A Few Thoughts on a Single Payer Healthcare System

Remember when the Patient Protection and Affordable Care Act (PP ACA, also known as Obamacare) was to serve as the pathway to a single-payer healthcare system as exampled in Great Britain and a number of other European countries?  At the time the supporters were quick to point out how low the cost of health care was for the average person and even the poorest would receive quality healthcare.  The opponents of the law saw it as government overreach and said that it would implement “death panels” where the state would choose who would live and who would die.  Of course, this idea was dismissed by those who supported central control as just outlandish foolishness.  Which brings us to today’s news.

First, there was Charlie Gard an 11-month who suffered from a rare and fatal condition, and the doctors of the National Health Service told to parents to just let him die as continued treatment was not going to be supported.  When they challenged this, it became apparent the NHS viewed young Gard as a ward of the state and the parents had no real say in the decision.

Now we have the second example before us, again the NHS is telling the parents of Alfie Evans they won’t offer additional treatment for what is likely a terminal illness.  They took him off oxygen and when he continued to breathe they stopped feeding him.  To further their position they won’t let the parents take him elsewhere where other doctors are willing to treat him.  Even the Pope has weighed in on the subject.

You can say what you want about capitalism versus socialism, private insurance versus government insurance, private healthcare versus public healthcare and all the other economic comparisons but at the end of the day it comes down to someone determining a cost versus benefit.  The question in health care is who should that be?

Clearly, for the British National Health Service (as supported by the courts) it is their position the nameless and faceless bureaucracy of the state is where that decision rests, it is after all the state that is paying for the care.  The rights of the parent are subject to state approval and control.  But is the system equal for all?  If the parents were the Winsor’s would the decision of the state be the same?  While I doubt it, I don’t know for sure, but I can’t imagine a bureaucrat being called before the Queen to explain his/her decision.

In our system, as flawed as it is, where does the decision lie?  The answer to that, of course, depends on financial status and the compassion of the various providers, both financially and medically.  There are children’s hospitals where there is sufficient financial support that the families in their care are not, as far as I know, asked to make the tough choice of what is affordable and can decide with their doctors on what is best for the child.

If we do eventually move to a “single-payer” system managed by a government bureaucracy the decision of life or death versus cost will become a part of the equation.  It is inescapable when faced with a fiscal reality of budget limits.  We see it in the VA today, and it is simply foolish to think it would not be there on a larger scale in a larger system.

For those who support the single-payer system be prepared to transfer your decisions on life and death to the state based on a simple algorithm of how much your life is worth to the state, versus how much will it cost to maintain it.

Betwixt and Between

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As of right now, I see Senators Chuck Schumer (D-NY) and Elizabeth Warren (D-MA) known best for their distain of the federalist concept, are now embracing the rights of the several states to govern themselves, at least when it comes to the legality of recreational drugs.

Lest anyone think these are long-held beliefs, let’s talk about their past positions.  Both are longtime advocates for a larger, more powerful federal government with increased regulatory authority to force upon the states its control and power.  At least until President Trump and the Republicans came into power.

Both believe the federal government, and not the states, must mandate the elimination of semi-automatic rifles that look like military rifles, and that there must be a national database of gun owners so that it can at some point reach out to take the guns should it determine it wants to.

Both support the federal government’s involvement in determining the rights of the states to set policies in education, housing, employment, banking, and voting.

In fact, with the creation of the Consumer Financial Protection Bureau, Ms. Warren advocated for the creation of regulatory agencies that even the Congress couldn’t control.   So, I find it interesting that all the sudden there is a cry for the states to have the power to regulate Marijuana growth and distribution as if it would not be governed by the same statutes that control the interstate commerce of other products.

As with most issues the DNC now champions it seems pretty clear this new-found faith in the States is based on a perception that legalizing Marijuana will result in new support for the upcoming election.  I wonder, is there a secret poll that suggests stoners will turn out in force to support the DNC?  As newly minted pseudo-federalists will they demand the voting locations have to offer snacks to entice voter turnout?

You Know, I Thought We Were Better Than That.

“I thought we were better than that,” has become one just another tired cliché.  I’ve pointed this out here, but this week while I was traveling another instance of our base ugliness made the news.  I am saddened that so many who view themselves as superior to so many others actually find ways to prove they are not.

On April 17^th Barbara Bush, wife of George H.W. Bush, passed quietly away after an illness.  By all measures, she was a fine woman, wife, mother, and First Lady.  She represented the strength and dignity of those who’ve become known as America’s Greatest Generation.  Before it became fashionable to recognize HIV/AIDS she used her position to bring a humanity to the plight of those infected.  As First Lady, she pushed hard to encourage America to read and be literate.  She was originally from Rye NY and will be buried today in College Station Texas.

Almost immediately after her death was announced, Professor Randa Jarrar, California State University, Fresno, felt compelled to take to Twitter to call Mrs. Bush and the Bush family all racists who deserved to die. She upped the ante when she pointed out she was a tenured professor who couldn’t be fired.  Completing the trifecta of petty, ugly, behavior she gave out the phone number of a suicide hotline for Arizona State University and told people upset with her to feel free to call her and debate the claim, thus closing the line to people who might actually seek counseling before attempting to kill themselves.

She was not the only person who felt compelled to show their ass but is the one I am most aware of.

Hopefully, her university and she will come to find there are consequences to their actions, but I am not holding my breath since so many believe being ugly to one another is somehow protected by the First Amendment and her supporters will claim any critic of her action must be a racist or (xxxxxx)phobe of some kind. 

Arbitrary and Capricious

Today I saw the U.S. Supreme Court upheld the 9^th Circuit Court's ruling in the case of Sessions, Attorney General v Dimaya that section 16 of the 18 U.S. codes was unconstitutionally vague. 

The issue stems from the government’s position that any immigrant, no matter his or her legal status is subject to deportation if convicted of a crime that falls under the definition of “a crime of violence.”  There are a number of statutes in question, including the Immigration and Naturalization Act and Armed Career Criminal Act.  The defendant challenged the law, and his deportation under the protections of the Fifth Amendment’s Due Process Clause.   The Ninth Circuit sided with the defendant, and the AG engaged to challenge the courts finding at the Supreme Court.

What makes this so interesting to me is that Neil Gorsuch joined the majority in siding with the defendant.  The court’s opinion was written by Justice Kagan and Justice Gorsuch concurred in part and with the judgment of the court.  His opening statement is what rings most important to me.

“Vague laws invite arbitrary power.”

It is good to see the Democratic politician’s hyperbole surrounding his confirmation not bear out.  I believe the role of the Supreme Court is to protect the citizen from the overreach of government.  Justice Gorsuch remains consistent with what he said during his confirmation.  He believes it is his duty to interpret the law as the founders would have us understand it, but if the law is unjust and it affects the citizen his first duty is to protect the citizen.

There will be those who condemn him for this decision, but most of that will be along the political boundaries we have divided ourselves into.

How To Make The World Safer

Think of all the things we could do to make the world safe.  Done?  Good.

Now ask yourself, what single thing makes the world safest for the most species and inhabitants?

Once you’ve got that answer, ask yourself -- of the 7+billion people on earth how many agree with your opinion and will go along with your idea.  Is your answer greater than 5 billion?  If so you have a great idea. Now you can proceed to the final step.

Get onto social media so the entire world can fall into lockstep with your plan.  You don’t need a lot of details, just a good meme.  Make sure you use a lot of profanity and vilification of the people who may disagree.  Perhaps suggest they are deranged or just plain crazy.  Finally, recommend they be locked up, isolated, or just “eliminated,” so the world can be safe. 

That is how you make the world a safer place.

The Road Not Taken

All things are possible.  Jesus looked at them and said, “With man this is impossible, but with God all things are possible.” (Matthew 19:26)

“Now I am become death, the destroyer of worlds.” (a quote made famous by Robert Oppenheimer originally from the 1944 Prabhavanada and Isherwood Translation of the Bhagavad Gita[1])

As we look toward the future there are always two options.  We can look forward to a better future with optimism, or we can see the deep, depressing gloom of a world lost.  The question each of us must answer individually is which path shall I take?

It is so easy in today’s world to choose the darker path because those who feed the information stream scream out all the ills of the world.  There are a variety of motivations for this, profit, fame, pettiness, or just selfish pleasure, but in the end, it all contributes to pushing us towards the negative.

For me, Robert Frost’s poem “The Road Not Taken” serves as a guide to follow my own heart and not be persuaded by the shouts of those who find pleasure in their own voices.

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[1] http://knowyourmeme.com/memes/now-i-am-become-death-the-destroyer-of-worlds

A View on Leadership in the Air Force (conclusion)

In my previous post I talked briefly about the fact the military is not like a commercial enterprise and often the tools the civilian leaders attempt to impose on the force cause more disruption than increased efficiency.  Then I dealt with what I view as flaws in the leadership development scheme.  They were “Change is Good,” “A Rigged System,” and “First Command.”  In this post I intend to discuss the more serious flaws I believe lead to disillusionment and lowering moral.  They are “Building an Unsustainable Force,” “Social Justice is a Core Mission,” “A Lack of Personal Accountability,” and “Performance Reviews are Smoke.”

We have built an unstainable force and are unwilling to admit it.  Obviously, we operate within a defined and regulated budget and the amount of money available to pay for everything all the politicians in Congress, The President, and the SECDEF would like is finite.  The office of the SECDEF sets guidelines the AF leadership must comply with to stay within its budget.  It also projects the costs into the out-years so it can plan for the force and force modernization.  As the Air Force looks to modernize to 5^th Generation Fighters they sought ways to pare the single largest cost in the Air Force, its manpower bills.  Based on the choices available we drew the force down to a little over 320,000 as an end strength.  That number is climbing slightly but the force today is far below what it was when we had a cold war.  Today we have a warmish hot war and the force is asked to do far more than what it had ever been built to do prior to 9/11.  In 1960, when the threat of nuclear war was the principal challenge the USAF faced had 813,474 personnel to meet its global commitments.  As the Vietnam war grew so did the AF, reaching a peak strength of 905,314 in 1967.  During President Reagan’s years, the force stood around 600,000, or just a little less than twice its current strength.  Back then we were a garrison force where most people spent most of their time training with short TDYs and an expectation they would be home within a week or two of leaving.  The longer rotations of 90 days were usually at locations that offered some social time off.  Even with the longer deployments, the stress of the force was manageable and an individual could expect a high demand assignment followed by a relatively stable one.

After Desert Storm, we began moving from a garrison force to a rotational force as we closed base after base to reduce cost.  This has created a situation where significant numbers of personnel are pushed forward for 3, 4 or 6-month deployments at something that hovers around a 1 to 4 ratio.  Following 9/11 that ratio when down to about 1 to 2.5 and for those forces in demand the ratio often approaches a 1 to 1. While we have been doing this -- new demands continuously flow down, requiring short notice response and a total force commitment where Guard and Reserve forces now carry a much greater percentage of the load then they were ever envisioned.  Meanwhile, we close bases, retire aircraft, and further reduce the force until the only people left to deploy are those who are not up for a new assignment or school slot.  The toll on the humans in this cycle are measurable in terms of divorce, PTSD and other mental issues.  Suicides are up, DUI is up, and separations are up for those who see no light at the end of the tunnel.

Those who’ve been recognized for their high potential don’t seem to be subject to the same rotational demands as their peers for they are serving as executive officers, on a command staff, in professional development, or serving at the higher echelons of a joint force to get the credits necessary for flag rank.  The result is obvious.  To use a farming analogy, we are eating the seed corn of tomorrows crop of leaders and commanders.  Those positions will still exist, but the quality of the officers and senior NCO’s that will fill them will be less than it was. 

We have reduced our ability to fill the pipeline as we reduce training capacity in UPT and UCSO (UNT for old folks like me).  Of course, we did this for sound economic reasons, but when individuals in the prime of their capability abandon their career the inexperienced airman needed to replace them just don’t exist.  We see this especially in the UAV/RPA pipeline where again to save costs we are now beginning to qualify NCOs as “pilots.”

We will never say “we must do more with less,” because of past experiences but isn’t that exactly what we ask of your airman?

Social Justice has become a core task or mission.  When I entered the Air Force we were in the middle of the social unrest caused by the Vietnam war, but there was a more fundamental issue, and that was discrimination of the black minorities.  President Truman, over the objections of his senior military commanders, had integrated the armed forces in 1948, but still subtle and not-so-subtle discrimination existed in 1974 when I became a Lieutenant.  The CSAF mandated equality training for all personnel and we did this until the service grew tired and declared success in racial equality.

President Obama did the same thing as President Truman for the LGBT community, and now the service is in the process of training its force that LGBT personnel must be treated fairly and equally.  Personally, I think President Obama’s choice was better than the direction of President Clinton which was “don’t ask, don’t tell,” but there are some significant morality and social issues that come with mandating individual support and implied approval of sexual orientation that does not arise when we mandate people not be discriminated against because of their race.

As we see in the civilian culture we come from there is an increasingly militant approach to demanding that society view itself in accordance with the most vocal voices of a pretty small minority.  The service draws from society and those same forces are at work.  The senior leadership, just like in Truman’s years, have one view of the world and the younger airman another.  We see in President Trump an attempt to return to a policy that would bring us back to an earlier time.  In my opinion that is a foolish choice that will only compound the unrest and delay what must be the ultimate goal of integration into a cohesive fighting force.

Whatever your view on the current social justice diatribes, the services inability to provide a consistent policy where all are treated equally is demoralizing the force.  Today we have some who demand equality, and others who view the minorities as receiving an unfair advantage.  Both positions seem to be relatively small, but both are vocal enough to detract from the unit cohesion necessary in a fighting force.

Let’s discuss accountability.  The one thing a bureaucracy does really well is to provide a shield or buffer for accountability.  For example:

Customer service rep: We can’t approve your form 123.

Customer: Why?

Rep:  Well it’s our policy not to approve this form.

Customer:  What should I do to get this approved?

Rep:  You need to submit another form asking for approval of this form

Customer:  Is there someone I can talk to?

Rep:  No, you have to submit form 123 to talk to someone.

By most standards the Air Force is a pretty good bureaucracy to work for, its Commanders and Senior Leaders are frequently voicing their support for some magical thing called “empowerment” where a conversation like I illustrated above won’t happen.  But on the other hand, we have all developed a “cooperate and graduate” kind of mentality where failure, except in the most extreme or most public situations is kind of pushed aside, so careers are not adversely affected by those mistakes.

For example, how many flying squadron commanders have been relieved of command by their commanders, but still make O-6 because they’ve filled all the squares and the relieving authority didn’t want to hurt a good officer they just didn’t trust to lead anyone.  What message does this convey to the subordinates?

Then, of course, there are those who go from bungling one job after another and their commanders pass them off as quickly as possible so they don’t have to deal with them.  At the end of the day their career experiences are really broad and look good on paper and all the sudden they are promoted to senior ranks and seemingly no one knows why.

Don’t get me wrong, I’m not advocating we return to the days of flogging or making the guilty sit in the town square in stocks but having someone swinging from the yardarm occasionally might be okay.  (This is humor, and I point it out just in case some are unfamiliar with the concept.)

There is a business management consultant named Peter Drucker.  He is best known for his theory that business can never be really efficient because people are promoted at least one level above their competence.  This is known as the “Peter Principle.”  My experience in the Air Force suggested long ago we will generally promote at least two pay grades above competence based on the masking of competence in the promotion recommendation files.   Which brings me to my last flaw.

The Promotion System is Smoke and Mirrors.  We have reached a point in the evaluation process where secret words and phrases are more important than actually telling individuals how they perform in comparison to their peers.  For rated officers, how well you do your primary job is hardly ever a data point, unless you happen to earn a DFC or MOH and then it will be noted in your records that you did well.

The people who do the evaluations may or may not be taught how to evaluate people or what the secret words are, and if they don’t know the secret words - every one of the people they rate will suffer the consequence.  Of course, there are good leaders who will sit down with the people they lead and who will provide honest and candid feedback on how the individual is doing and areas they can improve on.  In attempting to formalize this feedback system into a mandated requirement complete with specific form the bureaucracy condemns the majority to a perfunctory interview with the rater where he/she is usually working to complete his/her task as quickly as possible since they have multiple people to advise/counsel.

There is a management technique referred to a “Management by Walking Around.”  Personally, I find this the best and most effective way to provide both the leader with a clear understanding of those who are working and those who aren’t as well as providing quality performance feedback to the organization.  The most important aspect of this is a rather common-sense rule that seems to be lost in today’s world.  The boss should not condemn or belittle the staff in public, but if a criticism is necessary it should be done on a one and one basis in private.

Then we come to the idea of feedback for the Commander.  In the traditional sense of organizational behavior feedback traditionally flows down, not up.  The bosses boss ultimately determines if they are doing a good job or not, but over the past twenty years, the Air Force has become (in theory at least) an organization concerned for the welfare of its entire force.  Routinely they conduct anonymous climate surveys to give the Wings and MAJCOMs feedback on how the minions are doing.  This is a nice tool, but I don’t think it provides the direct feedback that forces the Commanders to reassess their personal style or techniques.  As I said bureaucracies are good at maintaining a lack of accountability.

I wonder what would happen if, when it came time for a commander’s performance report to be written there was a required entry on organizational feedback where the subordinates got to rate the officer on three-point scale (Definitely Promote, Promote, Do Not Promote) and the statistical average was placed next to the recommendation of the Senior Rater.  What would the promotion boards look like if they had to consider evaluations from subordinates as well as the senior commanders?

Once, when I was speaking to a boss about how as we are paring down reports to the minimum possible explanation of impact and capability I wondered how the board would know who should really be considered for readiness for promotion.  Without thinking, he made a candid statement he realized immediately was a mistake.  He said, “Don’t worry the board members know who should be promoted.” He then went on to say, “What I mean to say is an entire record is considered.”  

If we could be completely candid perhaps we would change the reports to reflect some of the dry humor the British are so famous for.  Consider these for reference.

https://www.strategypage.com/humor/articles/british.asp

Well, that’s about it for me.  I don’t have any answers to fix the problems, so perhaps I shouldn’t bother noting them, but I needed something to think and write about so this was as good as anything.

For those who are currently in mid-career, good luck.  Look for those choices you control and never believe you are a victim.  Remember, you control your life and your career, even when it’s not going as you envisioned.  Look for the good in your choices and keep moving forward.  Best wishes from an old Nav.