a reduction in pay. The Hunter Biden debacle (See part III) is just one example of hundreds of coattail relatives legally living off the elected person’s influence. Restricting family members from income derived from federal contracts is critical in fighting corruption. 

With states carrying most of the burden of social programs, the expansive bureaucracy in DC could be drastically cut. Shrinking, consolidating and dispersing cabinet departments would be possible and aided by the means of remote communication that we presently enjoy.

Radical conservatism may make sense. It probably won’t start this election if career politicians are elected. It may not happen ever, as it is a threat to the status quo, career civil servants and the power-hungry political class. 

The Omen

Part III

Sunshine is the best disinfectant. I have doubts about this in many medical aspects, although it is true that it kills most microbes including coronavirus. It is used as metaphor in cleaning up corruption by making acts and records public. In a representative democracy, citizens must know what politicians are doing.

The news media are an important adjunct in this regard. We depend on reporters letting us know about both the official and unofficial or off-duty actions of those elected or appointed. In the last decade or two, news has come to citizens through online agencies such as Facebook and Twitter and we search for information using Google, Bing or other search engines.

Totalitarian regimes have news services, too. They provide all the news they want you to see and modify or create stories to meet the needs of the state. They do this at the demand of the leader or committee and under threat if they depart from the official orthodoxy.

Anyone who read the beginning of part I of this piece may have noticed my cynicism about current news sources and my failure to expand on the topic. Part III is the expansion. Many who read the following paragraphs may perceive it to be a partisan jeremiad. My intent is to avoid being partisan while pointing out an issue that has become so. 

Most of the news media covered a fictional connection between Donald Trump and Russian intelligence based largely on a salacious document produced for and financed by the Hillary Clinton campaign using Russian disinformation. High Democratic official pushed this fiction for their political gain despite its unverifiable nature and a number of provable fallacies. It has been said so often that Mr. Trump is a Russian agent or controlled by Vladimir Putin that many people still believe it to be true. Why? Because that story fits how they see Mr. Trump. In other words, it support their bias. This effort by part leaders has been so successful, they continue to use the Russia connection today.

Joe Biden recently claimed that the story that broke a few weeks ago in the New York Post about his son, Hunter Biden, is Russian disinformation. However, that story, which implicates the Democratic candidate for president in schemes by Biden family members in pedaling access and influence for money, is highly verifiable, well sourced and with highly credible witnesses, in stark contrast to the Russian fable. For around two weeks, network broadcast media did not cover this highly sensational story. It received little if any coverage in print. Twitter and Facebook largely attempted to block it. People claim that the Google search engine directed inquiries away. There is an overwhelming amount of factual data showing that all these media platforms tried to suppress this story.

The drastic difference in publication of these two stories cannot easily be explained other than systemic differences in political preference. I’m no expert in political matters but I see only two or three reasons for the majority of media to demonstrate such flagrant bias. 

The kindest reason is based on one of my theorems of life, that we see the world from where we stand; Perry’s Relativity of Perception Theory, or PROPT. If we are on the political right, we perceive a centrist to be on the left, since we typically perceive ourselves to be rather centrist.According to PROPT, since 90% of reporters, et al. are on the political left—according to polling data—, their sense of umbrage and indignation is stoked by acts of people on the right and they view this as newsworthy. Their selection of stories to run is not to mislead with intent, just a reflection of their point of view.

A less generous explanation is that the purveyors of content know or believe their audience is on the political left and they feed them what they want to learn. They mislead with intent in order to enhance profit.

The harshest explanation is that some media moguls seek to change the political landscape. They publish propaganda to achieve their desired political end.

The reason matters less to me than the result. We, the people, cannot trust the media. I should note here that I am agnostic about the Hunter Biden story. I have no preference to believe or disbelieve. I don’t care if it’s true or false. My default is to assume that most professional politicians are excrement—I keep going back to Cicero—and corrupt. Hence, I wouldn’t be surprised if this story were true, neither would it surprise me to learn it was all an elaborate, campaign-related hoax.

Objective data confirms that we cannot blindly trust any media source to be globally honest. A few sources probably are more truthful and objective than others as media sources are not monolithic; they differ from one another and they are filled with individual reporters, some of whom seem to more reliable than others. Yet, all people are subject to my PROPT theorem and I remain disgustingly skeptical.

The  suppression of the Hunter Biden story may be an omen. Formation of dictatorships in Central and South American was aided many times by a press full of intellectuals who favored the far left and filled the pages with their perspective and propaganda. Later, when the totalitarian regime was in place, the editors who wanted to print adversarial matter were eliminated one way or another. We are seeing non-governmental censorship in the USA, which is completely legal. The real question to ponder is, when the vast majority of news sources are filled with leftist propaganda, what could possibly go wrong? 

Others may not see it that way. PROPT.

Good Reasons

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A successful maneuver for political power is usually driven by a compelling emotion with a rationale that dupes people into complying, or at least fail to vigorously oppose. Fear: Carbon is destroying the planet, so you can’t buy things we don’t approve and you must buy expensive substitutes that we do. We will save you and the world from burning up. Envy or anger: wealth is bad and rich people abuse you, so give me your power against them, so you will all be equal; equally ho-hum. Pride: Deutschland über alles!

Now a pestilence is upon us. What a fortuitous opportunity to allow government officials, abetted by the fear-mongering media, to drive the capitalist economy off a cliff and substitute a centralized socialist economy that concentrates power. It was so compelling and esoteric, the proponents even cajoled a president with the most conservative record in American history into complying. For a while.

Suppose political power were a zero sum substance with each adult endowed with an equal amount. The more one cedes to any level of authority, the less is retained. While this is likely a true and immutable principle, some visible factors such as wealth and weaponry sometimes confuse the picture. Jefferson, a Democrat, saw inalienable rights as at least part of this substance. The US was founded as an egalitarian society with individuals and states retaining much of this substance. This changed about one hundred years ago when a series of constitutional amendments changed the very fabric of the country. Some called this progress and claimed the euphemistic title progressives. (Federal income tax was a stroke of genius in this regard. Money is power and most of it ended up controlled by the central government.)

Mitigating the pandemic provides a compelling reason to abridge basic rights and thereby accrete more power. Manipulative words are used such as science, mortality rates, overwhelming collapse, etc. Indeed, infection management has provided many good reasons to curtail many civil liberties such as financial independence, going to work or school, recreating, even visiting with friends and family. The uber-adherent busybodies, like brownshirts of the 20th century, run about reporting noncompliance to the authorities. Shop owners and surfers get thrown in jail. Those who cower-in-place gradually become vassals of the state. That may sound extreme. It is, but if what is reported as news is true, then who can argue otherwise? Progressives (aka socialists) strive for their ascendency while forcing the common man to cede autonomy, control, and power. The “progress” in progressive refers to their vaunted social and political status. For the rest of us, it is a regression to the state of civilization that existed for most of the last ten thousand years.

Trying to prevent a catastrophic collapse of our hospitals is appropriate and laudable. It’s also the threat used to compel compliance with the diktats from the overlords in capitols across our once free land. It’s a better reason than most for extracting power from individuals and amassing it to the government. Surely, in a world and nation replete with geniuses, we can learn to do two things at once: keep the death rate reasonably low while feeding the economic engine that allows us to do so without amassing five or ten trillion dollars of additional debt.

The Off-Plumb Covid-19 Quiz

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  1. In the old, wild west, a financially distressed sheep rancher has to move his herd of one thousand to the stockyard to sell. One route is through Indian territory where feed and water are plentiful. He knows the Indians demand six lambs as the price of using that route. The other route avoids the Indians altogether but the route is longer, the terrain is rough, and feed and water are scarce. He knows he will lose only two or three sheep to wolves on that route and that his herd will sell for as much as 20% less because they’ll be in bad shape. Which route should he take?
  2. A hungry, fire-breathing dragon is outside an enormous medieval castle, where ten thousand villagers have fled for protection. The dragon, fluent in French of course, gives the Lord two options. One was that he could provide thirty people to the dragon for her consumption. The alternative is providing twenty people plus twenty-five percent of the livestock and grain, a food supply vital to the fiefdom for the approaching winter. Losing that much would result in famine and possibly a number of deaths by starvation. The Lord asked the dragon if she would like to choose the people for her meals? She said, after a flaming roar, that she didn’t care, but older, tougher meat was better for her dentition, yet it was always pleasant to enjoy something younger as an aperitif. If you were the Lord, what would you chose and why?
  3. It’s early in the evening and the urban bar is full of professionals. The bartender comes out of a back room, looking gloom. “What’s wrong?” the psychologist asks. “Conflicted? Loss? Disagreement?”

“The health department says the place has too many flies,” he answers. “I have to shut it down.”

“I’ll sponsor legislation,” the senator says before anyone else can say a thing, “to make sure you and your staff have plenty of money and that the rent is paid. I’ll make sure you get a tax break, too.”

“I have a ten-thousand volt fly zapper I could lease to you,” said the salesman.

“I can write you a prescription for oral and topical medications against vector-borne diseases,” the doctor says. “And you probably need blood work, a CT scan and a colonoscopy.”

“I’ll sue the city health department,” the attorney says. “And the mayor, the city council, the zoning commission and the treasurer. Then I’ll go after the county and the state. Then Donald Trump.”

An entomologist offered a genetically manipulated male fly that would mate but not reproduce.

“I can depreciate your business, consolidate your liabilities and inflate your assets,” said the accountant. “By the way, what do you want the bar to be worth?”

“Why don’t you fix your screens, dude?” The contractor asked. “I could do that tomorrow if you bring me a few more boilermakers tonight.”

Question:  Is advice from highly intelligent people invariably helpful?

This Covid quiz is based on an estimated mortality rate of 0.25% when the medical system is not overwhelmed and 50 – 200% higher when it is.

Act of War or of Criminal Incompetence?

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Was the Covid-19 pandemic due to criminal incompetence or an act of war?

The preponderance of evidence, at this time, suggests that SARS-CoV occurred naturally. While China claims the outbreak in late 2019 occurred naturally at a “wet market”, most western experts believe that it was stored in a virology laboratory near Wuhan China after discovery in 2013. US intelligence reported safety problems with at least one of two such laboratories about a year before human infection and spread began around December 1, 2019. Chinese government officials covered up an unknown number of details and lied about others as the epidemic raged in Hubei province where 56 million people live. In January, all domestic travel in and out of Hubei was halted. Six days later, aided by the World Health Organization, all international travel was also halted.

Chinese individuals, including at least one physician, who tried to warn the rest of the world about the gravity of the situation, disappeared. Misinformation poured from government sources and the WHO. Non-governmental voices were censured. It is objectively impossible to trust any information about this issue from any source in China including, in my opinion, professional medical publications. It is inarguable that the government has launched a campaign of propaganda to, at best, try to regain stature in the international community. At worst, the intent is to further the political and socioeconomic upheaval caused by the pandemic. Intent is difficult to clarify and often has several aspects.

China either failed to contain the virus, likely by virtue of bureaucratic ineptitude, or it intended to allow its spread. The latter, as evidenced by the six day window of continued international travel, would be tantamount to an act of war.

A perfect act of war is one that is subtle, seemingly natural, and arguably accidental. It results in devastation of enemies far and near. Such an act would bring no immediate military response, no critical resolution from the United Nations, and no harmonious chorus of condemnation. Victim countries would be torn by between those who see the infection as a hostile act and apologists that promote the perpetrator’s propaganda. If a dominant fraction of apologist media exists, public support of the notion that this was an act of war may never rise above a murmur.

What would China gain by release of virus worldwide? For one, while it harmed their internal economy, it has created for them an economic explosion of exports, both legal and blackmarket. They are selling products to affected countries faster than they can be produced at prepaid prices that approach astronomical. As a result, these countries go deeper into debt to make these purchases. Viral containment efforts in most western nations have resulted in economic contraction and widespread unemployment unlike any period in almost a hundred years. With much lower tax revenue and profligate bailouts, the budget deficit of the US, for example, from April 1, 2020 to March 31, 2021 could exceed four trillion dollars. It is plausible—a notion voiced by Senator Tom Cotton—that China didn’t want to be the only country to suffer economically and found it preferable that the world suffer with it. Again, it is almost impossible to have certainty about intent.

Economic collapse is typically followed by political chaos. Chaos creates opportunity for hegemony. Wars are fought to expand territory, control, power and/or influence. Every objective observer of history knows this.

The failure to contain international travel, the pervasive obfuscation and mendacity, the governmental culture of dominance, still cannot confirm that this was an act of war. If not, however, it was an act of genocide, a crime against humanity, and criminal negligence for which China owes every country in the world recompense. Their intent is irrelevant with respect to their debt to all.

Keeping  with the China theme, there is a Karma in life. In striving for the yang of the cheapest source, we reaped the yin of a decimated capacity of US manufacturing, making us dependent on others, including hostile powers. For the yang of shared commerce, we harvest the yin of cowering in place from yet another Chinese virus and panicking over toilet paper while simpering politicians dismantle our own economy.

The US recently became energy independent from the mideast. At the very least, this second (or third?) epidemic from China should serve as notice that it is time to be independent from them in every way. But first, don’t forget that they owe us trillions of dollars in damages suffered by us from their criminal attack.

The Eyewash Station

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I stepped into a remodeled cardiac catheterization lab and saw a new contraption on the faucet of the scrub sink. As I donned my lead apron, the manager explained it was an eyewash station. The more I learned, the more I came to see it as a symbol of how government increases healthcare costs while decreasing quality.

The gadget is designed to shoot water into both eyes in the event of something bad splashes in them. What hazardous liquids are found in a cardiac cath lab, you might ask, since every such substance is approved by our Food and Drug association for medical use, either topically or injected, and should be safe. Yes, iodine can sting the eyes. Yes, blood can and rarely does splash in the eyes, despite the Occupational Safety and Health Administration requirement to use eyewear.  Blood is sterile in the vast majority of patients and when blood contains germs, studies show that infection of the unfortunate recipient is virtually immediate. There is typically an eyewash station in the emergency room within a minute or two of virtually all cath labs but that’s not adequate for regulators. Getting to an eyewash station in twenty seconds is not superior to two minutes for any liquid one could acquire on an eyeball in the cath lab, yet the room must have one.

The station interferes with the normal operation of the faucet and increases contamination hazard, should one attempt a sterile scrub.  Leaks are common and lead to a wet floors with a subsequent fall risk, not to mention damage to the building. 

But the story gets better. To ensure compliance with OSHA guidelines, accrediting organizations, create reporting requirements for hospitals. A weekly audit of the device is required. The person assigned to this task often must complete hours of education. A record of the weekly assessments must be made, to include inspection of the nozzle dust caps position and functionality, water temperature and pressure, and whether the pathway to the station is clear and unobstructed. If weekly assessments are not properly recorded in the correct form, inspectors issue a black mark against the institution, jeopardizing Medicare payments. 

While the inspection method and parameters are highly structured, neither OSHA nor accreditors require teaching people how to operate the device. These appliances do nothing to improve safety or quality but they drain hospitals of money. Eyewash stations are aptly named.

Government involvement has used good intent to pave the road to high cost, low quality medical care. Prime examples are government run, single payer systems of Indian Health and Veteran’s healthcare (neither of which are a topic in this article.) The government (and everyone else) wants to prevent fraud in taxpayer funded activities. In this spirit, bureaucrats adopted a wasteful, costly, and arcane medical billing system developed by a communist commune in Chicago, also known as the American Medical Association.  In it, every physician I know has committed fraud. That sounds awful. I shall explain.

Medicare pays for Evaluation and Management services. A history and physical or a doctor visit is such. There are three to five levels of payments for E&M codes. Higher levels of payment require more data points of minutia in the note that documents the service. Insurance gnomes count the data points to make sure no one cheats. The feds also require compliance officers to do the same work inside the hospitals. Doctors are not stupid. They developed a workaround using pre-filled forms to insert the required data into the electronic health record.

The result of this in real life springs out of a discharge summary on a patient who died during a procedure that I read recently.  It listed eight drugs the (dead) patient was prescribed at discharge. (Would the mandated discharge planner need a seance to follow up on compliance?) As this patient was dying, a consulting physician rushed in to help. The patient was being resuscitated but, according to his note, she had a completely normal physical exam including normal heart exam (the patient was in cardiac arrest) and was “alert and oriented” when she was essentially dead. The note hit all the points required in order to collect payment. Accuracy was optional.

Notes that were once concise now obfuscate details in five pages of useless copy-and-paste to achieve higher payment. On the other hand, physician orders that were once illegible doctor scribble are crystal clear. That sounds valuable, however, my experience is that the orders often get lost in a morass of cyber confusion. When I see a patient hours after a procedure, it’s not uncommon to find the IV fluid that I ordered stopped is still flowing rapidly into a poor soul gurgling in excess water. Computerized healthcare is the law. It costs, I have read, over $50,000 per year per physician to create this unsafe and confusing debacle. I sometimes cynically opine that the EHR is a governmental solution to global warming in that has shortened life expectancy in the US.

In order for the practice or hospital to get maximal payment, coders send me their irritations about my documentation every week. (“I can’t bill a level three because you were two items short on your review of systems. Can you go back and edit your note?”) A coder is a person who has been to coding school, (an entity that also funds the aforementioned communists in Chicago) and received a certificate. There are levels of coders in this artificial industry, and certificates in various specialties from oral surgery to proctology. I chose these specific specialties on purpose because this malicious micromanagement is flavored with idealistic intent but excreted as *** (insert preferred scatological reference here. Or, more politely, “eyewash.”)

Elimination of most of of regulations and systems that govern Medicare medical billing would result in a large drop in healthcare costs, probably improving quality of service and care at the same time.

Another accelerator of cost which is at least as bad as the regulations on providers is the FDA. Before costs are addressed, consider its abysmal record of failure with drugs. Around seventy thousand people die in the US of illicit drug use annually. Additionally, thousands more die of drug misadventures in healthcare settings. Tens of thousands more die from infections that result from antibiotic misuse.

Perhaps to overcompensate for its incompetence, the FDA creates expensive piles of *** (see above)  through which companies must slog to bring new drugs and devices to market. By requiring far more data than is needed in any other country, it may cost as much as eight times more to gain approval for drugs and devices in the US than in Europe. Because of this, the US is usually last to gain access to new drugs and technology when they are finally approved. Yet, healthcare is no safer here than in Europe. 

Combine the onerous FDA requirements with a twenty year patent duration, that begins years before the drug is approved, and it is no wonder that new pharmaceuticals are unaffordable. Politicians seem to create problems that they use for their own political gain. They rail against the high cost of drugs, a problem of their own creation.

A far lower cost solution is to accept European Union approval for drugs and devices for the US.  This would eliminate a giant swath of costly bureaucracy at the FDA making drug and device costs much lower. If the EU asks us to help fund their approval process, we could agree to do so when every country in the EU meets their NATO obligation. (Is that quid pro quo  impeachable?)

Some call for more generics and shorter patents. The latter would harm the pharmaceutical industry. Generic drugs have looser standards of purity. Reports of lower efficacy are mounting. Many generics come from China. These low cost, less pure drugs, along with a host of other sweat-shop non-medical products, force Americans to support a communist regime that aspires to eliminate our way of life. But I digress.

A Negative Test For Covid-19 Can Kill

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A test that is positive for coronavirus, aka Covid-19, confirms the presence of infection, if you have clinical signs and symptoms of infection. If you don’t, it doesn’t. Alternatively, a test that is negative is helpful in looking at a large, healthy population but it means much less for someone who is ill. Even worse, negative tests in sick people result in infection and death of healthcare providers and family. Confusing? Yes. 

There has been a lot of discussion and concern about the late arrival of testing for Covid-19. In order to shed a little light on this issue, let’s look at the current understanding of the test currently in use for detection of the disease. The test is properly done by sampling mucus from the nasopharynx, the back of the nasal cavity above the uvula, the little “punching bag” seen at the back of the mouth. The RNA of the virus is amplified by the polymerase chain reaction until there is enough to measure. The test is highly dependent on two things, amount of virus in the site sampled and sampling the correct site with sufficient (meaning unpleasant) vigor. 

Machines are tested on standard positive and negative samples. The machine characteristics must deliver accurate results 99% of the time or higher. However, samples submitted are not like the standards.

Data from Covid-19 testing in a real life scenario are few. A study published in the journal Radiology looked at testing done in China on about a thousand patients who presented with symptoms typical of the Covid-19 infection. 600 PCR tests were positive and 900 chest CT scans were positive in this group. It could be assumed that 300 PCR tests were false negatives and that the CT scans were highly accurate.

Using this data set as a springboard, let’s look at two vastly different uses of testing to detect infection.  First, consider a cohort similar to the one published, with a 90% prevalence of disease and a test that has a specificity of 99% and a sensitivity of 70%. A 4 x 4 plot of true positives, false positives, and true and false negatives would look like this:

Test + Test – Total  (Key)

Disease present 600 300 900 TP FN

Disease absent 1 99 100 FP TN

The positive predictive value in this situation (TP/TP+FP) is 99.8. The negative predictive value (TN/TN+FN) is 0.25. Thus a positive test is helpful but a negative test clearly does not exclude disease and is useless in changing any aspect of management when the prevalence is high. In this scenario, the false negatives may result in infection of many others including care providers.

Now look at a second cohort with a prevalence of disease of 0.1%. This would be using the test to screen for disease. (At this writing, the number of cases in the US is almost 300,000 in a nation of 330,000,000, or roughly 0.1%) In this case, let us screen 100,000 people with the same test, of whom 100 will be infected.  The 4 x 4 plot follows.

Test + Test – Total  (Key)

Disease present 70 30 100 TP FN

Disease absent 1,000 98,900 99,900 FP TN

The positive predictive value here is 70/1,070 = 0.07, which in ordinary English means that only 7% of the positive results occur in people with infection.  The negative predictive value is 98,900/99,200 = 99.7.  Suppose a leader proposed isolating all people with a positive test in this situation.  93% of those isolated would not have the disease and would be isolated unnecessarily. Further, testing for infection in screening vastly overestimates the prevalence of disease, in this case by about ten fold. (100 with disease but testing positive in 1,070) In the US, if we tested about one third of the country, one hundred million, we would quarantine a million people unnecessarily. This might be acceptable to some governments but a lot less so to Americans who understand these numbers. We would not sentence 1,000,000 innocents to a month in jail to ensure that 70,00 criminals did time for their crime. Additionally, there is a growing suspicion that about 25% of those infected are asymptomatic or minimally symptomatic yet spread virus for weeks. We have no idea how accurate that figure is because false positives are blended with the silently infected.

The CDC and the FDA cooperate to an extent on development of tests for epidemics. Considerable regulation exists with the intent of ensuring high quality and accurate performance of laboratory testing. With this coronavirus epidemic, the hue and cry of the masses (mob?) has forced the suspension of many of the procedures that foster accuracy, just so a test is available. We will soon have tests flying off the shelves to be used to diagnose this condition. It is extremely unlikely that these instantly created machines will have better operational characteristics than the existing tests. It appears that the likely less accurate results will be ready a lot sooner.

On a more positive note, there are tests that measure antibody to the virus, a protein that shows up weeks following infection. These tests are generally more accurate with far fewer false negatives. This testing can give a better notion of the prevalence of disease but after the fact. It will help clarify the false positives versus asymptomatic carrier question.

The late appearance of testing for Covid-19 in the US began as a consequence of false statements from China that led to a misunderstanding of the characteristics of the viral transmission and underestimation of the problem, and obstructive regulations in place for years that might be acceptable in times of health but fail in times requiring an urgent response. Federal health agencies could adopt a more functional approach to respond to epidemics, one that provides a nimble response and production of testing mechanisms by private industry that is both massive and as accurate as possible, recognizing the limitations and strengths of acute testing. On the other hand, testing for viral presence in the nasopharynx will always have the limitations noted here. An argument could be made that such testing is of limited value in containing an epidemic and that the focus should be in changing behaviors and practices that limit spread until a vaccine can be developed a year or two later. Numbers from testing certainly help the news media industrial complex while giving many people anxiety and provoking other psychiatric reactions. Fear is a double edged sword. It motivates many to comply with infection control measures while it stimulates fraud and crime in others. It’s impossible to say at this point—or at any point—what effect on infection and mortality rates has been derived from government-dictated termination of selected business activities as opposed to a lighter touch with enhanced guidelines regarding occupation limits, spacing, masks, cleaning, etc. Just like we will know more about infection rates a year from now, we might better understand how devastating government actions have been on the economy, provided we have control states or economies where the restrictions have been less onerous.

Coronavirus will not be the last epidemic. All epidemics will not necessarily be viral as there is a rapidly expanding list of antibiotic resistant bacteria. Microbes owned our planet for two billion years. They want it back.

Never Trumper? Not quite.

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I’ve never met Donald Trump and probably never will, which is fine with me.  I don’t like his public persona.  His conceit and braggadocio make him obnoxious.  He is profane, contentious, unreliable and inappropriately manages subordinates often in public (Twitter) instead of in confidence.  I have a difficult time finding in him good leadership qualities or an overarching positive philosophy, political or otherwise.  Someone should shove his phone with the Twitter app far up inside him where the sun don’t shine, as he might put it.  He’s a city slicker. I’m a cowboy.  In short, I’m not a fan.

I’m a cardiologist, too.  Over the almost forty years I’ve been doing this I’ve had more than a few colleagues much like Mr. Trump; brilliant and arrogant jerks who threaten and cajole patients, administrators, other doctors and nurses to accommodate their personal aggrandizement or schedules.  I’ve witnessed an array of abuses that would fill a book.  (In fact, they provide abundant material for my several novels published or in progress.)  I know and have worked side by side, day by day with those with a Trumpian personality disorder and it has been unpleasant.

My personal experience has greatly amplified my disdain of Mr. Trump’s personality yet, as an objectivist, I applaud much of what he has done.  Admittedly in the legislative arena only one substantive bill, a tax reform, has been passed in his first year, due in part to the diversity in the Republican party and uniformity of Democrats.  Yet he has done a lot of good with his pen.  (And a lot of bad with his phone . .  ba-dum Pum!)  A number of analysts believe his first year has been more conservative than President Reagan’s.  He has eliminated vast amounts of regulations of the record setting regulatory Obama years and, in so doing, has fostered economic recovery.  There is a great deal more to do, particularly in medical regulations which drive costs up and quality down.

Perhaps unwittingly, Mr. Trump has illuminated the overwhelming bias in Washington, network media and in many “liberal” states.  (I place liberal in quotation marks as it has become a misnomer.  The Democratic party, once a bastion of free thinking and expression, has suffered ideological creep and has become illiberal in that it suppresses expression and supports goose-step political belief patterns.  These are fast becoming fascist states, the inevitable evolution of socialist ideology.  Many or most that vote Democrat are blinded to this and vote based on an illusion from the past.  This charade is promoted by media.  If one gets news only from network news and Yahoo, it would be difficult to vote other than Democrat.  But I digress.)

He has addressed head-on international issues that have grown due to procrastination.  He, apparently, recognizes that not making a decision is in itself a decision with consequences, something that physicians know all too well.   Lawyers and politicians, on the other hand, tend to benefit by putting off hard decisions.  Simmering conflicts of the past two decades or more, are being confronted, communication intensified and contingencies developed.  Uncomfortable, perhaps, like a discussion with partners or mates about irritations, but necessary to live in peace.

His election resulted in the resistance movement, a set of behaviors that reveal that personal and party animus has overcome both rationality and the fiduciary duty to govern.  This movement affects both Democrats and centrist or elitist Republicans.  We have gradually seen the unmasking of corruption in the upper tiers of the FBI and Justice Departments, a good thing to reveal.  It seems likely that more evidence of sedition in the so-called Deep State will become public in the next year or two.

We are governed by men.  To paraphrase Lincoln, a man without flaws has few virtues.  I’ll never enjoy the personality or querulous behaviors of the petulant Mr. Trump.  However, I acknowledge the reduction in central government and economic growth that has come about because he is in office.  I appreciate the light shined on the corruption within the government, the exposure of rampant media bias and the beginning revelations of an imbedded culture of D.C. (known as the deep state) that is pervasive in the influential pinnacles of our country.  Thank you, Mr. President.

J J Perry MD

Author of “Between Love and Money” as Martin Filson and “REAP 23” as J J Perry.  “Malpractice” is to be published later this year.

Fudge is dark matter.

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Around twenty five hundred years ago, Greeks had determined that the earth was round and orbited the sun. In a classroom in Neapolis (modern Naples) a twenty five year old pupil, Aeschylius, sat at the feet of Sapphocles, a renowned scientist and teacher.
“I completed my assignment from last week but I just couldn’t come up with your solution.” Aeschylius handed his abacus to his mentor.
“This is the answer I found at first,” he smiled and handed it back. “The problem is that it cannot be true based on the length of our year and the difference in shadow length of a standard staff between here and Alexandria at midsummer at midday.”
“You came up with the same number?”
“At first. Yes.”
“I feel a little better but the number is off by a factor of six or seven from what you published. Not six percent off but six times smaller.”
“I have invented a solution for the discrepancy, young Aesch.”
“Explain, Sir. Please.”
“Dark matter. We are surrounded by it. Can’t see it, feel, smell, taste or hear it but it fills the immensity of space. It alters the paths of planets and stars.”
There was a long period of silence. Aeschylius stood, brushed the dust of his tunic and asked, “You’re kidding, right?”
“I’m deadly serious, young man,” he stated with indignation.
“Dark matter? That’s the best you’ve got? I mean, the name shows no class, no chutzpa, no creativity. But,” he raised a finger, “I give you credit for making up a whopper as a fudge factor instead of admitting you have absolutely no idea what’s really operative here.”
“Young man!” He fumed. “The audacity!”
“The mendacity!” he countered.
“You little Aesch! Out! Get out of this school right now!” Sapphocles bellowed at the top of his lungs and pointed to the door.
“People in the future will laugh at you. Ha! Dark matter? Only a sap would accept that.” With that he ran, escaping the hail of epithets and chunks of gypsum.
Twenty five hundred years later theoretical physicists found that the mass at the center of galaxies was too small to keep all the stars together. The mass of the black hole and central massive stars were off by a factor of six or seven. So, they invented dark matter, stuff that can’t be measured or detected and declared that 85% of the universe consisted of it. They didn’t stop there. Dark energy is causing the universe to expand faster then they think it should.
So, we’ve made a great amount of progress in the last two point five millennia. Brilliant.
Oh, lets see how this dark drivel actually fits into the Big Bang Model (Big BM [Too crass? Go with BBM]) If dark matter preexisted the big bang and occupied our space, by its gravitational effects it could have accelerated the initial expansion of the infant universe, which is good because it had to grow at or above the speed of light for a while. If it were created with the Big BM, the universe could not have expanded as quickly as is hypothesized due to excessive gravitational effects. It must, therefore, have existed prior. But that can’t be right because nothing existed before, right? Conundrum.
More likely, the notion of dark matter is simply a compensation for ignorance of physical principles we have not yet defined, perhaps one in which the formula for gravity works accurately at the level of a solar system but not as well at the galactic scale.
Have I ever mentioned how string theory originated in the dark ages? No? Just wait.

Big Government is not new. Pharaoh Moans

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Pharaoh Moans
Or How To Attract Dysfunction.

Chapter One
Big Government

Circa 4,000 years ago a Pharaoh planned to travel from Luxor to Quseir, only accessible by an overland route from the Nile Valley to the Red Sea of almost one hundred miles. He had two hundred Jewish slaves to carry him, his wives, children and his personal slave, Fawks, in their residence on their shoulders over the dirt and stone road. A hundred slaves could carry this load at two miles per hour but each one could work for about an hour before they needed a break. A hundred replacements traded duty for twelve hours of travel per day. It would take about four days to make the trip.
Near the end of the first day, the pharaoh’s family wanted food prepared, so six slaves were taken from the contingent, placed in residence to cook and serve.
It was hot, so they wanted a bath and fans and people to operate them, so four more Hebrews went into the residence along with tubs of water and palm fronds. (The Pharaoh made certain that all those removed from the arduous work were members of Slave Empowerment Intranational Union or SEIU.)
They needed their beds made, the house cleaned, the honey pots emptied and cleaned, insects removed. Being desert, sand was everywhere so half a dozen bodies were added.
A four day trip is boring, so they needed entertainment. “More Jews!” the children cried and more were added so they could watch plays one after another after another.
The royals complained that the trip was too bumpy. The slave masters regulated how the bearers were to walk, their cadence and stride and also where they could step.
The grapes were soft, so a contingent of runners was sent back for fresh fruit.
These changes all resulted in a loss of speed to one mile per hour or less. The masters then created incentives. The slaves would be able to eat if they increased the speed back to two miles per hour. Otherwise they would miss their ration. They cut the rest periods and increased the work shift to keep one hundred under the house but the speed barely increased.
By the third day they were still short of halfway. One of the Egyptian masters pointed out to the Pharaoh that the additional weight coupled with fewer workers was slowing the procession. He was demoted to slave.
On the fourth day, despite increasing the carrying period to fifteen hours per day, it was clear they were not going to arrive at the resort that day or possibly even the next. The young children were ornery, the wives disgruntled and the pharaoh irritated. “I have a new game,” he said. “It’s called Stomp. On the count of three, everyone jumps up as high they can then hits the floor as loud as possible with their feet.”
“But won’t that bother the carriers?” Fawks, asked.
“What doesn’t kill you makes you stronger,” he said. “Besides, I’m the Pharaoh and I do what I want.”
He counted to three. When almost everyone jumped up, the carriers bowed and winced in pain. When they hit, the carriers could not bear the load and the platform fell, crushing those beneath.

Chapter Two
Making Sense of it All

The Pharaoh’s legs were broken. Fawks, also injured, said, “It appears that supporting more with fewer was a catastrophe.”
“According to my economic adviser, Canes, adding more to the platform should have accelerated our progress. So, slave, if you had a college education, you would not make such a stupid conclusion.”
Fawks scratched his head in disbelief, looked over the destruction and asked, “Is it right to have no checks on your power? When you have a whim, it hurts so many.”
“Silence, slave. I know best. Besides, it wasn’t my fault. It was clearly poor engineering and flawed construction by non-union slaves. And you, Fawks, probably had a role in this as well.”
The Pharaoh’s eldest son, a teenager and unhurt, clambered through the devastation. “I need my surgeon,” Pharaoh moaned.
“He’s back in Thebes,” his son answered. “Your regulations forbade him to leave the palace.”
“Where I am IS the palace!”
“Not by what is written in your law, the Aristocratic Care Act.”
“Then find another doctor!”
“The ACA has performance metrics. Because you are a high risk, I doubt any one will care for you because if the outcome is poor, it will be published, they might not be paid and could lose their position in the organization.”
“I’ll grant them amnesty. The pain is killing me. I need help! Get those slaves over there to carry me.” He pointed.
“They’ll be carrying me. The ACA utilization panel made the rule that if someone breaks both legs in the middle of the desert, we don’t waste resources on them.” He smiled.
“Then I’ll change the ACA. I have a pen. Or I had one. Fawks, where is my pen?”
“Somewhere in the rubble of your foolishness, your Highness.”
“Silence, Fawks!”
“Fawks provides a unique perspective, don’t you agree, dad? Anyway, if you can’t walk, I guess we’ll leave you out here in desolation.”
“I’ll pay half my fortune to anyone who will get me out of here,” the Pharaoh screamed at the top of his lungs.
“Remember the Frankendawd law you passed, the one to make the financial markets more honest? Well, you can’t liberate the royal fortune just like that. Besides,” the son laughed loud, “the treasure will soon be mine.”
“You can’t do this to me. When the people learn of this, they will revolt.”
“The news papyrus industry supports the Pharaocracy. It shall report only what I want the people to know. Which is that you died of a head injury. So, dad, have a nice eternity deep inside the pyramid.” The son lifted a rock and seconds later was the leader of all Egypt.

Story reported by Fawks.
To Joe Perry

Ten points you should know about healthcare reform

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  1. An individual should be free to purchase any legal service and product with his or her own money.  This includes healthcare.
  2. Insurance companies should be free to provide any type of insurance they choose as long as it covers legal products and services.  Free market dynamics should determine the feasibility, cost and profitability of such products.
  3. An unlimited amount of money could be spent on health or the perception thereof.
  4. A fee-for-service system of healthcare provides the highest level of service but also is the most expensive form of healthcare delivery.  When a provider of goods or services (a) profits directly from the number and type of those provided, (b) determines for the consumer the necessity of such and (c) sells them to consumers who acquire them with little personal expenditure, the number and total cost of these goods and services shall be high.
  5. Drivers of excessive care other than profit motive include (a) threats to the provider of loss of money, esteem, privileges and licensure and career, (b) lower levels of medical expertise that foster ordering of inappropriate specialty care, (c) consumer demand and expectations, (d) dissociation of payment from service and (e) desire to please the consumer.
  6. In a market sector driven by emotion (such as healthcare) and when there is a large knowledge gap between providers and consumers, the provider has an unfair advantage in all negotiations.  This dynamic is exacerbated by consumer demand to “do something.” Even when a majority of providers have high ethical standards, the combined effects of unethical behavior and insistent demand are large.
  7. When an individual pays for healthcare insurance either directly or through taxation there is a demand for service and expectation of payment when a perceived need arises.
  8. There will always a segment of American society that declines to purchase health insurance either for cogent reasons important to the individual or due to psychological denial or apathy.  Likewise, there will always be those that oppose specific provisions of insurance felt to be vital by others.  Finally, there are local and regional variations in need and demand for services.  Hence, forcing a universal insurance on all is both inefficient and an abridgment of personal freedom.
  9. Governmental regulation of healthcare has increased overhead costs of providing care while decreasing efficiency and adversely affecting satisfaction of the provider and recipient of services. Government funding of healthcare has dramatically increased overall funding thus the size and scope of the medical-industrial complex.  Both have combined to destroy most free market aspects of healthcare.
  10. The behavior of healthcare providers can be modified by rewards, financial and other.  Hence, lower total costs coupled with higher medical and service quality can be achieved and improved by crafted motivations.  However, a different set of problems will arise, some but not all of which are predicable.