Yesterday afternoon I streamed The Six Triple Eight on Netflix. Recommended. It’s the sort of movie Hollywood should be making rather than the historically revisionist patronizing garbage they seem to prefer. It had a brief theatrical release earlier this month so I expect the movie, Kerry Washington, and Tyler Perry to garner some nominations when Oscar time comes around. They’ll be well-deserved.

As Sam Clemens (Mark Twain) said about the weather, everybody talks about it but nobody does anything about it. What is going to happen with the federal budget? What should happen?

One small observation. There are more than 900 federal grant programs that account for nearly three-quarters of a trillion dollars in spending, administered by just under 20 federal agencies. Most of these grants are for healthcare but they extend to transportation, education, and dozens of other areas. Why do these grant programs exist? I think it’s because the Congress isn’t doing its job but delegating its responsibilities to the executive branch. The Congress should be allocating these grants itself or they shouldn’t exist. Not only would that be a lot of work and distract the members of Congress from their main jobs (raising money for their re-election campaigns) it would leave their fingerprints all over the place. Mustn’t have that.

I also think that in the final analysis the bickering over the budget is a sideshow. Our real problems are in entitlements and taxes not in what is referred to as “the budget”.

One more thought. When Social Security was enacted in 1935, full retirement age was 65. Life expectancy was 60. Today full Social Security retirement age is 67 and life expectancy for men is 75 and for women 80. That’s a bit misleading since those statistics are life expectancy at birth but you get the general idea.

From a post by Arnold Kling:

When I wrote my book, the United States was spending a larger share of our GDP on Medicare than other countries spent on health care for the entire populations. So anyone who thinks that making more people eligible for Medicare would solve our over-spending problem is delusional.

The over-spenders are us. We go for too many expensive tests that rarely make a difference to our lives. We get surgeries and take drugs for ailments that people used to just live with.

and the most upvoted comment there:

I am a physician. Been one since 1979. The system rewards procedures and is financed by healthcare being delivered in “units” rather than outcomes.

which you will note echoes observations I have made here.

There’s only one little, tiny problem with Arnold’s take. In the United States “we” (meaning patients) are not prescribing our own tests and procedures. That is done by physicians. That’s who creates the demand for healthcare services.

I thought you might find this graph interesting. Yes, costs were much more stable in 2023. That’s not the case now. The factors mentioend in the linked article include higher labor costs and consolidation among hospitals.

This piece from Health Services Research was cited in comments not long ago. I wonder if this passage was understood?

Overall, CMS projects that, under current law, after adjusting for inflation, spending for Part A and Part B services will rise by an average of 4.5% annually between 2023 and 2032, driven entirely by growth in the number of beneficiaries and growth in the volume and intensity of services used.

The emphasis is mine. Do providers potentialize the care provided to Medicare recipients? If my experience is any gauge the answer is undoubtedly “yes”. A factor that needs to be kept in mind is that in the United States at least much of the demand for healthcare is driven by providers. You may call it what you like but I would call it potentialization.

I’ve been having a back-and-forth on another blog about the prospects for a single-payer healthcare system in the United States and I wanted to solicit some opinions here. One of the arguments made for a single-payer system is that having everyone within a single-payer system will reduce costs. My view is that under certain rather stringent circumstances that might be the case:

• Providers accept a pay cut.
• There is enough unused capacity in our healthcare system to provide care of at least present quality to everyone.
• We close our borders, particularly our southern border.
• The will to constrain costs emerges.

but, since those are vanishingly unlikely, I seriously doubt that will happen. My own view is that the reason that healthcare is so expensive in the United States is not because we’re not all covered under the same system but that prices are too darned high and no one has the incentives to cut costs. Getting private insurance out of the picture might help a little but in the absence of real will to control costs it would only be a litte.

Let me explain just one of those. I don’t mention closing the border out of any prejudice against migrants. Will this single-payer system cover everyone in the United States or just some of the people in the United States and what percentage of the people need to be covered by it before the economies kick in?

Consider Illinois. In Illinois something between 5% and 15% of the population consists of illegal immigrants. Will they be covered under this single-payer system? If they are not, everyone in the country will not be covered by a single system. If they are it seems to me that the costs will be significantly higher than has been estimated (and the estimates are high as it is) plus is will add yet another “pull” force to attract illegal immigration.

It’s not just Illinois. California, Oregon, Washington, Colorado, and New York have large populations of illegal migrants as well. That may be part of the explanation for why those states’ Medicaid systems support illegal migrants.

I have a question. Israel is moving troops into Syria from the south. I’ve read some reports that Israel is planning to increase its settlement of the Golan substantially. There are fears that Turkey’s buildup of troops at the border may signal an incursion by Turkey is immanent. There are also some reports that Iraq is considering an incursion into Syria.

Lots of people are speculating about Syria’s future. Does Syria as we have understood it have a future? Today’s Syria is made up of a number of different Ottoman sanjaks and vilayets that have never cohered particularly well. Will Syria disintegrate?

Update

The United Nations reaction:

The UN Special Envoy for Syria concluded talks in Damascus on Wednesday, expressing optimism that the fall of the Assad regime could mark the start of a peaceful and democratic transition for the shattered country, while acknowledging challenges remain.

and

Members of the UN Security Council also highlighted the importance of an inclusive and Syrian-led political process based on resolution 2254 (2015) that is facilitated by the United Nations.

In a press statement issued late on Tuesday, ambassadors reaffirmed their strong commitment to Syria’s sovereignty and territorial integrity while urging all nations to respect these principles.

“They also underlined the need for Syria and its neighbours to mutually refrain from any action or interference that could undermine each other’s security,” the statement noted, emphasising the need to combat terrorism and prevent extremist groups like ISIL/Da’esh from regaining a foothold in the country – where they have been active for years.

Council members also reiterated the obligation to respect human rights, including the right to seek justice, and international humanitarian law in all circumstances.

That strikes me as at best aspirational and at worst fantasizing.

For the last couple of weeks there has been increased interest in reforming the U. S. healthcare system. I think many of the pieces I’ve read have been well-intentioned but miss a key point. This piece by Deane Waldman at RealClearHealth certainly fits that description. Here’s a snippet:

News media are replete with stories about the killing of UnitedHealthcare CEO, Brian Thompson. While the murder mystery elements still dominate, a constant subtext is the perpetrator was angry at greedy insurance companies like UnitedHealthcare and frustrated that care is unaffordable and inaccessible.

With Trump in the White House and with the DOGE (Department of Government Efficiency) advising him how to improve efficiency of federal activities, radical reform may be possible, transforming healthcare to become affordable and accessible. Might there be anyone opposed to such transformation?” The surprising answer is, YES!

Who are these people? There are three reasons why some would resist: self-interest, wrong reform, and fear of change.

I think there’s actually other reasons, even a group of related reasons, that there would be resistance to change in our healthcare system including longterm trends within the practice of medicine. Dr. Waldman is pretty forthright about how he thinks our system should be reformed. I think he’s engaging in wishful thinking and introducing advertising and price competition into healthcare are unlikely to result in the cost savings that are necessary.

I would like to open this post up to a conversation about reforming healthcare and air some of my own prejudices about it. I don’t believe that any conceivable reform will result in more, better healthcare at a price we can afford unless the incentives are changed and any attempt at changing the incentives in healthcare will be fought to the death by all of the stakeholders, e.g. patients, providers, insurers, employers, etc.

Please don’t say “well, other countries pay less for equivalent care so it must be possible”. That’s a cop out. Say what you think should be done and how it can be done. There are a number of things that should be kept in mind. First, there is no country that is actually comparable to the United States. There is no country that is as large as the U. S. and as rich as the U. S. and shares a 1,600 mile land border with a country with a median household income a quarter its own.

You don’t need to just take my word for it. At Defense One R. D. Hooker, Jr. illustrates how the U. S. Army is “top-heavy” and calls for reorganization:

Growth in staff size and the proliferation of unneeded headquarters is accompanied by a strong tendency to “over-officer” the force, one factor in the explosion of personnel costs since 9/11. In 2024, one in six soldiers is a commissioned officer (a 21 percent increase since 2000). About one-third of the Army’s personnel budget goes to officer pay and allowances. Between 1965 and 2018, the number of general and flag officers in the U.S. military as a percentage of the total force increased by 46 percent; of 4-stars by 114 percent; and of 3-stars by 149 percent. Such deliberate rank-inflation and over-staffing contributes to a bureaucratic culture that demands constant reporting from junior commanders, so much so that one authoritative Army War College study found a “suffocating amount of mandatory requirements” they are “literally unable to complete…forcing them to resort to dishonesty evasion.” Almost certainly, this environment contributes to an exodus of young officers who are frustrated by crushing administrative burdens they cannot reconcile with their duty to train their soldiers for war.

In short, the Army should shutter those organizations not deemed essential, reduce the officer-to-enlisted ratio, and streamline its bloated staffs. These measures will increase the number of billets available to operational units, decrease unnecessary reporting requirements on them, reduce personnel costs and increase the productivity and efficiency of those headquarters that remain. Leaner and flatter are watchwords in the private sector—and are clearly priorities for the incoming administration. America’s Army should adopt them as well.

That will have beneficial run-on effects that go far beyond remaining within its authorized end strength. The focus must be unswervingly on readiness and lethality.

In 2013 Rita Crundwell, the city comptroller of Dixon, Illinois, pled guilty to embezzlement in what has been called “the largest municipal fraud in United States history”. She was sentenced to 19 years in prison. As part of his mass pardon, President Joe Biden has commuted her sentence. NBC 5 Chicago reports:

Rita Crundwell, the former Dixon comptroller who stole more than $50 million in what some publications called “the largest municipal fraud in United States history,” had her sentence commuted by President Joe Biden Thursday.

Crundwell was one of nearly 1,500 individuals who had their sentences commuted by the president in one of the largest single-day actions in U.S. history, with the president also issuing more than three dozen pardons.

Crundwell served as Dixon’s comptroller for more than 20 years, and pleaded guilty in 2013 to embezzling more than $50 million from the city over the course of that time. She used the funds to build a massive championship-winning horse breeding and show operation, according to prosecutors.

Pardoning her is certainly clement but I believe it is a miscarriage of justice. She should serve her full sentence and not under home confinement.

Is pardoning her just part of a mass pardon? If so it illustrates the injustices of mass pardons. If not did someone advocate for her pardon? I believe the voters of Illinois deserve to know if their elected officials are advocating the pardon of their corrupt peers.