Obamacare, Death Panels and the end of life

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A friend of mine posted a very thoughtful article on end of life care written from a physician’s reflections upon his own demise. Doctors know the odds and some of them sometimes choose to forego further treatment and make their peace.

In the case of many diseases the probability of remission is poor. And as we approach the implementation of Obamacare, one of the key takeaways is that many of us will no longer receive the level of care that we had under our old policies.

We are seeing corporations limiting coverage and limiting working hours in a desperate drive to reduce exploding insurance costs. Already, the insurance companies battle every step of the way in approving many treatments. This is done in the name of cost management.

Now the government is stepping in adding another layer of cost and more roadblocks between patient and doctor. As a part of Obamacare, the Independent Payment Advisory Board is being formed to control costs. In the UK, the Liverpool Care Pathway has caused an uproar with the abuse of its principles by doctors and bureaucrats. Worse, the British bureaucracy has a direct function in approving and denying specific treatment.If a patient is determined to not deserve a certain treatment, it is not performed, resulting in death in many, many cases. It is not isolated and it a part of the system. There is extensive evidence.

And this is what is now being implemented here. Both Howard Dean and Paul Krugman have fessed up to this reality. Costs are out of control and growing exponentially. People are living longer. The technology to help resist disease and prolong life has grown immeasurably, along with costs.

And within all of these arguments and issues, the relationship between the patient, their doctor, and with the Great Beyond has become lost in the shuffle.

In the end the decisions must be between patient and doctor; not between patient and bureaucrat.

I had two friends who were told they had pancreatic cancer within a year or so of each other. Peter used every tool in the toolbox to fight back. He had radical surgery and highly aggressive treatment. He came back to work eventually, but 18 months later he was dead. He had bought himself two years and lived those years well knowing the eventual outcome.

Not too long thereafter I found out my friend Paul also had contracted pancreatic cancer. He was diagnosed in August and by mid-October he was dead. He had made his peace with God and chose palliative care and the first his friends knew of his condition was when we received a call or an e mail inviting us to the funeral.

Each of them chose their path as they saw fit. each of them were faced with difficult and life threatening choices. They made these decisions without bureaucratic intervention.

These are the most personal and agonizing of choices. And sometimes the patient is unable to choose as when they are on life support and unconscious.

In “The Ends of Human Life” Ezekiel Emanuel examines medical ethics on a spreadsheet and posits communitarian examination of the issues and the just distribution of medical resources. He discusses the politics and the justice of medical care. But he does not discuss how to frame the discussion that matters the most in the end. The ethical discussion. The discussion of choices to be made. As with the NHS and Obamacare, the assumption is the rationing of resources by the state.

The governmental medical bureaucracy has grown from the implementation of Medicare in 1965 to a behemoth today. Include programs such as the military TriCare program and the Veteran’s Administration hospitals and state programs and one can readily agree that there is already a massive public sector bureaucracy in place. This will be layered over by more indirect costs from the new bureaucracy being built. And the patients will get even more lost in the system.

How is this beneficial to our society and to the individual?

Today’s health care system is driven by spreadsheets and first, second and third tier case management. How does this deliver the best care at the lowest unit cost?

End of life care is expensive. CBS News stated that care in the last 2 months of life in 2010 cost the nation $50 Billion. The total size of the Medicare budget alone for 2012 is estimated at $536 Billion. Medical spending was estimated by the UN at 17.9% of the GDP of the United States in 2011; $2.8 trillion. So why are we having this conversation in the first place?

There are many problems to discuss about health care management. But government intervention in end of life care is not one of them. The issues are bureaucratic and administrative and there are many, many fingers in the pie. The other issue is control. Holding Grandma hostage is a powerful weapon. Statists like control. Single payer health care has been the stated goal of the left-wing of the Democratic Party for the past 50 years.

The conversation is really about control. And when doctors start talking in spreadsheets and when bureaucrats in both the public and private sector have financial stakes in the game and the decisions are made by corrupt and venal politicians who do not live by the same rules, it is wise and prudent to be very, very skeptical.

 

 

 

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Reading the Hieroglyphics in Egypt

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The world’s press is focused today on Cairo, where hundreds are dead in the crackdown by the military on the Muslim Brotherhood. Our government is at cross purposes and complicating this is a visceral hatred of the Obama Administration, and by extension, our government, by a vast majority of Egyptians.

In this country some cry for a complete cutoff of American aid and on the other side there is silence in the face of what must realistically be called a massacre.

But we must remember that there is a much larger game in play. It involves Iran and radical Sunni Islam. It is a battle for power. Part of it is being played in Syria, where the civil war has spilled into Lebanon and Iraq. Part of it is the continued attempts at destabilization in the Gulf States. Part of is the destabilization of states as far away from each other as Yemen and Afghanistan and Iraq. It also affects Israel.

Much of this is about a new Persian Empire. Iran with the support of Russia has been behind Shiite resistance in a number of states including Bahrain. The Muslim faith has been manipulated in the interests of temporal power time and again, and the vision of a new Persepolis still resonates in Qom and Teheran. The Salafist dream of a new caliphate is in direct conflict with this.

Events in Egypt play against the backdrop of the Syrian civil war, where the opposition has been recently reinforced by heavy weaponry from the Gulf. Remember the 20,000 M-16’s that disappeared from a Kuwaiti arsenal? They are now in play, but we don’t yet know where. Hezbollah has doubled down in Syria and the Sunnis in Lebanon are commuting to the war. Iraqi Shiites fighting in Lebanon are called Iran’s Foreign Legion. Former Egyptian president Morsi lent his support to radical Egyptian imam’s calls for volunteers.  Iran cannot afford to lose for it will affect their power everywhere.

The Western powers are dithering in their support of the rebels. The Sunni states are not. Disorder in Egypt is antithetical to their strategic interests.

The Iranian government is waging a proxy war on many fronts. Five years into our own administration, our Middle Eastern policy is incoherent and does not seem to recognize this. The Iranians have their fingers in many pies and the enemy of one’s enemy is one’s friend whether it is supporting the Sunni Taliban in Afghanistan or shipping arms to terrorists in Sinai and to Hamas in Gaza. The art of war can be ecumenical at times. Instability in Egypt, Jordan and other states is to the advantage of Iran.

What is certainly forming is a major Sunni – Shia conflict driven by Iranian expansionism. The Israeli fears of the acquisition of nuclear weapons by Iran also factor in for it is not just the Israelis, but all of Iran’s neighbors who have now become nervous. This ups the ante in Egypt even more.

The King of Saudi Arabia spoke forcefully today in support of the Army in Egypt. Stability in the heart of the Arab world is paramount in the face of multiple threats. Reuters reports this morning that the Muslim Brotherhood has been behind a persecution of Copts and other Christians in the country with 62 churches, schools, monasteries and other buildings burned down along with hundreds of businesses and hundreds dead.

What we are seeing in Egypt is the reaction to the Muslim Brotherhood’s attempt to create an Islamist state in the face of the opposition of the overwhelming majority of the people.

I spoke last night with a friend whose family is at the heart of the Egyptian establishment. His cousins, nephews, nieces and friends were in Tahrir square when the Mubarak regime fell. The are a mix of secular and religious Muslims, but they are all Egyptian nationalists with a very international perspective. They are clued in at every level to the events of the past 2 years.

From his conversations with friends and family he said 80% of the people oppose the Brotherhood vehemently. The Brotherhood attempted to change the government, the courts and the constitution as soon as they took power. The country has fallen into crisis because of the instability at the top. Ordinary citizens are fearful of Brotherhood thugs.

He also said that over 50 soldiers and police have been killed in the past 2 days. The army has been seizing Brotherhood weapons caches all over Cairo and elsewhere which include heavy weapons. They have been arresting Chechen, Afghan and Pakistani Islamist soldiers in Cairo. There is a lot more going on than is being reported in the Western press.

It has been reported that the Israelis and Egyptian Army have been working very closely to contain Islamic radicals in the Sinai who can move towards either Cairo or Tel Aviv if not contained. Again, these are mainly foreign fighters.

Egypt has had a taste of the Brotherhood for almost exactly one year, and that was enough. The Muslim Brotherhood is a violent organization. Members have staged numerous terrorist attacks against Egyptian leaders, including the assassination of Anwar Sadat in 1981. Evidence of a parallel fighting force and the hard-line tactics used by Morsi to accrete power had the country on edge for months. North Africa is awash in weapons from Libya. Conditions for a civil war were ripe.

The evidence so far in Egypt indicates the overwhelming sentiment that the Army is the savior of the country. General al Sisi commands the respect of the vast majority of Egyptians and is beholden to no one, especially our government. He is governing the country together the Grand Sheikh of Al Azhar University, considered one of the most important Islamic leaders, and the Coptic Pope, Tawadros II. This is seen as a unity government despite the resignation of Mohammed El Baradei.

The Syrian war is spilling into Iraq and Lebanon. Libya is still a seething cauldron. We cannot afford instability in Egypt as well. And remember, as the U.S. pulls out of Afghanistan there may be thousands of Islamist warriors willing to move on to the next jihad.

The Muslim Brotherhood will not go easily, but they will nonetheless go. Egypt does not want an Islamist state. They do not want religious repression. The Egyptian people do not identify with extremism. And they do not want our meddling or manipulation or incompetence. They want and need our humanitarian aid.

Our foreign policy has been playing checkers while the real game of chess has been ignored.

 

 

Yumpin Yemeni!

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Way back in the day when our ethnic groups used to self deprecate, Jumpin Jiminey was was an exclamation used by the Nordic ethnic groups. Today, in our great excitement, it seems our defense and political leaders have pulled the emergency handle on Yemen.

It seems that the NSA overheard a conference call between Ayman al Zahawari and his contacts in Yemen, Iraq, Nigeria, Uzbekistan, and elsewhere. He basically told them to “do something” from the news reports. Al Q’aeda in the Arabian Peninsula has been a special concern of the United States ever since Anwar al Awlaki decamped there, running much of the global organizations recruiting efforts.

Al Awlaki was the magical connection between 9/11 and the Ft. Hood bombings and the London bombings.He conducted a high-profile radicalization program in the UK from 2002-2004 before moving to Yemen to further the goals of Al Q’aeda. He recruited hundreds of  fighters and was one of our most dangerous enemies. It was a good thing that a Hellfire missile found him and sent him on his way to Allah.

He was hiding out in his family’s traditional tribal area of Yemen; Shabwa, which was one of the areas of the Aden Protectorate at the time where the British military fought a low-grade war for many years in the 1950’s and 60’s, primarily against the communists and the tribes associated with Gamal Nasser’s pan-Arabist movement. A perverse coincidence but indicative of the culture of warfare.

South Yemen is a land of treachery and vendetta and home-grown terrorism long before the was an Al Q’aeda. During the Emergency the two major rebel organizations fought each other and the British, tossing hand grenades into British children’s parties and in on case blowing up an airliner full of civilians. Shabwa was a major center of insurgency. Today it is no different.

Nasir al Wuhayshi, the leader of AQAP is from Mukayras not far from al Awlaki’s Shabwa. he was ignored for the most part by intelligence services in favor of al Awlaki and other high value targets. He was Bin Laden’s secretary, probably the person closest to the terrorist mastermind for the longest period of time. Bin Laden’s Boswell, if you will.

Now he is the head terrorist in charge in the wildest, most violent corner of the world. It is a country with a little bit of oil and a useful port and that’s about it. AQAP is much more interested in infiltrating Saudi Arabia next door, but it is a safe haven for the bomb makers.

al Wuhayshi’s family connections as well as al Awlaki’s are vital to AQAP. They extend  into the very heart and soul of Yemeni identity. The al Awlaki clan is among the most powerful in south Yemen. And underlying all of this is the hatred between North and South Yemen.

The People’s Democratic Republic of Yemen (South Yemen) was the only socialist country in the Middle East, primarily because of the union movement when it was called Aden under the British. It had a history of intrigue and violence that would make a great movie.

So you have North Yemen, formerly run by the sheikhs and traditional in nature and South Yemen, which was ruled for 20 years under a radical Marxist, xenophobic regime. And in the hinterlands, the tribes, who never changed.

Many reporters are now writing about losing Yemen. This is absurd. We never had Yemen to begin with. Our strategic interest is to, as the British did, suppress piracy and to keep Al Q’aeda bottled up like bees in a jar. Cut off their travel options. Let them trash their own country and forget about them. And if they ever try to pull something, lay waste to them.

The Death of Old Media?

There have been some major headlines in the past week that have largely been ignored for their meaning by the same denizens of the world they live in. Newsweek has been killed off. The Boston Globe, which was purchased for $1.1 Billion, was sold off for $70 Million by the New York Times, a staggering 93% loss. And just a short while ago it was announced that Jeff Bezos is buying the Washington Post’s primary newspaper operations for $250 Million in cash.

It is deeply ironic that the Times chose to run a crocodile tears article about Newsweek this morning. But then, the problems and cluelessness at the Times have been evident for many years.

In visual media, CBS and Time Warner Cable are at daggers points over programming fees, the ones that continue to inflate your cable bill as viewers seek refuge with Netflix, Roku and other alternatives.

Tina Brown, the publisher of Daily Beast/Newsweek said “It doesn’t matter how talented you are right now. You used to be judged by your performance, but now it doesn’t matter what you do,” she said. “It is quite a business.”

Except that in each case these media empires have run themselves into the ground. The first step was in alienating huge swathes of the demographic base. A merchant, whether of news or other products, must appeal to the most profitable audience it can in order to survive. In the case of the newspapers the alienation was political in nature.

The newspapers and magazines simply stopped caring about presenting objective news. Their political views seeped from the editorial pages to the hard news sections. It is hard to recover when almost 50% of your potential audience will not purchase your product.

The networks face the problem of poor content and poor return on investment. There are a very few winners but with hundreds of channels, most of those networks are scraping by. And with each of them adding a surcharge onto the customer’s bill, the wheat must eventually be separated from the chaff.

Hollywood is crying the blues as well. Spielberg, Lucas and Clooney decry what Hollywood has become and yet their entire careers have been made on big money productions including some very expensive vanity projects. Salaries for the top talent are still in the $20 Million per picture range but somehow it is the financiers fault.

In a way, the same trends in defining downward we see in industry and commerce we are now seeing in the media. Inferior product is driven by inferior thinking and especially in today’s groupthink bubble, there is a crisis not only of content, but of rational thought.

In the case of each of these media meltdowns the old adage has been reversed. Failure has many fathers and mothers.

California’s invisible 35% tax increase

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Last October, California Governor Jerry Brown signed into law SB 1234, the California Secure Choice Retirement Savings Program. This has been hailed by progressives as a solution for those workers in the state without retirement savings or programs to provide for their income as they grow older. It forces them to contribute 3% of their income into a state managed retirement program.

With Social Security on the brink of failure by 2030 and incomes increasingly challenged by the part-time job phenomenon it is challenge enough for California’s workers to plan for retirement. With exorbitant energy taxes, a carbon tax and recent tax hikes falling most heavily on the poor, the state has grown ever less competitive as it has grown ever more expensive to live in.

But with the Democrats holding a supermajority in both houses of the legislature they can do anything they please.

The state has arrogated a power unto itself that didn’t exist without consultation or input from the public. And all of this has occurred largely under the radar screen. The newspapers and media have been silent.

The devil is in the details and the details of SB 1234 are vague. How the program is managed, safeguards, etc are all to be worked out later on. But California already has a history of mismanaged pension plans to reflect upon. How will this huge pool of money be different?

The state has been pilfering its existing pension plans to plug the gaps. It has raided gasoline taxes and highway funds. What makes it different this time?

California has the highest gas tax in the country at $0.72/gallon, which just went up 3.5 cents on July 1.With a 9.3% income tax rate that kicks in at $48,029 and a base sales tax of 7.5% rising as high as 10% in some cities and counties. The middle class has become an illusion.

The new retirement program will cost an additional 35% to the income withheld from low wage worker’s wages and will be managed by the same people who have gotten the state into a mess in the first place.

The money grab by government in California has been done by stealth and subterfuge. The state has unsustainable pension obligations for its public worker’s. The unspoken agenda is that the unions and their cronies come first and the rest of us be damned.