First, Do No Harm

At last, the seven-year-long Republican obsession with repealing Obamacare is about to come to fruition. Or not. The proposed Senate bill doesn’t exactly repeal Obamacare, but rather subjects it to a slow death of a thousand cuts. Thus, the decades-long saga of America refusing to come to terms with the medical needs of its citizens continues.

Oddly, the fans of “repeal and replace” rarely explain how their legislation will be better for the people you’d think would be the point of the exercise – patients. Instead of talking about health, they talk about economics. So, they complain that Obamacare is socialistic income redistribution, that is, higher taxes on the wealthy were used to help subsidize healthcare for the less affluent. But only an accountant would describe a doctor’s care when you’re sick as income. Helping those in need used to be called charity, not socialism. Jesus seems to have been in favor of that.

It is also argued that the goal is shifting power to the states for Medicaid, which helps fund healthcare for 73 million working poor who don’t get healthcare on the job, for their children, for 65% of elderly people in assisted living, for the disabled, for half of all births. According to Republican theory, the states are “laboratories of democracy,” and from 50 experiments will come healthcare improvements.

But in practice, quite a few governors don’t want Obamacare repealed since they can’t afford to fund Medicaid either. So, this looks more like a game of hot potato on the part of Congress. The upshot will be worse healthcare or none for people in poor or ideologically pure states. The quality of the care Americans get will depends on the luck of the draw, geographically speaking. Be careful where you’re born.

A slightly less farcical claim is that we simply can’t afford to provide healthcare for all those poor, old, underemployed, disabled, pregnant people. But this is a species of Social Darwinism. Some people, the fittest as defined by employment or net worth, deserve all the healthcare money can buy. Those who can’t afford it deserve nothing, having proven they aren’t worth investing in. Shades of Scrooge and his enthusiasm for eliminating the “surplus population.”

But even on the most gimlet-eyed green-eyeshade level, we can afford to provide healthcare for everyone. In fact, those who can’t afford insurance still end up at hospitals or emergency rooms where they cost more in critical care than if they had had preventative care all along. We just choose not to provide care rationally. Every other developed country has been able to figure out this puzzle. The Japanese, Germans, French, English, Canadians, Scandinavians and many others have some form of universal healthcare. In almost every case it costs less per capita than we are spending, and health outcomes are better than ours.

So, the objection to offering some variant on those systems isn’t that they don’t work or aren’t affordable. It’s that they require everyone to pay taxes and the government to control costs. This in anathema in America, where doctors are capitalists who earn millions and often preside over several profit centers giving them a piece of the tests or imaging they prescribe. (Doctors in Congress illustrate the point. Tom Price, the Georgia congressman turned head of HHS is worth $13 million, Sen. Rand Paul, $3 million, Rep. John Barrasso, $3 million, Rep.Phil Roe, $4 million.) Many hospitals are now for-profit monopolies. Big Pharma is big business. Payment in America is per procedure, so there’s an incentive to do a lot of tests and procedures whether the patient needs them or not.

And the original sin of American healthcare was linking insurance to employment. During World War II, employers had a hard time competing for employees since wage and price controls had been instituted, but they could offer a health insurance benefit in lieu of a higher wage and get a competitive advantage. That worked fine when most people were working for huge corporations for life, and when they all offered the same benefit, but those days are gone.

That, rather than the laziness beloved by Republican ideologues, accounts for the growing number of the uninsured who are one illness away from bankruptcy. And don’t forget that a society that relies on private insurance rather than public financing is automatically facing higher costs. Numerous studies have shown that as much as 17 cents of every healthcare dollar goes to pay for insurance overhead and profits. Aetna, Humana and the rest aren’t providing coverage for free. By contrast administrative expenses for Medicare are a trivial two percent.

In fact, rah-rah capitalist congresspersons ought to consider an alternative to fix healthcare. Since they are never going to adopt universal public health insurance, why not give every child when he’s born an account funded with a healthcare index fund. These have grown every year for the last decade and a half by 10% a year, before Obamacare and after, through recession and recovery. You can go broke needing healthcare, but not owning it.

Clearly the present system is crazy, and the proposed cure is crazier, assuming the goal is caring for the health of 320 million Americans efficiently, rationally, and economically. But that isn’t the goal. Cutting taxes on the wealthy is a goal. While ten or twenty million people will lose care under the legislation, the top two percent of taxpayers will get $272 billion in tax cuts. Reducing government expenditures is a goal. And getting reelected is a goal for people who have been promising to destroy uppity Obama’s programs. Everything else is negotiable.

But what if voters have long memories? Candidate Trump ran on the promise to replace Obamacare with something better. And he promised never to take away Medicare or Medicaid. At first, he celebrated the passage of the House bill, but someone must have told him it would not create better care than Obamacare, but less — and that it would slash spending on Medicaid. So, he called it “mean” and demanded that the Senate do better.

The Senate has done worse, cutting deeper into Medicaid. But it has timed the cuts to phase in over several years, so those running in 2018 might not have to face the backlash. But by 2020, Trump voters who took him at his word could be attending his rallies with pitchforks. Because whatever the Republicans pass will go further to making us a nation of healthcare haves and have-nots, a patchwork of states in which some provide a healthcare safety net and others where you can die on the street. Perhaps the drafters of these fixes should have remembered the Hippocratic oath: First, do no harm. And not just to your donors.


During my working life, I was not a suit. I wore them five days a week, but “the suits” are the executive class, the people who have the power to make the rules that make other people miserable. They also have the power to make ill-considered decisions that screw up the entire enterprise. I was, at my most exalted, only a kind of foreman, a cog in the machine, not someone pulling the levers.

The suits that “the suits” wear are semiotic signs, which is the new fancy way of saying clothes don’t just make the man but describe him. Suits represent the wearer’s clout, their place in the hierarchy but also the nature of their endeavors. As everyone has noticed, the tech billionaires don’t even bother to put on a sport coat, preferring faux egalitarianism. So, Steve Jobs opted for the beatnik chic of black turtlenecks, Zuckerberg wears dorm room T-shirts, and Gates, until he became a bridge-playing philanthropist and got a tailor, dressed in the engineer mode of tieless white shirts that looked lost without their pocket pen protectors.

Heavyweights in fashionable fields like fashion, media, movies and advertising wear expensive, stylish, designer suits. Bankers tend toward the other end of the spectrum with conservative, out-of-date models, and industrial CEOs may even stoop to proletariat off the rack numbers, at least when visiting the plant.

What got me thinking about this subject was seeing Senators Richard Burr (R-NC) and Mark Warner (D-VA) of the Intelligence Committee in a joint interview. At first, I thought someone had been messing with my TV’s settings and had chosen an odd aspect ratio for the picture or set it to ‘stretch,’ but the other people on screen looked normal.

Then I realized that both senators had simply adopted the political suit. As it happens, I have actually been in rooms with each of these men for interviews. In person, they are normal-shape, normal-size Americans. But you wouldn’t know it from their political suits. A day later I saw Rep. Tim Ryan (D-OH) on the tube wearing an even more extreme version of the suit.

He looked as if he were wearing the packing carton his refrigerator came in. That is to say, the political suit is really boxy. Also, in an era when a natural drape has become the norm, the political suit has hugely padded shoulders that make the wearer look as if he is about to kick a field goal rather than pass a bill. All this shoulder padding also has the unfortunate effect of making the wearer look pea-headed.

Such suits are an anachronistic throwback to an earlier era. They are reminiscent of the thug suits familiar from the gangster movies of 1930s and 1940s. Luca Brasi wore one to the wedding that opened “The Godfather.” I suppose they had to be roomy to accommodate the gat, the bulletproof vest and all that pasta. Edward Arnold, who played the corrupt rich guy in movies like “Mr. Smith Goes to Washington, also wore this ancestor of the political suit, as did J. Edgar Hoover, speaking of thugs.

The thug suit went out of style in the 1960s when youthful John F. Kennedy opted for chic, modern duds that made the thug suit look antique. But they came back with a vengeance when Ronald Reagan made everything new anathema and everything old ideal. Who can forget his foursquare suits, frequently in an unfortunate brown. They may have inspired David Byrne’s big suit, roughly the size of an untethered zeppelin, in “Stop Making Sense.” Check it out on YouTube.

You’d have thought this look would have been made unacceptable forever among gaudy patriots like Reagan and today’s pols since, for decades during the Cold War as Americans got more hip, it was the signature look of the Kremlin, encasing the square frames of communist brutes like Leonid Brezhnev. This bulky communist suit was strictly an assembly line number, so blocky and generic that the reviewing stand at the May Day parade often looked like the loading dock at an appliance factory.

Yet members of Congress now regularly sport this totalitarian look, despite the subliminal message it sends. Not, “I’m a humble servant of the people,” but “I’m a Humvee that will crush you like a bug if you get in my way.”

Interestingly, the president doesn’t quite wear the classic political suit, but a sort of variant. Perhaps because he is the fattest chief executive since Taft, his suits are big, too, with the kind of shoulders last seen on Joan Crawford. But rather than falling boxily to his thighs, Trump’s suits tend to billow with yards of extra fabric. If he keeps gaining weight, he may be forced to end his term in robes like a Saudi prince.

Luckily, neither Trump nor members of Congress are likely to start a fashion trend that will be emulated. John Lennon sang, “if you go carrying pictures of Chairman Mao, you ain’t gonna make it with anyone anyhow.” And the same rule applies if you go dressing like Chairman Burr or President Trump.

Potemkin Signings

Grigory Potemkin was a favorite lover of Catherine the Great. He was assigned the task of rebuilding the Crimea after it was devastated by war. According to legend, that was too much like hard work so he constructed stage set villages.

As the barge of the Empress progressed down the Dnieper River, paid extras dressed as phony peasants waved from the phony villages on the shore. Overnight the villages would be moved downstream and the entire charade reenacted the next day. Viola! The region is on the mend.

As befits a story about fraudulent villages, the story itself may not be true. But the Potemkin Village has become a metaphor for any fraudulent display meant to make viewers believe things are better than they actually are. For decades visitors to the Soviet Union or Mao’s China, for example, were carefully herded by their minders so they saw only those sights that would serve the aims of the regime.

Today, the Trump administration has gone the Potemkin Village one better. On the one hand, much of what is actually up is hidden from view, so the Senate is drafting a healthcare overhaul that even members of the Senate don’t get to see, military actions have been outsourced from the White House to Defense Secretary Mattis and occur without meddling from the President of the United States, revised regulations that favor special interests are instituted by stealth, and government actions that feather the Trump and Kushner nests are allegedly being put silently in place.

Meanwhile, what is on view is designed to distract attention from administrative incompetence, fecklessness or malfeasance, and from multiplying investigations by House, Senate, special counsel and investigative journalists into electoral meddling, possible collusion with Russia, financial chicanery and so on. This actual news is fake news, according to Trump. In its place, we are given a Trump innovation, the “Reality TV” of the Potemkin signing.

The president surrounds himself with administration and congressional extras, and a few selected members of the public who will supposedly benefit from some measure that the president signs with a flourish and proudly displays to the cameras. The standard photo op, in short.

Except the Trump version isn’t a bill signing creating a new program or appropriating money to help create jobs, make healthcare more affordable, protect our borders, or improve our infrastructure. The hapless, understaffed, disorganized administration and the bickering congressional Republicans are incapable of accomplishing any major task.

So, Trump is signing memos. Recently he hosted a lad who he extolled for turning around his life by finishing an apprenticeship program that made him gainfully employable. Good for him. But he was only there as a prop as Trump signed something he claimed would do the same for many more struggling Americans.

in fact, Trump’s memo suggested that the appropriate department study the idea and recommend how to make more of such programs available. And if they ever compete such a study, it might be sent to Congress which might deign to design such an endeavor, but probably won’t, and would be unlikely to appropriate any funds to finance it. Still, as far as the audience knows, this is just another day of Trump making Americans believe things will eventually be great again, or adequate, or won’t get too much worse.

Those who attended Trump University eventually discovered to their sorrow that it was a con, but outside observers may have believed it was for real. Trump may even have believed it was real. And today, he may even believe the Potemkin signings are accomplishing something. Or he may think they are serving the useful purposes of getting him his daily dose of airtime and distracting the attention of the public from the investigations his lawyers claim are not actually taking place or targeting him. Fake news of a nevertheless cruel Witch Hunt. Sad.