The Lash of St. Francis Cuts Deep 84 Years Later.

Posted on | August 20, 2023 | Comments Off on The Lash of St. Francis Cuts Deep 84 Years Later.

Mike Magee

On September 25, 1939, Southern California woke with fear of The Lash of St. Francis or El Cordonazo on the horizon. The term refers to northwestern tracking, cyclone-laden storms that can hit the western shores of Mexico and California most commonly around the Feast of Saint Francis, on October 4th. This one made landfall at San Pedro, California.

The calamity that day in Southern California was a rare event, the only one of its kind in the 20th century. The last one to hit, prior to this was in San Diego on October 2,1858. The Earth’s rotation normally assures that such cyclones in this region move from east to west, and out to sea. But the 1939 storm was the exception, and the big problem was the rain, some 5 1/2 inches over a 24 hour period (though the town of Indio, in the Coachella Valley of Southern California‘s Colorado Desert region experienced 7 inches and buried the valley in 4 feet of water. Forty five died on land, and 48 perished at sea. One positive – the storm marked the end of a 1-week heat wave where Los Angeles reached 107 F degrees and claimed 100 lives.

History repeated itself 84 years later this weekend, with a memorable “Lash” on the backend of a summer heat wave. The human, economic and ecological tolls remain to be calculated. But one thing is for certain, global warming has arrived and with it the production of both heat and water, and a new, all too familiar meteorological phenomenon, the “atmospheric river.”

NOAA defines “atmospheric river” this way: “Atmospheric rivers are relatively long, narrow regions in the atmosphere – like rivers in the sky – that transport most of the water vapor outside of the tropics. While atmospheric rivers can vary greatly in size and strength, the average atmospheric river carries an amount of water vapor roughly equivalent to the average flow of water at the mouth of the Mississippi River. Exceptionally strong atmospheric rivers can transport up to 15 times that amount. When the atmospheric rivers make landfall, they often release this water vapor in the form of rain or snow.”

To be clear, these drenching above-ground collections of water are generally a blessing because they provide most of the much needed precipitation to California dry areas and replenish the water cycles in the region. But as the Earth has warmed, they more frequently represent “too much of a good thing”, and are now responsible for 90% of California’s flood damage.

NASA reports that “the increases in water vapor are a consequence of global warming. Higher temperatures increase evaporation of water over land and sea. The warmer area holds on to more water vapor, and slows down condensation and precipitation. The trapped water floating in the sky absorbs even more heat, which in turn attracts even more water vapor – creating a disastrous “positive feedback loop.”

By sucking up water vapor, the phenomenon makes dry regions drier, and by forming and dumping the “rivers”, creates wetter wet regions and tragic flooding. Specifically, here are five predicable repercussions of human behavior induced alterations in global atmospheric health.

1. Heavier Rainfall: For every 1 degree Celsius (1.8 here F) rise in atmospheric temperature, air is able to absorb 7% more water. Since pre-industrial revolution, atmospheric temperature has risen 1.3 degrees Celsius. By the end of this century, if trend lines are uninterrupted, rainfall amounts could increase up to 60% over current levels.

2.  Massive Infrastructure Destruction: Flood damage in the billions is nearly certain as storms become more intense, prolonged, and closer spaced. Atmospheric river events could increase three or four-fold compared to pre-industrial times. Expect an additional $1 billion in flood damage for every 1 degree Celsius rise in temperature.

3. Diminished Snowpack Reserves: Atmospheric rivers are associated with less snowfall in western U.S. mountain ranges. Intense rainfall on existing snow accelerates melting and extreme flooding from rapid water runoff. Termed “rain-on-snow” events, areas at greatest risk are the Canadian Rockies, the Sierra Nevada, and the Colorado River network.

4. Geographic Shifts: Warmer atmospheres show signs of altering the jet stream, pushing it closer to the equator. Experts have predicted that this will result in winter expansion of atmospheric river events in Southern California. Paradoxically, soils are drying out due to increased soil evaporation, less snowpack cover, and erosion from rapid downpours.

5. Loss of Sea Ice: Recent studies reveal that shrinking ice cover in the Artics is not simply a function of warming temperatures. A new contributor is that the atmospheric rivers are increasingly moving north toward the Arctic pole. It is now believed that the resultant water on ice is responsible for at least 1/3 of the loss of winter ice. They do this not only by the melting effect of direct water on ice over 10 days following each downpour , but also by magnifying “downward long wave radiation”

As this most recent weather calamity confirms, human instigated extreme climate driven events are now inescapable in the short term. This storm is currently dumping 3 to 6 inches across the region, with 10 inches in some locations coming close to overwhelming the deep LA water trenches. Equally evident is that our modern (and aging) infrastructure – including roads, spill ways, bridges, dams, building codes, and rescue and safety operations – require a rapid redesign.

Tocqueville Warned of Trump. America Wasn’t Listening.

Posted on | August 14, 2023 | Comments Off on Tocqueville Warned of Trump. America Wasn’t Listening.

Mike Magee

This week, with a fourth indictment come due, a tragic Donald Trump headed back to social media, digging himself into a hole that will eventually lead to some personal hell. But before Donald Trump, there was William Frederick Kohler. 

He made his appearance on the American stage on February 28, 1995, an historian who had just completed his “Great Work” – The Guilt and Innocence of Hitler’s Germany. He was odd and dark and duplicitous. His life’s work was ready to go. All that was left was to write the introduction to his book. Instead his attention was diverted, as he followed his impulse to memorialize his own story dedicated to the “concealment of history beneath my exposition of it.”

Secretive and opaque, he was focused on a very special audience he labeled the “Party of the Disappointed People”, a group with whom he shared the affinity “that the loss has been caused in great part by others.” He hid the pages of the new and very personal (but incomplete) story from wife Marta inside the pages of the near completed Nazi history. And for some reason, he inexplicably headed to his basement and began to dig a tunnel to escape (or uncover) evil.

Kohler, like Trump, was not normal. Those who have analyzed his character describe him this way:  “Preoccupied with evil, the nature of truth, and the effects of an individual’s relationship with others, he recalls his bookish childhood with a mother who drank to remember the ‘good old days’ and a bigoted father; graduate work in prewar Germany, where he hurled a brick on Kristallnacht; his unhappy marriage; and the lost love of his life, Lou, a former student. Kohler’s story exhibits the same inconsistencies and deceits he finds in history: Kohler, the personal memoirist … is as unreliable as Kohler, the eminent historian. A virtuoso performance without a grand finale.”

Kohler is the fictional creation of philosopher and novelist William H. Gass, author of the award winning novel, “The Tunnel.”  The author is described in the opening line of his 2017 New York Times obituary as “a proudly postmodern author who valued form and language more than literary conventions like plot and character.” He died on December 7 of that year, at age 93, in St. Louis, where he had taught philosophy and linguistics for 30 years. Born in Fargo, North Dakota, he was translocated to Warren, Ohio at 6 months, and raised according to his own account by “an abusive, racist father and a passive, alcoholic mother.” These revealing personal details trace back to a writing style he developed and labeled, “metafiction,” or stories in which the author inserts himself.

Of more relevance to America’s current political dilemma is that Gass received his PhD from Cornell in 1954, in return for his dissertation “A Philosophical Investigation of Metaphor.” A metaphor, as we know, is “a figure of speech in which a word or phrase literally denoting one kind of object or idea is used in place of another to suggest a likeness or analogy between them (as in drowning in money).” 

Gass’s love of metaphor is on full display in “The Tunnel”.  You can almost hear the beloved high school advanced placement English teacher pleadingly asking her sleepy students “What do you think the tunnel represents?” Of the novel, one critic wrote, “As the novel progresses we see the lies, half-truths, violent emotions, and relative chaos of Kohler’s life laid bare, and while he continues to dig away at the memories of his past he also begins digging a tunnel out from the basement where he works, a reflection of his tunneling through himself.”

Beyond Gass’s own story line, and that of William Frederick Kohler, one can easily catch glimpses of  Donald Trump.  As he entered the strange world of politics, he embraced the use of metaphor with memorable 3 and 4 world phrases like “drain the swamp”, “the system is rigged,” and “take our country back.”

Andrew Hines, PhD,  a specialist on the history of metaphor theory in the western tradition, traced the use of metaphor back to ancient times, to leaders seeking control of the “body politic.”  Reflecting on Trump’s rise in 2016, he wrote: “In classical rhetoric, Aristotle even went so far as to say that the ability to discern these types of similarities was a sign of genius. As he saw it, a similarity between two things – a workforce and an army, say – can generate a new type of meaning for the listener. It can collapse all the complex problems and ideas together and thereby make them both intelligible and gripping.”

Trump mixes old, worn out “dead” metaphors like “take our country back” with occasional “live” ones. When he hits the mark, he makes news. For example, in a 2016 foreign policy speech, he used the metaphor, “shake the rust off American foreign policy” only to have it within days appropriated as a headline in the Financial Times.

Some have described Trump’s fragmented, sometimes confusing and incoherent style as “metaphorical chaos.” But Georgetown linguistics professor Jennifer Sclafani has suggested it is intentional, commenting that his speeches “may come off as incoherent and unintelligible when we compare it with the organized structure of other candidates’ answers. On the other hand, his conversational style can also help construct an identity for him as authentic, relatable and trustworthy, which are qualities that voters look for in a presidential candidate.”

Dr. Sclafani is the inventor of the term, “idiolect,” which she is careful to remind “is not the language of idiots, but an idiosyncratic form of language that is unique to an individual.” Nonetheless, she believes Trump’s style qualifies and works as authentic and relatable. His supporters, to deploy another metaphor, see him as “a straight shooter.” The problem for him now is complex. He has run out of targets who care what he says, and the hole he has dug has left him increasingly isolated even from those who fear him the most.

In the classic 2010 New Yorker article titled “Tocqueville in America” by literary critic James Wood, the writer picks apart some of Tocqueville’s less flattering observations about the nation he visited as a French aristocratic traveler in 1831. Considering the epic two volume “Democracy in America,” he prophetically lets loose with these words, “In the book’s second volume, he warns that modern democracy may be adept at inventing new forms of tyranny, because radical equality could lead to the materialism of an expanding bourgeoisie and to the selfishness of individualism… In such conditions, we might…meekly allow ourselves to be led in ignorance by a despotic force all the more powerful because it does not resemble one…”

Sadly, his words remind of another influential essayist, Kenneth Burke, whose 1939 masterpiece, The Rhetoric of Hitler’s Battle, is required reading for graduate students from English to Philosophy, and from Political Science to History and Religious Studies. The piece’s main focus involves a critical analysis of Hitler’s Mein Kampf (“my struggle”) which includes this stark warning.

Leaders of the free world need “to discover what kind of ‘medicine’ this medicine-man…concocted, that we may know, with greater accuracy, exactly what to guard against, if we are to forestall the concocting of similar medicine in America.”

Trump too has written his own fictional story; a despotic force with his own signature “idiolect”; as admiring of Nazism as William Kohler and as taken with sticky metaphors as William Gass in search of his own “Party of the Disappointed People.” Loyal indeed, like zombies, his followers and the Republican Party have followed him into the basement, and are heading down a tunnel which has no end. It has been  “a virtuoso performance without a grand finale.”

Why We Need To Hold Bad Lawyers (and Their Law Schools) Accountable.

Posted on | August 7, 2023 | 2 Comments

Mike Magee

In 2002, psychologist Emily Pronin and her co-authors, in an article titled, You Don’t Know Me, But I Know You: The Illusion of Asymmetric Insight, laid out the concept of “Naive Realism.”

As she explained, “We insist that our ‘outsider perspective’ affords us insights about our peers that they are denied by their defensiveness, egocentricity, or other sources of bias. By contrast, we rarely entertain the notion that others are seeing us more clearly and objectively than we see ourselves. (We) talk when we would do well to listen…” Point well taken, but these (most would agree) are trying times.

The problem of our divisions is certainly worse now, two decades later, than when it was first labeled. 2023 headlines speak to “political polarization,” “division,” “factual inaccuracy,” and “loss of civility.”  And yet, we hold tight to the “rightness”of justice under the law, and set out to demonstrate with extreme confidence that our democratic institutions, under assault, have mostly held.

Madison was well aware of extreme labeling of opponents as “unreasonable, biased, or ill-motivated.” He warned on February 8, 1788 in Federalist 51 that “If men were angels, no government would be necessary. If angels were to govern men, neither external nor internal controls on government would be necessary. In forming a government which is to be administered by men over men, the great difficulty lies in this: you must first enable government to control the governed; and in the next place oblige it to control itself.” His solution? Our legal system, and checks and balances.

Hamilton, in the first paragraph of Federalist 1, tees up the same issue, in the form of an unsettling warning. He writes, “It has been frequently remarked that it seems to have been reserved to the people of this country, by their conduct and example, to decide the important question, whether societies of men are really capable or not of establishing good government from reflection and choice, or whether they are forever destined to depend for their political constitutions on accident and force.”

The “force” on January 6 was no accident. Hours before the armed insurrection of Congress that morning, USA Today published  “By the numbers: President Trump’s failed efforts to overturn the election.” The article led with, “Trump and allies filed scores of lawsuits, tried to convince state legislatures to take action, organized protests and held hearings. None of it worked…Out of the 62 lawsuits filed challenging the presidential election (in state and federal courts), 61 have failed…Some cases were dismissed for lack of standing and others based on the merits of the voter fraud allegations. The decisions have came from both Democratic-appointed and Republican-appointed judges – including federal judges appointed by Trump.”

By all accounts, our nation and her citizens, owe our Judicial branch (its judges, lawyers, and legal guideposts) a debt of gratitude. Without hyperbole, now understanding Trump for who and what he is, our Judiciary saved our democracy – for the moment. Literally thousands of lawyers were engaged, heard rational and irrational arguments from multiple sides, considered evidence and facts (or their absence), and decided these cases under urgent conditions on their merits.

Much of the credit goes to attorney Marc Elias (Duke Law School/1993), a voting rights expert, who headed the team that resisted the “Elite Strike Force Legal Team” in the 62 cases above. The six Trump co-conspirators who led the Strike Force were long on credentials and short on ethics and values. They included Rudy Guiliani (NYU/1968), John Eastman (U. Chicago/1995), Sidney Powell (UNC/1978), Jeffrey Clark (Georgetown/1995), Kenneth Chesebro (Harvard/1986), and Boris Epshteyn, alleged #6 (Georgetown/2007.)

As Attorney Elias  reminds us, “In the intervening years since the 2020 election, many of these lawyers have become objects of ridicule, the punchline in jokes. But mocking the lawyers who facilitated Trump’s criminal conduct risks minimizing their culpability. More importantly, it obscures the deep and problematic culture that appears to pervade the ranks of the Republican legal establishment…The indictment makes clear that this was not a conspiracy of sleazy political operatives or even violent insurrectionists. Instead, the indictment reveals that this attack on democracy was effectuated by lawyers using bad faith legal maneuvers and intentional acts…Over and over, the indictment alleges that these lawyers enabled and carried out a criminal conspiracy against democracy in an attempt to ‘disenfranchise millions of voters.’ Trump may have been the ringleader, but he alone could not have filed frivolous lawsuits, enticed fake electors with concocted legal theories or used the law to try to pressure the vice president.”

If “societies of men are really capable… of establishing good government from reflection and choice,” we need a Judiciary steeped in values and the law, people like Marc Elias. As well, we need to hold lawyers who have disgraced their alma maters and dishonored their profession to be brought to justice. The place for that is not the public square where “asymmetric insights” might be questioned or challenged as concocted or biased. Rather, it is in a court of law, with camera and lights aglow, where Guiliani, Eastman, Powell, Clark, Chesebro and Epshteyn (alleged), may be afforded the very rights they worked so diligently to undermine.

In a 2021 discussion of the role of lawyers and law schools in fostering civil public debate, Jennifer Robbennolt and Vikram Omar write, “Lawyers are not immune from these human tendencies. But good lawyers have, and good law schools teach, values, knowledge, and skills that can aid in fostering and modeling more productive debate and resolution of conflict.”

Facts Matter And Truth Doesn’t Hurt.

Posted on | August 2, 2023 | Comments Off on Facts Matter And Truth Doesn’t Hurt.

Mike Magee

If you wanted to create a motto for the summer of 2023 – one that would stand the test of time from the medical exam rooms of Ohio to the gilded bathrooms of Mar-a-lago – it would have to be Jack Smith’s “Facts matter!” If that is true on a national scale, it is equally true in states across the nation where doctors increasingly are coming out from behind self-imposed clinical curtains and going public. 

As reported in ProPublica last week, “Doctors who previously never mixed work with politics are jumping into the abortion debate by lobbying state lawmakers, campaigning, forming political action committees and trying to get reproductive rights protected by state law.”

A few examples:

1. One thousand Ohio doctors signed a full-page ad titled “A Message to our Patients on the loss of Reproductive Rights” in the Columbus Dispatch in response to actions of a state legislature highjacked by radicalized Republicans enacting a 6-week abortion ban post the Dobbs decision. This was after their coalition delivered a protest letter with 700,000 signatures earlier to the State House.

2. Dr. Damla Karsan, a Houston obstetrician, faced off Texas legislators  on July 20th, lending truth to power when she said , “I feel like I’m being handicapped. I’m looking for clarity, a promise that I will not be persecuted for providing care with informed consent from patients that someone interprets is not worthy of the medical exception.”

3. In Nebraska, the doctor-led “Campaign for a Healthy Nebraska” raised $400,000 to hire political consultants to launch a women’s health rights campaign which helped the Nebraska Medical Society “find its inner voice” and openly oppose abortion restrictions in that state.  State Senator Danielle Conrad was impressed. She said, “It’s really just incredible from my vantage point to see how these doctors have been able to not be hobbled by those decades of political baggage, to step forward with this fresh, clear medical perspective and be able to engage more people.”

4. A month earlier, Dr’s Katie McHugh, Gabriel Bosslet, Caroline Rouse and Tracey Wilkinson penned an Op-Ed in STAT in support of their colleague, Dr. Caitland Bernard, who had come to the rescue of a 10 year old Ohio rape victim who had fled to Indiana to gain access to an abortion. Caitlin was shamefully fined $3,000 by the Indiana State Licensing Board. Her colleagues wrote, “While a relatively minor punishment, this finding should send a chill through the medical community and beyond. But that chill shouldn’t be silencing.”

5. In Michigan, a doctor-led group, the Committee to Protect Health Care, teamed up with the ACLU, and successfully passed “Proposal 3, a constitutional amendment to enshrine reproductive rights into the state constitution.” Dr. Rob Davidson declared, “This is a historic victory for reproductive rights in Michigan, and the Committee to Protect Health Care was proud to help get Proposal 3 across the finish line.”

Yesterday’s indictment of  Donald Trump, the citizen, squarely places him and his legislative enablers in Washington and Republican led statehouses across our nation on the wrong side of the truth. As reported, he is accused of “three conspiracies: one to defraud the United States; a second to obstruct an official government proceeding, the certification of the Electoral College vote; and a third to deprive people of a civil right, the right to have their votes counted.” 

But what he and his Republican supporters in Washington and state houses across the nation are primarily guilty of, is not simply lying and deceit, but attempting to destroy our democracy and disenfranchise our voters. That is why prosecution under Civil Rights statutes employed in the past to address the savagery of the KKK, are totally appropriate here. Jack Smith’s “stand tall” leadership is a model for us all, and that includes our doctors and nurses.

As I have repeatedly argued, the health of our democracy is inseparably interwoven with the health of our system of caring for each other. At the helm of this system, our health professionals have survived the hurricane force winds of a pandemic, an inequitable and inefficient health delivery system, and a medical-industrial complex that is more focused on seizing patents than serving patients.

And yet, today we take heart. Our care givers, in growing numbers, are rediscovering their strength and their voices. Like Jack Smith, they are speaking up, in opposition to a small group of bitter and evil leaders, who have earned our active condemnation, and now must face the weight of the law. 

“Draining The Sink” On Drug Pricing Will Be Messy Business.

Posted on | July 26, 2023 | 9 Comments

Mike Magee

Last week’s New York Times headline said it all: “Drugmakers Are ‘Throwing the Kitchen Sink’ to Halt Medicare Price Negotiations.” It called to mind a story our aging legislators might sooner forget from two decades ago.

But how the nation gave away the bank to these corporate characters (which include not only pharma, but insurers, big drug distributors and PBM middle men) is a bit of medical history worth recounting.

The Biden administration is about to announce the first 10 medications that will be subject to price negotiations with Medicare under a new law. Drugmakers are fighting the measure in court. The action is a part of a Biden legislative victory titled the Inflation Reduction Act, which allows the government to to negotiate prices which are projected to save just under $100 billion over the next 10 years and significantly cut seniors expenditures for their prescription drugs. But to succeed, they will have to reverse history.

Let’s begin the story with the 2000 Presidential election of George W. Bush, who had courted major leaders from medicine, pharmaceuticals, hospitals, and insurers and expressed interest in privatizing the management of Medicare and Medicaid, as well as covering pharmaceutical costs for seniors over 65.

That election provided the still loosely organized MIC or “Medical-Industrial Complex” (including industry giant PhRMA, health insurers, hospitals, and the AMA) proof of concept that quietly colluding and cooperating with one another in Washington, DC, while publicly appearing to compete with one another around the country in support of patients’ interests, was a winning strategy.

After Bush’s victory, the number of MIC lobbyists grew exponentially. Pfizer government relations alone funded 82 lobbyists in 2000 to support Republican control of Congress and the White House. A year later the pharmaceutical industry as a whole spent $78 million on lobbying activities and employed 623 different lobbyists.

 In the run-up to the 2002 midterms, the GOP spent just under a billion dollars, ran 1.5 million television ads, and gained eight seats in the House. More important, in achieving a net gain of two seats in the Senate, Republicans now enjoyed a majority of 51 to 49 and controlled both houses of Congress.

 The MIC list of legislative objectives now was focused on Medicare prescription drug coverage and the privatization of government health plans. Funding drug insurance coverage was a high priority since it would expand sales for the pharmaceutical industry, reimburse hospitals for drug costs, and provide new sales opportunities for insurers as legions of seniors purchased partially privatized Medicare Advantage (Part C) plans.There was a growing recognition that health care resources were not unlimited and that, if cost control were to be part of their combined future, the MIC was best positioned to manage and profit from the process.

The MIC had made the calculation that it simply needed more paying customers for its existing products. Insurers would profit from sale of the policies, doctors and hospitals would have fewer “no pay” customers, and drug companies would sell more drugs. But winning the election turned out to be easier than expanding prescription coverage under Medicare.

The Bush administration pushed legislation called the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 intended to put the popular entitlement program on firmer financial footing while expanding prescription coverage. Most of Washington now agreed that reform was necessary to bring the cost of managing seniors with illnesses under control, but the bill’s proponents were hammered from both sides with arguments that private sector incentives had gone either too far or not far enough. By June 2003, budget resolutions in the House and Senate committed $400 billion for Medicare reform.

The battle centered on the Medicare Advantage or Medicare Part C plans that had been created in 1997.These federally subsidized Medicare plans offered seniors who voluntarily chose them, rather than choosing traditional fee-for-service Medicare, additional benefits like health maintenance and wellness offerings and, in varying amounts, prescription coverage. Private insurers had been recruited by the Clinton administration to manage these plans, and shared in any profits derived from management efficiencies. But absent price controls, as costs of hospitalization and drugs rose steeply in the late 1990s, insurers pulled back on extra benefits, especially pharmaceuticals, and the numbers of aging citizens choosing Medicare Part C declined.

Bush’s original plan was to provide his new prescription benefit only to seniors within Medicare who chose his partially privatized Medicare Part C—Medicare Advantage. But when the administration was presented with an outcry of unfairness from both Republicans and Democrats, he backed down and decided that a freestanding drug benefit, dubbed Medicare Part D, should be available as a voluntary choice for those who decided to stay with traditional Medicare as well. 

To protect the interests of his key pharmaceutical and insurance industry supporters, Bush agreed that the plans would be administered through private insurers which, in turn, would negotiate against one another and with the newly empowered intermediary Pharmacy Benefit Management (PBM) companies like Merck’s Medco and CVS Caremark over pricing.

Insurers would be allowed to use various formularies that generally grouped drugs into two or three categories or tiers, with the best prices for consumers restricted to cost-effective drugs in column one, and higher-price options dropping into column two or three and costing consumers considerably more. Protecting the industry’s need for choice and coverage of me-too “copy-cat” drugs, the legislation also required that each category of drug have at least two options available. With this scheme, Bush committed to no direct government negotiation on Medicare drug purchases. In addition, he declared importation of Canadian low-cost drugs illegal. 

To further sweeten the deal for pharmaceutical companies, Bush agreed to a rule that would force 6.5 million “dual eligible” individuals (those then covered by both Medicaid and Medicare as a result of disability or extreme poverty) into Medicare drug coverage. This group was currently receiving its drugs through state Medicaid programs which enforced “lowest cost” provisions. In transferring dual eligibles to the Medicare Part D plans, where drug costs had no government controls, Bush assured the pharmaceutical companies of an additional markup of 25 percent on drug revenues from these patients. 

The American Medical Association (AMA), was an early supporter. Its’ members generally believed in expanding coverage for their patients, but their primary concern was the long-standing anxiety that any changes would be a foot in the door for socialized medicine. Once Bush established that there would be no direct government negotiation with drug companies, others lined up as well, including the American Association of Health Plans, the American Hospital Association, and the Business Roundtable. 

The health insurance industry saw the legislation as a source of new revenue, and as a solution to the deteriorating Managed Medicare (Medicare Part C) situation. By establishing another source of federal dollars to cover their pharmaceutical cost, industry sponsors of Managed Medicare (Medicare Part C) plans could once again offer a range of extra benefits that would entice seniors into these lucrative options and away from less profitable traditional Medicare. If the MIC coalition held, Medicare Part D and its new drug benefits could reinforce Managed Medicare and ensure a brighter future for all.

The media was not giving a pass to this complex sweetheart deal in which the MIC was paid in full and patients were saddled with partial coverage and ever more billing complexity. E. J. Dionne, in a Washington Post story titled “Medicare Monstrosity,” wrote, “How do you know this bill is such a great deal for the drug companies and HMOs? On word of an agreement last week, share prices soared.” 

Bush’s advisers had cautioned that the Iraq invasion that spring would distract Congress from focusing on the bill, and yet the Senate Finance Committee produced a “bipartisan agreement” in June. Seven days later, the two-page outline had taken on flesh, thanks to some heavy lifting by MIC lobbyists, and from there it emerged as a rather complete 90-page tome, which passed out of committee on June 13.

AARP remained the big unknown. Having sealed a profit-sharing deal with the fastest-growing national health insurer, UnitedHealthcare, to provide its members with supplemental health insurance, AARP was now more than ever heavily invested in the commercial side of the Medical Industrial Complex and positioned to be a major beneficiary of Medicare Advantage Part C and Part D plans that carried the new pharmaceutical subsidies.

Even so, it surprised the Democratic leadership to discover on the morning of November 17, 2003, that AARP had committed $7 million to a public campaign in support of the Bush bill. “The endorsement provides a seal of approval from an organization with 35 million members,” one analyst noted. “Republicans also hope it provides political cover against charges by some Democrats that the bill would undermine the federal insurance program for the elderly and disabled.” 

Five days after the AARP announcement, at 3 a.m. on a Saturday, after a full day of arm-twisting and dealing, the House bill was allowed to come up for a vote. After 15 minutes, Bush’s supporters were 15 votes behind, and the bill was held open. After further concessions to individual holdouts, it was still two votes short at 216–218. With everything at stake, HHS secretary Tommy Thompson was sent to lobby on the House floor, an action seldom taken.

President Bush himself, just back from a visit with the queen of England, was awakened at 4 a.m. to lobby the few remaining undecideds. The “longest roll call vote in history,” lasting just under three hours, came in at 220–215 in favor. Three days later, after some political maneuvering, the bill passed in the Senate. 

On December 8, 2003, with great fanfare, President Bush signed the Medicare Modernization Act in a heavily staged event. Declaring the legislation “a victory for America’s seniors,” he went on to say, “I’m pleased that all of you are here to witness the greatest advance in health care coverage for America’s seniors since the founding of Medicare.” With no evidence of irony, and no acknowledgment that within living memory the Republican Party had called Medicare a threat to the American way of life, he added, “And today, by reforming and modernizing this vital pro- gram, we are honoring the commitments of Medicare to all our seniors.” 

With the help of Big Pharma and Big Business generally, Bush comfortably won reelection over John Kerry. The AARP and its partner, UnitedHealthcare, secured a hefty chunk of the expanding Managed Medicare (Medicare Part C) and Medicare Part D business, and the pharmaceutical industry indulged privately in a self-congratulatory celebration. 

But now two full decades after these events, the most lasting impact of the deliberations that led up to the Medicare Modernization Act was the conversion of the MIC from a loose network of major sectors with casual connections to health delivery, and a penchant for joining forces only when its own status quo was threatened, into a complex syndicate committed to self-control and distributing the profits secretly among its members in the form of opaque negotiated rebates, invisible to the consumer, at the point of sale. 

In the center of the food chain were the MIC’s newest creations, the Pharmacy Benefit Managers, or PBMs, designed as vehicles to organize the movement of data, drugs, and money throughout the MIC supply chain. Now two decades later, as the headline above suggests, they are more than up to the task of “‘Throwing the Kitchen Sink’ to Halt Medicare Price Negotiations.” 

When It Comes To Water, Weather Matters.

Posted on | July 16, 2023 | Comments Off on When It Comes To Water, Weather Matters.

Mike Magee

We forget that the water cycle and the life cycle are one.
— Jacques Cousteau

When the Simon Pearce restaurant and glass blowing studio flooded on the banks of the Quiche Dam in Vermont during Tropical Storm Irene in 2011, it was supposed to be the result of a once in a century event. But this past week, it happened again. Welcome to New England 2023 – and multiple locations around the globe – where atmospheric rivers, and massive epic cloudbursts, have revealed not simply the effects of human induced global warming, but historic underinvestments in water infrastructure and Integrated Water Resource Management (IWRM).

Global management of water resources was first discussed at a global water summit organized by the UN in Mar del Plata, Argentina, in 1977. By 1992, water was a central theme at the World Summit of Sustainability Development in Rio. By 2009, all nations agreed on a definition for Integrated Water Resource Management (IWRM): “IWRM is a process which promotes the co-ordinated development and management of water, land and related resources, in order to maximize the resultant economic and social welfare in an equitable manner without compromising the sustainability of vital ecosystems.”

The hydrological cycle itself, throughout human history, has been dynamic.  It is now generally accepted that the assessments of the Intergovernmental Panel on Climate Change have accurately identified that global temperatures will rise 1.5 C above pre-industrial levels by 2030 largely as a result of the emission of greenhouse gases especially carbon dioxide (CO₂). In response, ocean levels are rising, more energy exists in the climate system, and the global hydrological cycle is intensifying.  How will this be expressed?  We have already seen changes in amount and intensity of precipitation, in seasonal distribution, and in frequency.  These events in turn will lead to changes in magnitude and timing of water runoff, intensity of floods and droughts, regional water supply levels, levels of surface and ground water.  In short, “terrestrial components of the hydrological cycle amplify climate input.”  Translation, when it comes to water, weather matters.

Precipitation across the globe is highly variable from highs of 2400 millimeters per year in the tropics to lows of 200 millimeters or less in the subtropics. Soil is a significant reservoir for water.  Amounts are not only driven by the rates of precipitation and evaporation, but also by soil type and depth, vegetation, topography, and seasonality. The top two meters contain the majority of the moisture.  Significant water also collects in subterranean spaces.  Groundwater is the predominant strategic reservoir on Earth, some 30% of the global fresh water total and 98% of the drinkable and potential accessible supply. Critical to human development and in the past 50 years, with advances in drilling and pump technology, groundwater has rapidly become the worlds “most extracted raw material”. And compared to surface water, there is very little loss to direct evaporation.

The challenge remains how best to scientifically manage this raw material to assure long term, sustained development.  This requires a better understanding of how the ground water systems function, their recharge processes and their relationships to surface water bodies.  It also means managing and protecting the purity and integrity of the resource, a knowledge of the geology, better monitoring of groundwater levels, and real-time data of depth, flows, and extraction levels. 

As water seeps into groundwater aquifers it also seeps out through watercourses, wetlands and coastal zones.  Recharge rates are highly variable and affected by changes in surface vegetation, surface water diversion, changing water table levels, and climate cycles.  Sustainability issues include inefficient use, social inequity, unsustainable extraction, icy weather reductions, aquifer damage, land compaction, and ecosystem damage.  All of the above are under human control.  Aquifers are far more resistant to contamination than are surface water bodies.  But once contaminated, aquifer damage is difficult to reverse.

As with most enlightened policy, good planning and prevention pays off.  Sound system design, proper land use rights, ongoing investment in technology, stakeholder participation, and careful monitoring, design and operation are critical.  But what’s unique about water is that water flows.  And in flowing, it crosses multiple jurisdictional borders.  So proper management and planning require intergovernmental cooperation. 

The human touch has left its mark.  From industrial heavy metals to acid rain, from leaking storage tanks, accidental spillage, and domestic sewage, to municipal waste and agro-industrial effluent, people and water definitely do mix.  Besides affecting the quality of drinking water, secondary impacts have become common.  For example, the discharge of organic material, high in nitrogen and phosphorous, into surface water fosters abnormal and explosive plant growth depleting oxygen and affecting the entire ecosystem and the life forms it supports.  Twentieth century ecosystem degradation has resulted in the loss of 2/3rds of our wetlands profoundly impacting fresh water species.

 Water on the move cannot be separated from solid and particulate sediment. Much exists as suspended matter, actively in motion.  In fact, more than 50 billion tons of suspended sediment are carried by river waters to the oceans each year.  What lands in surface water and ground water bodies is increasingly a function of human action and planning.  For example, creation of solid surfaces (contributing for example to the 500-year flood in Houston, TX in 2017) increases volume and rate of runoff, downstream flooding, and human chemical deposits into surface water.  Over-mining of ground water impacts water levels and the capacity to live off the land in stressed locations around the world.  High surface runoff carries with it expanded sewage runoff in urban environments.  Poor liquid waste disposal and hazardous chemical spills travel rapidly above the ground and easily penetrate below the ground in many locations.  And as these collective actions impact lakes, rivers and streams, habitats and species diversity declines.

There is then a natural, interconnected, and crucial water cycle upon which all life on earth depends.  Humans have always required a dependable water supply to survive and thrive.  As we have grown in numbers and in concentration; as we have built and infiltrated among, and at times, in opposition to other life forms, we have created future health challenges that must now be addressed.  Global warming is an accelerant. The time for each of us to better understand the nature of water, and its relations to weather, ecosystems, agriculture, industry, urban planning, sanitary systems, and value of Integrated Water Resource Management (IWRM) is long overdue.

 

Is Health Tech’s Magic Wand Anti-Social?

Posted on | July 11, 2023 | Comments Off on Is Health Tech’s Magic Wand Anti-Social?

Mike Magee

In George Packer’s classic 2013 New Yorker article titled “Change the World: Silicon Valley transfers its slogans – and its money – to the realm of politics,” there is a passage worth a careful reread now a decade latter.

Packer shares an encounter with a 20-something techie critiquing his young colleagues who said, “Many see their social responsibility fulfilled by their businesses, not by social or political action. It’s remarkably convenient that they can achieve all their goals just by doing their start-up. They actually think that Facebook is going to be the panacea for many of the world’s problems. It isn’t cynicism—it’s arrogance and ignorance.”

Packer’s assessment at the time was “When financiers say that they’re doing God’s work by providing cheap credit, and oilmen claim to be patriots who are making the country energy-independent, no one takes them too seriously—it’s a given that their motivation is profit. But when technology entrepreneurs describe their lofty goals there’s no smirk or wink.”

Or, as others might say, “They believe their own bull shit.” Where many of us are currently focused on issues of values, fairness and justice, those in the shadows of Silicon Valley see the challenge to be inefficiency and incompetence, and the solution amenable to technologic engineering.

Back in 2013, a Belarusian immigrant student at Stanford named Evgeny Morozov coined the term “solutionism” for those with unshakeable confidence in hi-tech solutions.  A decade latter, Evgeny is now Visiting Scholar in Liberation Technology at Stanford, and a colleague of Larry Diamond (director of Stanford’s Center on Democracy) who coined the term, “liberation technology.” 

Stanford describes their focus this way: “The Internet, mobile phones, and other forms of ‘liberation technology’ enable citizens to express opinions, mobilize protests, and expand the horizons of freedom. Autocratic governments are also learning to master these technologies, however. Ultimately, the contest between democrats and autocrats will depend not just on technology, but on political organization and strategy.”

Evgeny naturally bridges this world of individual entrepreneurship and public policy.  His current focus is on AGI (artificial general intelligence) and its interface with his original concept of neo-liberal “solutionism.” He believes we have all been sold a bill of goods that technology is inevitable and beneficial, and that it will expand our intelligence and fix our inhumanity.

Evgeny says that it is already clear that the rise of entrepreneurial capitalism and destructive profiteering (let alone massive income inequality and segregation of tech gazillionaires) is altering representative democracy and replacing it with libertarians on steroids.

It is useful to remind ourselves that we’ve been down this road before. For example, it was none other than Margaret Thatcher who said, “There is no such thing as society.” How has that worked out in the post-Brexit period for the UK? 

Were she alive today, she would likely agree with AGI fans that private beats public, efficiency solves social troubles, and adjusting to change is a great deal quicker and easier that addressing core weaknesses in human or societal behavior.

Health tech’s recent “boom and bust” cycle laid truth to the lie that “really smart people” versus venture capitalist corporations are driving the information technology revolution. In the vast majority of cases, in health care and beyond, the “charm offensive of heavily subsidized services” is followed by “ugly retrenchment, with overdependent users and agencies shouldering the costs…”

In 2021, Health Tech managed to break all the records. The digital health market gained 43% more investors than in 2020, with $30.7 billion – a 107% rise – in venture capital. By 2022, the 85 corporations devoted to the field had collective valuations that had tripled to $73 million. 

Were these ideas category-defining? Were they sustainable? Were the investors a source of expertise or wise guidance? Were any of these products driving impactful change that would equitably change the life trajectory of the humans served? Did they lessen the populations fear and anxiety? Did they expand hopefulness and community engagement. Did they make America and Americans healthy?

Not according to Evgeny. He says, “The open agenda is, in many ways, the opposite of equality and justice. They think anything that helps you to bypass institutions is, by default, empowering or liberating. You might not be able to pay for health care or your insurance, but if you have an app on your phone that alerts you to the fact that you need to exercise more, or you aren’t eating healthily enough, they think they are solving the problem.”

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