SOLVE SCHOOL SHOOTINGS?
                   MORE THAN MEETS THE EYE

Even if I were thirty years younger with great charisma and unlimited funds, I could not be elected president, nor any other significant office. You see, I’m neither conservative nor liberal. I’m not even centrist. I hate political parties and their platforms. If I were asked what I would do if I won the office, I would have to answer, “I don’t know.”

I do know this much. I would take the country’s problems one by one, locate people from all over the spectrum, and study the problem. I’d seek to establish the known facts, as opposed to theory. Then, with the help of the study committee, I would list all the possible options. Finally, I would narrow them down and choose which ones to implement FIRST to see what happens. The choice could be a mixture of things that could be easily done and actions that give the best chance of solving the problem. Then, we’d evaluate the results, not defending nor attacking them. Are they working or not? If not, we’ll modify them or change them completely.

>I fully recognize I’d need to get Congress on board with this. That’s part of determining what can be done and easily done.

There’s no underlying philosophy about big or small government. We would constantly ask, however, whether the states or cities could do this more effectively.

Even more important, we would never assume only one thing caused something, nor that only one thing can fix it. Most of the major problems that worry us, like gun control and school shootings will not be solved by simple answers, nor even two or three. In the time since I first wrote the two drafts of this blog, I read last week that Charles Williams who shot people from the tower on the University of Texas campus back in the 60's had a tumor with pressure on the amygdala region of the brain. Other shooters on autopsy have been found to have pressure in this area. He is said to have left messages asking people to stop him because he felt the urge to shoot people, knew it was wrong, but was afraid he could not stop it. That's the first time in 20 years following school shootings I have seen that! What else is out there? Is there any way to use it to head off other shootings?

Then, just a day or two later, I read that several of the shooters had saved stories of the Columbine school attacks before they were even born! Some copied those shooters apparel, like trench coats, and weapons. Are some of these "copy cat" murders? And if so, how do we use that info?

Moving right along, here's another example of the complexity: We have a problem with similar attacks in other places like nightclubs and Las Vegas. How can we stop or greatly reduce these events and save lives? The solution(s) will involve considering 10-12 different contributing causes. Here are a few we often see.

1 - Guns - the favorite "solution" currently being promoted by many students and others is restricting guns. They have several proposals.

   A - Registration: Tighten registration with a view to registering all guns eventually. Require private sales and gun shows to register their sales. Anyone watching TV crime shows knows the advantage of police tracing weapons used in crimes. Registration also gives the opportunity to exclude certain folks who may be dangerous with guns from getting them. However, it's a illusion to think that gun control would stop the shootings. The student murderers regularly took their parents' guns or weapons their parents bought or them. Education in locking up guns and ammunition will help some, but again, teen aged boys are usually trusted by their parents.

    B - Improve and expand background checks for all purchases  - including a delay (72 hours?) while completed. Decline sales to those with records of mental illness, felonies involving violence, domestic violence, etc. To do this will require keeping the data base up to date and continually reminding various agencies to keep up their input. But see A above.

    C - Ban “automatic” assault weapons. Actually these are semi-automatic, requiring a finger pull for each shot. The problem is twofold:

   1. Large magazines that hold two or three dozen bullets and thus a longer time before reloading. I’ve heard several numbers, most often six or nine, as a limit. That would not stop the attacks, but would reduce the casualties, hopefully by a considerable amount, and provide safe time to take down a shooter while he reloads, which happened in a restaurant shooting.

   2. Bump stocks. Many recommend banning these attachments that convert the semi-automatic to a weapon closer to automatic, thus firing more shots faster and not allowing time for victims to disperse. In a recent Waffle House shooting the gunman paused to reload or fix a jam, and a customer took the gun away, saving other lives.

> AT THIS TIME I have no problem with any of this. We already have the registration system set up. It does need to be upgraded and used more effectively. However much this may help, it will not solve the problem which is way more complicated.

>A major hold-up on the gun fix solution is the idea that the government will one day use the registration to confiscate all guns and enslave everyone. I simply do not believe this. In the US, “government” does not refer to a strongman or a cabal. The government includes legislative, executive, and judicial arms that serve as counterweights to each other. Both Obama and Trump have experienced the frustration of not being able to get their bills through Congress. When they have resorted to executive orders, the courts have stopped them. Yes, there are people who would eliminate guns entirely, but they are a minority, and it will not happen.

>Note the motivation of the guns lobby is to sell more weapons and ammo. Follow the money.

>As late as 20-25 years ago, many high school students carried rifles and shotguns in a gunrack in the cabs of their pickups. They went hunting before and after school. There were no school shootings. Obviously, the availability of guns is NOT the only factor involved.

D- How do the mass shootings apply to the killings by police of blacks and the retaliatory shootings of cops? Are they related, and if so, how?

     1. - I have seen videos of police shooting men who were running away from them. They are shooting them in the back. I have seen a video of an officer having a suspect on the ground in a chokehold with four or five other officers helping hold him down. The man later died, most likely as a result of the unnecessary chokehold. The hold may have been appropriate in the takedown, but after help came, why continue it?

    2 - Obviously a few cops are cowboys and some are prejudiced. Fire them, prosecute them, sure,but that will not bring back the dead. There must be better recruiting and training to get rid of the bullies and hostility toward other races.

    3 - The black community must commit to non-violence with respect to police. Most of the killings of police seem to be random, as if someone said, “Let’s go shoot some cops.” So they are more likely to shoot a friend of blacks than an enemy.  Neither most cops nor most blacks are enemies of the other.

    4 - The gun issue above applies here also. But race is much more at the center of this one. And that opens all sorts of worm cans from prejudice to education to law enforcement to sociology.
E - The school shooters are all white males of high school or college age. This is the biggest terrorist threat in America right now. Not those from the Middle East or Mexico.
F - Mental health facilities are often mentioned as needing upgrades. As a counseling pastor, I have been involved with mental health for at least 60 years. I have helped establish a parish mental health center and a pastoral care counseling center. All of these school shooters have mental health issues - obviously.

   1. - Law enforcement needs to be doing a better job keeping guns away from individuals who are already drawn to their attention. Several more recent shootings were done by young men who had several times been flagged to law enforcement. Perhaps police need to secure search warrants for them and remove any weapons from their houses and vehicles.

  F - Legislatures may need to look at updating laws to enable those warrants. The border between law enforcement and personal liberty in the case of mental illness needs to be studied and accounted for in the law. This raises the very tough question of the rights of citizens, especially the mentally ill. Another can of worms for another day, but it illustrates the complexity of today’s decisions. 

G - Police response and Intelligence - Particularly in the FL shooting, it looks as if the shooter had been tagged enough times for the cops to have anticipated trouble. Some kids would still be alive if the law had come down on this guy, kept guns away, and forced him into psychiatric care. Just yesterday (March 31 - see how this keeps changing) police found a Chinese “student” with a collection of guns, including assault weapons, and set him up for deportation. Obviously, this was a shooting that didn’t happen! Yesterday (April 4) a rare shooting by a woman happened at YouTube. This morning the news reported that her brother had repeatedly warned police about her.

H - 9/11 was the most radical act of terror in our country since Pearl Harbor. In addition to launching two wars, the vicious act appeared to trigger the fear of other terrorist acts, especially from militant Islam. Indeed, several Islamic radicals have tried to hurt us. Most have been stopped, probably more than the public knows.

How much has the combination of “9/11” and individual acts by Islamists contributed to an atmosphere of fear, conducive to planting ideas of violence in unstable minds? Yet Columbine, the first, happened in 1999, two years before 9/11.

I - News coverage: Some claim that coverage of Columbine and each subsequent school attack planted the idea in fragile and/or hostile minds. That may well be so, but what are you going to do? Certainly an attack that kills and injures many children (and adults - as in Vegas) is news on many levels. That leaves many questions, however. Is there a way to slant those stories in, perhaps, a shaming way to discourage copycats. I will be interested to see if the woman’s attack at YouTube results in more women aggressors.

J - Gangs and drugs: Police all over the county tell us that by far the majority of crime is drug related, often theft to buy drugs. A large number of shootings come from inter-gang warfare. I’m willing to explore whether “stop and frisk” should be allowed and tried again in high crime areas, especially shootings, until the crime rate comes down significantly. I’m a strong advocate of neighborhood policing, where cops focus on an area and get to know the people while building up a reliable grapevine of confidential informants. This would also emphasize ethnic cops in ethnic neighborhoods, e.g. black police in the "quarters."

K - Moral education - I agree strongly with separation of church and state. That’s another issue for a later blog - equally complicated. But we need to attack this on several fronts. It doesn’t take religion to teach in our school system, that while there may be occasional school ground fights, we should all grow past the childish solution of hitting each other. Our non-PC high school principal told the boys of the school to come to the football coach before a fight, and let him fit them with boxing gloves. After the fight, shake hands and become friends. Anger management needs to be built into our curriculums nationally! This not only tackles mass shootings, but innumerable acts of violence, from spousal and child abuse to road rage - maybe even reducing gang violence.

J - I wonder whether our intense athletic competitiveness increases our division into highly antagonistic sides. In government, we don’t need to compete. We need to unite with a view to solving problems the best way we can.

SUMMARY

Do you see why I maintain most national issues cannot be solved with simple 1-2-3 solutions? I haven’t yet mentioned the question of violent video games such as Call of Duty, where the player actually shoots at realistic human enemies. Studies have so far found no correlation between the gamers and increased violence. Still, I can’t help but wonder whether the school shooters had “practiced” on such games. And there are many more issues.

I would call for the government to study this as a public health issue, as an educational issue, and a law enforcement issue.

I would call for the churches and other religious institutions of the country to learn how better to teach and then focus on teaching relevant morality to its children, teens, and young adults. The time is now to preach and teach more frequently on the Sixth Commandment: Thou shalt not murder, along with Jesus’s comments on it.

I would call for legislation and enforcement of universal gun registration, limitation of magazine size, and banning both bump stocks and military type weapons in private hands. But note that I do not expect short term results, but I do think long-term, over years, it will make a difference.

And I would call on the American citizen to quit looking for simple solutions. The world has become immensely complicated and it is time to embrace the necessity to THINK, THINK, AND THINK SOME MORE! Include the thought that if these don’t work, CHANGE and do something ELSE!

Note I expect a lot of trial and error in the process. If something isn’t working, try something else. And into the process we must seek to preserve and defend the Constitution! Which brings me to the last suggestion. Let's re-write the Second Amendment to omit the militia clause. A simple statement to the effect that "Private citizens have a basic right to own guns for self-protection, hunting, and sports. Government has the right to register those guns and regulate their use in a manner consistent with the first clause. No effort shall be made to remove citizens' rights to keep and bear arms.

Perrygraphs – Tribal Divides

Let's learn something from the Arabs. Famously, it is said they only trust their immediate family and then their tribe. That's why Saddam surrounded himself with people from his hometown Tikrit, also from his tribe. His sons, five I think, each had a palace and responsibilities. They were all Sunnis, hated Shiites, Sufis, and Kurds.

Their nations, the Arabs don't trust so much. Westerners, like the Brits, divided up the Middle East with ignorance of the peoples, but knowledge of geography. Their wars over the years have been trying to straighten this out. Oh- throw in their two big political religions: Sunni and Shiites, plus some random ethnic groups here and their like the Kurds. Thomas Friedman in two earlier books on the ME, suggested one way to bring order to an Arab country was with a strong man. So we find Saddam, Assad, Erdogan, and the Saudi king and princes.

Tribes. Can America be tribal? My high school fight song was a faint modification of “Illinois Loyalty:” “We're loyal to you Neville High...” All our schools have their local pride and mascots. Years later, we still identify with our various alma maters, ever if we've not be back in years. Half the buildings are replaced, none of the faculty is the same, and the student body has turned over a dozen times, but we are still loyal to the schools whose names are at the top of our diplomas. In a similar way we may be loyal to our state, our town, or our church.

I wonder about this intense rivalry that we feel – even encourage in high school and college athletics. Can this be training us to strengthen our natural “us and them” division? A few – very few – communities join together and build one large stadium rather than several smaller ones. Instead of everyone playing on Friday nights, they could rotate playing on Thursday, Friday, and Saturday nights. How many nights in your community do two or three stadiums remain empty while each team plays half its schedule out of town? One cooperative stadium makes far more sense, even financially, but imagine the resistance if you try it.

Does this transfer to politics? In high school, the president of the student body is always a popularity contest. Most schools I've known have no requirements beyond his or her becoming a passing senior. Campaigning does make a difference, but because the kids know each other, especially in smaller schools, popularity usually wins.

When you run for civic office, the situation changes a bit. Whether there is a political party involved, most often there are local parties or blocks, who seek some agenda. Their partisans vote for the candidates they feel will most likely support that agenda. But the larger the city, the less the populace knows the individual politicians. Enter advertising. Enter money. Parties get more complicated: capital and labor, for example. Uptown and downtown. Suburbs and projects. EACH ONE OF THESE CRYPTO-PARTIES DEVELOPS AN IDENTITY AND A FOLLOWING. Over time, the same old school loyalty develops to that party.

To a degree, the party advertises what it stands for. But more and more they are looking for sound bites, slogans. “Make America Great Again.” Political speeches hammer at emotions, not logic. And platforms re-enforce these.

I personally hate platforms. The two main parties craft their platforms in large part to separate themselves from the other party. Republicans want less government, but not everything on their platform carries that out. What does anti-abortion have to do with that? Surely, there are many pro-abortion Republicans as there are certainly pro-life Democrats. Louisiana's present governor is a good example. The mere fact that we seek party loyalty and conformity to the platform insures the growth of hostility and legislative logjams.

Recently about 40 in Congress from both parties sat down to discuss how to fix health care for the people of the US, not for the parties nor the insurance companies. They also intended to put aside party lines and slogans. I personally love this idea. Why not a Common Sense Party? Why not a Congress and President aimed at tackling one problem after another, collecting experts in the areas affecting those problems, and crafting a way to improve the situation. Do this without needing to defend the choices, but simply trying them out, adjusting them where they don't work, until they find a way that does?

This would require a new way of thinking. The other fellow is not your enemy, but your collaborator. You don't set out either to get government out of the problem, nor to make sure government is the solution. Rather, the sky's the limit on solutions, with the understanding that all solutions are temporary and open to constant change and improvement.

News: Fake or Real?

The day I wrote this, Trump and Putin met at the gang of 20 meeting in Hamburg. The spin on that meeting was as widespread as any I've seen. A neutral observer would call it a draw if it were a competition, which is how the media billed it. Actually, it was not a competition, it was a meeting between two heads of state to discuss mutual problems. Each got some of what they wanted. Personally no fan of Trump, I'd have to score him as the winner if I scored it. Note the media spun the story as a competition, like a championship game.

First, Donald kept the meeting to just the two of them, along with their Secretaries of State and two interpreters: six in all. Putin wanted to bring several more. Score one for Trump, though a couple of news sites mentioned it in passing, not one seemed to recognize it as part of the competition. On the contrary, he who sets the ground rules scores big time.

Next, Trump seems to have kicked it off by bringing up the election right off the bat. He moderated it in the eyes of many by saying the American people wanted an answer about Russian interference. Tillerson commented afterwards that he pressed Putin more than once on the issue. Of course Putin said they were innocent. Did the media expect him to fall down in abject repentance and guilt? They seemed to think Trump should have hit him with increased restrictions and threats. Odd, since Obama could have done the same thing and received effusive praise while conservatives excoriated him. My major point here is not a critique of today's coverage, but to point out an excellent example of how the media spins news. Today's was exaggerated.) If Trump had nailed Putin at the very beginning, he would have hurt our chances to get concessions elsewhere that might save lives.

Obviously the most important immediate impact is the truce in SW Syria. Whether it holds or not depends on other factors as well, such as the militias fighting there under the control of neither country. Nevertheless there's a chance for a break in the fighting and discussion over time. Note there was no mention of Iran in this discussion or anywhere else, though they may have talked about it and not reported it. After all, they talked over two hours, and a large part was on Syria.

Tillerson and his Russian counterpart gave contrary interpretations to what happened. I'm sure both had their respective countries' audiences in mind. Thus to the Russian, Trump accepted Putin's disclaimer on the election hacking. Tillerson said Trump kept bringing it up. Between the two I would think our Secretary of State more likely to be telling the truth.

Now let's go back and pay attention to what I would call the meta-conference. In business it's well known you have a power advantage if you get someone to come to you on your territory. You can see home-field advantage documented in sports. This was a neutral site, but the arrangements for the meeting determined certain things. Most important, the two men were basically alone, six people instead of 16 as Putin would have wished. This was huge! Trump nixed it (or his aides) showing he would not be bullied nor intimidated. Had Putin showed up with a dozen, do you think the atmosphere would have been the same?

A neutral observer might feel that the most important thing was the leaders of two great powers met to discuss world affairs. With North Korea thrown into the mix, the meeting takes on even more importance. Most of the sites I read indicated there would be follow-ups, an excellent thing, indicating that it went well enough to continue talking. No one stalked off muttering threats!

I've been meaning to write this blog about how to distinguish between reliable and biased news for awhile. I couldn't pass up the opportunity today. If you are serious about learning to distinguish real from fake news, read about the confab on five or six different news sites and pay attention to the differences!

FAKE NEWS

HOW TO TELL IT?

Tomorrow, Vivian and I will take the dangerous trek to and across the Shreveport traffic to the LSU specialty clinic to see an audiologist in hopes of keeping Vivian's hearing from getting worse.

Actually, we aren't. That's fake news. Furthermore it's poorly written, and for those who know me well, it should be obvious it's fake. Let's rewrite it:

Tomorrow morning, Vivian and I will cruise down the interstate, enjoying what promises to be a beautiful day, to see her audiologist for a tune-up on her hearing device. After the tweak to make it better, we plan to find a place to enjoy a meal.

Still fake news. At this writing, we have no appointment at all. But pretend we wanted to write a “straight news” sentence. What would it look like? Try this:

Tomorrow, Vivian and I will go to Shreveport to see her audiologist for a checkup.

If she did have an appointment, that would be a “straight news” way of writing it. What is “straight” news? Most journalism classes teach that straight news is “just the facts, ma'am.” There are few, if any, adjectives or adverbs. It's written with nouns and verbs. And even those nouns and verbs are chosen to be neutral and accurate. For example, “trek” and “traffic” are nouns, but they add to the pessimistic slant of that first sentence. I just wrote “go” in the neutral sentence.

The motive of keeping her hearing from getting worse makes it appear extremely serious, which it's not. Actually, if we felt she was in danger of getting worse, we'd be seeing a doctor, not an audiologist.

Back to the class. In beginning journalism I was taught that basic news was to be neutral. In those days, news stories did not even have the writer's name or by-line on it. By-lines were reserved for the Opinion Page. Some flexibility was allowed in the Features section and the Sports section. So if you read an article on the internet, pay attention to whether it is slanted by the modifiers or choice of words.

Notice how often headlines are used to get you to read the story, and that info is given way down in the story. It's seldom as radical as the headline promises. But that same memory of the headline may bias your reading all the way through. Some bias is just the news media trying to get its share of attention. That's why the headline is usually much more exciting than the story.

Other bias can be striving to slant or spin the news in someone's favor. To spot that, learn to identify the source of the news. Despite Mr Trump's insistence that it is all fake news, the mainstream news media do less of it – IN THEIR STRAIGHT NEWS STORIES – than others. I will publish later an analysis of the media's reports of the Trump-Putin meeting.

I've found The Guardian and the Christian Science Monitor do the best jobs of telling the facts straight. They're not perfect, but much better. Another good source is Quartz, which at times leans left, but usually gives good info.

When news breaks, and you want to get a grasp of reality, start with the Guardian, which is Free. Then check the Drudge Report, which will be conservative and The Huffington Post and Slate, which are liberal. Sometimes you can hardly believe Drudge and Slate are reporting on the same event.

By the way, it is standard practice for journalists to report something as fact only with at least two sources. They also like to name the sources and tell why they are commenting. What the Secretary of Defense says about N Korea should be more important than a rap singer. It's also standard practice to report both sides of an issue or analysis. If you see only one side, check the sources very carefully and be skeptical.

PERRYGRAPHS 4/10/17

AMERICAN HEALTH CARE

To bring down the cost of health care, someone will have to lose money. We forget that. Somehow the arguments mostly do not deal with that – with one exception. Most of those who like the single-payer option favor much of that financing comes from high taxes on the wealthy. Indeed, in Canada, England, and Europe taxes seem to average 35%. A figure I saw today said in the US the current average of income tax plus Social Security is 25% of income. After WWII, the top rate was 95%!

But who else would lose money? Would it be the doctors? With office calls running often to $150, would physicians drop them to $100 and take longer to pay off their student loans? Would they hire less staff? Would they charge less for surgery?

How about hospitals? Most hospitals are running hard to break even. Small, rural hospitals are gradually disappearing. Two regional hospitals in my area have in the last few years transferred from public to private hospitals. The first thing the new companies did was cut staff. In one specialized unit a nurse told me the head nurse quit because they wouldn't give her enough staff to feel the patients were getting adequate post surgical and crisis care. One doctor moved from that same hospital to a Catholic hospital that was also beleaguered, but didn't reduce quality.

Specialty hospitals are cropping up, especially surgical units and rehabs. The advantage they have is they are not required to have Emergency Rooms. In case you missed it somehow, ER's always lose money, because many indigent – or supposedly indigent – people use this as their only source of medical care. Thus they come in to get sinus prescriptions instead of paying a doctor. The hospital has to eat the cost. Why don't they refuse them? Because the law requires them not to turn them away. Further, if they do turn someone away, and they die, the family can sue them for millions – and they have! I would favor Congress and legislators reworking the law to protect the ER and their staff and allow them to decline to treat patients who are clearly having minor needs.

At this point, the legislators also need to consider reworking the liability law among health professionals. Liability insurance in case they are sued is extremely high, according to what several doctors have told me. But most legislators are lawyers, and lawyers make a good deal of money on both sides of a lawsuit. (Did I say someone has to lose money?)

Another source of high expense is the pharmaceutical companies and skyrocketing drug costs. Someone on Facebook recently commented that he required an epinephrine pen that cost him $ 600 whenever he needed a new one. For the three or four months I'm in the “donut hole,” I must pay close to that amount before I hit the “catastrophic” stage in July or August and only pay 5% for the rest of the year.

Big Pharma excuses the high cost due to Research and Development expense that requires three rounds of testing before any drug can be released. Then they are patented for many years. While the patent lasts, they can set prices pretty much at what the market will bear. Meanwhile, their spread sheets do not publicly say how much is actually spent on R &D.

NOTE: Often there are cheaper drugs, even generics available for ten bucks or less. But generics are those whose patents have expired. Thus to use a generic means to lose the cutting edge drugs to older drugs. True, some of these are very effective, but many don't come close to matching breakthrough drugs in effectiveness.

So far, there are only two partial solutions I have thought of The first is government regulated prices. Medicare already does this. When I get a Medicare report, it shows what the doctor or institution charged, how much of that Medicare allowed, and 80% of the latter figure that Medicare pays. I'm left with 20% of the allowed amount. Possibly Congress can authorize a branch of the Medicare system to regulate prices – at least by capping them. Thus a regular office call might be capped at $75 for an FP and $100 for some specialists. I recognize that regulation is anathema to some people, but by definition bringing down the cost of medical care means someone has to lose money. Until now, only the patients lose money.

The second concept that would bring down costs is aimed at drugs. Many have already suggested that Medicare and Medicaid be allowed to conduct an auction or bargaining for drugs. If they know they will pay for a million prescriptions of superbiotic next year, they could allow competitive drugs to bid. So far the drug industry sets its prices with little outside interference.

Finally, I have a personal prejudice against lobbyists and PACs. We have set up rules for them, which seems to me to be regulating corruption. With the Supreme Court decision recently, I have no hope to outlaw them anytime soon.

HEALTH CARE

I knocked on the trailer door. An elderly man opened the door, and I introduced myself to him as his caseworker. In 1960 I was a social worker assigned to Old Age Security in Tulare County, and I needed to carry out an annual review on his case and perhaps his wife’s case if they came due near enough to each other. In the course of discussion, I asked after their health. He replied he had been having angina attacks. He said he couldn’t afford to go to the doctor, buy medicine, and also buy food. They chose to buy food. Social Security was just starting to kick in, and there was no Medicare. I remember at the time thinking the man should get as good a care for his heart as a wealthy man. Maybe the rich guy could get a swanky room and food, but the actual medical care should not depend on how much money he had.

Segue 55 years into the future. Medicare and Medicaid have kicked in, but we still debate vociferously the cost and availability of health care. I want to try to analyze this issue to see whether we can find a more objective set of ideas.

1 – SOMEONE MUST PAY FOR HEALTH CARE OR HEALTH CARE WILL NOT EXIST.

            Actually, all the ruckus about the ACA, aka Obamacare, is only about insurance: who pays who and how. The fuss has never actually dealt with the cost. We repeatedly talk about reducing the cost of health care, but we really mean reducing the cost of insurance. Let’s look first at the cost of health care itself, then insurance.

In 1985 I went as pastor to Hodge Baptist Church. In the congregation, there was a recently retired physician.  While visiting his wife in the hospital I asked him whether he was completely retired or carrying a smaller case load. He replied that he couldn’t afford to work part time. To do so, he would have to pay for all the overhead: office, utilities, receptionist, and nurse. As I remember he had estimated it would take $40,000 a year to break even, and he didn’t want to work that much.  That was in 1985 dollars.

Most of my pastorates have been in smaller towns with rural hospitals that struggle to stay afloat. People prefer local hospitals for “normal” illnesses such as when flu or pneumonia puts you in bed with an IV. But even in a 50 bed hospital, you can see how many people must be paid and how many services offered. There’s at least one RN on every shift on every unit (I know, they sometimes cheat), and LPN’s or aides to give patient care. There will be a lab with at least one technician a shift, plus an x-ray. Then most places have an ER, which is one raison-d-etre for local citizens to demand a local hospital. Lots of lives get saved during heart attacks and kids legs and arms splinted. Then there’s housekeeping, including maids and floor moppers and waxers, and a maintenance guy or two. And you have to keep up to date reasonably well with lab and x-ray equipment. Then you have to pay utilities and insurance. On top of all that come the administrator and clerks, perhaps more office personnel.

How do we pay for all that?

Well, the patient does. The patients do. That’s why there’s a basic room fee. At the end of the day, we have to collect enough money from all the patients to pay the salaries of everyone plus all the other bills. If all these people and equipment total, say, $350,000 a month, then we have to average that much in patient fees. Some county hospitals may receive help from tax funds or various grants, but someone somehow pays for it, or the hospital shuts down.

There is no free lunch.

There is no free health care.

No public figure I know has discussed in the media how to reduce health care costs, only how to make insurance affordable. That means we expect the insurance companies to pay for our medical care. OK, but where do they get the money? We’ll talk more about that in a minute, but right now let’s dive back in before the insurance comes in.

How do we reduce the actual cost? The actual amount charged each patient?

I’ve noticed only one thing in the last 55 years, and you may not like it. Actually, I’ve only noticed in the last 15 years since I became eligible for Medicare. I observe that every bill I get has several columns.

First comes the charge for the service. Example $150 office visit

Next a column headed “Medicare allows” Ex - $100

Medicare will pay 80%                                                80

Patient may be charged                                              20

Note in the above example, that the government set the prices. Now I am sure this triggers a game between the med providers and the government – and other – insurance. If they will cut my $150 fee to $100, what will I get if I charge $175? And this goes on all the way up and down the line. Private insurance does the same thing, by the way. Plus, they will add some to the cost for their profit, unless they are a mutual insurance company. (That’s the theory anyway.)

Can you see any other way to reduce the actual cost of medical care apart from government regulation? I know the whole idea of regulation is anathema to the business world, because it limits profits. In many areas I would agree, but medical care to me is an exception. I still don’t think a homeless guy having a heart attack on the street should get less quality care than a millionaire who lives in a penthouse.

And yet – if we have regulation, it must be intelligent regulation. I hear all the time people having to postpone surgery while their doctors hassle the insurance companies to get the surgery approved. I envision some high school graduate at a computer feeding in the data of the patient and the condition and the surgeon’s recommendation, then waiting for the computer to say yes or no. Few doctors will prescribe antibiotics for a sore throat over the phone without having the patient come in for an examination. And we make potentially life or death decisions a thousand miles away by computer? Saying the surgeon on site with years of training and experience doesn’t know?

We must have intelligent regulation.

LOUISIANA DETOUR – Adjust this discussion for your state. In Louisiana, we have what’s left of a state hospital system that has been radically cut the last ten years along with colleges, because of repeated budget crises. The theory is that the indigent can go to one of several state hospitals scattered in major cities for health care. These are generally attached to med schools or at least staffed by residents from med schools. Every general hospital in the state must have an Emergency Room, and each ER must treat any emergency who comes in. In actual practice they must treat anyone who comes in, emergency or not, for fear of lawsuit if they turn away a patient who subsequently dies or has a major complication bring him back. As a result, many poor use ER’s as their primary care because they can afford nothing else, or they don’t want to spend the money when they can get it free. As a result, private ER’s do enough treatment to make sure the patient is not critical, then ship them off to a state hospital. Still, the high volume in the ER makes it very difficult to make the hospital operate in the black.

But other issues affect costs as well. So let’s turn now to pharmaceuticals and equipment.

DRUG COSTS          

A guy bought a pharmaceutical company that owned a critical drug for cancer care. He raised the price from a barely affordable $100 or so to several thousand! In physics “every action has an equal and opposite reaction.” I’m not sure if it was equal, but there was definitely a major reaction, not to say explosion, from the entire country. Did he assume insurance would cover the outrageous price? Did he believe that being the only curative drug for that disease would force people to round up the money? I don’t know. The last I heard the price went down, but not as low as at first.

Personally, I take three meds that total $5-600 a month. Medicare reduces the cost to be affordable, except when it lands me in the coverage gap, aka “the donut hole.” Other drugs I take have generics that cost only $2-10 a rx. Drugs are patented when they first come out to protect them from other companies and generics, so the inventors can pay for the research and developments costs which can be quite high.

A patent lasts for 20 years, but may be issued at any point during the development process. Exclusivity comes after FDA approval and prevents others from marketing the drug for, usually, 3-7 years depending on the type of drug. A company can spend hundreds of thousands of dollars on research to discover new drugs, but after that discovery, must spend sometimes more to test the drug in three stages, each of which must be completed before moving on to the next phase. Only after the third round of trials are successful will the FDA approve the drug to go on the market.

It is reasonable for a company to use its exclusive marketing opportunity to recover the cost of all those scientists and lab work to bring the new drug to market. A problem arises, however. Even though these companies are publicly traded, they do not publish the cost of developing and testing the drugs. The funding of R&D is largely hidden as a trade secret. That means we have no way of determining when they have met the overhead on that particular rx and gone into profit. Nor can we say what amount of profit is reasonable. Certainly as an end user paying $300 for a script I might have a different idea than those who invest in that company, not to mention the major owners and managers.

The same principle applies to all medical equipment companies – AND THE DISTRIBUTERS AND PHARMACIES. A drug store has to pay for the meds, plus the salaries of one or more pharmacist, clerks, rent, utilities, and the like. The same is true of medical supply houses. You can see there are several levels that must first break even then make at least some kind of profit to stay in business. Each level from Pharmaceutical company to wholesaler to pharmacy must make a profit, or the owners would shut the business down.

What’s a reasonable profit?

How do you decide?

Who decides?

Market based economics would answer that we should allow supply and demand to work. That works fine in many industries where competition keeps prices down and responsive to market demand. But what about the guy who jacked up a price out of sight because he had exclusivity and NO competition.

Medicare Part D providers deal with the situation by dividing drugs into different categories. Generics they will mostly cover. Then there are “Preferred Drugs,” determined by the company to be reasonable, so they discount these quite well. At least to the donut hole. Then there are other drugs that the Med D people are reluctant to cover. If there is a generic drug that does the same thing as a newer one, they will pay for the generic, but not the newer one – or at least with a smaller discount on the new one.

What this practice says is the doctor cannot treat with the latest meds. If the patient wants the lowest prices, he or she will have to accept five-year-old quality medical care. The insurance position is understandable, and we’ll look at it in more detail in a bit, but getting the cheapest medicine comes at a cost of quality care.

A little over a year ago I had an attack of A-fib. Twelve years before that I had a heart attack and was taking meds to manage cardio-vascular disease. The doc shocked my heart back into rhythm and then changed me meds from a generic to two new meds to prevent the new risk of stroke. These are two of the high-priced ones that Med D doesn’t want to pay for.  (Yes, there are work-arounds, but this is already a complex discussion, so let’s not complicate it further.) There are cheaper meds they used before these two came out, but I can afford these, so should I take less than cutting edge treatment?

HEALTH INSURANCE

Now let’s look at how we pay for all this medical care and drug costs. The really old-fashioned way, going back 150 years or so, is the simplest. Cash. Or in the famed cases of country doctors with chicken, eggs, vegetables and the like. Does anyone do that anymore? If so very few. Enter insurance.

The concept of insurance depends on spreading the risk and the cost. Let’s assume a random collection of 100 people of varying ages. In most years, only a small percentage will go into a hospital. Maybe half will see a doctor and two thirds take some kind of meds. So if each of the 100 pays $1000, there will be a pool of $100,000 which will pay for, or at least help pay for the expenses of those who use medical care that year.

An insurance company will develop “actuarial tables” that take into consideration the population they serve and the cost of their medical care. Then they take that overall cost and divide that cost among all those they serve as premiums. My understanding is that in good years, where less people are treated and at less total cost, the company increases its profits, but does not drop the cost of the meds. That’s why people buy stocks. They want dividends coming back from profits, and buying the stock is what gives the drub company the money to create and manufacture drugs. If government restricts profits, stock sales will fall off. That means the pharms will have less money to develop drugs, so new drugs may not appear as quickly.

Obviously, those who seek “single payer” insurance are correct that this form of insurance will be the cheapest. Why? Because the pool of people covered include the whole nation. If every individual is paying into the pool, that includes millions of young adults who may go years without seeing a doctor, taking meds, or needing a hospital. Their premiums make up for the older folks who are always having stuff go wrong and running up bills steadily.

The problem with this form of care, as we find in Canada, England, most of Europe, is the cost. Proponents think it can be done by taxing the rich, but at least in the above countries the tax is much more widespread. A Canadian physical therapist where I work out has a “green card,” which he showed me. Talk about being disconcerted: it was white! Like a credit card. White! Nevertheless, I asked him what the taxes were like up there on average, and he replied around 35%. I googled European taxes and found they were indeed much higher than in the US.

This means that in single-payer societies, the patients still pay for their health care. It also means you close all the private insurance companies, throwing millions out of work and greatly restrict the profit of all other medical entities. American doctors are already complaining about the limits Medicare and Medicaid pay them. The Canadian system puts most doctors on a salary except for the few who hold out for the wealthy who can afford private care.

But with a total actuarial pool, you do have the lowest possible rate. In a profit based system, the insurance companies juggle the costs for their own particular pool. For example, they may refuse to cover pre-existing conditions. By ruling these people out, you are automatically omitting certain costs because of their on-going illness. So it’s not surprising that even many who don’t like the Affordable Care Act do approve of the provision requiring the insurance to cover pre-existing conditions. But as I write this at the end of 2016, much publicity has gone out that the costs of insurance, even under the ACA, is going up as much as 25% next year. Why? I’m sure one reason is that adding all those people to the pool who were destined to high medical cost from pre-existing conditions ran those companies into losses. Also, not nearly as many young and healthy adults signed up as were expected. Why is this a surprise? They’d much prefer to pay a comparatively small fine than the larger premium. But this healthy group is what gives the insurance providers the money to pay for the chronically ill bunch.

THE TAKEAWAYS

1 – Someone must pay for medical care. We mostly do that through insurance. The national argument has been on what kind of insurance set up is best for the most people.

2 – At this point, the only way I personally can see to reduce the actual cost of medical care is regulation. We’ve had that for a long time both with private insurance and Medicare.

3 – This raises the question of what is a fair profit in medicine. That carries with it the problem of who is to decide that?

4 – What can you do personally to keep your medical costs down? First, stay in front of your health. Get checkups and begin treatment, following your doc’s advice, as soon as a problem pops up. Plus you’ve heard over and over: exercise, keep your weight down, eat right.

I recognize this is incomplete and needs much more thought. I will add to it as I learn more and change my mind here and there. If it sounds technical and difficult, you are beginning to grasp the problem!

HEALTH CARE

I knocked on the trailer door. An elderly man opened the door, and I introduced myself to him as his caseworker. In 1960 I was a social worker assigned to Old Age Security in Tulare County, and I needed to carry out an annual review on his case and perhaps his wife’s case if they came due near enough to each other. In the course of discussion, I asked after their health. He replied he had been having angina attacks. He said he couldn’t afford to go to the doctor, buy medicine, and also buy food. They chose to buy food. Social Security was just starting to kick in, and there was no Medicare. I remember at the time thinking the man should get as good a care for his heart as a wealthy man. Maybe the rich guy could get a swanky room and food, but the actual medical care should not depend on how much money he had.

Segue 55 years into the future. Medicare and Medicaid have kicked in, but we still debate vociferously the cost and availability of health care. I want to try to analyze this issue to see whether we can find a more objective set of ideas.

1 – SOMEONE MUST PAY FOR HEALTH CARE OR HEALTH CARE WILL NOT EXIST.

            Actually, all the ruckus about the ACA, aka Obamacare, is only about insurance: who pays who and how. The fuss has never actually dealt with the cost. We repeatedly talk about reducing the cost of health care, but we really mean reducing the cost of insurance. Let’s look first at the cost of health care itself, then insurance.

In 1985 I went as pastor to Hodge Baptist Church. In the congregation, there was a recently retired physician.  While visiting his wife in the hospital I asked him whether he was completely retired or carrying a smaller case load. He replied that he couldn’t afford to work part time. To do so, he would have to pay for all the overhead: office, utilities, receptionist, and nurse. As I remember he had estimated it would take $40,000 a year to break even, and he didn’t want to work that much.  That was in 1985 dollars.

Most of my pastorates have been in smaller towns with rural hospitals that struggle to stay afloat. People prefer local hospitals for “normal” illnesses such as when flu or pneumonia puts you in bed with an IV. But even in a 50 bed hospital, you can see how many people must be paid and how many services offered. There’s at least one RN on every shift on every unit (I know, they sometimes cheat), and LPN’s or aides to give patient care. There will be a lab with at least one technician a shift, plus an x-ray. Then most places have an ER, which is one raison-d-etre for local citizens to demand a local hospital. Lots of lives get saved during heart attacks and kids legs and arms splinted. Then there’s housekeeping, including maids and floor moppers and waxers, and a maintenance guy or two. And you have to keep up to date reasonably well with lab and x-ray equipment. Then you have to pay utilities and insurance. On top of all that come the administrator and clerks, perhaps more office personnel.

How do we pay for all that?

Well, the patient does. The patients do. That’s why there’s a basic room fee. At the end of the day, we have to collect enough money from all the patients to pay the salaries of everyone plus all the other bills. If all these people and equipment total, say, $350,000 a month, then we have to average that much in patient fees. Some county hospitals may receive help from tax funds or various grants, but someone somehow pays for it, or the hospital shuts down.

There is no free lunch.

There is no free health care.

No public figure I know has discussed in the media how to reduce health care costs, only how to make insurance affordable. That means we expect the insurance companies to pay for our medical care. OK, but where do they get the money? We’ll talk more about that in a minute, but right now let’s dive back in before the insurance comes in.

How do we reduce the actual cost? The actual amount charged each patient?

I’ve noticed only one thing in the last 55 years, and you may not like it. Actually, I’ve only noticed in the last 15 years since I became eligible for Medicare. I observe that every bill I get has several columns.

First comes the charge for the service. Example $150 office visit

Next a column headed “Medicare allows” Ex - $100

Medicare will pay 80%                                                80

Patient may be charged                                              20

Note in the above example, that the government set the prices. Now I am sure this triggers a game between the med providers and the government – and other – insurance. If they will cut my $150 fee to $100, what will I get if I charge $175? And this goes on all the way up and down the line. Private insurance does the same thing, by the way. Plus, they will add some to the cost for their profit, unless they are a mutual insurance company. (That’s the theory anyway.)

Can you see any other way to reduce the actual cost of medical care apart from government regulation? I know the whole idea of regulation is anathema to the business world, because it limits profits. In many areas I would agree, but medical care to me is an exception. I still don’t think a homeless guy having a heart attack on the street should get less quality care than a millionaire who lives in a penthouse.

And yet – if we have regulation, it must be intelligent regulation. I hear all the time people having to postpone surgery while their doctors hassle the insurance companies to get the surgery approved. I envision some high school graduate at a computer feeding in the data of the patient and the condition and the surgeon’s recommendation, then waiting for the computer to say yes or no. Few doctors will prescribe antibiotics for a sore throat over the phone without having the patient come in for an examination. And we make potentially life or death decisions a thousand miles away by computer? Saying the surgeon on site with years of training and experience doesn’t know?

We must have intelligent regulation.

LOUISIANA DETOUR – Adjust this discussion for your state. In Louisiana, we have what’s left of a state hospital system that has been radically cut the last ten years along with colleges, because of repeated budget crises. The theory is that the indigent can go to one of several state hospitals scattered in major cities for health care. These are generally attached to med schools or at least staffed by residents from med schools. Every general hospital in the state must have an Emergency Room, and each ER must treat any emergency who comes in. In actual practice they must treat anyone who comes in, emergency or not, for fear of lawsuit if they turn away a patient who subsequently dies or has a major complication bring him back. As a result, many poor use ER’s as their primary care because they can afford nothing else, or they don’t want to spend the money when they can get it free. As a result, private ER’s do enough treatment to make sure the patient is not critical, then ship them off to a state hospital. Still, the high volume in the ER makes it very difficult to make the hospital operate in the black.

But other issues affect costs as well. So let’s turn now to pharmaceuticals and equipment.

DRUG COSTS          

A guy bought a pharmaceutical company that owned a critical drug for cancer care. He raised the price from a barely affordable $100 or so to several thousand! In physics “every action has an equal and opposite reaction.” I’m not sure if it was equal, but there was definitely a major reaction, not to say explosion, from the entire country. Did he assume insurance would cover the outrageous price? Did he believe that being the only curative drug for that disease would force people to round up the money? I don’t know. The last I heard the price went down, but not as low as at first.

Personally, I take three meds that total $5-600 a month. Medicare reduces the cost to be affordable, except when it lands me in the coverage gap, aka “the donut hole.” Other drugs I take have generics that cost only $2-10 a rx. Drugs are patented when they first come out to protect them from other companies and generics, so the inventors can pay for the research and developments costs which can be quite high.

A patent lasts for 20 years, but may be issued at any point during the development process. Exclusivity comes after FDA approval and prevents others from marketing the drug for, usually, 3-7 years depending on the type of drug. A company can spend hundreds of thousands of dollars on research to discover new drugs, but after that discovery, must spend sometimes more to test the drug in three stages, each of which must be completed before moving on to the next phase. Only after the third round of trials are successful will the FDA approve the drug to go on the market.

It is reasonable for a company to use its exclusive marketing opportunity to recover the cost of all those scientists and lab work to bring the new drug to market. A problem arises, however. Even though these companies are publicly traded, they do not publish the cost of developing and testing the drugs. The funding of R&D is largely hidden as a trade secret. That means we have no way of determining when they have met the overhead on that particular rx and gone into profit. Nor can we say what amount of profit is reasonable. Certainly as an end user paying $300 for a script I might have a different idea than those who invest in that company, not to mention the major owners and managers.

The same principle applies to all medical equipment companies – AND THE DISTRIBUTERS AND PHARMACIES. A drug store has to pay for the meds, plus the salaries of one or more pharmacist, clerks, rent, utilities, and the like. The same is true of medical supply houses. You can see there are several levels that must first break even then make at least some kind of profit to stay in business. Each level from Pharmaceutical company to wholesaler to pharmacy must make a profit, or the owners would shut the business down.

What’s a reasonable profit?

How do you decide?

Who decides?

Market based economics would answer that we should allow supply and demand to work. That works fine in many industries where competition keeps prices down and responsive to market demand. But what about the guy who jacked up a price out of sight because he had exclusivity and NO competition.

Medicare Part D providers deal with the situation by dividing drugs into different categories. Generics they will mostly cover. Then there are “Preferred Drugs,” determined by the company to be reasonable, so they discount these quite well. At least to the donut hole. Then there are other drugs that the Med D people are reluctant to cover. If there is a generic drug that does the same thing as a newer one, they will pay for the generic, but not the newer one – or at least with a smaller discount on the new one.

What this practice says is the doctor cannot treat with the latest meds. If the patient wants the lowest prices, he or she will have to accept five-year-old quality medical care. The insurance position is understandable, and we’ll look at it in more detail in a bit, but getting the cheapest medicine comes at a cost of quality care.

A little over a year ago I had an attack of A-fib. Twelve years before that I had a heart attack and was taking meds to manage cardio-vascular disease. The doc shocked my heart back into rhythm and then changed me meds from a generic to two new meds to prevent the new risk of stroke. These are two of the high-priced ones that Med D doesn’t want to pay for.  (Yes, there are work-arounds, but this is already a complex discussion, so let’s not complicate it further.) There are cheaper meds they used before these two came out, but I can afford these, so should I take less than cutting edge treatment?

HEALTH INSURANCE

Now let’s look at how we pay for all this medical care and drug costs. The really old-fashioned way, going back 150 years or so, is the simplest. Cash. Or in the famed cases of country doctors with chicken, eggs, vegetables and the like. Does anyone do that anymore? If so very few. Enter insurance.

The concept of insurance depends on spreading the risk and the cost. Let’s assume a random collection of 100 people of varying ages. In most years, only a small percentage will go into a hospital. Maybe half will see a doctor and two thirds take some kind of meds. So if each of the 100 pays $1000, there will be a pool of $100,000 which will pay for, or at least help pay for the expenses of those who use medical care that year.

An insurance company will develop “actuarial tables” that take into consideration the population they serve and the cost of their medical care. Then they take that overall cost and divide that cost among all those they serve as premiums. My understanding is that in good years, where less people are treated and at less total cost, the company increases its profits, but does not drop the cost of the meds. That’s why people buy stocks. They want dividends coming back from profits, and buying the stock is what gives the drub company the money to create and manufacture drugs. If government restricts profits, stock sales will fall off. That means the pharms will have less money to develop drugs, so new drugs may not appear as quickly.

Obviously, those who seek “single payer” insurance are correct that this form of insurance will be the cheapest. Why? Because the pool of people covered include the whole nation. If every individual is paying into the pool, that includes millions of young adults who may go years without seeing a doctor, taking meds, or needing a hospital. Their premiums make up for the older folks who are always having stuff go wrong and running up bills steadily.

The problem with this form of care, as we find in Canada, England, most of Europe, is the cost. Proponents think it can be done by taxing the rich, but at least in the above countries the tax is much more widespread. A Canadian physical therapist where I work out has a “green card,” which he showed me. Talk about being disconcerted: it was white! Like a credit card. White! Nevertheless, I asked him what the taxes were like up there on average, and he replied around 35%. I googled European taxes and found they were indeed much higher than in the US.

This means that in single-payer societies, the patients still pay for their health care. It also means you close all the private insurance companies, throwing millions out of work and greatly restrict the profit of all other medical entities. American doctors are already complaining about the limits Medicare and Medicaid pay them. The Canadian system puts most doctors on a salary except for the few who hold out for the wealthy who can afford private care.

But with a total actuarial pool, you do have the lowest possible rate. In a profit based system, the insurance companies juggle the costs for their own particular pool. For example, they may refuse to cover pre-existing conditions. By ruling these people out, you are automatically omitting certain costs because of their on-going illness. So it’s not surprising that even many who don’t like the Affordable Care Act do approve of the provision requiring the insurance to cover pre-existing conditions. But as I write this at the end of 2016, much publicity has gone out that the costs of insurance, even under the ACA, is going up as much as 25% next year. Why? I’m sure one reason is that adding all those people to the pool who were destined to high medical cost from pre-existing conditions ran those companies into losses. Also, not nearly as many young and healthy adults signed up as were expected. Why is this a surprise? They’d much prefer to pay a comparatively small fine than the larger premium. But this healthy group is what gives the insurance providers the money to pay for the chronically ill bunch.

THE TAKEAWAYS

1 – Someone must pay for medical care. We mostly do that through insurance. The national argument has been on what kind of insurance set up is best for the most people.

2 – At this point, the only way I personally can see to reduce the actual cost of medical care is regulation. We’ve had that for a long time both with private insurance and Medicare.

3 – This raises the question of what is a fair profit in medicine. That carries with it the problem of who is to decide that?

4 – What can you do personally to keep your medical costs down? First, stay in front of your health. Get checkups and begin treatment, following your doc’s advice, as soon as a problem pops up. Plus you’ve heard over and over: exercise, keep your weight down, eat right.

I recognize this is incomplete and needs much more thought. I will add to it as I learn more and change my mind here and there. If it sounds technical and difficult, you are beginning to grasp the problem!