GOODBYE FROM OBIRON

This will be the last blog post from Obiron.

It has been an interesting experience to put my ideas about current events into words.

There has been little dialog,  perhaps because of the format,  or because others don't have the same interests.

I will avoid  ranting and being always disappointed.  Life is too short and there are many ways to enjoy it.

Best and good health to all.

KERRY HOWLEY'S VIEW OF AMERICA

If there is one book you don't want to read this year it is BOTTOMS UP AND THE DEVIL LAUGHS (2023) by Kerry Howley.  Why shouldn't you read it?  If you want to believe that you are safe in your country,  and the people protecting you are competent, don't read it.  If you want to believe that you are protected by our government's effective security system, don't read it.  If you want to believe that all the leaks and reports on the government are junk, don't believe it.  If you want to believe that a patriotic young woman who wants to serve her country will be honored,  don't read it.  For everyone else,  who is disillusioned about the current state of the nation,  this book provides additional data on certain problems.  It is journalistic and provocative,  but it is hard to place it clearly in Red or Blue.  It is more like "a pox on all your houses".  

The book is an expansion of a biographical article Howley wrote for the New Yorker on Reality Winner (her real name) a young woman who served in the air force and was later jailed for revealing top secret information.  This narrative is the guiding thread of the book,  but it is put in the context of the "leaks" of Assange,  Snowden,  and Kiriakou, only the last of whom has been prosecuted.  The narrative is also augmented by the John Lindh story,  a young man who wandered off the reservation to Afghanistan,  too late to support the US effort,  and unwanted by the Taliban.  Unfortunately he was labeled a traitor by the USA and became a CIA success story for capturing and jailing a traitor American, who conveniently hailed from Marin County CA, far from the Texas heroes Bush and Cheney.   

The narrative takes many unexpected digressions,  which introduce characters who play a significant role in the Winner story,  or try to.   The narrative is simple: 1) A naive young woman from rural Texas decides to go in the Air Force,  after 911,  and learn a language to go and fight the Taliban.  2) She joins the Air Force, is taught Pashto,  serves her enlistment at a desk at an NSA site translating intelligence messages for information that might involve national security.  She has Top Security clearance for this.  She is never involved in any major intelligence discovery.  3) During this service, she becomes bored,  reads other documents and copies one reporting on Russian hacking of the US election of Trump.  She thinks this is important for the public to know,  and copies it against Top Secret regulations taking it with her off site.  4) Soon after her discharge,  while searching around for a new job, she decides to "leak" this information to INTERCEPT,  a site that claims to publish important documents on line, anonymously, a clear violation of her Top Secret clearance. 5) Instead of releasing the information anonymously,  INTERCEPT "by mistake" leaves markers that clearly lead back to Reality and her printer.  6) Reality is arrested on espionage charges,  and spends 6 years in jail,  mostly shuffled around pre-trial,  and eventually pleads out to avoid further incarceration.  She is one of a handful of persons ever successfully prosecuted for leaking documents,  in this case documents that had significant public interest and no danger to espionage.

The story of John Lindh  provides an example of a total "naife" who is labeled a dangerous traitor despite the reality that he had no real contact with Taliban,  and despite the fact that the Taliban had little to do with 911.  He is tortured despite having no useful information (and other examples, and the controversy about waterboarding are included for good measure).   He is held up as a symbol of traitors to America by a government who is betraying the country with lies about nuclear weapons and fails to manage its military efforts.  This same government institutes the TSA,  integrates Homeland Security, and vastly increases the labeling of documents as Top Secret to avoid public disclosures.  Howley's point is that Lindh is a tool for misinformation by the government's propaganda system, and had no significance as a terrorist or a source of useful information.

The subsequent "leaks" of more sensitive information by Assange and Snowden are examples of important disclosures of how extensively the governments around the world are spying on their citizens,  including the "democratic" government of the US of A.  Are these "leakers" heroes trying to reveal the collapse of democracy and free speech that is underway?  Or are they traitors revealing information that may compromise the lives of loyal spies out in the field?  Who decides?  Since the information is Top Secret,  it is impossible for the "average citizen" to evaluate the leaks in the context of the information being gathered.  Howley describes reports that drone attacks kill the wrong person because the data is based on incorrect phone info and other sources.  Is all this information gathering making us safer?  or killing the wrong people and supressing individual freedoms?  The simple answer is that we must trust our government to do the right thing.  This is where Reality comes in.

Yes, Reality Winner did leak some Top Secret information to INTERCEPT,  but it was about other countries attacking America.  Why was that secret?  And if it is,  why is her trial so secret, and her attorney never able to get access to the claims against her?  And why is this confused little woman being presented as if she is a major danger to national security?  Don't we have bigger fish to catch?  Maybe not.  Did they publicize her trial to send a message to other "confused kids" not to mess with this?  No.  Another "confused kid" Jack Teixeira recently did similar things as a member of, not NSA, but the Massachusetts Air National Guard where he had access to Top Secret documents.  Doesn't anybody pay attention to who has access?  Do they let just anybody have access to Top Secret documents?  Then why are they TS?  Or are they not that important and nobody really wants to decide?  (That is Howley's view.)  An especially quirky story is about Kiriakou who wrote a paper that was submitted to a different agency, and distributed it even though he did not have clearance for that agency, and became the first CIA officer convicted for leak as a result. This sounds like somebody doesn't know what's going on.  These are the agencies that protect our country from others, in secret,  to keep us safe.  Don't read this book unless you want to have nightmares.

Where does the title come from? (Spoiler alert: don't read on if you want to read the book) The penultimate chapter described a legal battle between an energy drink company and a fundamental Christian who believed the symbols on the can meant the drink was demonic.  (I told you not to read this.) Her chant is "Bottoms up, and the Devil laughs".  This chapter describes the chaos of the Jan 6th situation,  including a Realtor storming congress who stops to promote her company.  Folks,  you can't make this stuff up. 

CALIFORNIA DREAMING: FANTASY OR NIGHTMARE?

A recent survey of other Americans reveals many negative attitudes about California.  

https://www.latimes.com/california/newsletter/2024-02-14/golden-hate-survey-highlights-the-nations-negative-perception-of-california-essential-california

Many of the respondents have never been here,  so it is reasonable to assume that much of the response is based on media reports and other secondary information.  There is a peculiar political divide as well.   In response to this,  I put down some of my thoughts about the experience of living here  as honestly as I can:

There is no perfect place to live. I have never regretted moving to Los Angeles, CA 13 years ago (to be near the next generation of our family) but living here is far from perfect. 

It is more expensive to live here than most of the US.  You pay a 10% state income tax for the privilege of living here.  More people live below the poverty line here than in some other states.  This cost deters many from relocating, which is a realistic decision.  If enough people decide not to relocate,  the housing costs would go down.  But this does not appear to be happening,  because new people are always arriving.

According to the survey 48% of Republicans think CA is “not really American”.   It is a dramatically diverse melting pot where a casual walk along a trail may pass people speaking ten different languages.  Ethnic Hispanics make up a sizable population (many of whom predated Anglos),  as do people from asia, pacific islands,  Europe, and other regions.  A significant “native American” population is growing larger.  So those who view “American” as white people of European origin are correct that things have changed here (even more rapidly than they are changing everywhere in the US).  Whether this is a deficit for CA or the limited view of the Republicans surveyed is open to debate.  There are lots of Republican majority areas in CA.  And no one here seems to mind the other ethnic groups who make money,  do jobs,  and support the state’s economy.

It is the 4th (or 5th) largest economy in the world,  and a major component of the US economy, so it is not just going away. The cycle of job opportunities goes up and down,  and the economy is very fluid with rapid changes in both directions. CA (and LA) were idealized as wonderful places to come to live and work in the 60s and again in the late 90s and early 2000s.  Economic inequality is obvious and areas of extreme wealth contrast to very poor regions. Homelessness is a problem in all the major cities,  in part due to the lack of affordable housing, and in part due to the willingness of people to come here and live on the street in a milder climate,  with significant social welfare support.

The weather along the coast is often lovely,  but more extreme a short distance inland.  It is one of a few places where you can go surfing in the ocean and skiing in the mountains on the same day by car ride.  And if you wish can also go off road in uninhabited desert.  There are regions of incredible beauty Yosemite,  Joshua Tree N.P., Big Sur  and they get more crowded every year.  The distances even within regions are long, and the traffic can be terrible at times.  Your life depends on your car.

There are many natural threats:  earthquakes and tsunamis,  terrible fires,  torrential rains with mudslides and flooding, intense Santa Ana winds, and dry dessicating heat waves.  Most people rebuild on the sites of their destroyed homes,  even when that decision is probably inviting repeated damage.  Insurers are reluctant to insure homes in CA because of repeated damage and the cost of rebuilding (though this does not include the cost of land).

Many people move here from somewhere else, and building community depends on being able to blend with people different from you,  and with “native Californians” who are wary of newcomers.  There are regions of very rapid development like the Coachella Valley and Palm Springs which is becoming a new population center, especially for retirees.  There was a time when going to California was the idealized fantasy of many Americans.  This was fueled by intense marketing by the railroads and other state promoters to entice a growing population.  The expansion during WW2 and after made all this unnecessary.  But the glow continued for years after.  The reality of California today is more nuanced.  It is a wonderful place to live,  if you can afford it.  It is a beautiful place but not an easy one.  It is one vision for the future of other states,  with a diverse population, and a bureaucratic state government.  (Texas is a different model for the future.  Both can coexist in the same country and attract different folks.) 

Political Fictions

 

POLITICAL FICTIONS by Joan Didion begins with the campaigns of  Dukakis and Bush.  There are long sections about the role of the insiders creating a political message that captured the public response without considering the issues of the people at all.  She awoke to this well after the Kennedy-Nixon campaign that emphasized media promotion on TV.   She does not consider the Reagan campaigns though she was a strong opponent of what that administration did in central America.  Later she discusses the Clinton-Lewinsky scandal and seems to support Starr's condemnation of Clinton, one of the great producers of "political fiction".  The Clinton era is disappointing, but there is little exploration of the dis-ingenuous Clintons.  The last part of the book describes the rise of the Religious Right and she paints a broad negative picture, and fails to explore the effectiveness of their rise to power.  In this last section, she misses a fundamental point, about which the PBS special on the 60s is instructive. The "baby boomer" generation has a clear split:  those who smoked dope, had "free love", and believe that the world should tolerate personal gratification, and those who studied and stayed home, and believe that their self denial and discipline is essential for a good society. While the narrator of the video seems to value the 60s rebellion as the seeds of social change in various countries, Bork, Meese, and Buchanan narrate the events as the failure to respect authority, and self indulgence without any social value. This is the fundamental conflict of the 60s, which is embedded in the political world of the 90s and beyond.   It is fundamentally about values and reflects a failure to maintain a consensus in the culture about "appropriate" social choice. 

The “rebel” agenda appears to be about relaxation of social constraints:  pro-abortion,  decriminalizing marijuana, social rights for gays,  more social and economic recognition for women,  and (to a limited extent) racial equality.  Characterized by opponents as “self indulgent” and creating moral chaos,  the position is largely responding to the social reality:  women were getting too many illegal abortions, MJ is freely used,  gays became a major minority in the population and needed care for AIDS,  and women make up an important component of the economy as labor moves away from physically demanding or aggressive jobs. African-Americans also have significant advances in the economy.  The country is becoming this reality, but expressing these values over the years from 1960-1990 had little power to enable the changes.

Clinton was the archetypal “rebel”:  he was a self indulgent, brilliant, self motivated person, willing to take whatever position necessary to gain his personal power.  It seemed  in office his goal was to lead an “inclusive” and caring government,  but was often the opposite:  It favored the grow of wealth in the super-rich.  It grew the economy with limited benefit to labor. “Welfare to work” was no boon to the welfare mothers.  It encouraged minority groups to a very limited symbolic extent.  And it had limited success in international policy.  The administration did not make any long range contribution to American society, neither upsetting the status quo nor advancing it. 

The “Conservative” agenda (cf “moral majority”, “Religious Right”, “compassionate conservative”) is just that:  an attempt to return to a value system that rejects most of the social changes that have been experienced in the country since the 60s.   On the face of it, this seems to be extremely naïve:  there is no evidence that a political system can enact laws, policies or whatever to counteract the prevailing social mores of a society.  (The most that will happen is a major conflict of legitimacy within the society,  at worse, a turn at totalitarianism, and then a collapse of the regime.   Will we go through a cycle of south American politics to learn this?)  Perhaps this position is simply a counterbalance to slow social change and allow it to be assimilated more easily.  This group has mobilized political support from “church ladies” and channeled that support effectively into political power more than in the past (though the Temperance movement temporarily created a nationwide change in behavior!).  It is frequently accused of being anti-democratic but is able to mobilize support in key campaigns, so this is incorrect.  

The Reagan administration was viewed both during and afterward as a high point in the “conservative” vision.   Though Reagan himself is given credit for this, it is increasingly clear that he “took direction” and “followed the script” from everyone around him,  because he was in the early stages of Alzheimer’s disease.   Events like the “invasion” of Grenada, and the Marine debacle in Lebanon, were examples of a poorly worked out foreign policy which later “took credit” for the “collapse of the Soviet Union and Communism”(which began long before their administration and to which they made almost no contribution).  They failed to take American Foreign policy in new directions as the “sole superpower” except for major disruptions of governments in central America.  They created tax cuts for the wealthy and excessive spending that drove the country into its worse deficits in history, despite prior Republican demands for reduced government and fiscal conservatism.  Didion’s portrayal of the Reagan administration as a sort of movie script in the Iran-Contra mess is not far fetched,  and expresses the underlying wish for a macho, morally black-and-white outcome, the product of years of watching Hollywood “oaters”.

The script writers and media fabricators (“Wag the Dog”) of contemporary political discourse assume a public with very limited capacity for ambiguity and discrimination.  This public requires simple adolescent style heroes, and cannot tolerate moral complexity or compromising competing interests.  The voter is encouraged to ignore physical and economic needs, in favor of social values. When this leads to losing jobs, someone must be found to blame for this loss, or magic policies created (the mortgage fiasco) to avoid recession.   In such a discourse, the leader becomes the cowboy hero despite the myriad failures and impotence of his administration.  The fifties are idealized as a high point in American moral culture despite the betrayal of personal liberty by HUAC and McCarthy (which ultimately had to be stopped by the US Army!), the ineffectiveness of an FBI led by a (closeted homosexual/transsexual?) leader blackmailed by organized crime.  JFK is a bold new visionary cut down before his prime accomplishments, despite his inability to move civil rights in the congress,  his initiation of a dangerous course in Vietnam,  the failure in the Bay of Pigs,  and his drug addiction and sexual distractions.  And the murders of Kennedy, his brother, and King were "allowed".

Didion's book came before internet politics,  before "Citizens United", and before voters were willing to express acceptance of views that are counter to any method of validation (lies). Two party politics seems to support the ability to maintain balanced consensus in the general society (where parliamentary government supports several competing positions that must find a way to compromise).  

The current "political myth makers" have a no compromise view of reality, only on who has political control.  This interferes with the broader tasks of government. In this "political fiction", the nuances of reality are so collapsed that no adult, interest balancing approach to governing society is possible.  It is no wonder that with increasing frequency we are selecting leaders for the country who portray themselves in fundamentally adolescent terms (and often behave that way).  The public is encouraged to believe that the country is weakening because of its failure to fulfill its adolescent dreams (either “rebel” or “conservative”) instead of recognizing that an adult world is never so clearly defined and requires complex compromises.  How did the country fail to educate its citizens in the reality of being adults?  Who created the "fictions" on which the current social fantasies are built?

 

 

 

 

 

THE US HEALTHCARE PROBLEM AND ITS SOLUTION (REVISED)

  There is growing evidence that the healthcare system in the United States is not providing the services appropriate to a society with advanced economic development, and that the services being provided are far more expensive for their value than those in other developed countries.  There is even some limited evidence that the federal government is aware of this.  Over the last two decades many books have been published addressing the problem:
 https://www.redoxengine.com/blog/70-healthcare-books/   which include:  The Price We Pay: What Broke American Health Care--and How to Fix It    The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care  An American Sickness: How Healthcare Became Big Business and How You Can Take It Back  and others. Each author focuses on a different aspect of the problem,  not the complex system that must be modified.  

Despite claims to the contrary, by many measures the US healthcare system is not the best in the world,  and a higher percentage of Americans are dissatisfied with their system than are the citizens of other developed economies.   The factors that contribute to this dissatisfaction are:
1)    uncovered lives.   Over 40% of Americans are not covered by health insurance at the present time,  and a significant number of the other 60% feel that the amount they are paying is more than they can afford.   And this problem is intensified by businesses trying to shift more of this cost onto workers.
2)    Excessive costs per capita:  This brings up the next issue:  the cost of US Health services,  even given the limited % of insurance covered lives,  is higher than in any other developed country.  Either Americans are much sicker people than other countries citizens,  which seems doubtful from our shared genetic roots, or our healthcare system is not efficient at delivering the necessary services and avoiding unnecessary ones.
3)    Poor overall outcomes:  Evidence that the higher cost is not delivering superior care comes from outcome data:  overall mortality,  infant deathrate,  and other measures of overall care are worse in the US than other developed countries and even worse than some developing countries.   So clearly the increased costs are not buying better “health” as measured by overall statistics of the population.  So what are they buying?
4)    Uneven distribution of care:  The delivery of services is disastrously uneven.   Over 30% of Medicare dollars are spent in the last month of life.  There are major inequities in the differential of delivery between richer and poorer patients, urban vs. rural patients, and an excess of services are delivered to “well insured” patients. 
It is necessary to define the problem in systems terms and then develop the appropriate solutions. 
What is the goal (the “mission statement”) of the healthcare system?  
To provide healthcare to the largest percentage of the population possible while keeping costs as low as possible and ensure that the maximum number of citizens are capable of productive service to the society.

Instead,  the current healthcare system operates with an “apparent mission statement”: To provide healthcare services in proportion to the available payment, to ensure that providers and suppliers of materials get the best possible chance for income, to maximize cost controls by agencies not directly involved in care,  and to make every effort to ensure entry into life,  and prolong death, for those who can afford to pay,  for as long as possible. An important difference is the goal of “productivity”,  vs “prolongation of death”.   The latter goal makes sense in a for profit model,  though often held up as a “moral imperative”.  Unless this fundamental issue is addressed in any system of funding delivery of services,  no real change in the care system will occur.  

In countries with single payer systems,  an implicit triage principle occurs.  Those with very high income have a separate healthcare delivery option which ignores  goals of the primary system.  This division raises moral issues for the society, but takes some burdens off the cost of healthcare for the general society.   The opportunity to waste personal funds to those who are so inclined, supports a special group of providers.

The healthcare system/process should keep the members of the society functioning  as effectively as possible.  Persons with less ability to participate (on health basis) will have fewer services,  and those about to die (and no longer contributing) will have very few.  This is rationing services,  not correlated with the socio-economic status of the individuals.  It has moral implications for the society.  The goal of “eliminating illness” applies to certain controllable problems which are almost always related to public health or sanitation issues,  including the use of vaccines.   The current healthcare system fails to achieve this goal in several ways: 1) a disproportionate amount of care is delivered to elderly with limited productive capacity, for example data (several years ago) that 30% of Medicare was spent in the last month of life, unlikely to be productive.  2) emphasis on treatments that affect the quality of life but not productivity have an excessive role; 3) mental health and addictive disorder disability have an enormous impact on productivity,  but are not effectively addressed or funded (mostly considered, in effect, untreatable). 

In order to achieve this goal there must be appropriate distribution of healthcare services.   The number of providers and institutions for delivery of services must reflect the population,  its age, and likely illness, and must be adjusted as these change.  It is especially important to avoid over-concentration of services in locations where providers are trained and in regions that have high socio-economic status.  The compensation of providers must be adjusted to reflect the relative  desirability and challenges of delivering services in different regions.  (This is less of a problem in a smaller country like England, than in a larger one like US, or Canada.)  Organizing delivery of services by simple fee-for-service and/or for-profit corporate management are both inadequate to meet these objectives.  Simple fee-for-service badly skews services toward affluent users,  and corporate management exaggerates this problem by emphasizing employer based coverage and cost control decisions about funding.   Associating  healthcare with employment is consistent with the goal of productivity,  but complications arise when the benefits become part of labor negotiations.  And loss of healthcare with injury or disability prevents recovery of employ-ability and productivity.  Healthcare insurance, corporate or individual,  manages demand for services,  cost of services,  and providers income, proportional to services delivered (though very different for different classes of providers).  The variable or increased demands by users are not easily adjusted by closed systems, and relatively inflexible.  A series of corporate interventions which claimed to be addressing these issues have not succeeded in regulating care or costs.  Concerns about the cost of current healthcare in the US come from insurers or care providers, and individuals charged dramatically increased premiums.  The statistic usually stated is the cost per capita where the US is about one third more than the next country.  (https://www.statista.com/statistics/236541/per-capita-health-expenditure-by-country/) "Managed care corporations" were created to address cost containment by insurers without a clear mandate about which costs and how to accomplish their goal.  How to differentiate the costs of increased number of users,  increased cost per user, and increased cost of service provided remains challenging. 

When talking about who pays for healthcare,  people sometimes lose sight of the economic reality that the society as a whole always pays for all the healthcare.  It is an economic allocation of resources to a sector, that may have a multiplier effects to other sectors as well. That is why productivity is what matters to the society.  Individuals amy make decisions to behave in ways and use resources for personal life enhancement.  The two sometimes overlap, but not always.  The healthcare debate is always about how the payments are divided up between members of the population, and how much each individual can claim in return.  That is why middle and upper class payors always want less coverage for the poorer members.  They are paying the costs, whether in increased insurance costs or through taxation in a single payor.   In the US this has now reached the point of measurable deterioration of care in healthcare statistics, etc. but is being challenged by Obamacare. 

The statistical data quoted might reflect a higher percentage of the population using services,  or higher costs of the services provided, or both.   The higher costs of medications in US, even compared to neighbors like Canada, and the higher cost of health services and procedures in US, are both important contributors to the extra cost.  The "managed care" solution  had limited ability to address either of these issues,  and could only  limit delivery of services, resulting in social and legal backlash,  And did not reduce costs significantly.
The development of “managed care” in the 90s was an effort by insurance carriers to provide a system for reducing the overall number of healthcare events, and per event costs.   It was a clear statement that providers were not motivated to reduce the numbers of events,  which will be discussed next.   Initially,  this process was successful in reducing the numbers of events,  but it has lost effectiveness for several reasons:  1) it has no impact on uninsured events.  This problem is now being taken up by states who are hiring managed care companies to address the utilization in Medicaid delivery of services.  2) The return to the companies diminishes with their effectiveness.   Bonuses that come from decreasing the number events eventually hit an asymptote that results from the absolute number of events needed for care of ongoing health problems.   Reducing necessary events leads to increased liability,  and eventually lawsuits with significant economic penalties.  As this process has taken root (it was intensively opposed in the courts for years),  the result is the direct competition between the profit motive and health service goals.  3) Increased costs are incurred in the system by the administrative and management costs of an additional layer of management which must be included in the overall cost of healthcare.  Future healthcare delivery must control the  management costs.
 

The Kaiser-Permanente solution was merging the insurer and provider organizations into a combined healthcare system.  Large provider corporations have subsequently taken over much of the healthcare delivery in the US.  These corporations purchase provider practices, and create exclusive relationships with insurers (or merge with them) to control provider costs.  Overall costs have not gone down in private for-profit versions of K-P!   The money saved from lower level workers and providers is appropriated by senior management, and paid to shareholders for stock price enhancement.  So there is no reduction in healthcare cost.  Lowering payment to providers sometimes results in compromised  services, and closure of low profit hospitals.   None of these corporate changes have any commitment or financial benefit from public health measures,  which was painfully obvious during the Covid crises when the demand for hospital services were overwhelming,  and the costs remain unresolved.  There is no evidence that the for-profit motivation in corporate management does anything to improve the quality of care or reduce the overall costs over time. Corporatization of health care delivery is driven entirely by profit motivation.  This is especially true where the services provided are chosen to be the most expensive,  as in cardiac surgery.  The American experiment in for profit corporate organization of healthcare has been a total failure for patients, providers, and insurers.  Only the senior management of the corporation and stockholders have benefited.   ANY healthcare system which is primarily driven by private enterprise capitalism favors profit returns over healthcare statistics and will not extend to covered lives unless a profitable funding source is attached. This does not mean that a multi-payer system cannot work,  but it does mean that some way to prioritize service delivery over return on investment must be included or the priorities will never be aligned with the needs of patients.  

 

This would be publicly recognized and government regulation instituted if it weren't for the major lobbying of this industry, several members of congress were the heads of corporate healthcare companies.  If the current corporate system were instantly removed, US healthcare would collapse.  The apparent exception is the Kaiser-Permanente system,  a corporate entity that merges payor and providers relatively successfully because Kaiser is a non-profit entity.  No excess funds are extracted from the care system for stockholders.  The lesson from these experiments is that some regulation of delivery of services is necessary,  but for-profit entities, motivated by other corporate goals than the overall delivery of healthcare,  are not cannot provide it.  Recent debates on the healthcare situation in America have made the issue “single payer” vs “free choice”, as if configuring the system one way or the other will somehow magically solve the many problems of the current system.   This places the debate in a politically divisive issue without solving the basic problems. The solution has several elements:  1) The metric of healthcare system performance must be the productivity of the members enrolled,  regularly measured publicly available data.  Quality of services, fairness of delivery, and overall satisfaction are secondary considerations.  2) Cost containment is necessary.  Delivery of services must be regulated by amounts,  providers, and location.   

Providers are not motivated for cost containment and should not be expected to be the controllers.  The simplest model, provider control of the delivery of events, only performing those  needed for patients, has clearly not worked.   Ignoring the fraudulent claims for services,  which are a significant drain on the system,  there is still clear evidence that unnecessary events were and are being delivered.   Most providers dispute this on the basis of two sorts of concerns:  events are needed to protect providers from liability concerns of malpractice,  which are not deemed necessary by managed care companies, and  providers and some consumers determine the quality of services by the frequency of contacts not the outcome.  Users are variable in expectation of services, and comparison shopping of quality is almost impossible for consumers, especially in crisis situations. 
Some component external to the delivery system must evaluate the two factors and regulate performance of providers.  Two different models  can be defined: A) in the single payer model (government or other) there is one countrywide regulator to which users pay an annual fee.   This entity sets standards for services based on annual experience.  This is the Medicare model and numerous problems in fraud, government administration, and political intervention have plagued this system.  B) Several regional non-profit entities (similar to the airline system, but non-profit) receive payments and negotiate or integrate with provider entities to lower cost of services.  This creates a competitive model for quality and control,  but the overall costs of administration are higher.   A separate requirement is needed for public health services,  and these may be included by providers as they are in some countries, or provided by government entities. The US is slowly moving toward the multi-component model,  but for-profit corporations are dominating the system and this must be regulated or challenged.
Providers include more than the physician/nurse/specialist individual service providers and the aggregate corporations that contain them.   It also includes a large number of institutional providers,  hospitals, nursing homes,  specialty care facilities,  which provide structure for delivery of services which cannot be delivered on an ambulatory basis (ie,  some surgery).  The factors impacting costs in these institutions is even more complex than the problems in regulation of individual service providers.   And therefore the task of reducing events and the cost of events is more complex.  To the extent that such institutions compete with each other,  their attempts to improve services and maximize quality of event delivery are good for the consumer.  But when competition leads to decreased occupancy in  the competing facilities, it contributes to increased costs of delivery.   This can only be controlled by regulating the overall number of facilities in a given area,  a process that is partially managed by the Certificate of Need process for hospitals but not for other facilities.  The other conundrum of institutional care that has emerged in recent years is the competitive negotiation over managed care contracts.   As large institutional provider systems have emerged in metropolitan areas, it has been possible for them to negotiate on a relatively equal basis with managed care organizations with the potential to refuse care to the patients covered under the managed care contract if a desired rate is not obtained per service.   This results in improved income for institutions but limits the effective control of costs by the managed care mechanism, or at least converts it into another form of bargaining with the patient group in the middle.
A complicating factor in cost containment is the role of healthcare in the overall American GDP.  A chart shows that US is on the high side of both per capita and percentage of GDP spending on healthcare.  (https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/)  What is not stated in this is the important economic role in the overall economy of hospitals, providers, drug companies, medical equipment companies, and the rest of the industry.   A sudden reduction of cost containment of 5% would certainly put the economy in recession!  So no political entity will enact rapid changes to challenge the overall costs!

After considering the contribution of providers to the number and expense of healthcare events, another contributor is the cost of pharmaceuticals.   There is a strongly market driven presumption that the newest and most expensive drugs and technologies are better than older ones, and patent protection of new products, allows pricing for maimum return over 17 years.   This drives a constant pressure for use of the most expensive products for treatment.   These products are not competitive with prices in the rest of the world, and recently the FDA has blocked the importation of less expensively priced versions of the same drugs from Canada and Mexico,  despite any evidence that the agencies of these countries are not any more lax than the FDA in examining the products they regulate.  Just because a pharmaceutical company can demonstrate efficacy of a new product, there is no assurance that it is more effective in comparison with already available agents, and there is no basis for concluding that it is more cost effective.   The tendency for pharmaceutical companies to develop drugs for common diseases in competition with other already available drugs only magnifies this.
A similar issue can be found in the use of biotech components and procedures.  Newer high tech scanning technologies are much more sensitive than older techniques,  but they are vastly more expensive and institutions are attempting to amortize them more quickly due to the likelihood of  becoming obsolete more quickly.  The same is true for new high tech surgical procedures, etc.   There is no doubt that many of these new techniques are more effective,  but the costs of upgrading healthcare delivery are substantial and must be carefully controlled both in time and spatial distribution or they become an unjustified additional cost to the system.   An example can be seen in the situation of coronary catheterization procedures.   These are very lucrative both for the practitioner and the institution in which they are performed.   So many facilities have been set up to do procedures, with a substantial setup cost, creating increased demand for their performance.    How often are procedures done on questionable indication?  Who would have the authority to evaluate this?   
There is the issue of indigent care.   Institutions that are required to deliver care to uninsured incur an unreimbursed costs that must be shifted to other payors somehow.  As a higher percentage of the society becomes insured, this cost goes down, as in the impetus for “Obamacare” or vice versa.  Some institutions get around this by defining their role in a manner that avoids any responsibility for such care.  Which reduces their unreimbursed services at the cost of transferring it to other facilities.   So this solution, while economically favorable to the involved facilities, is not a workable solution for the society. 
In order to discuss the process of controlling healthcare costs in any system of delivery,  it is helpful to consider a “healthcare event”:  this is any instance in which a healthcare service is delivered and a cost incurred by the system.   To lower the cost of healthcare,  the system must reduce the cost of events,  by either decreasing the number of events, reducing the cost per event,   decreasing the number of “very expensive events”, or some combination of each.   This leads naturally to:  How to reduce the number of events?  How to reduce the cost of each event?  Four distinct types of healthcare event can be distinguished, which are not currently  effectively differentiated in payment plans:  
“Routine Healthcare events" (RHCE) include vaccination for children,  screening for cancer,  hypertension, diabetes,  and cholesterol screening,  along with other known treatable diseases,  and a number of other visits for minor recurring problems seen in the majority of the population (e.g. minor cut requiring sutures,  sinus infection,  etc.).   These events are a significant component of healthcare services,  they are not insurable as unpredictable low incident risk to be distributed across a population.   The evidence that screening procedures lower the overall cost of delivering care once the illnesses are diagnosed is not supported by studies in managed care companies.  RHCE fall most clearly under the “public health” rubric and some of these services are delivered in this manner in the U.S.,  e.g. tb screening.   Most are delivered in a mix of public health clinics,  family practice and pediatric offices,  and specialty care facilities.   More efficient and cost saving delivery can be effected if a serious commitment to public health care were to develop in this country.   Recent experiments in locating service delivery for these services in drug stores and supermarkets show a positive trend,  but the regulation of such delivery methods is not yet in place.
“Insurable Healthcare Events” (IHCE) are those events with a low enough rate in the whole population to allow for risk and cost distribution to be spread across a group in insurance risk models.   In such events,  the larger the paid group,  the lower the overall event cost per person (but the actual event cost is not a function of group size except when economies of scale are achievable in delivery of services).  In this group,  we also find the routine trauma of auto accidents,  stabbings,  and other events of the routine urban emergency room. From an insurance perspective,  only the IHCE are appropriate for insurable coverage.   Expanding coverage to all members of the society will increase the total number of IHCEs per unit time, and cost control depends upon attention to the specific costs of delivery of the unit service.
“Exceptional Healthcare Events” (XHCE) are those events for selected patients (usually a small number) which incur extraordinary costs.   This would include neonatal intensive care services for premature babies,  coma care for severe head trauma,   and life support for brain dead,  or severely compromised end-of-life patients.  The high percentage of Medicare costs utilized in the last month of life certainly attests to the delivery of this sort of service,  though it is only in retrospect that the practitioner can often tell that it was “the last month of life”.   These events while rare for the society as a whole,  impose a significant percentage of healthcare event costs,  but attempting to limit them comes squarely into confrontation with social and moral questions of the sanctity of life and when to discontinue expenditure and delivery of healthcare events. XHCEs pose a special problem in cost control.   Almost by definition,  these events deal with the decision to preserve life or not.   Thus the decision to withhold services amounts to a decision to allow death,  a moral act in our society.   Litigation over the payment for bone marrow transplant and other cancer treatments have already begun to address this complex area,  along with cases like that of  Terry Schiavo and Karen Quinlan. 

“Voluntary Heathcare Events” (VHCE)  include plastic surgery procedures with no direct functional benefit,  fertility procedures for infertile couples,  psychotherapy for other than return to adaptive function in the community,  and lifestyle enhancement interventions (e.g. lasix eye correction procedure).   These events contribute to overall healthcare costs but are usually borne at least in part by the individual.  The extent to which such services fall under insurable events or are misplaced there is not entirely clear. 
The  process of controlling the number of healthcare events creates many moral issues for any society.    Triage of healthcare services (and events) is already occurring in American healthcare.   The poor and those living in distant rural areas have dramatically less access to healthcare delivery systems than insured persons living in urban areas. This has been recognized since the 1960s when the NHSC was developed but the split continues to worsen.   If a more universal system of care is the goal then these problems must be addressed.
Even gradual cost containment requires several issues: 1)The cost of training of providers.  The current US education system burdens the training of providers unless they enter the military.  This creates a cost for the individual or the system and has affected the charges by providers, and the distribution of services.  The solution to replace more expensive providers with less expensive ones is a partial answer, but it increases the cost of the replacement providers, and may lower the quality of delivery of care.  2) The cost of pharmaceuticals.  Pharmaceutical innovation is both a strength and a weakness of the US healthcare system.  New and effective treatments have benefited users,  but many ineffective or marginal treatments have also flooded the market and new pharmaceutical costs are poorly regulated in the US.  Companies often target similar "blockbuster" medications seeking large long term profits which are protected by patent law.  The US is a huge market and despite this the government has been unwilling to set price limits, (though individual states have). There is room for negotiation here.  3) The cost of medical treatment  and equipment.  A similar process is involved in the costs of medical devices and treatments.  Various insurers decide on when or how much they will pay for the new devices,  but patients are rarely informed of the options.  Hospital charges are notoriously inflated in expectation of being "written down" by insurers.  The creation of a realistic cost based pricing system in healthcare delivery seems an unattainable goal without regulatory intervention.

This leads to the last consideration of healthcare,  the consumer.  There is a long history of giving the consumer no information about the differential value, and differential cost, of various treatments.  This can be viewed as the provider's attempt to deliver more expensive care,  or the insurer's unwillingness to fund more expensive care, but in either situation the patient is left out.  How can an individual in need of services decide on what the best and most affordable course of action should be?  The evidence that this is not a trivial issue can be found in the reports of doctors who refuse cancer chemotherapy because they do not believe that the additional time provided is worth the side effects or cost.  Hopefully this is done after a review of the literature that patients are unable to perform.  How to provide more informed consumers?   TV advertising has flooded the airwaves with promotions for various medications,  and their terrible side effects,  which further confuse the consumer.  Providers are not the source because they are motivated toward specific treatments.  Insurers will err on the side of lack of value.  Some other source of expert evaluation must be created, and ongoing, and available to patients.  There is a need for a process of effective cost benefit review of treatment courses framed in language accessible to patients.  There is also a need for the consumer to evaluate their own ability to make health benefiting choices.  The role of diet, exercise, certain nutrients, and social activity have strong documentation.  Yet the US has dramatic obesity across the age pyramid,  despite its impact on health.  And the prevalence of excessive alcohol, tobacco, and other drug use are also major health dangers.  There are many public health messages about these dangers,  which appear to have limited benefit,  so some process of individual reward/cost for individual behavior is likely to be necessary.  (The willingness of pharmas to rush into the "treatment" of obesity with new drugs is a dangerous sign!) 
Recent critics of the current healthcare system have pointed to the archaic information system in most healthcare environments,  and proposed that a national healthcare data bank would somehow be a solution to the healthcare problem.   Implementing  major improvements in healthcare info systems has three main problems associated with it:  1) cross compatibility:  to implement standards of data collection and cross platform distribution.  Technically this is not a problem.  But politically it involves competition among providers for product exclusivity.   The fact that facilities like the VAH system have already achieved such a system illustrates how much easier it is to accomplish this goal in a single payer model, and how much it favors that model.  And 2) absolute cost:  in a system that is already experiencing cost increases well beyond inflation, this suggestion imposes massive additional immediate costs,  with no immediate guarantee of cost savings.   To impose this cost on an already too expensive system as a solution to the expense problem is totally unrealistic to all but the purveyors of hardware and software, who are the major proponents.  3) privacy and confidentiality is already a difficult issue in HIPPA requirements and maintaining these controls across communicating systems would require additional encryption technology.  This critique does not challenge the overall benefit of improving, incrementally, the data management of healthcare systems.  But all businesses that have endured the investment in data management systems know that the costs are always greater than predicted,  the problems always more complicated than anticipated,  and the results never as efficient as promised.
Another critical variable in the cost of healthcare events is management.   The  troubling report that the chief of Cardinal healthcare was taking home a mega paycheck in the face of rising costs, which his company was supposed to control, raises serious questions about his role in reducing costs for the healthcare system versus increasing profits for his company.  An inescapable conundrum of for-profit management of healthcare delivery is the issue of how management compensation is based on profits for the company or reduction in overall costs of healthcare in society while preserving quality.    The two must be linked,   that more consumers use the company because of lower costs and better service.   But this has not proven to be the case.   In many instances,  profits have been achieved by negotiating exclusive contracts with companies and then saving expenses by delivering less satisfying services.   The result has not been lower costs for companies as these managers have failed to control rising event costs,  but they have succeeded in improving executive compensation the way the rest of American industry has:  but cutting the costs of  services delivered.  This has generally been described as “aggressive management”  until the decline in services loses customer support and then a new management team is brought in to repeat the process.  Is it possible to define an evaluation tool/process that would measure effective cost saving that preserves critical quality of care delivery of services (and one that is not too expensive to implement)?   If such a measure can be defined who would be empowered to require both for profit and not for profit delivery systems to measure their systems,  who would audit that the measurements are accurate,  and who would have the authority to require both agencies to link their return and compensation to these measures? 
The most difficult issue is who will initiate and regulate the changes needed?  The Federal government would provide the most general standard but would be subject to all the politics that are currently degrading the system.   State governments will be most motivated to require configuration of services that reflect the politics and economics of their citizens.  This is a plus and a minus.  When abortion intervention was only available in some states, women traveled to others, an undesirable and economic hardship.  Citizens would likely relocate over a generation to states that best fit their image of healthcare needs,  with interesting but counter-productive effects on the population.  This will occur if the current pressures on the federal government are transferred to states.  There the public will have more direct influence,  but also more potential to under serve  certain populations.

Whoever is assigned the role of regulating services has some responsibility to limit availability (triage), an essential issue in costs.  It is about denying more expensive drugs,  treatments, surgeries,  etc.  And it is also about denying life preserving interventions in elderly, or younger dying persons.  A peculiar view of modern healthcare is that it exists to prevent death.   Stated in this way,  it is clearly impossible!  A realistic statement is that healthcare interventions delay death and facilitate productivity in those who are able to contribute.  The  view of the last century that delaying death is the "humane" thing to do seems to be changing with the increased incidence of laws supporting assisted euthanasia. 
This brief review supports the following plan for the remediation of the American healthcare system: 
1)    while increasing the covered lives to near universal coverage, 
2)    the aggregate cost of delivering services must be reduced to the per capita range of other developed economies.  At the same time,  
3)    indices that measure overall quality of healthcare delivery,  including consumer satisfaction,  must be increased to be in line with other developed economies.                                             
 Accomplishing this will require
4)    correcting the uneven distribution of services across economic levels  and the urban/rural continuum.                                                      
 Steps to implement these changes will require reducing the per unit cost for delivering “healthcare events” by
5)    modifying provider compensation for events to include reducing cost per event and improving outcome,  and some differential for serving underserved populations
6)    greatly reducing un-reimbursed institutional services (see 1)
7)    careful auditing of institutional services for misrepresentation of costs
8)    negative compensation differential for utilization of newer more expensive procedures, unless clear documentation of differential cost/benefit has been established
9)    control of excess distribution of expensive high cost services providers by regulation of numbers of providers to demonstrated need
10)negative differential reimbursement for newer more expensive drugs and equipment unless clear documentation of differential cost/benefit has been established
11)improved utilization of public health care and distribution of routine universal services to lower cost delivery
12)effective moral/economic regulatory process for authorizing the delivery of high cost extreme events
13)clear discrimination of voluntary costs and elimination of them from universal coverage of services
14)clear definition of the funding sources for the insurable events (IHCE) with a suitable balance between personal direct cost,  personal indirect cost (taxes),  and employer direct costs.
15)Establishing review agencies ( not for profit or governmental) with the authority to set terms for reimbursement of health care events.  
16) Establishing review agencies ( not for profit or governmental) with the authority to set terms for location and distribution of service providers (specially high cost specialty services)
17) Link compensation of management of review agencies to the overall goals of reducing costs of events while preserving effective outcomes and quality; unlink from ROI considerations whether for profit or not
18) Incrementally improve the overall information management of the national healthcare system to provide the data necessary for the above steps
19) Assign contracting for the review of data and compliance to organizations without conflicts of interest with regard to stakeholders, providers,  etc.
20) determine a distribution of payment for a system with these features and controls that balances reward of individual healthy habits in the individual component,  and assigns a secondary component to the work environment based on productivity,  and to the government based on the need to fund the return to productivity of those in need.
 

IN SUMMARY  This exercise shows that the tasks for improving the US healthcare system require identifying reasonable goals and redesigning the system to achieve them.  The goal of the healthcare system is (should be) to maintain the productivity of all members of society at the highest level possible,  while preparing new members to enter the society productively.  In order to achieve this goal there must be appropriate distribution of healthcare services with control of their costs.
The problem is political.  The entrenched stake holders in the system have resisted reform beginning in the ill-fated Clinton effort, and even with the Obamacare partial solution.  Historic interventions addressing these issues have not succeeded in regulating costs or distributing services more effectively.  The lesson from these experiments is that regulation of delivery of services is necessary,  for-profit entities are more motivated by other corporate goals than the overall delivery of healthcare, and are not effective.  Some other approach to regulation and cost containment is needed, at a government or independent agency level.  This cannot be done willy nilly by repealing laws of the current system without introducing alternative methods,  or the role of the system in the economy will result in devastating problems.  (It appears that some are too stupid to understand this even now.)
WHAT WILL IT TAKE TO TRANSFORM AMERICAN HEALTHCARE?
WILL LEADERS CREATE A COMPLEX SERIES OF COMPROMISES AND REVISIONS OVER A REASONABLE TIME?
OR WILL THE COUNTRY WAIT UNTIL THE HEALTHCARE SERVICES SYSTEM FAILS TO MAINTAIN A PRODUCTIVE WORKFORCE? 

TIME WILL TELL

FIXING THE INTERNET: An overview of choices

The internet is a digital system of communication which now links most of the people on earth through satellite and other transmission to computers, tablets, and digital phones.  The changes to human interactions and the impact on communities and the political system are just beginning to be appreciated.  This series "Fixing the Internet" is intended to describe several aspects which would benefit from more careful consideration by users.  No recommendations are made to the companies that supply the network, the companies and provide individual access, or specific companies providing internet services.  There are literally millions of recommendations by viewers, journalists, and advisors to these organizations,  which so far have had negligible effect.  Instead, this series of blogs is aimed at helping the user be more educated and mindful about the process of interaction with the internet in order to make better personal choices.  One sometimes gets the impression that the interaction is completely controlled by the providers,  but this is incorrect,  the result of failure to understand the process of interaction.  Different blogs will focus on separate areas:

#1 OWNERSHIP:  Who owns the data, sender or receiver?  Or the transmission service?

#2 PRIVACY AND SECURITY  How to ensure that the message is only received by the intended receivers? How to maintain privacy or disregard it for economic benefits?

#3 EVALUATING DATA CONTENT: Is the data true?  Is it legal?  Can it be used to make decisions?  How is it biased?

#4 CAN YOU MAKE MONEY FROM THE INTERNET? Can others steal from you over the internet?  How to prevent this?

#5 THE SOCIAL AND POLITICAL IMPACT: What social and political effects does this communication provide and should it be politically regulated?

#6 PARTICIPATION:  How does the individual decide whether to use/participate in some aspects, most aspects, or totally reject participation?

Subsequent posts will address aspects of each of these topics.   Each blog will focus on some aspect of the basic issues. The topic is open ended and ongoing with the changes in the internet.  AI is an example of a recent  consideration which is not restricted to the internet but will impact its influence and services in dramatic ways.

FIXING THE INTERNET 3: ELON MUSK AND DISINFORMATION

A review of several books related to the internet by Jennifer Szalai provides an opportunity to focus on the topic of valid information. 

 ( https://www.nytimes.com/2023/12/31/books/review/elon-musk-trust-misinformation-disinformation.html )

Elon Musk's struggle with Twitter (now X) provides a useful guide.  There are many speculations about why he chose to buy Twitter and refashion it.  But his claim to make it more accurate seems undercut by the first changes he made to stop putting so many resources into maintaining the trust, including charging for blue check verification,  suing an organization that tracks hate speech and falsehoods on social media , rejecting legislators’ calls for transparency, and now charging researchers up to $42,000 a month for access to data-gathering tools that once were free.  By reveling in the chaos, Musk has turned X into an experiment in whether “the best source of truth” means anything.   If we take him at his word that he was trying to make X more valid, then it is not clear that he succeeded.  But then some of Space X rockets blow up,  Tesla autopilots drive into trees; engineering is an imperfect skill that deals with imperfect information.  Musk’s vision for an information free-for-all on X  makes the goal seem impossible to  achieve — and the enormous challenges of any workable fix plain to see.   ( https://www.newyorker.com/tech/annals-of-technology/what-we-lost-when-twitter-became-x  )

(We do well to dispatch the character attacks on Musk, his erratic moods, his alleged ketamine, and other drug use.  These may have relevance for his responsibility to his workers and investors, but it is hard to see how this can be used to explain his failures at X.  https://www.forbes.com/sites/zacharyfolk/2024/01/07/elon-musk-claims-not-even-trace-amounts-of-drugs-in-his-system-after-report-detailed-drug-concerns-from-tesla-spacex-execs/    https://fortune.com/2024/01/07/elon-musk-drug-use-worries-tesla-spacex-leaders-report/    https://nypost.com/2024/01/07/news/elon-musks-drug-use-has-executives-at-his-companies-concerned-report/  )

Szalai provides a distinction between “Misinformation” (= false information that people sincerely believe and unwittingly spread) and “disinformation,” (=  (what the Soviets called dezinformatsiya) deliberate goal oriented deception).  This seemingly clear distinction is quickly confused when persons disseminate "disinformation" without realizing that they are doing so.   “On Disinformation: How to Fight for Truth and Protect Democracy,”  Lee McIntyre,  writes about “truth killers”  “to spread disinformation out to the masses — in order to foment doubt, division and distrust — and create an army of deniers.”   The originators of the disinformation may be lost in the masses of misinformation!  McIntyre claims the information about vaccination was competing against a "fire hose of falsehoods" on social media and the internet.  Can "real truth" be washed out by large numbers of lies?

 Thomas Rid explains, in “Active Measures: The Secret History of Disinformation and Political Warfare” (2020), that Russian disinformation is nothing new;  Russian trolls placed thousands of ads on Facebook — but none of the most popular contained what Rid, a political scientist at Johns Hopkins, calls “sharp, corrosive disinformation.” Rid claims the internet has actually made such campaigns “harder to control, and harder to isolate engineered effects.” Isn't there a long history of mis- and disinformation, including much sent by the US to other countries?  Was Radio Free Europe "true"?  Or propaganda?  This is precisely the kind of argument that Jeff Kosseff presents in “Liar in a Crowded Theater: Freedom of Speech in a World of Misinformation” (2023).  Kosseff, a professor of cybersecurity law at the United States Naval Academy, urges caution. He doesn’t deny that technology can amplify lies, and that lies — whether deliberately engineered or not — can be dangerous. Does it make sense to give government the power to decide on the "truth" of information?  Doesn't that amount to the sort of mind control in 1984?

Despite the liberal/libertarian claims of Silicon Valley, companies like Meta, which makes billions from advertisers,  have a vested interest in promoting the idea of an impressionable public susceptible to being influenced on platforms that are “magically persuasive” to sell advertisers. Most people would agree that the level of "truth" in advertising is extremely low, to non-existent.

Who is in charge of "truth" anyway?  In a cover story for Harper’s Magazine in 2021, the BuzzFeed reporter Joseph Bernstein (now a reporter for The Times) wrote about what he calls “Big Disinfo”: an industrial complex of think tanks, media companies and academic centers that emerged during the Trump years to study the effects of disinformation.  The RAND CORP has published the results of a study on the erosion of truth in society which they call TRUTH DECAY.  (https://www.rand.org/research/projects/truth-decay.html)(It is available for download free at ( https://www.rand.org/pubs/research_reports/RR2314.html )
 They identify this as the declining use of “data and facts” in political discussions over the last decade.  They recognize this has been a feature in US society historically, "yellow journalism", etc. They see four trends:
    disagreement about facts and their interpretation
,  blurring of the line between opinion and fact
,  increasing the role of opinion,
 and decline in trust of "respected sources".  They identify four drivers:
  cognitive bias as a human characteristic
, changes in information systems in news media,  changes in internet social media
,  breakdown of the education system,
  and polarization of society,  politically and economically.  Data supporting these observations is generally strong, and social media is only one of several factors.  They assert a need for agreed upon “truth” for every society,  and  that making decisions for the society based on these “truths” is the best course of action.
  In this view,  the problem is not the breakdown of valid communication of information,  but the intentional biasing of information for advocacy. 

TO PROCEED it is useful to be clear about three different kinds of truth:  1) Certain beliefs common to religious groups and certain social communities are accepted as true statements, without any independent validation.  "The bible says it's so."  2) Peirce's pragmatic truth “Inquiry properly carried on will reach some definite and fixed result or approximate indefinitely toward that limit” (1.485)1 and, “The opinion which is fated to be ultimately agreed to by all who investigate, is what we mean by the truth” (5.407).  This closely approximates what scientific knowledge would provide if it were not distorted by other social values. and 3) Consensus reality the common group of beliefs held by a community based on varying levels of observation and reinforced by social consensus. (As in the Ash experiments in social psychology.) (Tart has written the strongest descriptions of the power of social consensus.)  If there are other ways of validated "truth" (outside of mathematical logic),  I am not aware of them. 

 The range of "truth" is relatively narrow.  Facts that I observe as an individual based on my sensory experience are the basic level of “truth”.  Even at this level the information is imprecise.  I may overlook important details,  or see an event occurring and misinterpret it,  as in observing a traffic accident.  Once the process of observation becomes complicated by scientific instrumentation,  various procedures of standardization (calibration) must be done.  And if the information is reported by another, either verbally, or using audio-visual media, the bias that person introduces must be considered.  Even a simple report like “it is hot today” may involve bias,  not to speak of complex reports like “voter fraud is everywhere”.   “Scientifically” performed observations can easily be biased if the method of observation or reporting is biased.  This supports the postmodern view that most information is biased by the source and must be interpreted,  so that “truth” is relative.  “Fact checking” politicians amounts to identifying if they make statements of advocacy pretending that they are based on “real events” or “data”.  They are not bound to make true statements “under oath” most of the time, so it is unclear why people expect them to do so.  The current Liberal attacks on the POTUS for his constant, patently false statements simply reaffirm his intention to annoy them and support his followers.  The idea that the Clinton presidency was mostly truthful is equally inaccurate, and the failure of Liberals to acknowledge this confuses their current outrage.


Based on these versions of truth, the Rand concept of "Truth Decay" is not about disagreement of facts,  but about the breakdown in a consensus of how agreement is reached by the society.  There is a common liberal/conservative confusion about communication:  liberals  believe that transmitting "accurate data" will drive optimal decisions,  while conservatives believe that emotional bias drives decisions regardless of data and emphasize emotional communication, an apparent conflict between data and consensus. Increasingly, the liberal position has lost its data focus. (The reader will recall that RAND at one time produced studies on the magnitude of overkill needed to prevent a nuclear war, not "fact based"!) The social system creates its own reality and enjoys or endures the consequences.  This is more obvious in economic decisions,  but applies in all social decisions.  TRUTH DECAY is an attempt to “explain” how the conservative approach to communication is “overwhelming” and eroding "truth".  But “big data” continues to be utilized by businesses for decision making.  The supposed disregard of facts is mainly in the arena of politics and social policy, and a strong division of values in current US society is driving this advocacy messaging.    

A clearer understanding is the breakdown of social consensus in the country over the last half century, the result of 1) economic inequality, 2) failure to protect workers as a class, and 3) scapegoating of minorities as a method of avoiding the effective decision making of leadership, which intensifies social silos.   Chris Hayes book “Twilight of the Elites: America After Meritocracy,” published in 2012 describes how elite malfeasance: the forever wars after 9/11, the 2008 financial crisis undermined the public’s trust in institutions.  The election of Obama further challenged the country's sense of consensus (whether or not he was an effective leader).

The role of the internet social media is a multiplier.  It expands access to varying opinions, and if these are used according to criterion 2) will eventually lead to valid decisions.  But more often,  the result is the creation of consensus subgroups 3) with conflicting opinions on major issues.   "truth" is not overwhelmed by a large volume of lies,  though this process may sometimes occur.  This problem is not new and the American public has been misinformed on a consistent basis by its government through much of its history, e.g., the Pentagon Papers.  And America has actively participated in disrupting the information of other countries, most recently in the "Arab Spring".  

Legislative solutions,  government interventions, and economic models like paying users for the information about them, all put the responsibility for managing the system outside the user.  It is likely that the new AI systems will attempt to circumvent any interventions that interfere with the algorithm goals, since they are goal-oriented programs!  When the user intentionally manages the response to the algorithms, the AI will react.  The user/interface dynamic must be used to control the viewing experience, so it is up to the user to express the control and direction he/she intends.  If platforms attempt to prevent this by limiting the users ability to select,  the choice is to abandon the platform.  Many platforms,  like MYSPACE,  have disappeared.  The idea of trusting the government to somehow legislate this consensus is the most dangerous of all,  and truly encourages "mind control" and 1984.  Most congressmen have so little understanding of internet and social media as to be ludicrous.

Enhancing the  interaction between user and AI system does not address the tendency of users to favor their own perspective and suppress other information.  It does not address the user's tendency to accept viewpoints of others with similar perspective, even when they are false observations.   The problem of the fragmentation of our social system is not caused by the expansion of social media,  though it facilitates diverse social networks.  This has generally been viewed as a great disaster on the Left when it fosters conspiracy theory sites like QAnon, or Right wing militant groups,  but also on the Right when the result is "cancel culture" of narrowly focused Liberal groups.

Educated viewers of TV do not believe most of the information promoted in television ads,  nor should they believe much of the information promoted in internet ads,  or even internet "postings" that purport to be shared by "friends" but are really ads, sometimes from BOTS.  Viewers are bombarded with false information in all media, and bear the responsibility for recognizing and dealing with this.  The only real solution to the integrity of internet communication is educated participation by users who are mindful of its limitations.  This requires an educated media viewer who is informed of the processes and can manage their own interaction with the system.  This training must begin at an early age because media actively engage young viewers into passive viewing habits.  Unless the country supports these changes in users,  the process will not be managed. 

IN A DEMOCRACY THE PEOPLE MUST TAKE RESPONSIBILITY FOR POLITICAL ACTION WHICH INCLUDES THEIR INTERACTION WITH THE VARIOUS FORMS OF MEDIA USED TO INFLUENCE AND MANIPULATE THEM.  WITHOUT THIS DEMOCRACY IS THREATENED.

DECLUTTERING or FOCUSING

 The New Yorker re-posted a classic of its articles (according to them) "A Guide to Getting Rid of Almost Anything"   https://www.newyorker.com/magazine/2022/02/28/a-guide-to-getting-rid-of-almost-everything-decluttering

True to the title,  it is mostly about how to get rid of stuff mostly by posting online at various sites,  with some interest in recovering compensation for doing so ($$) but also comments on charitable donations.  Nothing much is said about why  to get rid of the stuff,  only that you no longer need or care about it. 

I am also currently in the process of "decluttering" but I don't call it that and don't think if it that way.  I am getting older.  I realize that there is no burial mound or pyramid being prepared to hold all my clothes, books, and other stuff for my journey into the next world (whatever that is).  My stuff will not go with me.  (For those interested, listen to Kate Wolfe's "In China or a Woman's Heart".)   I still enjoy listening to some  recorded music,  and even on occasion watch a (not streamed) DVD movie.  I have re-read a few books,  but most of them will never be read again,  and sit on the bookshelf only to inform others of my reading history.

I am still very much interested in life,  my life right now,  and my life as it unfolds today, tomorrow and whenever, until it ends.  But much of my past life does not interest me, except when recounting it at parties in response to other's prompts.   The past is over, and lives in the present by how it has molded and guided me.  Our house has many objects that are associated with travels or other past events.  They are the stimulus for enjoyable memories from time to time.  The things we hold onto as stimuli for special memories are anchor us with the past, but must not replace the present, or distract from  its unfolding.  

More and more,  I think of removing things from my life-space to reduce the distractions of the past and facilitate focusing on the present,  and its unfolding into the future: FOCUSING.  There is only a finite amount of human life time,  measured in seconds, minutes, hours, days, and by actions that I choose to do.  Each action uses some of this time, and must supersede other possible actions that are not done.  And the stuff around me calls out to attend to it,  to use it, or to do something else.  

What if some day I change my mind and decide to do "that" action instead of "this" action?  What if I really need that guide or tool or instrument or something  to do some action, instead of what I am doing now?  This is the "Frost Dilemma": "two roads diverged in a yellow wood,  and would that I could travel both..."  Holding onto things, books, tools, is grounded in the dilemma of commitment.  If I decide to follow one path,  and still hold onto the resources for another, in case I need it sometime in the future, seems to make good sense.  But it reveals the uncertainty and anxiety of my commitment to the decision being made.  It is a "hedge against failure", and eventually life gets filled up with these "hedges".  My life does anyway.

So I am clearing out things that do not contribute to the life I am living now, and accept that by doing so, they will never contribute to my life in the future.  And that is OK,  that is the reality of the finite-ness and limitation of being human.