Current Global Vision Matrix

I have been sitting down to try to seek, understand, list and express what seem to me to be our core American values. I know I am not alone in feeling real fear and foreboding that our great nation, this great experiment in democracy, liberty and justice is precarious, that it is in danger.

America, we must come home.

We must find common ground. Remember our shared values. Reconnect with some unity of purpose.

Yes, I know. These are cliches. Shibboleths. Everyone says them. “All men are created equal”. “Life, liberty and the pursuit of happiness”. “To form a more perfect Union”. These words once possessed near religious meaning. The were enough to create a nation. But what do they mean now? Too often empty expressions. Catch slogans. Blah blahs.

I have tried to discover, for myself, what do I believe are our common values. What binds us together as a people, a culture, a nation, an idea. If in fact, anything does. If we articulate what are our values, those ideals and principles we all really share, then maybe we can determine if we are being true to them, and if not, how might we be.

I started by listing for myself as many of what I believed were truly core American values as I could. Then I looked through my somewhat chaotic list of values several times, trying to find common threads, to group them, to make coherent what looked almost random.

I found that, in broad strokes, our American values, for me, fall into seven basic categories and principles.

1) We value a general respect for fairness.
Not that everybody’s lot be equal, but that the system is fair for everyone.
That the rules are developed in a manner which we can see and understand.
That the rules are applied evenly.
That everyone has the opportunity to make of themselves as much as their ability and effort can take them.
That we give each other a fair shake.
That each of us is expected to play by the rules.

2) We value a rule of law which is consistent, impartial, evenly distributed and upheld.

That the law for one person is the same as the law for another.
That justice is separate from politics, that leaders don’t use the judicial arm of the state to enforce their political purposes.
That there is a consistent and agreed upon set of constructs, principles and norms which govern every person fairly and impartially.
That every man and woman has “their day in court”.
That the courts are fair and honest.
That justice is, as they call it, “blind”.

3) We value a reliability, trustworthiness, dependability of our respect for tradition, our adherence to precedent, and to principle.

That our word is our bond, and that we are as ‘good as our word’, both at home and abroad.
That when we give our word, that when we make an agreement we can be expected to keep it.
We respect that value in individuals, calling it by names like integrity, and we value it as a nation.
We expect that our allies can count on us.
We expect that we will keep up our end of a bargain, that we will hold fast, not blindly, but whenever we can, to our end of the bargain to our word, to our principles, to our ideals, our norms and traditions.

4) We value truth, and honesty.
And also intellectual honesty. We don’t like it when politicians, scientists, public servants, the press, or anyone bends, slants or compromises facts, and the truth to fit their own private opinions and agendas.
We may not all agree on what is true, but we value the honest pursuit of truth.
We value a free exchange of ideas in a fair, open and available intellectual public square.

5) We value respect for the dignity and the rights of individuals.
Ideally of all individuals. Of all races, colors, genders, creeds, nationalities, it is in our DNA to do so.
We believe that individuals have intrinsic worth as human beings. Well meaning Americans may differ on whether that dignity and intrinsic worth of an individual automatically guarantees them, say, entrance to the country, for example, or government assistance – and those are fair policy disagreements to have, but as Americans we value individual rights and dignity. That includes those rights enshrined in our Constitution and Bill of Rights, of course, such as the right to peaceable assembly and a free press, but it also means a respect for certain traditional norms and standards. Although some may tolerate it to achieve other goals, I can’t really believe that taunts, slurs, insults, and ridicule are not what Americans wish to emulate in leaders.

6) We value in general a certain decency, a certain dignity, a decorum, standards, civility.
A certain willingness to respectfully listen to one another.
We may for a time decry “political correctness”, but we don’t really value in the long run public servants or leaders who speak like street toughs and ‘hooligans’, who are ill mannered, ill tempered, crude.

7) We value the ideal of progress, opportunity, a chance to succeed.
We cherish that each individual have a chance to have that mythical American Dream.
We value the ideal that each generation leaves the nation better than they found it.
We value the belief that we continue to improve and that the lives our our children will be filled with more opportunities and a better world than we had.
We value the notion that humanity can get better. We may not believe it, but we value it.

Of course there are so more things we value, our lives and our families and our safety, security, shelter, and the like, but those are common to all mankind. And I am sure there are values which I have either left out or expressed differently than others would have them, but the categories of values expressed above capture, I hope, a good deal of what it means to be an American.

And, America, we have to come home. Come home to American values. Come home to ourselves. To who we really are.

Now, I don’t wish to be too coy, or devious, or to make out as if this is part of mystery novel with an unexpected ending. This is at heart the beginning of a political statement, a series of political statements. The thesis of these statements will be that in the coming election the only way to come home and to honor our values as Americans is to vote democratic.

Note please, note well that I am not claiming that this will always be the case. There could well arise in future elections candidates who are conservatives, republicans for whom one could vote and still be upholding in every respect those values we cherish as Americans.

But not this time.

In future writings, and very soon I hope, I intend to show specifically why, based on these above stated values and on the actions of the current president and administration, to come home, to be America again, means to reject Donald Trump.

For the moment, and this is The Moment, I would respectfully beg the reader to consider these values, to ask if these are really fairly called American values, and if so, to ask how well they are being represented in the current administration and the environment they have created.

Then we well talk again soon.

Dear Bernie,

I am asking you as a democrat and someone who wants both a chance to regain the decency of winning the election, and having a chance of accomplishing our shared goals.

Not to drop out. Your ideas are worth hearing. No question.

But to stop running your campaign against other democrats in such a way as to try to make them out to be the enemy.

That’s what you did when you undermined the trustworthiness of Hillary Clinton in 2016. You succeeded in creating questions about her honesty. Congratulations. She didn’t win.

Let me be clear. If you win the nomination, I will vote for you, and actively support you. But I don’t think you will win. Because, as honest, and caring as you are, as much as your heart is in the right place, the Republicans will not run against you.

They will run against Socialism. And they will win. They will not even mention Bernie Sanders. They will run against Nicolas Maduro. They will run against Fidel Castro, Joseph Stalin, and Mao Tse Tung. They will run against Kim Jung Un. And they will win.

Please look at my “Why I am not feeling the Bern” from 2016. I think the arguments are just as good today.

None of this is to say you shouldn’t run. You feel you have something to say. The things you say are important. If your arguments prevail, and you win the nomination, I will support you.

But please, for the present, please stop trying to attack other democrats who are at least just as likely to be the nominee. It undermines them. Makes it much less likely they can beat a sitting president in a time of relative prosperity.

I heard your speech.

It might have been gracious to have congratulated Joe Biden on some remarkable victories. But okay, let that go.

It’s one thing to race against the Greed of Wall street, drug companies, and the fossil fuel industry.

It is, perhaps not as helpful, at least to the chances for a Democratic victory, to attack someone who has statistically at least a fifty percent chance of being the nominee as having “voted for the war in Iraq”, imply he voted for cuts in Social security and Medicare, voted for ‘disastrous trade bills’, representing the credit card companies, and implying he is in the pocket of all those demonic Billionaires.

Just as a fact check, he didn’t vote “for the war in Iraq”, he voted to authorize the President to use the threat of force to compel compliance with UN mandates. He was wrong, and has admitted it. Bush had another agenda. History has shown that, and several of us, yes, myself included, thought it at the time. But let’s be honest, the measure passed overwhelming, it was supported by a large majority of democrats, including some well respected and prominent, such as two of our last three nominees, both of Obama’s secretaries of state, and our current senate minority leader. It was not the vote of a war profiteering war monger, and you should stop pretending it was a decision out of keeping with the majority of the members of our party. It wasn’t.

This attempt to cast your “establishment” opponent in morally questionable light is exactly what you did in 2016, when you joined with the Republican talking points to cast doubts on Clinton’s honesty, it is partially what kept her vulnerable to aspersions on her sincerity and trustworthiness, which reinforced Trumps ability to take advantage of the perceived weakness, and it is one good reason why President Trump won then. And, face it, he probably why he will win again. Even with a fully united front it is difficult to defeat an incumbent president in a time of relative peace and unquestioned prosperity.

A united, progressive, but still inclusive and consensus building party of decency, competency, rule of law and respect for national and international norms can win. But not if you continue to undercut the basis of trust. Hillary didn’t release transcripts of her talks to private banks. You hounded her on that until you succeeded in undermining trust for her. Congratulations, Bernie, Hillary didn’t win.

So if you go ahead and undermine Joe Biden, Trump can win re-election.

And, you know something. A re-elected, emboldened and legitimated Donald Trump might not be as kind, decent, truthful, law abiding and compassionate as he has been these four years. His phone calls, as “perfect” as they were already, might get even more “perfect”.

Perhaps you are playing the “long game”. Perhaps you think that if a moderate democrat gets trounced, democrats will wise up and turn to socialism.

I don’t think that is true.

What is more likely is that if socialists make it impossible for democrats to win, then centrist democrats will have to seriously consider becoming moderate republicans.

Not asking you to stand down. That would not be right.

Perhaps though if you could “tone it down”, and look for some mutual respect and consensus, we could run a democratic ticket with some chance in hell of winning.

Bernie Sanders has called for “Medicare for All”. Joe Biden rolled out this week a plan, and argued that “Medicare for All” would end Obamacare – which is what Donald Trump wants. Pete Buttigieg suggests “Medicare for all – who want it”. Kamala Harris wants a single payer system. Kirsten Gillebrand wants a transition period. And, in the first Democratic presidential debate, there was a clear divide between who would raise their hands to eliminate private insurance.

How to provide and pay for health care is one of the most central points of contention, debate and difference between the Democratic candidates for president. It is one of the most salient points of difference and contention between the Democratic and Republican parties as a whole. And it is one of the major issues of genuine and shared interests to all who live in our country. And has been so for at least half a century.

Just about anything that can be said about health care has been said, however everything said has been said in fragmented, multiple, diverse, and separate ways. This issue continues as perhaps the greatest key flash point in our national dialogue and division. The arguments remain every bit as heated as they were in 2010 when the ACA was being debated, as they were in 2001 when Hillary embarked on her famously ill fated attempt to reconsider our health care delivery system, and, truth be known, as they were 60 years ago when Medicare was first being proposed and derided. But with all the heat, I am not sure we have one candle power more light.

I am a physician who has provided front line care to patients for forty years, four decades when concern over health care costs and delivery have done nothing but soar. I have also been an interested witness of the system. From time to time I have tried to comment, albeit with little success. My first attempt at a cost containment article, (unpublished, not for lack of trying) was written in the early 1980s. My first play featured, perhaps of minimal interest to the audience, admittedly too much talk on the subject. (One LA Times reviewer called it ‘more like a surprisingly candid panel discussion than a play’) At the time I first tried to comment it was feared that costs could reach 100 billion a year. Now over two trillion and climbing.

With now half a century of arguement, it is not clear to me that the issue has been presented broadly enough, or comprehensively enough, for the majority of our citizenry to really come together and find common ground. We still lack the common language necessary to weigh and assess the issues and arguments. We still do not articulate what really separates either the voices in the democratic debates, or the difference between the general left and right about the issue. Shibboleths like “socialized medicine”, and “health care for all” get thrown around at each other, continuing to generate anger and resentment, but not enough understanding. The heat, again, generates little light.

We still have left well over a year before the 2020 elections. It is my hope that in that time, through the multiple debates, discussions and diatribes which will ensue, we can find a way to understand together enough of the basic issues to make some reasonable and common analysis of why we are were we are and what are some options going forward.

I hope to reframe a view of the basic issues behind the unsustainable growth of health care costs. I also hope to make the point that the calls to allow so called “market forces” to regulate health care costs as based on a false assumption, and that health costs can never be subject to market forces. I hope to show how any large restructuring process, such as the ACA was, and such as are being proposed now, while not perfect, have roots in the purpose of addressing those issues. I hope to show where other efforts will continue to be needed if we are to succeed in bringing both costs, service and their balance into line.

Let me propose that for the moment we entertain the following premises:

1. There is more than enough blame, lack of communication, partisan bickering, special interest, and lack of understanding to go around in the health care debate. It is almost impossible to find a single clear comprehensive statement about the nature of the problem. The sound byte culture has not allowed anyone to offer a vision or conceptualization clear enough or accessible enough for the expert to find it valid, for all stakeholders to find it fair, and for the average citizen to claim to understand it.

2. The costs of the system are the key to defying a ready solution. Although most of us wish there were no one without health care, the moral issues regarding the uninsured are not the only concern for the majority of the American public. The need for reform has to be framed both in terms of fairness, but also in terms of the unsustainable costs to our society and our future. The system which President Obama sought to fix was not out of control just because insurance companies denied people for pre-existing conditions. Insurance companies denied people for pre-existing conditions partially because the costs of the system were out of control. We don’t spend a fortune on health care because we have millions without coverage, we have millions without coverage because we have to spend a fortune on health care.

3. Our nation includes those who hold widely divergent philosophies about the role of government in the common welfare of its citizens. We encompass very different views of the nature of health care, whether it is a ‘right or a privilege’, a market service or a commodity. There is a vast difference in the personal financial impact both for those working in the healthcare ‘industry’, and all other participants in the economy as a whole. There are vast differences to all citizens, and residents, of this nation depending on how we approach health care reform. There will be widely differing political consequences for the two parties depending on whether and how the health care conundrum is solved. These wide divergences of view, philosophy, financial impact and political consequences would make it extraordinarily challenging to ‘fix health care’, even if we all agrees that it has to be fixed.

4. Finally, even if we were to compact together to try to overcome the blame, lack of communication, bickering; even if we were all incredibly motivated to save the money we waste, even if we were willing to try to bridge the gaps in our philosophies, views, financial impacts and political consequences, still we would have a difficult time reeling in such a massive, complex, multiple player, multi-layer, multi-trillion dollar system which effects everyone at the most vulnerable moments of their lives. Given the very best of intentions, even if there were the commonality which we lack of vision and purpose, still the very complexity of the issues involved would make solution near impossibly difficult.

Let us then, for the moment, accept these premises and still try to move forward in framing the issues and difficulties.

What are the real costs of health care?

The figure is often quoted that we spend a much larger percentage of our dollars on health care than do other industrialized nations. Specifically, we spend almost 18% of GDP on health care, versus the average of 9% in the OECD (Organization of Economic Cooperation and Development) states, which is comprised of 30 democratic market economy countries, all first world, including such countries as the major European democracies, Canada, the USA, Japan, Australia and New Zealand. We hear the percentages, but rarely has it been articulated what this really means. Let’s “do the numbers”.

In 2009 the US GDP was 14.2 trillion dollars. The percentage of that GDP which was spent on health care is 2.34 trillion dollars. If we spent on health care what the average OECD country spends (8.9%), we would be spending 8.9% of 14.2 trillion, or 1.26 trillion. That is 1.08 trillion dollars less per year than what we now spend.

In other words, as a nation, we are spending one trillion dollars more a year on health care than we would be spending if we spent at the same rate as the average OECD country.

For perhaps a specific example. There is wide variation among OECD states and perhaps we don’t want to compare ourselves to Turkey or Slovakia., Let’s take Germany as more comparable. Germany spends 10.9 percent of its GDP on health care. If the USA spent the same percentage of its GDP on health care as does Germany, we would spend 10.9% of 14.2 trillion dollars, or 1.54 trillion dollars. That would still be 800 billion dollars a year less than we spend now.

(This figure, derived here from primary data, is the same figure I heard President Clinton cite in the only discussion of the concept I have ever heard publicly expressed, so I think we can take the 800 billion or so as reasonably accurate.)

So let’s examine what we could get for that 800 billion dollars every year. The size of the US National Debt is currently about 22 trillion dollars. (It was 11 trillion at the beginning of the Obama presidency, it was 19 trillion at the beginning of the current administration, so rising by about a trillion a year in both administrations, perhaps a shade faster now.) If the amount saved in health care each year by spending the same percentage of our GDP as does Germany were applied directly to the principal of the debt, the debt would change as shown in the attached graph, and we as a nation would be debt free for the next generation. (This graph was constructed in 2012 when debt was smaller and growth of debt per year smaller, so it would now be somewhat later, since since this calculation doesn’t account for the interest).

Fig 1.

This would be a very valuable use, I think most would agree, for any savings which could be realized if we could somehow bring our spending on health care to the level of a comparable country like Germany,

How about if we didn’t use the savings to pay down the national debt? How about if we used it to build things? Well, at about 25 million dollars for a hospital, that would be 32,000 new hospitals a year. Schools? About 53,000 new schools a year.

Let’s say we are military minded? Many of the detractors of Obama care and any current proposal have a strong belief in the importance of national security, as do we all. If we spent the same percentage of our GDP on health care that Germany does and devoted the rest to our military, it would easily more than double our defense budget. For the extra money spent on health care we could buy about 178 new Nimitz class aircraft carriers a year! We could put about 5031 new F-22 raptor fighters on them a year! We could pay for another two wars like Iraq and Afghanistan each 18 months -we could, well, you get the picture. (I am NOT advocating that as the best use of the money! But some might. At least we’d then have the money to argue about!)

To consider how we could save the money difference between what we spend and other industrial nations spend, we need to ask why is our care so expensive. In other words, what ‘drives’ our health care costs so much?

What are the Real ‘Drivers’, or ‘Driving Principles’ of Health Care Costs?

One reason that it is difficult, even without the dramatics, just to intellectually discern a way forward is that it is difficult to dissect the drivers of health care costs.

Table I lists a comprehensive, but by no means exhaustive list of those factors which have been cited as ‘drivers’ by various commentators on the health care crisis.

Table 1
List of Drivers….

The sources I used to compile this list of drivers ranged from university based, presumably objective scholarly treatises to short admittedly and obviously biased blogs, and they range from progressive to conservative commentators, but even a quick glance can show that dozens of factors can be implicated as causal in the nation’s “out of control” health spending. Those factors which any one analyst indicates as a driver of health care costs often depends on which side of the issue one stands on.

Providers may target administrative and legislative costs. Insurance executives complain of the rising prices of care given. Payors focus attention cite demographics, the aging population, obesity and point out the high costs incurred in the care of ‘outliers’, i.e., that relative small proportion of very ill and complicated patients who use the bulk of health care costs.

More liberal analysts will indict the lack of a comprehensive national system while those on the right more blame restraint and regulation of competition.

And everyone implicates increasing technology, except that new technology has the benefit often of years of useful life associated with it, and improvements in technology allow shorter more focused stays in hospitals.

I would propose we step back from the ‘trees’, and try to look at the ‘forest’ from a more comprehensive perspective.

I propose that we can frame the real “drivers” of health care costs as being subsumed into the following four (what I will call) Overriding Driving Principles of health care costs. We may not be able to alter these drivers, and some might argue we should not, but, in my opinion, until we address them explicitly all attempts to move forward will be filled with the kind of anger, frustration, misunderstanding and bickering that have characterized the debate so far.

The “OVERRIDING DRIVING PRINCIPLES” of health care costs

1. The Multiple Layers of Profit Motive.
2. The Incentive Structure of Health Care Reimbursement.
3. The Expectations of the American Patient.
4. The difficulty for patients of maintain our own health, alcohol, tobacco, weight, drugs, firearms, chronic disease.
5. The Concurrence of Fear of Litigation with Fear of Patient Dissatisfaction and profit motive ALL compel practitioners to do more.

And it must be recognized that each of these ‘Overriding driving principles’ move the cost of health care in the same direction – towards more expensive care, not less.

DRIVER # 1: Multiple Layers of Profit Motive

One the one hand, the right to fair compensation, commensurate with an individual’s abilities and efforts, for work performed, risks taken and value discovered and added is an essential feature in our capitalist system. It is a central tenet which has contributed to the development in our society of a growing, inventive and effective economy, and one which has provided a high standard of living for the majority of its citizens. The capitalist incentive has also given rise to technological progress and advancement in almost every area.

It is also true that there are areas within our society where the motive and ability to make a profit are simply not part of the service rendered. There are services which the society simply requires so reliably that the ability to generate profit and gain compensation are subjected, in the notion of a greater good, to other considerations, and the profit motive is controlled and regulated.

In plainer terms, the society offers some essential services to its citizens at a nominal fee, and some public servants are not expected or even permitted to use their role in rendering service to maximize their own individual financial well being. Clear examples abound. Our fire departments, police departments, postal services, public education, public utilities, parks and recreation services, for example, are all provided almost free of charge to all citizens as a right of citizenship, or even of residency. The same is partially true of the military, which, while it has several arms manufacturers which may make exorbitant profits, is as an overall societal effort meant to be paid for essentially by taxes. Individual citizens are not expected to pay private insurance to make certain their personal homes are not invaded by enemies. We don’t pay separately for “missile strike insurance.” Protection from foreign enemies is a service provided to all who live within our borders by the government as part of its responsibility to maintain the state.

I am not suggesting here that the medical system should copy law enforcement, the postal services or the military as a model. Nor am I attempting to demonize those who profit from the provision of health care. I am simply pointing out that while the profit motive is a key part of our society; it is not the only model by which essential services are provided in our country.

We may realize that there are broad philosophical differences between our views of the role of private enterprise in the provision of medical services to our populace. However, broader philosophical issues aside, what is practical and necessary to notice in the instance of health care is that profit motive exists separately at every layer and level in the healthcare industry.

That means profit, on top of profit, on top of profit, on top of profit. Follow the chain. The physician wants and deserves a decent living. So do the nurse, technician and aide. Fair enough. The hospital where they practice wants to make a profit. Or at least make enough to support its administrative expenses and capital expenditures. Many hospitals are designed and run specifically to make a profit, and those publicly owned for profit chains have a legal duty to maximize their profits to their shareholders. Fair enough. The pharmaceutical and medical device industry needs to make profit, enough to justify its continued expenditure and risk, so it says, but also, as many if not most drug companies are publicly traded, have a first duty to maximize profits to their shareholders. Fair enough. (?) The whole system of care delivery is generally paid for with insurance dollars. Insurance companies need to make enough above their expenditures for care to support their administrative structures. And, as many or most are publicly traded, have a primary duty to their shareholders to make a profit. Fair enough?

These multiple levels and layers of profit making thus insures that the providing of profit for each of the various players becomes in itself one major, perhaps the primary cause of expenditure. When I buy insurance for example, the premiums I have to pay are high, in part, yes, because if I get sick I will need expensive services. They are high also because my premium has to be called upon to supply a profit to the insurance company, the drug company, the hospital company, the hospital, and the professional actually providing my care. And many of the players in that long chain, as corporations, have a legal primary duty to their shareholders to maximize that profit.

One’s view of the ultimate moral place of profit making aside, one cannot deny that profit making at every level is at least one major class of drivers for our health costs, costs which, again, which run about $800 billion (170 Nimitz air craft carriers a year) more than other industrialized nations.

One essential plank of any serious attempt to reign in costs would have to be directed to mitigating this particular “driver/driving principle”, that of the multiple layers of profit. The ACA, “Obama care”, through its exchange mechanism tried to enhance competitive pressures on the insurance industry by forcing insurance companies to be more transparent and more competitive. The plan sought in that way to cause insurance companies to lower their prices. That was meant to moderate profits. Not eliminate them. But lower them. By forcing insurance companies to cover the sick, not just the profitable, that would take some of the profit out. Not all, but some. In turn, insurance companies would have (in order to maintain any profit) to lower what they will pay hospitals and doctors. Hospitals will then have (to maintain any profit) to lower what they will pay for drugs and devices, and this will lower some of the profit to those entities.

In essence, through the device of forcing the payer furthest upstream, the insurance company, to become more competitive and less selective in picking out the healthy patients and denying the sick, the Obamacare idea was designed to have the effect of gradually moderating some (but not all) of the profits out of the system all the way down the line. It is a very slow and gentle way of doing it.

The present administration encouraged tremendous antipathy and has sought first to eliminate then to provide obstacles to Obama’s plan. Remember this was, essentially a plan in which private insurance remained the primary payor but with enhanced regulation and facilitated competition, transparency and more universal delivery. Now, Obamacare, the “affordable care act” with its emphasis on mitigating the profits of private insurance, weakened, threatened and compromised, there is arising among the more progressive democratic wing an increasingly insistent demand for either a single payer, or a public option added to the existence of private insurance.

Those on the further progressive wing insist that the single player plan, so called “medicare for all”, would be much more effective, in providing care and controlling costs. Others, more centrist argue both that such a change it is not in keeping with the capitalist approach of the rest of our society, and that any sudden attempt to effect such a change would be much more disruptive. They have argued for either adding a public option to the already existing ACA (Medicare for all who want it), taking a gradual path in transitioning toward a single payer, or just improving the current ACA, making more effective its reliance on improved regulation and competition among private insurance carriers. Each of these seeks to make the Payor (government or regulated insurance” pay less, and thus control costs by slowing payment.

I believe that the difference among these positions can not be effectively resolved without making more explicit the goal that either, or any, of these approaches is seeking to achieve. I believe all candidates need to explicitly state that:

“To lower the costs of healthcare, we must modify some portion (perhaps not all, but some) of the multiple layers of profit existing within the current system, and to start off by putting some downward pressure on the insurance companies is one effective but gentle way to do it”. To eliminate insurance companies altogether would be a much more drastic attempt to achieve the same global goal”.

Once the goal has been stated explicitly, and the reason for this goal made explicit, reasonable thinkers could then weigh and balance the risks and benefits of various methods to achieve that goal.

DRIVER # 2: The Incentive Structure of Health Care Payment

This issue has been mentioned every time health care economists say that they want a system to pay doctors for better outcomes and not for each procedure they do. The most common method of reimbursement in the current payment for health care is called “fee for service”. The doctor, or hospital, are paid separately for each service they perform.

The drawback is well known, namely that “fee for service” may have the incentive and result that more reimbursed services will be performed and then billed for. Of course no one expects physicians to do unnecessary procedures just for the billing. But it is considered to be possible that when there is no great scientific evidence for one course of action over the other, there may be an incentivized proclivity in a fee for service system to opt for the more billable course of action. Not saying it happens – just saying it is possible.

Far more cost effective ways of reimbursing providers are known. These more cost effective ways served as the essence of the Managed Care companies who became the villains of the nineties. These are the companies, which, by the way, squeezed so much from the cost of health care that their profits from the savings became legendary. If those profits had been uniformly returned to the society and not given to CEO bonuses, we might have remembered with a far more generous attitude these organizations, intended to lower costs, than we have done.

It is not my intention to review all the devices of managing care, but it is worth using one example to make the point, and I’d like to contrast ‘fee for service’ reimbursement with what was called ‘capitation’ – not to further exhaust a subject which is well known within the industry but to illustrate for the general reader the essence of some ideas which underpin some of the current dialogue.

In the “fee for service” model, as we have said, the provider and hospital are paid for every service they provide. Let’s provide an example. Let’s say a patient comes to the emergency department. They get a fee for using the hospital (a ‘facility fee’) as well as a fee for the physician’s services (the ‘professional fee’) From the hospital, they get billed for every lab test ordered, every intravenous line started, every medication given, every x-ray taken. Again, for the x-ray, they get a bill for the x-ray itself, and a separate fee for the professional radiologist reading the x-ray. Now, again, to be clear, I am not suggesting that the hospital or the doctors do more tests because they have a financial incentive to do so. However they have no financial incentive to refrain from doing so.

If pure “fee for service” gives the most incentives to spend more, then pure “capitation” was perhaps the most effective cost containment tool in the armamentarium of the managed care companies because it provided the strictest incentives to limit expenditure. Capitation, in essence, provides a total lump sum for the care of a specific number of persons, and leaves it up to the health care providing system how they chose to spend that money. That system was designed so that it was now in the provider’s financial interests to spend as little as they need to. If, say, a million dollars is to be divided between a thousand persons, then spending the whole million on two patients would leave nothing more for the rest. The company would have to pay for that extra care from its savings, or profits. It therefore gave the incentive to restrict care to that which is really necessary. That would, hopefully lead providers to spend fewer dollars over the year for their thousand patients than they were allotted, and then save or distribute the rest. Using capitation, however companies drove costs way down, and, sometimes by denying what many thought was necessary care. Some, as we all know, pocketed the huge profits made…or saved, depending on how you look at it.

Since the insurance companies already know from observing their managed care competitors over decades that the best ways to lower the cost of care involve managing care (with incentive structures akin to capitation), it is expected that when forced to cut medical outlays to maintain some profit, the insurers will have to reintroduce, perhaps gradually at first, the principles of managed care of provider incentives, because they know the principle:

To lower costs, we need to change the incentive structure by which costs are paid.

Now, why didn’t managed care, with its very effective, scientifically designed and empirically demonstrated ability to cut costs continue? Because in its own desire to maximize profits, since companies were not being rewarded but rather financially penalized for spending resources on tests and procedures, they limited and restricted the tests and procedures in such a way that the patients covered began to feel, sense and realize the the managed care system was limiting their care – and often in such a way that it seemed not in the patient’s best interests. It felt like the managed care industry was putting profits in front of patients, and, thus it ran smack into the third driver/driving principle of health care cost increases – the strongest and most intransigent driver of them all.

DRIVER # 3 – Patient Expectations

I saved this area for later in the discussion for two reasons. First is for lasting emphasis. The question underlies every discussion, yet is never explicitly isolated as a cost driver. We are constantly reminded that the kind of care which is found in Canada, the United Kingdom, France, Germany, and most of the industrialized first world would not be acceptable here – that the level of care provided to virtually every other modern state would not satisfy the expectations of the American patient. We never ask, however whether perhaps those expectations may be realistic or sustainable. Or, perhaps to frame the question more palatably, we don’t ask whether it is worth it, to satisfy those expectations, to forego the $800,000,000,000 every year we spend to try to meet them.

I finish with the question also for a second reason. It is unpopular, perhaps politically impossible, and for some offensive to discuss anything that has the faintest whiff of “rationing” care. I don’t think we should ration care – but why can’t we rational-ize it?

It is pointless to put that question first, because we would run into such resistance. But perhaps after viewing the vast difference in our nation’s expenditure on health care, examining the role of layer upon layer of profit motive, and examining the inherently cost increasing effect of the most common current incentive structure, and suggesting how these can be changed, we can now dare point out there are efforts individuals might make in examining their own expectations which could have some effect on viewing how we delivery health care.

As an emergency physician with board certification and experience in internal medicine and critical care as well, with former teaching posts at both Harvard and Yale, and also decades of experience in urban and suburban emergency departments, I have seen first hand for thirty years that many American patients expect to be able to come to the emergency department for events which are, perhaps, not really emegencies – colds, bumps and bruises. It is also true that many American patients expect that every sniffle needs a chest x-ray, every bump on the noggin a CT scan.

More costly, but also more morally challenging are the issues on the other end. I have seen many times situations where, no matter how hopeless the prognosis nor how (apparently) limited the quality of life, any family can demand a virtually unlimited amount of resources enormously costly and often futile intensive care in the last few weeks and months of life.

And it is not always clear to the patient or even the physician which bump on the noggin needs a CT scan, or which apparently hopeless person may, in fact, get out of the ICU for another few months, so we are, as physicians inclined, by our nature, culture and training to support expectations of patients no matter how superficially unrealistic, with the traditional “full court press”.

It was precisely this wall which managed care ran into. There does exist, albeit in development, ways to minimize expenditure on both unnecessary and futile care. The managed care industry had developed effective (and truth be told, not so dangerous) ways to limit expenditures. But many of them limited access beyond what Americans expected and believe they deserve. Patients who want to be able to just go straight to the Emergency Department were told, instead, that they had to access 24 hour demand management telephone triage systems, whereby a specially trained nurse or other health care provider, using computerized decision support systems would tell the patient whether they could go to the ED or not. Primary care physicians, “gatekeepers” told patients when they could and could not go to specialists. Managed care companies, employing physicians (whose primary duty was to contain costs) decided who needed procedures like hip replacements, and when. And no one wants to be told, when they believe they have a health urgency, emergency or necessity, that it is not to be had.

This is precisely the limitation that Americans seem to find so odious about the more public care systems of other advanced nations. We have not been accustomed to delay or limit our expectations for the most advanced and immediate technology. And no one has really articulated the case why we should not have it.

The massive expenditures mentioned above, those on the other end of life are a related issue, and emotionally charged issue. Care at end of life is a deeply emotional issue, but one which needs to be discussed carefully both on an individual and societal level. Opponents, when the very notion was originally broached, called such discussions “death-panels”, perhaps in the effort to further make insoluble already difficult questions. However, in the long run, the difficulties in dealing with end of life care, and related questions such as whether nonagenarians should receive dialysis, fall within the rubric of patient expectations. There is no question that with increasing technology, we can offer patients who would otherwise die extra weeks, often months of life, spending the time, technology and money necessary to do so. Whether it is morally appropriate in all cases to do so is a worthwhile discussion. And one which we should have. Is there a balance between one the one hand, an individual’s perceived right to have if they wish access to a veritably unlimited expenditure on sometimes futile intensive care, and on the other hand the need for a society to use its resources in an effective and efficient manner?

This driver, the driving principle of the need to meet our American public’s patient expectations will be the most intransigent, and will not yield easily. It didn’t fade before the clearly demonstrated effectiveness and efficiency of managed care. But with work, time and education, it could be tempered. However, it first has to be explicitly and honestly identified as a driver! To make any change in health care lasting and satisfactory will require a long, careful and systematic process of national reflection about our demands and expectations, so that we can look specifically at what our expectations are, and weigh whether those are supportable or not.

Perhaps I have not listened enough, but to my knowledge no one has expressly addressed the role of overly unrealistic expectations about care. Perhaps no one else believes they exist. Perhaps eveyone knows that it is a politically impossibly tough sell. In either case, I think the American people know, instinctively, that you can’t lower what we spend on health care without lowering a little what we expect and demand, and to address this conundrum more explicitly and more honestly would, I believe, be helpful.

DRIVER #4 – The difficulty we have as patients maintaining our own health.

Addiction, whether it be to food, alcohol, tobacco, drugs, violence, and difficulty in doing the hard work of monitoring and maintaining our own health in chronic diseases such as COPD, heart failure, diabetes, asthma are neither simple, straightforward nor unique to our society. And it is by no means clear that any change in health care financing will have an effect on any of those issues, at least over the short run. At present, doctors struggle on an individual basis to counsel their own patients, often to little or no avail.

It is also true that with our present form of health care delivery, the is little or no national level stake in the population’s overall maintenance of its health. No single accountable, overriding agency stands to lose when too many people smoke, drink, overeat, take drugs or fail to take their heart failure medication. True, as part of the ACA, Medicare placed some incentives, there are becoming more demands, for instance, to have patients with chronic heart failure better manage themselves at home. In many cases, now, repeat hospital admissions within a short period of time are not compensated or penalized. We can ask though what overall entity is at risk, though, when too many people engage in non-health protective efforts.

In the days of the 1990s when HMOs were in ascendency, some made increased and active efforts to develop preventative health programs. To do so on a nationwide and effective scale would probably take a very long and concerted effort. Look at how many decades it has taken, more than half a century, to bring down the rates of smoking. Still, if we treated alcohol, obesity, smoking, drugs, and firearm violence as health emergencies causing damage to the whole economy, we might find ways to begin to address them.

This argument does not mandate any particular solution, but I propose that when we recognize self destructive behavior as well as the inability to maintain good health maintenance preventative care as a primary DRIVER of health care expenditure, we will perhaps be in a better position to start to manage it.

DRIVER #5 – The Concurrence of Fear of Litigation with other drivers

Both physicians, and opponents of health care reform in general have both emphasized the role of so called defensive medicine. Proponents of tort reform identify it as the primary and preferred method of cost control, while those who have studied its effects say the defensive medicine adds a very small fraction of the costs of healthcare. What can be said, I believe, as a practitioner is that fear of litigation is in itself a minor factor but one which combines with all the other drivers to move in the same direction.

Let us say that I were a physician practicing in a hospital which, using fee for service, makes a profit on CT scans, and also say that my community’s patients expect that they will get one when the hit their head. Let us further guess that my patients might write to my chairman if they are dissatisfied, or at least give me a bad score on a patient satisfaction survey. And let us further notice that my department takes patient satisfaction, that is, specifically, the satisfaction of patient expectations, seriously. And now add to that my awareness that in the hopefully very unlikely chance that I send home a patient with a normal neurologic exam after not doing the CT and they end up with the very rare occurrence of having something bad happen, I may get sued.

The fact is, if I’ve documented well, and avoided a really egregious error in judgment, I will probably win the suit. I don’t do the CT specifically to avoid litigation, but, and this is the key point, since I am paid by a hospital which profits from the CT, and my patients expect the CT, and they will make my life less pleasant if I disappoint them, and they might sue me if I don’t and miss something – I DO THE CT.

And that’s the point. Every single driver in our multilayer, multiplayer, multi-trillion dollar juggernaut of a health care system works together to drive us to spend more.

Having looked, I hope, explicitly at the Overriding Drivers, let us look at one oft touted but I believe unreliable solution.

The ‘Myth’ of the Role of Market Forces on Health Care Costs.

Those who generally oppose any central government role in the regulation of health care point to the market, to ‘market forces’ as a solution to the issue. The notion of “consumer driven health care” has received considerable attention especially in conservative leaning publications. It is suggested that when consumers (patients) are spending their own money, which they have been encouraged to save through tax advantaged specific health savings accounts, they will be more frugal than they are when third parties, i.e., insurance companies pay. Fewer unnecessary tests will be done, lower cost providers will be sought out, and the market will act as it is supposed to do to lower costs. Examples in which this has occurred, such as in plastic surgery, are cited. It is held that insurance should not be used for routine visits, but only for true catastrophes.

There is one major fallacy in the market theory of health control. With other goods or services the consumer’s informed choices determine the price of the goods or service both by putting suppliers into competition with each other, and by buying only when the value of the good or service purchased seems worthwhile for the price demanded. With the case of health care, much of the time, no real option exists to decline to use the service. Oh, yes, of course, you can put off elective preventative care for years (how many of us put our colonoscopies off as long as possible!?) However, in the face of severe pain or loss of function, especially to a child or loved one, there is simply no option other than to go to the doctor, and do what one is told. Shopping around for the lowest cost provider when you or your child is writhing in pain, or afraid for your life, is a non-option.

Furthermore, current internet empowerment notwithstanding, the patient is simply in no position to say what is appropriate to do. Physicians don’t always agree. The patient simply does not fulfill those criteria of ability to make an informed choice to choose or decline an expensive service, especially in a moment of extreme pain, fear or disability. The criteria which are necessary to make market forces a real controller of a market simply do not exist. Healthcare costs can not be controlled by “market forces”. It is an illusion.

Suggested Principles which might inform a comprehensive health care debate.

Now, I have reviewed and detailed what I believe are the real Overriding Drivers of HealthCare Costs. How can we begin to address them? I can’t claim to have the definitive answers, and I am not going to take specific sides at this juncture between Bernie, Joe, Kamala, Pete and Kirsten! I am going to seriously hope that they will find a way to elevated this discussion from a sound byte contest to a serious a joint and mutual consideration of these important aspects.

It is my wish that those candidates running for office would make the effort to articulate then discuss from the point of a common understanding of some of the issues what might be able to be done. I believe that would lead to a more fruitful evolution of thought, and ability to choose our candidates, then the current hand raising to single dimension questions.

Here are some suggestions of ( what I might call ) ‘Guidepoint Concepts’ which might help focus such a discussion.

1) Some efforts are large enough, complex enough, and demanding enough to require that the primary controller be governmental. That was true of the second world war, the development of the atomic bomb and the trip to the moon. The needed role of government as a provider of health care was clearly and explicitly acknowledged in the creation of Medicare. Those who think that if we just step back and let “the market” work are at least 60 years behind the times. The government is already ‘up to its ass in alligators’ in health care. Let’s discuss how best to make it work.

2) Personal resources and savings cannot be relied upon to pay for health care. Some form of insurance is needed. It is a pipe dream to believe that personal resources or “health savings accounts” can pay for health care. Perhaps most upper middle class people can afford the occasional few thousand for an ER visit, or maybe even to have your gallbladder out. But very few could come up with a few hundred thousand for a coronary bypass, and almost no one for the potential millions of dollars plus of a truly catastrophic illness or injury, stroke, paralysis, birth injury which happen every minute to someone across the country. Just can’t be done.

3) The larger the risk pool, the greater the number of covered persons, the safer, more stable and more resilient the insurer is. If three of us in a room decide to pitch in, say, five thousand dollars a year to cover each other, and one person gets a million dollar injury, we cannot cover it. If three hundred of us do it, we are a little better. If thirty thousand, then there is enough to cover most contingencies. If all three hundred and fifty million of us throw in a few thousand, we get closer to being able to cover the whole. The larger the contributing pool, the less likely any risk is to take down the system.

4) Fee for service is not the most cost effective way to pay for medical care. There exist and have been developed and researched and put into practice multiple more effective methods. While the “capitation” model caused much dissatisfaction to patients and providers, much of that could be mollified if the purpose of capitation were not to generate profit. And fair compensation could still be found for all health care professionals, albeit probably not at the upper levels now found in some specialities. Another longer discussion.

5) The competition among insurers, and the multiple layers of approval, fee setting, price comparison, network policing, to say nothing of shareholder distribution, marketing and the like mean that huge proportions of money available are spent by private industry over what a governmental system would provide. This is not to say that there is no role for private industry, just that costs inevitably go up.

6) We may be compelled to accept, in some manner, a multiple tiered health system, as much as that may be anathema to some. We have mandated as a society that no one should starve, and we provide necessary food to all who live here. That does not mean the the best restaurant in New York accepts food stamps. There will always be some disparity between the services received in any sector by the richest and the poorest. The difference, however, may be in amenities, it should not be in necessities. If the nation creates a system whereby all who live here receive all the care necessary at a reasonably cost effective manner, then it should not be impossible for those who can afford it to have, additionally, private access to ‘luxury’ services. I don’t object to the existence of the so called “cadillac health plan” if there exists no one in the country without reliable, safe, decent and affordable access to a clean, comfortable and punctual bus. (Maybe not the best analogy but hope it makes the point!)

7) A broad governed system, even if it evolves to an ultimate single payer type plan could still experiment with the optimal ways to regulate and distribute care. Perhaps Managed care plans and captivated plans are best for some, more specific isolated and partially self insured plans may work for others. There have been “demonstration projects” and, I believe, under the rubric of a more centrally planned system there still may be room to experiment with a variety of different such projects.

8) Finally, whatever comes to be the best, final, optimal solution, it will of necessity take some time to transition. That is not to say big big changes cannot be made, but there will be some evolution period needed. This is not only due to patient expectations, and the strength of the financial industry as it currently exists, but because for major change to occur, those who have spent their lives working in the industry will need to participate in its evolution as well. I think the vast majority of physicians will tolerate evolution of health care such that some element of autonomy, and profitability has to be sacrificed to a longer and more wide ranging good. I think, perhaps naively, that as a system changes to make health care less of a profit maker and more of a universal service, most if not all of the executives who run the systems will either change their own expectations, or enter other more appropriately profit driven industries. But these changes will not happen immediately, any more than it could happen immediately for patients to learn that they have to call a telephone triage demand management system before going to an ER or the doctor. Any major effort to really bring our nation to the point when we both have that extra 800 billion dollars a year, and a safe and satisfied populace, will take us time. And education. We need to be aware of this, and factor it into our own expectations for change.

BOTTOM LINE IS IT TAKES REAL DISCUSSION AND KNOWLEDGE, not sound bytes and one liners.

I would call upon those running for office, especially on the democratic side (but if republicans want to join, I mean really join in the discussion why not have them) to reject single line answers and hand raises, simple sound bytes and emotional appeals. I hope and call upon the field jointly, together, in the process of the debates and discussions to follow, start to expose, examine, analyze and then put together a serious and complete proposal.

In that manner, perhaps only in that manner, can they expose the bankruptcy of the “repeal and replace” simplicity of the current administration, draw a meaningful distinction and prepare to take back governance.

I hope that the issues pointed out in this article are relevant to evaluating the current arguments. I wish that out of the “everything that has been said”, these things had been said more clearly. I hope that those running for office can find a more focused way to address than is allowed by raising your hand to a simple yes/no question.

If these arguments were more explicitly framed, the American people would then be better able to ask and answer what may be the best ways forward.

How would that hurt?

Dear Senator McConnell,

It would be a bad bargain to gain a conservative majority while losing the nation’s shared respect for the legitimacy of the Court and the Rule of Law. That would not be a “good deal”. Senator McConnell, when you do something as patently and obviously outside of the bounds of fairness, equality, and lawfulness as denying a hearing to one president for reason of proximity to an election, then turn around and grant the same hearing to another of your party, you erode, degrade and will ultimately destroy our nation’s sacred basis, that we are united in being governed by consent and the rule law.

The Rule of Law has been defined as “a principle of governance in which all persons, institutions and entities, public and private, including the state itself, are accountable to laws that are publicly promulgated, equally enforced and independently adjudicated…”

Let me tell you what the “rule of law” has meant to me. It has meant that my parents taught me, and I taught my child, that the police are our friends. That when I choose charities, I include national and local police. That when, as an emergency physician, a police officer comes to see me that I take them, sometimes out of line, as quickly and effectively as possible in recognition for the service. That on those times I have served as a juror I have, whether rightly or wrongly, taken the sworn testimony of a police officer as having more weight than the accused against whom the officer is testifying, and convinced others to do so. That in general I offer respect and gratitude to the officers of the court and of the law, and finally – and most importantly – that I obey the law, do not attempt to skirt it, even on my taxes, even when I think I could do so.

Your party has been trumpeting on about the “illegal” entry of persons into this country, but you yourself have, and are, undermining, compromising, and ultimately destroying the very respect for law you insist on. I suspect this is not only true for me, but true as well for tens of millions like me.

President Obama had the legal right and duty, when a vacancy came up on the Supreme Court, over a year before the end of his legal tenure in office, to name a replacement. You were derelict, and intentionally so, in your sworn duty and legal obligation to advise and consent. That in itself compromised my respect for the rule of law. And by extension those charged with supporting it. It left my respect for institution severely damaged. But you would have a chance to shore it up. If you do not you will leave it hanging by a last thread if at all.

The precedent of not considering the legitimate nominee of a sitting President was at best questionable. However, if you were to apply that very same standard now to a President of your own party, it might serve at least temporarily, to shore up some shred of belief and respect for that, we would like to believe, impartial and legitimate institution of our courts and laws.The issue could then be, as it should be, impartially adjudicated at a later time.

If, however, you go ahead in what even to you must clearly be a hypocritical and obvious deviation from the notion of the law applying equally to all, then you will, for me at least and I suspect for millions of others, permanently compromise, subvert, and leave in taters what has for me been, up to now, a heartfelt respect for the institution of law in our nation. If the Supreme Court is compromised, the Law is compromised. If the law is compromised, respect for its enforcement is also compromised.

In such a case, I myself, for example, a hitherto very compliant and law abiding citizen would no longer feel it incumbent to support the institutions of the law. Those should be based on equality, impartiality, and fairness. But if, when in power, you don’t support them, then why should I?. Not that I would start undertaking ‘criminal acts’, I wouldn’t. I would no long feel inclined to count law enforcement as a primary target for my charity, nor feel it necessary to automatically give the ‘benefit of the doubt’ to the police in a court of law. As representatives of a system whose integrity is, at least meant to be, above question and above politics, I have done so. In the future, I am not so sure.

I hope that you could find your long term duty, and the best interests of this nation, to stand, politics and personal preferences, and servility to your party aside, for the fair, impartial, and equal application of the rule of law. Then I would also continue to struggle to do so. If, however, you will not, and you just do what you have the temporary power to do, then why should I stand for the law, for fairness? I think that the overall diminution of respect for our legal structure and norms is not a legacy you want to leave. That would be a bad trade for your conservative justice. A bad deal.

I know the chances of you every reading a word of this are close to zero but I hope you do, and I hope you consider as you rush toward trying to cram a conservative enough candidate through a deeply divided senate to please a clearly divisive president, what the long term implications will be. Your conservative justice will, last for decades as is well known.

But the lack of a common and shared notion of legitimacy, the lack of respect for the institutions of our nation, the lack of regard which your actions will create for the notion of the rule of law and those who enforce and adjudicate it will last far, far longer.

Consider it, Mr. Senator. Consider the real duty is, of those sworn to uphold our constitution and the rule of law in our nation.

With respect,

A citizen who has traditionally loved and supported our nation for its sincere attempts to govern itself through the rule of law and the principles of democracy.

I. Hillary Clinton is widely acknowledged to have the edge on intellect, reasoning, foreign and domestic policy experience.

A. On Tuesday a letter was signed by 370 economists, including 19 Nobel Prize winners, saying that HRC’s economies would be better for the nations, Today the respected journal The Economist endorsed her

The position held by these 300+ economists is clearly echoed by foreign policy experts , a prominent group of GOP experts in foreign policy, Even Republican foreign policy experts have cautioned that Donald Trump would be dangerous to the nation’s security.

The prestigious journal Foreign Policy, hitherto bipartisan academic journal has broken its long-standing tradition and endorsed Hillary Clinton, as has the Atlantic Monthly. In fact, over 186 major newspapers, including NYT, LA Times, Washington Post, and just recently The Economist have backed HRC. Many of these are traditionally Republican.

B. Yes, six papers have endorsed Mr. Trump, about one thirtieth of those endorsing Clinton. They are the St. Joseph News-Press, the Santa Barbara News Press, the Waxahachie Daily Light, The Hillsboro Ohio Times-Gazette and the Las Vegas Review Journal.

Few reasonable persons would argue that HRC is not clearly more experienced, capable, intelligent and competent than Mr. Trump. Still many oppose her because they believe she is so ethically flawed and criminal that they can’t vote for her. Which brings us to the next argument.

II. The long standing drumbeat of accusation and innuendo, including the FBIs recent suggestion that they are looking at new emails, without knowing if they are pertinent, fits into a long standing pattern of suggesting that HRC, and President Clinton are engaged in some sort of ‘vast criminal conspiracy’ and they suggest her ‘crimes’ range from theft to perjury to murder. In fact, she has NEVER been charged with a crime, any NONE of the dozens and dozens of investigations uniformly by Republican investigators have ever found evidence of crime, or wrong doing.

One cannot document this argument nearly as well as I’d like here, but an earlier argument on this same site details a rebuttal to these accusations, and one hopes that if there is anyone who really knows in their heart that HRC is the more capable but somehow cannot abide the idea of her ethical challenges, one might suggest they please take the time to see that rebuttal of the innuendo.

III. Mr. Trump has challenged and subverted those very things that actually make America great.
Our most fundamental liberties are the liberty of speech, press and religion. He has said he would exclude people on the basis of their religion, he has thrown reporters out of his rallies for disagreeing with him, he has repeatedly advocated for violence against protesters exercising their right of free speech. He has called for torture. He has called for the killing of the families of adversaries. He has called for jailing his political opponents. “Lock her up”, when she hasn’t been convicted or even arraigned for a crime? I think they call that kidnapping, so he advocates what might be a capital offense in some states. He has suggested that gun rights advocates could might be able to prevent HRC doing what they like…you know the implications. He has stiffed his employees, probably cheated on his taxes or at best bent the rules but he will not release his taxes for us to know, and his statements about the reason are not, shall we say, true. As a matter of fact people keep lists of his statements which, to put it politely, are not correct.

IV. Our children look to our leaders as role models. HRC may not be the angel her supporters feel she is, but the argument that he is a better role model is so false as to be, well, insulting.
Even if you assume the worse, that HRC was so sloppy as to leave a confidential memo on an unsecured source how would that ‘crime’ stack up against Mr. Trump’s demeanor in this election? He started by saying Mexican immigrants were rapists, all but “some whom, he assumed, were nice people”. He went on to infer an native born American judge couldn’t be fair because of who his parents were, inferred that a respected female right wing new-caster couldn’t be fair because she had “blood coming out of her…what-ever”. He has insulted, and perhaps assaulted woman, on tape!

V. The potential downsides of Trump presidency outweigh the potential downsides of a Clinton presidency by a large margin.
Markets are in the business of assessing risk. Here is an image of the Dow Jones industrial average since Friday October 28, when the FBI announced it was looking at the possibility of other emails. Until that announcement, an HRC presidency was considered by most to be inevitable. Here is what happened since that announcement:

Moody’s Analytics has analyzed a Trump presidency and found it likely to lead to very negative consequences for the American economy. They predicted, in contrast, a large positive effect for a Clinton election.

The Economist, another respected journal, listed a Trump presidency as one of the top ten global risks and just today endorsed HRC.

Mr Trump endorsed a Brexit vote, calling it “taking their country back”, and compared his victory to the unexpected Brexit victory. Let’s look at the effect of Brexit on the British economy. The following is a graph of projected British growth pre and post Brexit:

The data projections, from reliable sources such as the Bank of England, Thomas Reuters show a clearly decrement in estimates of GDP and growth.

This parallels very closely what could be expected, America Great rhetoric aside, from a Trump presidency. Or at least so say Moodys, the Economist, and several hundred prominent experts including numerous Nobel Prize Winners.

VII. In summary, HRC represents a better political philosophy, one which addresses better the concerns voiced by the supporters of her opponent than his would. She is more capable, more experienced, supported by far more economists, foreign policy experts and incomparable more and better editorial boards. Her temperament is vastly better for the position, and the objections to her have been, (pun intended) trumped up, exaggerated innuendoes and implications, none of which have ever been shown meritorious.

The arguments above are passionate, but they are logical and supported.

An election is a time to make an intelligent and informed decision, not a time to vent anger. I know the decisions I have made when I have been angry. They are not always the best decisions.

If someone is asking you to make your decisions out of anger and resentment for the system, you might not be making the best decisions.

Think it over.

This is Part II, the second article in which my hope is to frame the election not as a contest of personalities, but rather with recourse to the differing political philosophies, progressive versus conservative, which underlie the platform and vision of the two parties and candidates.

Between these two personalities of the candidates, and the baggage that each brings, from the constant reminders of email controversies, allegations of sexual predation, the inflammatory rhetoric and insults, discussions of temperament and the like, so much attention has been directed at two individuals and the issues of their personae, that almost completely lost has been any awareness of the two governing principles being contrasted. Ultimately, while the personal peccadillos of the candidate are of key importance, no less so is their approach to governance.

In Part One of this article I argued that a progressive, “liberal”, center left approach to government, at the present time, was most likely to solve the overall threats to our society, and world.

In this, Part Two, I would like to drill down to the issues which seems (when any issues are discussed at all) to get the most attention. That is globalization, trade, immigration – basically our relationship to the outside world and how it effects our overall economy, our employment picture, and how the benefits of the last seven years of recovery have been distributed, or rather not distributed throughout our society.

I will try to research the benefits and detriments of so-called globalization, whether it is inherently harmful to our overall economy and also to the middle and working class, and whether the damage done, if any, can be corrected by different trade policies and barriers to illegal immigration. It is worth considering whether, regardless of the personalities involved, liberal policies would be more helpful in alleviating and addressing the distress caused by globalization, or whether conservative policies would be better. I will argue for the former.

I am aware that at this stage of the game, the election may come down primarily to personality, whether the number of people who view Hillary as a cheat and liar outnumbers those who think Donald is a megalomaniacal fascist and sexual predator. Perhaps that is the nature of elections in this day. Still I think some consideration of the political principles which ultimately inform the two camps is worthwhile, and I hope I can draw distinctions which a reader might find useful.

Globalization and the differential effects on different segments of the work force

It would be pointless to argue that “globalization” has been of universal benefit. It has been of mixed blessing and detriment. Even experts who have advocated for increased globalization argue, that globalization has failed to live up to its potential” to bring benefits to both the developing and developed world.

On one hand, economic analysis shows a beneficial effect of globalization on overall growth.

Some economists have a positive outlook regarding the net effects of globalization on economic growth, citing variables such as trade, flow of capital, GDP per capita and direct investment. However the largest effect has been in the transfer of wealth to well-educated and technically skilled segments of the economy. For those not at the top, however, the benefits have been considerably less. It has been noted that

“as labor-intensive industries move to developing nations, demand for labor in the United States decreases, thus reducing wages for non-college educated workers. At the same time, globalization increases demand in the United States for professionals, skilled labor and capital, thereby increasing incomes for college-educated workers and widening the gap between the rich and poor.”

The need to compete with workers in poor countries leads to decreased wages for non-college educated workers. Certain domestic industries, ranging from consumer electronics to textiles are “endangered due to comparative advantages of other countries” Further, growth in competition which inevitably follows growth in trade leads to domestic companies having to down-size to improve efficiency and increase profits. (Labourec

It is interesting that globalization has also lead to a worsening of the position of unskilled relative to skilled labor in developing markets.

Stiglitz, an economist known for his concern over growing inequality, argues that this is because special interests have constructed the rules to benefit themselves and that has lead to the detriments to those not so happily connected. He was referring primarily to the growing imbalance between rich and poor, industrialized north versus developing southern global economies, however the success of Donald Trump’s candidacy in bringing out real passion, real anger over this issue is clear evidence that such disparities exist in out developed country as well.

Donald Trump’s answer to the adverse affects of globalization on lower economic sector wages is to institute a form of trade protectionism. While this may have short-term benefits, in the long run it lowers general competitiveness and weakens overall world growth, as it was said to do in the great depression and lead up to the Second World War. At that time short term and temporary gains in local employment were ultimately followed by longer-term decrements in trade, productivity, and prolongation of depression. Isolation of American products from international competition has not been shown to increase, in the long run, the competitiveness of American industry, as was demonstrated by the growth of Japanese presence in the car industry at a time when American’s rested on an increasingly non-competitive standard.

There are real questions about whether, for example, NAFTA had a net benefit or gain. One recent Wharton school of business analysis concludes that, while there have been a net loss of some jobs, automotive jobs, for example, from the United States there are certainly gains for North America, and that had there not been a NAFTA, most of the jobs that have gone to Mexico would have gone to China. Interestingly enough, the author also concludes that the NAFTA facilitated improvement in the employment situation in Mexico has brought migration of Mexicans into the US to a virtual standstill. That is not what we would hear from Mr. Trump.

There is not one single “liberal / progressive” view on whether to increase globalization, and many well remember that in the primaries the more progressive wing of the Democratic party looked with great suspicion on a process which enriches the upper echelons to the detriment of the workers. However I believe a center left position would look, rather than to kill trade with protectionist policies, to help workers retrain and retool for growing industries. That is, at least, Secretary Clinton’s position.

The effect of immigration on American workers

The effect of immigration on American work force and wages is complicated. Some reports have suggested that rather than lowering economic opportunity for native born Americans, immigrants actually increase the opportunities for American jobs and incomes. This is because of a concept called “complimentarity”, which essentially says that if a low paid, less skilled worker can help a higher skilled person to get their job done (the person who builds what the architect designs), then both benefit. Providing services that the higher skilled work might otherwise have to take the time to do, house keeping, gardening, home care and the like, frees them to do more productive jobs.

“Not so fast” argues GW Bush speech writer, David Frum . He argues that the positive effect proposed for native American workers will obtain only if the presence of the lower skilled newly arrived worker can allow and facilitate the transfer of the native to a higher paying job. In his examples,

“The immigrant groundskeeper can’t speak English very well, so the lawn service hires a bilingual Mexican-American to supervise him. The rising numbers of immigrant nannies call forth specialized payroll firms that hire native-born workers to process checks and pay taxes.”

Frum goes on to argue that any positive effect of immigration might not really occur. It is not so easy for, essentially blue collar workers to move from less to more skilled jobs. “Up-skilling” as he calls it, requires time, effort, money, flexibility and it can “force older workers to begin again at a time in their lives when they felt settled to risk failure at a time in life when risk is not appreciated”.

Given these challenges, which are admittedly very real, it is not such a stretch to see why an apparently simple and straightforward solution such as Donald Trump suggests is appealing, and not so easy to demean or laugh off. The fact that these concerns are real, persistent and vocal on the part of Trump and his supporters, it is incumbent on a liberal, progressive and Democratic candidate to say how she would address the concerns.

How might a progressive approach the threats to worker well being from Globalization and Immigration?

The effect of Education. Globalization is surely not without its detrimental effects, however there are opportunities created for those with more competitive educations. Unfortunately for the US, the presence of a globalized increase in competition for lower skilled jobs, and an increase in the value of jobs that require improved education is occurring just at the time when the position of US education with respect to other countries has decreased. Due to increased international educational efforts, especially in emerging economies such as China and India, the US has fallen from 1st to 8th nation in the world in the percentage of students finishing high school.

Our competitiveness in advanced educational skills has fallen even more dramatically. In a compendium of recent studies we have fallen to 14th in reading skills, 17th in science, and a whopping 25th place in math! In other words, “the results from the world’s global education report cards show that American students are not well prepared to compete in today’s knowledge economy. A host of developed nations are surpassing us in education”.

The Effect of Health Care Costs on American competitiveness

It has been long known and well documented that the high cost of health care, relative to other developed countries, and the fact that it falls mostly on employers can have adverse effects on the global competitiveness of our industries. Put simply, if an American corporation has to factor the costs of health care for its workers into the price of a product, especially when that cost is high and growing, it forces the product to be more expensive and therefore less competitive.

Asking workers to forego healthcare in their contracts is well known to be a non-starter, but any system in which some of the burden is shifted from employers, and some of the costs increases of health care are mitigated would tend to increase our competitiveness.

Analysts of the effect of the Affordable Care Act have concluded that, while it is too early to know for sure, (and there are clearly some fixes needed), there is a real possibility that the provision of near universal care, care whose cost is rising more slowly, and care which can be separated from the burden to the employer may make our industries more competitive. Certainly a liberal progressive agenda would seek to improve on the promise of more universal and less expensive health care, something which the conservative surely would not.

So what could a more progressive, or center left administration do to address the damage to the American worker which globalization and immigration have created, and why would these responses come more likely from a democratic administration? Here are some possible answers.

1) Investment in American infrastructure would create jobs and opportunities for workers which are much harder to “out-source” to other countries. I have previously argued (see Part I of this article) that such a massive investment in infrastructure would require public private partnerships, debt assumption which only the full faith and credit of the government in partnership with industry could accomplish, and some element of public planning. All of these are more likely with a progressive administration.

2) Public investment in education, both at the primary level, but more to the current point at the retraining level would help make American workers more competitive compared to workers in emerging economies where educational advancement is occurring more rapidly.

3) Public efforts both improve the economics of health care delivery could relieve a tremendous burden from American export industries. Thousands of dollars are added to American cars, for example, decreasing their international competitiveness. Although the “public option” is currently too progressive by far to take hold, certainly public efforts to reign in spending are needed for us to remain competitive, and a return to an unregulated fee for service, such as might occur with the repeal of the Affordable Care Act runs the risk of putting the competitiveness of our products even further back.

In conclusion, I have tried to analyze how a liberal, or progressive agenda might approach one of the most glaring issues of the day, compared with how a conservative might do the same thing. I have tried to do so without a single reference to either candidate’s personality, temperament or trustworthiness. Certainly those issues are not without their importance, but I believe we, as an electorate, would be better served by far to try to debate the issues from the standpoint of principle over personality.

My conclusion continues to be that while there is not easy fix, a liberal, progressive, center left agenda continues to be the one with the most chance of addressing both the longer global issues (see Part I) and the more current issue of globalization, trade and immigration.

The present election cycle has focused almost exclusively on the personalities, temperament, idiosyncrasies and supposed inadequacies of the two individuals running for the presidency. Lost, in large measure, has been a serious discussion of the most important issues, and lost completely is a discussion of the underlying principles which would inform a discussion of the two parties and the two approaches to government.

I believe that we are losing, in this personal slugfest, an opportunity to engage in the investigation of those underlying principles. Were we to bring the basic concepts, reasoning behind, arguments for and against, and implications of the progressive platform versus the conservative one, we could at least, as a nation, take steps forward more guided by an underlying conceptual structure, than the present teetering between issues and personalities of the day.

I hope to make a plausible argument here that a central, liberal, “progressive or left” leaning conceptualization for the role of government and its efforts is better for this nation right now than the conservative “right” leaning approach. I think that argument can be made even were we to have two equally capable and equally untarnished candidates. I will leave untouched for this article whether that happens to be the case or not.

I will make this argument with the points which follow.

Questioning the Basis for the Moral argument for conservatism.

I assert that the romantically imagined ‘rugged individualist’ argument for a moral basis for conservatism is a flawed argument. The argument, stated quite articulately and compellingly by Ayn Rand and F.A. Hayek, holds that when an individual alone, by dint of their own personal capacities, talents, efforts, courage, willingness to take risks, to work tirelessly, suffer mightily and bear any hardship to create something in the world, they should be able to reap, unencumbered and unfettered, the benefits which result from the fruition or success of their labors.

This argument is further extended by the assertion that the way in which the less gifted and accomplished majority surrounding that productive individual can share in the benefits produced by that individual is only through the coercive power of the state, either implicit or explicit, to compel the individual to give away from what is rightfully theirs to those who did not share in its production. This has been called a “Road to Serfdom”.

The argument finally extends to state that it is human nature to work for one’s own wellbeing, and that of one’s family, but once a productive individual finds the fruits of his or her labor being ‘redistributed’ more an more widely one’s motivation to work will crumble, and everyone will sit around waiting for others to do the work (after all, why should they do anything) and the productivity of the society will collapse.
This is, as I can see it, the clear principles which underlie the right, the conservatives, in their conception of national policy and finance. All of the concern about ‘redistribution’, tax structure, the size of government and regulations obtain from this underlying structure of thought, that the individual creates and produces, and the government has no right to interfere.

The argument is flawed for two basic reasons.

First, although there are exceptions, the vast majority of those who ‘produce’ do not achieve what they achieve in a vacuum. Most people who “make it” do so within the context of considerably enhanced opportunity compared to less fortunately endowed. They are born into more successful families, endowed often with more intellectually favorable genes, but more to the point with more achievement oriented influence, they are held on the lap and read to from infancy, shown to recognize and reproduce letters almost from the time their little eyes can discriminate shapes. They get pre-school, nursery school, and, even when not enrolled in a better or private schools, they are usually lead to know from Day 1 that school is special, important to be taken seriously and exceled at. They are generally well supervised, often well tutored, usually well travelled and culturally enriched. Those meant to be successful go to summer camps, get riding lessons, learn a musical instrument and are expected to compete and succeed in literary, artistic and musical endeavors. They are, in a word, groomed. Not everyone who succeeds, but the vast majority. To assert that the world is like a race in which we all are given an equal start and is therefore somehow fair is simply not true. If a race were run where some started halfway to the finish line on bicycles and the others started behind carrying bags of cement, we would not call it fair. This is an exaggerated image, of course, but not completely off the mark. The underlying “fairness” argument for the conservative approach to government is, rugged individuals aside, not really fair.

Second, to the extent that the productive individual’s talent and effort are translated into a deliverable and reward-able product or service, still the vast infrastructure which was needed to allow its production and distribution do not belong to the individual, but are the produce of a vast history and society. The roads along which the products travel to market were made by hundreds who came before, on land which was settled by thousands in decades and centuries passed, defended by the blood, sweat, and tears of millions who died preserving the right to build into the future. The hedge fund hero or the dot com maven owe most, of course, to their own efforts, but a significant contribution to their success was made as well by the unknown communist comrade who fell at Stalingrad, or the son of an immigrant dying in the sands of Iwo Jima. “You didn’t build it someone else made it happen” was a line that earned President Obama a firestorm of criticism, but the speech articulated this argument quite to the point.

The rugged individualist, Man on his Own, is not really on his own. It is a romantic notion, I admit, and few adolescents can escape the thrill of Atlas Shrugged, but a fair and, I believe mature understanding of the way the world works will call into question the claim of the conservative rugged individualist that no one else has a share in their success. The claim is not accurate.

Notice I am not claiming, here, a moral superiority to the progressive view that we are “all in this together”. Most religious teachings argue a mandate to share with the poor. But I will not make this argument here. I only assert that the moral argument for conservatism is at best questionable, and if the moral arguments for the right and the left are, at least, equal, then we should look to what is most effective a way to run a society.

The “straw man” of socialism.

For the record, not even the so called socialists call for a system in which individuals are not rewarded for their individual efforts. While it is always popular to attack progressive agenda by calling it socialist and Stalinist, implying that the productive will work and the others will lounge, that is simply no one’s position. The progressive agenda admits the right of individual achievement and private property, but calls for broader distribution of opportunity and a more comprehensive safety net. It also calls for some segments of the economy which are traditionally private and profit motivated to transition to being viewed as societal and universal. As we progress now into the main points of the argument, it is at least dispensing with the view that the left is socialist and will lead to sloth. It is not, and will not.

Four Pillars of Arguments for a more liberal leaning worldview.

1. The enormous and growing disparity of wealth, income, power and opportunity

, but within the nation and internationally are inherently destabilizing and are the largest cause of increasing conflict and war. Although some argue that inequality has mixed benefits and threats, most view the level of increased inequality in the world as a threat. Certainly the majority of conflicts have some major discrepancy in opportunity as part of what might appear an otherwise sectarian struggle. Although no single point of view has a monopoly of concern over this growing threat, I believe it is clear enough not to need specific citation to know that liberals and progressives view wealth inequality as threat to the nation and world stability, while conservatives tend to favor policies which only promote that inequality.

2.
Those challenges which must be met to bring our nation and the world further into the next century will demand investment and coordination

of resources which can only be done with a national, somewhat centralized public private and planned approach. The needed investment in urban infrastructure and the creation of world class city regions, investment in the complete overhaul, modernization and maintenance of local, regional national and international transportation infrastructure for both people and goods, the massive development of information infrastructure, health infrastructure and so on will require, most likely, tens if not hundreds of trillions of dollars world wide over the next decades. It will require intelligent planning and coordination on a scale unimaginable for a single private enterprise.

Private entities could not have put a man on the moon, nor could they have won the Second World War. There is a time for a coordinated, public and national response. I would assert that time is now. A progressive and liberal government could see that. A conservative outlook will not. Partially that is because:

3.
The next step in our national evolution will require a very long-term vision,

one that sees our development in the context of technological and social changes extending into the next several decades. It is highly likely that the national “balance sheets” would have to be ‘in the red’ for several decades before this generation’s investment pays off for our children and grandchildren. Corporations report to their constituencies on a quarter-to-quarter basis. A government informed primarily by a corporate mentality simply is less likely and less able to respond to the longer view.

4.

The majority of issues of the conflict in the world

can be easily framed in a black and white, us versus them, good guys versus bad guys, we win means you lose motif. And, sometimes, that is true. But more often, to really get a longer term, difficult problem solved requires extensive cooperation, negotiation for mutual benefit, give and take, willingness to hear another’s view points, and a willingness to come out of an argument having achieved some but not all of what one wanted. Efforts by recent conservative administrations to impose unilateral and non-consensual solutions by unilateral force, for example in Iraq, have been, I think most observers would agree, been less than successful. The effort to achieve a fair, sustainable, if not total solution in Iran used a different, consensus building approach.

The rhetoric of the guys with the white hats sallying forth to confront evil is very appealing, but rarely, not never, but rarely works. At least not without broad consensus building and compromise. A liberal and progressive agenda tends to look for compromise, consensus, and diplomacy, using military intervention sparingly and as a tool of diplomacy. That is sometimes, but, I would assert, less often the approach of a conservative government.

I could go on to list specific issues, climate change, our relationship with our super-power rivals, our approach to regional conflicts, tax policy and the like, and view review them in the context of these pillars of difference. I will not do so at this point, only to reiterate that from the standpoint of what can clearly be argued as our greatest threats and challenges, a left of center government, sustained over a several election cycle will be much more effective in address those threats and challenges than any but the most moderate center right.

The specific threats to the American electorate in terms of globalization and automation are real. In the next part of this article I will attempt to address those within a more liberal leaning framework, which is, I believe, much more likely to succeed than one steeped in conservatism, nationalism and xenophobia.

Notice I have not considered the persona characteristics of the two candidates for office in this article. I have attempted to argue for voting liberal rather than conservative in any situation in which the two candidates are of equal capacity, leadership qualities, character and temperament. I suppose, if there were a situation in which the candidate of the Republican or conservative faction were clearly superior, I would consider for one election voting for that candidate.

I do not believe that to be the case in this election, so will continue to vote for the candidate I believe best represents the more liberal leaning, center left approach to governing. I hope I have demonstrated it to be more effective, and at least as well morally grounded.

It is my purpose of this article to “unpack”, “debunk” or “deconstruct” the constant and pervasive litany of accusations and insinuations against Hillary Clinton. It has become a well known mantra and fundamental to all the Republican attacks in this campaign that the ‘American People do not trust Hillary’.

Few attacks are made against her policy vision, almost all against what she has or has not been transparent about in the past. This distrust has lead to the fact that a candidate with as questionable qualifications as her opponent has has drawn dead even in the polls as of Labor Day. A Google search of “Hillary Clinton Lies” easily reveals multiple sites dedicated to simply listing and cataloguing the “lies” she has supposedly told the American people. The drum beat of accusation and insinuation is constant and unflagging, and is meant to establish by repetition an aura of credibility and non-deniability about these constant accusations. Individual ‘new’ revelations, for example that she may not remember a specific discussion about email confidentiality are framed within this over arching narrative of supposed Clinton dishonesty. This is meant to have the effect of giving the new “revelations” more traction that the single event itself might have, as it is framed as part of a story, a collection of instances and innuendos.

Although the constant drum beat of suggestion and innuendo has undoubtedly taken its toll, I believe that a systematic review of the accusations will show that although long and oft repeated, they really have little or no merit in assessing the overall trustworthiness, veracity, intention and capabilities of Mrs. Clinton. They are a story concocted to imply something about the candidate which, I believe, genuine and fair assessment will find vastly exaggerated if not down right untrue.

Personal disclaimer in order. I believe that given the difference in the positions, visions, the morality, the experience and capability, and, yes, the temperament of the two candidates, I personally believe that the case could be made to vote for Clinton even if she has lied or exaggerated about, say, the circumstances of her landing in Bosnia, whether one or all of her grandparents were immigrants and even exactly how consistently she characterized the motivations of the attackers of our consulate in Benghazi during the first hours and days, pr even her email server. However I understand that the implications of dishonesty and untrustworthiness have stuck, so I think it worth the time to try, through my reading of publicly available sources (the only ones I have access to), and my own reasoning to debunk or at least place into context the vast attempt which has been made to, in my judgement, recycle a collection of old accusations to try to make some case where, really, there is none.

There is no lack of availability to the collections of accusations.

1. She reported landing on the tarmac in Bosnia under sniper fire, when in fact the video proves her landing was completely peaceful.

2. She left the White House “dead broke” when in fact she and President Clinton had resources and were soon very wealthy.

3. She claimed that her grandparents were all immigrants when in fact only one was an immigrant.

4. She was named for Sir Edmund Hillary when in fact she was born before he climbed Everest.(Sounds like something her mother might have told her when she was a little girl to motivate her, but it is hard to ascertain that now)

5. She claimed she tried to join the Marines when it appears that at the most she considered joining the Army.

6. She accused Trump of making “all” his products overseas, when in fact he makes some products in the US.( Fair enough, he makes “many or most” of his products overseas.)

7. She stated that whites are three times as likely to get a mortgage as non-whites. (The truth is that African -Americans are almost three times more likely to be rejected for a mortgage, but that is mathematically not exactly the same, since whites are only about 10% ‘more likely’ to get a mortgage.)

8. She claimed that under the Affordable Care Act health care costs are lower than they have been in fifty years. (In fact, the GROWTH of health care costs is the lowest it has been in fifty years, but the increase is still there)

9. She said “Mike Pence “slashed” education funds for his state. (Fair enough, he didn’t slash them. He cut the INCREASE in education funding in half from what it’s previous ten year average had been, making Indiana the 35th state of the union in education spending. “Slash” was an exaggeration.)

10. She exaggerated her role in the Northern Ireland peace talks, saying she was instrumental when the actual negotiators described her as peripheral.

11. In the Whitewater scandal from the early 1980s, several people were indicted and served probation and time for a shady real estate deal. The Clintons lost money in that deal, but were accused by some of using their political influence to gain financial advantages for some of the players. The Clintons were never charged with a crime but the implication has many times been made they should have been.

12. Finally, the two largest accusations. Benghazi, the accusation being that Hillary was responsible for grossly negligent mismanagement of a deteriorating security situation and later lied to the families of the fallen and the American people about it. (will treat in some depth below), and

13. She maintained her private email server illegally and compromised national security by doing so.

There are few really trivial ones which can find combing the email lists, (She apparently expressed she had concerns that Chelsea had been riding her bike on September 11 when she knew she was safe at home), but the twelve accusations and innuendos above are the main stuff of attack.

Of the Baker’s dozen listed above, again, all taken from prominent sites seeking to defame Clinton, several are, in my opinion, trivial enough to dismiss. Does it really matter if she says she was named after Sir Edmund Hillary? One can easily imagine she heard that somewhere as a child, can’t one? Parents tell their children things like that to motivate them. I don’t think this makes Hillary a liar, really, do you?

Is it really a deal breaker if when she speaks of her grandparent’s immigrant experience, only one was an actual immigrant, the others being children of immigrants?
Does it really matter that she said whites were three times as likely to get a mortgage when she really meant, correctly, that blacks are three times as likely to be refused one? Other “lies” listed on these most prominent sites are, admittedly, not completely accurate, but are they really lies? Pence didn’t “slash” education, true. He cut its growth in half. Fair enough. Trump doesn’t make “all” his products abroad, perhaps just most of them. The Affordable Care Act decreased the rate of growth of health care spending more than any time in fifty years, but health care costs still grow. Do these make her the great liar she is purported to be?
I think not.

So, given that the litany of “7, 10, 12 or 20 major lies” is clearly nonsense, still there are some serious concerns with things she has said which might not bear intense scrutiny. I will focus on attempting to “Debunk, unpack or deconstruct” the four most often cited and potentially concerning accused or suggested lies. The accusations, and my response follow.

#1. The Arrival in Tuzla. In her 2008 campaign against then Senator Barack Obama, Hillary Clinton attempted to draw a distinction in her record of service by citing her experience in travel to troubled areas and said that she had “landed in Bosnia” under sniper fire. Review of the video and memories of others shows that she actually landed in peaceful situation and was greeted by a child with flowers. She later had to apologize for this miss-statement. Donald Trump has cited this episode several times as an example of her being a “world class liar”.
Let’s see if we can shed some light and perspective on this episode.

Review of the reports from the time and the statements made demonstrates the following:

Hillary Clinton made a trip to Bosnia in 1996. From the Washington Post story of the time, we see that one of the speech writers on the flight with her reported (in her words):

“I was on the plane with then First Lady Hillary Clinton for the trip from Germany into Bosnia in 1996. We were put on a C-17 — a plane capable of steep ascents and descents — precisely because we were flying into what was considered a combat zone. We were issued flak jackets for the final leg because of possible sniper fire near Tuzla. As an additional precaution, the First Lady and Chelsea were moved to the armored cockpit for the descent into Tuzla. We were told that a welcoming ceremony on the tarmac might be canceled because of sniper fire in the hills surrounding the air strip. From Tuzla, Hillary flew to two outposts in Bosnia with gunships escorting her helicopter”

Another witness, a diplomat experienced in Bosnia at the time reported a briefing that the then First Lady received as follows.

“I found myself almost rolling my eyes as the briefer went on and on about the possibility of snipers and what the plan of action would be (essentially, making a beeline to the armored vehicles parked nearby). As the briefing continued for what seemed like half an hour, one of the journalists, a little worried, asked me if it was going to be that dangerous. I explained I was not going to contradict the briefer, but, whispering, I told him I seriously doubted we would encounter any such threat. For heaven’s sake, I explained, it was a U.S. military base with thousands of troops, where there had not been a single such incident in the three months they had set up camp. He was relieved, but those more attentively listening to the briefer were not, as they contemplated that soon they could be running for their lives across an open tarmac a la “sniper alley” in Sarajevo.

Thus, we have two witnesses who reported at the time that Hillary Clinton and her party were briefed at some length regarding the possibility and presence of snipers active in the area and that they were kept in an armored cockpit and issued flak jackets. As it turned out, threats of snipers were clearly exaggerated, and the arrival was safe and welcoming.

Now, when she recalled the episode some twelve years later, in 2008, Hillary Clinton at first recalled that she had “landed under sniper fire”. Video shows she didn’t and she is thus labelled a ‘world class liar’.

Isn’t it rather possible, just possible, that she may have remembered what was by several reports a threat taken seriously enough to prompt an extended briefing about sniper fire? Isn’t it possible that this threat, probably not routine for anyone, even a First Lady, took a higher place in her memory, twelve years later, than perhaps the subsequent events might have justified? Especially given that her only child was with her? Isn’t that explanation possible?

Hillary Clinton landed in Tuzla in 1996 after being briefed extensively about the possibility of sniper fire. This is confirmed by more than one concurrent witness. She remembered, when recalling the incident twelve years later, the sniper, even though the warned of fire had never actually materialized. A memory reported with a little exaggeration of the danger, to her own advantage. Yes, perhaps. A “world class liar”? Ask yourself. Being fair.

2. The Whitewater Scandal. The accusation is that in participating in a complicated land deal, the Clintons and several co-investors were involved with some shady and mysterious transactions, and that Bill Clinton used his political clout as Governor to obtain favorable financing for some of the investors.

I am not sure it is worth the time to attempt to disentangle and go through a point by point rebuttal. Even at the time few could really figure out what the issue was. This is so long ago, so obtuse and, since there was never an indictment made despite several investigations that it really shouldn’t even count as innuendo, but for those who want the details, there is a long account available.

For the sake of the present discussion, I would just observe the following two points.

One, the Clintons themselves were never prosecuted, after three separate inquiries found insufficient evidence linking them with the criminal conduct of others related to the land deal, and,

Secondly, on April 22, 1994, Hillary Clinton gave an unusual press conference under a portrait of Abraham Lincoln in the State Dining Room of the White House, to address questions on both Whitewater and the cattle futures controversy; it was broadcast live on several networks. In it, she claimed that the Clintons had a passive role in the Whitewater venture and had committed no wrongdoing, but admitted that her explanations had been vague. She said that she no longer opposed appointing a special prosecutor to investigate the matter. Afterwards, she won media praise for the manner in which she conducted herself during the press conference. Time called her “open, candid, but above all unflappable…the real message was her attitude and her poise. The confiding tone and relaxed body language…immediately drew approving reviews”.

Considering the multiplicity of the deals, bankruptcies and suits which Mr. Trump is a part of, this issue should not be even considered in the equation. It should be noted, however, that the innuendo continues to be that the Clintons must have pulled off some nefarious criminal activity that they ‘got away with’. This implication colors all future stories. Perhaps as people who say they respect the rule of law, the fact that innocent until proven guilty should apply at least to the extent of innocent until EVEN CHARGED!

Let’s get to the ONLY two ‘real’ issues.

#3. Benghazi. The accusation is that the consulate in Benghazi was left woefully underdefended, given the deteriorating security situation in the region, that repeated calls for help were ignored and unheeded, that when the event occurred the response was incompetent and inadequate, but more to the point of Hillary’s trustworthiness, the accusation is that she attempted to cover up the true nature of the event, declined to call it terrorism, blamed it, deviously, on an an-Islamic video and “lied” to families about the true nature of the attack. She is accused of callousness and playing politics with American lives. Let us examine the event.

The circumstances surrounding these events, the placement, position, construction and defense of the Consulate in Benghazi, was well as its role and its relationship with the Embassy in Tripoli; the reasons we were in Libya in the first place, and the circumstances of Gaddafi’s fall; the intelligence assessments and responses to the now obviously fluid and deteriorating security of the Benghazi outpost, the distribution of security assets, relationships with local militias charged with defense and our contingency planning regarding possible risks are have all been investigated several times . Nine times, as a matter of fact. The connection if any between the apparently planned September 11 assault and a concurrent international furor over a video released that day, the details of what, when and by whom reports were made to the American people and what Secretary Clinton said to the families of the fallen have been investigated, debated and questioned both privately and publicly, officially and informally, now for nearly four years. They are complex and I don’t know that they can be completely disentangled in a few paragraphs here.

One point, however, deserves making. This point was made by Clinton at the beginning of her several hours of testimony, but bears, in my mind, repeating and elaborating here. The four Americans who died in the attack in Benghazi were not the first Americans to die by terrorist assault. Two hundred and forty Marines died in a truck bombing in Beirut under President Reagan ; and three thousand died in the Twin Towers under President Bush. Dozens died in the bombings in Tanzania and Kenya, nineteen in the Khobar towers , seventeen in the bombing of the Cole .

But while this was by no means the first, and certainly by no means the largest loss of life in terrorist attacks, it is to my memory the first time it has become used as a political attack. People asked whether the security of the Marine compounds appeared to be lax.Some publically wondered whether the Bush administration responded enough to the message that Al Qaeda planned an attack on US soil or that there were pilots who just wanted to learn to fly, not to land. Recommendations were later made, and put into place to address the fact that, as was said in the passive voice the “dots were not connected”. Unless I missed it, however, there were not eight investigations during which the security apparatus and intelligence community and national political leaders were publicly grilled to find and demonstrate fault. Not for 9/11, not for Beirut, not for the Embassies, the Khobar Towers, or the Cole. So, while it is certainly reasonable, and in fact necessary to dissect the event of Benghazi, to conduct the operational analyses and learn the lessons, it should be noted that the “review” of the events of Benghazi is unique both in its political targeting, and its vitriol, in any investigation in my memory. That is true, even though the casualties of this tragic event, in number, remain fewer than 1/10th of one percent of the number of casualties in other events which received non-personal and non-political scrutiny.

That being said, let us examine the record.

The most recent, most comprehensive, and, arguably, most politically motivated investigation was recently chaired by Trey Gowdy, not a noted Clinton supporter. The conclusions of this Republican, and admitted politically motivated committee regarding culpability, were summarized on page one of the 800 page report with the following key points:

1)Both the President and the Secretary of Defense ordered the deployment of military assets.

2)A White House meeting was convened but apparently split focus with the reactions to the YouTube Video. Despite there being “no mention’ and “virtually no discussion” of the video by those actually on the ground, half of the action items developed at the meeting referred to the video. This may not have seemed so out of place, of such low yield, or so politically motivated at the time as seems to be seen through the eyes of critics today. From a few sections further in this, again, Republican lead committee report,

“On September 10, 2012, the day Stevens arrived in Benghazi, American military forces were reminded to “do everything possible to protect the American people, both at home and abroad.” That day the President conducted a conference call with key national security principals to discuss the steps taken to protect U.S. persons and facilities abroad and force protection.

Leon E. Panetta, Secretary of Defense, one of the conference call participants acknowledged they were already tracking an inflammatory anti-Muslim video that was circulating on the Internet and inciting anger across the Middle East against the United States” and that they braced for demonstrations in Cairo and elsewhere across the region.” (These facts, I remind you, are from the report of Trey Gowdy’s Republican lead committee)
Due to the Arab Spring, it was a time of heightened concern for that region in general. In particular, the discussion focused on several areas including Cairo, Tripoli, Tunis, Khartoum, and Sana’a, due to intelligence indicating potential demonstrations could erupt in those areas.
Based on the September 10 conference call with national security principals and the President, the Defense Department placed its forces on“higher” alert because of the potential for what could happen.” Yet, the intelligence and the call for a “heightened alert” did not cause any actual adjustment in its posture for assets that could respond to a crisis in North Africa. Some assets were in the middle of training exercises, and others were in the middle of inspections. No fighter jets or tankers were placed on a “heightened alert” status.

SEPTEMBER 11, 2012

In the hours preceding the attacks in Benghazi , a protest of approximately 2,000 demonstrators assembled outside the U.S. Embassy in Cairo, Egypt.
Cairo is some 600 miles east of Benghazi. Plans for a demonstration in Cairo first began to ocoalesce in late August 2012 with the designated terrorist organization, Jamaa Islamiya, calling upon its supporters to protest the continued incarceration of its leader, Sheikh Omaar abdel Rahman, also known as the “Blind Sheik.”Rahman is serving a life prison sentence for his role in the 1993 World Trade Center bombing.Additionally, in the days preceding the September 11 demonstration in Cairo, an Arabic version of a trailer for a little known anti-Islamic film, produced in the United States , was posted on YouTube.

We can wonder now, why a clearer differentiation was not made at the time between a pre-planned attack on the Benghazi compound and the more spontaneous outbreaks of region wide protest over the film, however it is not inconceivable that the conflation of the two was not political but really had to do with the so called Fog of War.
In any event, the committee’s report goes on to analyze the White House meeting.

3)Troop deployment was made contingent upon Libyan state agreement and direction to either Tripoli or Benghazi.

4) Further, despite the early recommendation to be at highest alert, the entire security apparatus was not present at the meeting due to the Vice Chairman of the Joint Chiefs of Staff being at a diplomatic dinner.

5) Military assets did not meet timelines, in some cases sitting ready to go for hours without orders.

6) Libyan forces with whom the CIA and State Department had developed relationships did not come to the rescue of the compound.

Further review of the Benghazi committee reports show that over both the long run and in the weeks, days and hours leading up to the attack, there are several areas in which complex events negatively impacted the security situation. The conclusions of the report discuss a failure of intelligence. One indication of the lack of real time intelligence is the fact that Ambassador Stevens, upon receiving a security briefing after having arrived in Benghazi was seen as ‘surprised at how far the security situation had deteriorated’, according to one of the briefers. Other examples include the fact that security which at been provided by one Libyan militia up until two days before Ambassador Steven’s return to Benghazi was suddenly withdrawn over criticism of the US government regarding a candidate which the militia thought was being supported in national elections. Another example is that security had been decreased in Tripoli, the capital of Libya where the actual American Embassy stands, so there were no extra agents to send to the smaller consulate in Benghazi.

I will not further detail my selection of portions of this report, it is readily available on line. I will just observe that despite a strong political motivation to do so, the committee specifically could not find culpability or bad faith in the way the Secretary of State handled the event.

The results of our clearly, admittedly inadequate military preparation for the growing security threat in Benghazi, and failure to respond effectively in real time are a real tragedy, and one which we can all as Americans hope never occurs again. One would hope, that with the 9 investigations into the event, enough has been learned to try to assure such does not occur again. What is also clear is that the attempt to politicize this event is both unprecedented, and ineffective. Secretary Clinton’s role in Benghazi has been investigated intensively many times, some of which demonstrably with an agenda to take her down. There has never been a conclusion made in any of the official reports that she was in any way culpable.

Would Republican heroes, Bush and Reagan withstand the same level of scrutiny were, say, the wisdom of the placement of Marines in Beirut, or the addressing of the threat by Ben Laden, or the planning for a post invasion Iraq subjected to eight investigations from a hostile Congress? One wonders. It is said politics ends at the shores. I wonder how much our current Republican congress has embraced that notion.

4. The Email ‘Scandal’. Certainly, this is the accusation which has the most traction, and in large measure because there is the semblance of a “there” there.

To be fair, even the most dyed in the wool Hillary Clinton supporter has to concede that,

(1) the choice of a personal email address for government business is on its face problematic,

(2) that the use of such a server for classified or sensitive information puts that information at more risk, perhaps than a government server would.

(I say perhaps because there are now multiple instances in which the state department itself, a major political party, and even major industry servers have been hacked. It may well be, ironically, that secrets were just as safe or safer in Hillary’s basement than they would be on a government server, but then at least she would not be to blame!),

(3) when the use of such a server came to light she was not as prescient about the risks to her campaign and reputation as she should have been, and that she did not get out in front of the story quickly enough or transparently enough, and finally

(4) she has consistently attempted to minimize, belittle, dismiss and rationalize criticism of her actions with regard to the server.

These are all grievous faults. And “grievously has Caesar paid for them”! Were there to have been no Clinton email server controversy, the likelihood is that Republicans would be struggling to prevent a 50 state sweep, not being ‘dead even’ on Labor Day. It is a problem, it is a wound, it is a concern.

But before addressing this concern, though, please take at least take a moment an review my arguments that the Context of supposed Clinton Dishonesty into which this event has been placed is, upon scrutiny as outlined above, not really fair, and not really accurate. Then let’s proceed.

Secretary Clinton has many times acknowledged that his was an error, and that she would not make a similar error again.

James Comey, originally appointed to the Justice Department as Deputy attorney general by George W. Bush, appointed FBI director by President Obama. He was, at least until he disagree with the desired Republican outcome widely perceived to be fair.

Taking all into consideration, and with his reasons clearly articulated, the highest law enforcement official in the land put his reputation on the line to state that there was no basis for a criminal prosecution of the
Secretary. To fair minded Americans, it seems to me, that has to mean something. This even considering the number of ‘I do not recalls’.

It is completely valid to wonder, and pains even those of us who are Clinton supporters, to realize that having a private Email invited unwanted scrutiny and showed less than stellar judgment. It was, one has to agree, in Director Comey’s words, “careless’, perhaps even “extremely careless”, at least with regard to threat assessment. That is a concern for a US president, even the most die-hard Clinton supporter has to concede. And perfectly fair, then, to ask the American voter, taking each part of the public record available for both candidates, to consider their history of judgment.

Still, the fact remains, that in the judgment of the top law enforcement officer in the land, one respected enough to have been appointed by both democratic and republican presidents to the highest offices in law enforcement, Hillary Clinton is not a criminal.

It remains ironic that those who claim to be most in favor of “law and order” are happy to ignore law and order when they don’t agree with it. “Lock her up”, was the most often articulated platform of the Republican party. What is it called when you “lock up” someone who has never been charged, much less convicted of a crime? It is called kidnapping. That is a felony and in some states, I believe, was a capital offense. If the party of ‘law and order’ is calling for felonious assault on the freedom of someone who has never been charged or indicted, what does that tell you about the sincerity of their wish for real law and real order?
There continues to this day to be attempts to find some hidden ‘smoking gun’, close to a year and well over 30,000 emails later. There appears, at least after a year of intense scrutiny, to be none.

So finally, those of us who passionately support Hillary Clinton, and who wish to ask those who don’t to at least take a long, hard look again at the two candidates are left with four questions.

(1) Why is it that Hillary Clinton cannot consistently represent herself with the transparency, and capacity to accept responsibility for fault, which would lead others to see her as honest, trustworthy, and likely to learn from rather than repeat mistakes regarding transparency.

(2) Do those instances in which Clinton has either misperceived a threat, or presented herself or her decisions in such a way as to minimize her own culpability really constitute threats to her ability to govern effectively?

I cannot answer these first two concerns definitively. I would observe that taking responsibility for one’s errors, and public mea culpas tend not to be the stock in trade of most politicians, perhaps doubting oneself publicly is not a good survival tactile for them.I would also make one additional observation, based on my experience as a physician and that is this. As physicians, we do sometimes make errors, and errors which hurt people. If we could not, in front of our peers and teachers, admit and dissect our mistakes, we could not become better. This is the culture of the medical “mortality and morbidity rounds”. However, for the longest segment of our history, we have known that if we make these admissions of error too publicly, or to the wrong ears, we are likely to be sued. It is a dilemma. How do we privately learn from our errors without giving fodder to those waiting to take advantage, sometimes unfair advantage, of our honesty.

My guess, and it is just a guess, perhaps just something I wish to believe, is that Secretary Clinton has dissected every step in the error of her email saga, just as I am sure she has with the run up to the attacks on the compound in Benghazi. The current political climate, I think a fair person may agree, is not conducive to airing one’s errors in public. Still, even as in medicine, where the public stance has now shifting to early public acknowledgement and apology for error, it may have been a better time for the Secretary to have clearly and unequivocally acknowledged poor judgment, ‘confessed’ the error, and taken her chances with the sympathies of the press and public. Should she lose this election for failing to do so, it will be a sad irony for someone who worked hard on the Watergate hearings, where an otherwise remarkably skilled leader compromised his legacy for failure to quickly admit error and wrong doing. I hope that does not become the case, and would ask the reader to indulge be a few more moments of time in review of the next two finishing concerns we must ask ourselves.

(3) How do Hillary Clinton’s supposed ‘lies or concealments’ stack up against those of prior leaders? How does “email gate” stack up against Johnson’s Gulf of Tonkin Watergate, or IranContra, or the the run up to the war in Iraq? Or even the Monica Lewinsky scandal, which she handled, I think with real dignity? Even if she has mischaracterized her mis-remembered that “C” meant classified on at least three documents, where does this place her in the hierarchy of presidential dishonesty?

(4) Finally, this is, as we keep hearing a “Binary” election. I suppose, if Hillary Clinton were running against liberal Giants of the past, Clinton versus Roosevelt, Clinton versus Kennedy, Clinton versus Carter, or even against Clinton 42, Obama, or even Gore, Biden or Kerry, we might consider how important these, in my view, if not white, then fairly pale “lies” are. Even if she were running against a frighteningly practical, philosophically open, and central leaning Republican, one could at least ask the question. But running against Donald Trump?

I would ask the reader, please, in the name, not just of our future as a nation, but in the name of our tradition of giving people a fair and decent hearing, perhaps one of our best American values. Please examine the innuendos, the dark suggestions, the implications, the drum beat supposed accusation of fraud, lying, dishonest, “crookedness”, examine them in the light of the real data. I think for all the reasons outlined above, a fair consideration of the record will show that Hillary Clinton is honest enough and trustworthy enough that she should be considered, with respect to her opponent, not on this continued drum beat of suggestion, but rather on the merits of their positions, visions and arguments, and capabilities.

Because, in the long run, that is what our elections are supposed to be about.

Respectfully proposed,

Dr. Richard Nierenberg