Myths of Medicare for All

The Democrats appear to be all in on proclaiming that healthcare in America should be provided in a "Medicare for All" system.

To hear the candidates speak about it you would think that Medicare for All will cover everything and cost nothing. Bernie Sanders is continually stating on the campaign trail that his Medicare for All plan will have no deductibles and no coinsurance. People will pay nothing for their care other than a little more in taxes. Of course, he argues that almost all of that additional tax burden will fall on "the rich".

Sanders also states that there will be no private insurance as part of the system. It will be government-run to eliminate all of the profits and administrative costs in the current system.

Let's take a look at some of these statements by looking at how Medicare actually works right now for senior citizens. When you understand how the current Medicare program  works I hope you can see how misleading all of this "Medicare for All" talk is.

Let's look at some of the Myths of Medicare for All.


The Funding of Medicare

Medicare was originally established as a program to cover Hospital costs (Part A) and non-Hospital costs (Part B) such as doctors visits, diagnostic tests, etc. A 1.45% payroll tax is levied as part of the FICA taxes on payrolls to fund Part A. This tax applies to both employees and employers so it amounts to 2.9% on all payrolls in the United States. It is a flat tax so it applies to everyone. It is not a progressive tax like the income tax.

Part B is paid for with 80% federal dollars (paid with general revenues) and 20% by those on Medicare through a monthly premium. That current premium is $135.50 per month. There is no reduction for those on low incomes. Everyone has to pay it to have Part B coverage which is optional. Those with joint annual incomes above $170,000 pay more.

Prescription drug coverage was not a part of original Medicare. A big reason is that very few drugs were used in treatments in 1965 when Medicare was enacted. Drugs are now covered under Part D of Medicare but that requires an additional premium for coverage and there are also separate deductibles and coinsurance with that program as well.

Keep in mind the current Medicare FICA tax is to just pay for those currently on Medicare. How much higher would that tax have to be to also cover those under age 65 today? How high would the monthly Part B premium be under Medicare for All? What about the premium for drug coverage?


Medicare Does Not Pay Everything

Medicare as it exists today has fairly substantial deductibles and coinsurance amounts in addition to the monthly premiums and payroll taxes in effect.

There is a $1,364 annual deductible under Part A. That means the first $1,364 in hospital costs are paid by the individual. If you are in the hospital for more than 60 days there is a $341 coinsurance payment required to each day up to the 90th day. That goes up to $682 per day for days 91-150.

Under Part B there is an annual deductible of $185 and you also have to pay a 20% coinsurance amount on every bill.

As you can see, there are fairly substantial out of pockets deductibles and coinsurance under Medicare. The deductibles are also adjusted upwards each year with inflation.

Medicare also does not cover you for any medical services outside of the United States. While private insurance typically covers you for foreign travel, there is no coverage under Medicare.

How is it that Bernie Sanders believes that "Medicare for All" would have no out of pocket costs when Medicare today has extensive deductibles and coinsurance?

Private Insurance

Due to the fact that Medicare does not pay for everything a robust private supplemental insurance market has been developed by private insurance companies to cover the gaps in coverage.

About 80% of those on Medicare have some type of private insurance to supplement Medicare. These "Medigap" plans, as they are popularly known, have different core plans with varying costs based on how much of the "gap" they cover, the age of the individual, where they live and whether they smoke. Here is an sampling of rates for Decatur, IL. Costs in larger urban areas would typically be higher.

34% of those on Medicare rely on Medicare Advantage plans that are totally administered by private insurance companies. These are plans that Medicare enrollees can elect to participate in and forego traditional Medicare. The private insurance companies receive a flat amount from Medicare and the private companies assume all the risks and costs for the coverage of the individual.

These plans have proven popular as enrollees in these private plans typically get better coverage with lower premiums than with traditional Medicare.

As you can see, private insurance companies have a significant presence and role in Medicare. Is it realistic that the Democrats are going to completely eliminate private insurers from the healthcare landscape?

Administrative Costs

A big argument of the Democrats for Medicare for All is that under such a system there would be enormous cost savings because all of the private insurance company costs and profits would be removed from the system.

However, as I have pointed out in a previous blog post, if you removed all of the costs of the insurance companies out of all the health expenditures in the United States you will still have 93% of the costs remaining.

Elizabeth Warren claims that private health insurers made $23 billion in profits last year and getting rid of them will make everything great.  I will assume her numbers are correct. However, almost $4 trillion will be spent this year in total healthcare expenditures in the United States. That means insurance company profits make up only 0.58% of total costs---about one-half on one percent. How much difference is that going to make?

The Democrats also like to target the large pharmaceutical companies and the price of their products. However, drug costs make up only 10% of all healthcare costs. Again, the profits of drug companies cannot represent more than 1% of all health care expenditure in the United States. And those profits are the reason most of the innovation in drugs in the world takes place in the United States.

In other words, the insurance and drug companies are good targets for campaign rhetoric but eliminating them from the system will have almost no impact on total costs.


Medicare Reimbursements

What is likely to occur if we were to convert to a "Medicare for All" system is that countless numbers of hospitals would be forced out of business and we would surely see many doctors retire or quit the practice of medicine.

Why?

The truth about Medicare is that, on average, it only pays healthcare providers at a level that is about 85% of their costs. In other words, many hospitals would have to drastically cut services and/or costs in a Medicare for All world or they would quickly go bankrupt.

Doctors would see their revenues and incomes drop drastically. Since almost 50% of doctors in the United States are 55 years of age or older it is not hard to predict that many would choose to retire rather than to continue operating their practices.

Credit: https://www.statista.com/statistics/415961/share-of-age-among-us-physicians/

The current system only works today because private insurers and payers pay providers at about 120%-140% of their costs. In effect, the private sector is subsidizing the costs of public sector programs such as Medicare and Medicaid.

As Medicare and Medicaid have restrained reimbursements over the years the private sector has had to pick up more of the tab as this graph from the American Hospital Association shows.

Credit: http://truecostofhealthcare.org/hospital_financial_analysis/

How do we not see substantial cutback in services if the revenues of healthcare providers are not reduced to the level of Medicare reimbursements?

How do doctors, nurses and others who provide healthcare services not see their compensation reduced if the government is the only payer?


Conclusion

Don't believe what you are being told about Medicare for All.

Most of what the Democrats are talking about are myths.

Medicare as we know it is going bankrupt as it is. The current payroll taxes are insufficient for the long-term needs of the system.

Medicare would already be bankrupt without the enormous amount of subsidies the private sector is providing to the health care system which simply could not function with current Medicare reimbursement rates.

Medicare is not free and it has extensive deductibles and coinsurance amounts in place.

Medicare relies heavily on private insurance companies to cover gaps in coverage.

You can take all of the costs and profits of private insurers and drug companies and you would barely put a dent in the nation's total healthcare expenditures.

Medicare for All is simply not workable without massive tax increases on every American and/or substantial reductions or cutbacks in the access to care that they are used to. There is no other way around the math wherein we spend about $4 trillion per year on health care in the United States.

 Anyone who tells you anything differently is simply not being honest with you.

Negative Yields In Our Future?

I have written before about the enormous amount of debt in the world that nows carries zero or negative interest rates.

In that blog post I featured this chart from mid-June that showed the share of government debt in various countries around the world that are bearing negative yields.

In the last two months the amount of global debt that carries negative yields has soared by another $4 TRILLION!

There is now $17 trillion in debt around the world that carries negative interest rates. In effect, the saver has to the pay the borrower to take their money.

Negative rates have previously been confined to government bonds, but in Europe Zero Hedge points out that we are now seeing negative yields on a large percentage of investment grade corporate bonds as well. In July, 2/3 of AA-rated Euro bonds and 1/3 of A- rated Euro yielded less than zero. The developments of the last month has undoubtedly increased these numbers.

What is truly amazing is that some high-yield corporate bonds (1/5 of BBB-rated and nearly 1/10 of BBB- bonds) have also gone to negative yields.

However, the most shocking statistic in the Zero Hedge article is that the United States now has 94% of all the positive interest yielding investment grade bonds in the world!

The average yield on the $27.8 trillion in non-U.S. investment grade bonds worldwide has declined to just .16%!

Taken alone, non-U.S. sovereign yields average a mere .02%.

What does all of this mean?

We have reached a point in which the only place in the world that a saver or investor can obtain a positive return on an investment grade bond is to invest it in a U.S. dollar denominated bond.

Is it any wonder that the Federal Reserve has to cut interest rates?

I also find it interesting that recently I have seen several articles suggesting that all of these negative interest rates are natural.

"The Non-Weirdness of Negative Interest Rates" appeared in Bloomberg Businessweek recently which suggests that all of this is normal and to be expected in a world with ever-increasing wealth concentration, low rates of global growth and lots of cash.

Negative rates are showing up everywhere, seemingly turning on their heads traditional notions of lending and borrowing. Negative yields just don’t seem to make any sense. A lender is supposed to get paid to part with capital, while a borrower is supposed to pay to use that cash for some purpose. It seems crazy that anyone  would voluntarily part with their money, only to end up with less of it.

But what if negative rates are totally normal? 

The article goes on to suggest that there are storage costs with almost all assets. It costs money to rent a safe deposit box, or store gold, grain or oil. It costs money to own real estate. It costs money for you to have someone manage your stock portfolio. Why is it weird to think that you should also have to pay to store cash?

There’s lots of money out there and a limited capacity to store it all. So increasingly, savers are going to have to pay for money storage services. And although it’s not much consolation, we can at least remember that whether it’s fees for oil tanks, safe deposit boxes, security guards, insurance, or wealth managers, there's nothing unnatural about being forced to pay to preserve your wealth.

Another article on the subject appeared recently in Quartz in which the title question was "Are Negative Interest Rates Unusual, Natural or Both?"

Negative rates may have been unthinkable for most of civilization, but they are now part of our reality. The evidence seems to suggest much lower, and perhaps even negative, rates are being driven by market forces, which makes them natural. But this only shows things change, and one day the old order could return.

Negative rates unthinkable for most of civilization? That is an understatement when you consider that the concept of a loan requiring that the borrower pay positive interest dates back as far as 2500 BC.

I could not find a graph of interest rates that went back 4,500 years but I found one that went back to 1703 in the U.K.

Credit: @EdConwaySky

Is there anything normal about negative interest rates? I am not aware of any other period in history when it was not natural to expect to be paid interest when you loaned someone money. It has never been seen before through all kinds of economic conditions that have included recessions, depressions, revolutions, wars and technological upheavals.

I also don't buy the argument that this is all due to increasing wealth concentration.

For most of mankind's existence most people lived in poverty. Wealth concentration was much higher in 1519, 1719 and 1919 than it is in 2019. The royals and a few others controlled almost all the wealth in any country in the world.

In fact, one study showed that 94% of the world's population lived in extreme poverty and 84% lived in poverty in 1820.

Those numbers have fallen dramatically, especially in the last 40 years. Those living in extreme poverty have fallen from over 40% of the world's population to less than 10% today.

I also don't see the relevance that you have to pay storage fees for gold, oil, grain or other assets so it should also apply to loans of your cash. Yes, those assets require storage fees but the asset owner also has the expectation of a possible return on the investment in the underlying asset. The storage fees are friction costs.

That is not the case with a bond. Interest on the bond is the investment return. There is nothing else to compensate the investor other than the return of the asset at the bond's maturity. Of course, negative yields mean there will not be a full return of the principal.

The one thing that is true is that negative yields have become a reality around the world.

How long will it be before those negative yields start appearing in the United States?

It may just be a matter of time if recent global trends continue.

Is it natural? Will this be the new normal?

4500 years of history says NO. However, in the short term anything can happen.

We are seeing that right now.

Things I Learned This Week

Every week you should be learning something.

If you are not learning, you are not advancing in life.

If you are not advancing, you are dying.

Here are a few random things I learned this week that might also advance your knowledge.

Left Handers

National Left Handers Day was celebrated this week.

Researchers who study hand preference believe there is a natural inclination for most people to be right-handed due to biological and genetic causes. This is because language and speech is controlled by the left hemisphere of the brain. The left hemisphere also controls the movements of the right hand as well as the movements necessary to produce written language. All of this has resulted in millennia of evolutionary development that is biased genetically toward the right hand.

It is estimated that 15% of humans have a preference towards the left hand.

However, look at these statistics on the percentage of left-handers by country around the world.

Credit: https://twitter.com/NorbertElekes/status/1161359595077591043

The United States and Canada are the only countries in which left-handers are close to that number. There are clearly a lot of parents and/or teachers in other countries interfering with Mother Nature.

Of course, this also used to occur in the United States if you look at the historical numbers of left-handers in the population.

Credit: https://twitter.com/NorbertElekes/status/1161380722336251904

Is it a coincidence that in baseball left handers seem to have an advantage in getting to the major leagues or that 2/3 of NHL players shoot left-handed?

% of batters who are left-handed----37%

% of pitchers who are left-handed---27%


Summer Heat

We hear a lot about global warming and climate change in the news but the reality is that the weather in the United States this summer is (and has been over the last few years) much cooler than average.

Credit: @SteveSGoodard

Can you imagine the climate hysteria if we saw anything close to what was experienced in the summers in the 1930's?


1946

Did you know that three Presidents of the United States were born in 1946?

Donald Trump     June 14, 1946
George W. Bush  July 6, 1946
Bill Clinton         August 19, 1946

Did you also know that Trump is older than both Bush and Clinton?

By the way, the three leaders in the Democrat primary polls are:
Bernie Sanders: born in 1941,
Joe Biden: born in 1942.
Elizabeth Warren: born in 1949.

There has not been one President who was born in the 1950's. Barack Obama was born in 1961.


Presidential Primaries

Running for President has become a big business in building the "brand" of a politician and increasing social media presence, book sales and speaking fees.

Why else would so many candidates be running in 2016 and 2020?

Keep Your Eyes On Hong Kong

I have been watching the protests in Hong Kong with a great deal of interest.

The last two days have seen the protestors encamping at the airport causing the cancellation of all flights in and out of Hong Kong.

The prime lesson it should teach us is how difficult it is to take something away from the people.

Hong Kong was a British colony or dependent territory for over 150 years. The people of Hong Kong got used to the freedom they had under the British and the thriving economy that they built was in stark contrast to what was occurring in Communist China.

In fact, without the economic success of Hong Kong as evidence, you have to wonder whether the Communist Chinese would have ever introduced the market reforms which has led to the transformation of the Chinese economy.

The British ceded control of Hong Kong to China after obtaining guarantees to preserve its systems, freedoms and way of life for at least 50 years. This has become what is known as the "one nation, two systems" policy that makes Hong Kong part of China but allows its economy and freedoms to continue as before.

The current Hong Kong protests began when China backed a provision that would have allowed extradition of those accused of a crime in Hong Kong to mainland China.

Protestors saw this as an erosion of the "one country, two systems" policy and protests are continuing even though China has suspended support for the provision for now.

Research in behavioral economics shows that people feel twice the pain in losing something as the joy they get in gaining something of equal value.

You definitely see that playing out in Hong Kong.

All of this puts the Chinese communists in a most difficult predicament.

Do they put down the "rebellion" with force?

This is the way authoritarian governments and dictators limit dissent and keep the populace in line.

Dictatorships end when the leaders (or their military leaders) lose the will to kill large numbers of their own people to quell rebellion. I have seen this in my lifetime in Poland, East Germany and the Soviet Union.

When there is no fear of retribution or consequences, the natural impulse of the people is going to be to seek the light of freedom. Once that flame is lit it is difficult to put out.

China's leaders have to understand that and they must know that their power and prestige rests on how they respond to the protests in Hong Kong.

Do they stand back and let the protests play out and hope the flame dies out?  However, what if the flame keeps burning and carries over to the Mainland?  If that occurs the ruling Communist leaders risk losing their hold on power. This situation would not be dissimilar to what started in Poland and Eastern Europe and eventually carried over to Mother Russia a generation ago.

Do they use significant force and quell the disturbance?  This solves the short-term issue but this response risks widespread global condemnation. It also comes at a terrible time for the Chinese as their economy is already weakening. It would also provide President Trump with an enormous political gift in his trade war with China. Who is going to be on China's side anywhere in the developed world if the Chinese start using tanks against the people of Hong Kong?

Who can forget this iconic image during the Tiananmen Square massacre in 1989? As many as 10,000 pro-democracy student protestors were killed when 200,000 government Chinese troops were brought in to bring the protests to an end.

Credit: The Independent.co.uk

We are talking high risk/high stakes scenarios for the Chinese on what is going on in Hong Kong. China is much more connected to the world community and economy than it was 30 years ago. This means that there will be much more scrutiny and greater economic harm for China should it resort to forcefully ending the protests.

What is also interesting is that the protestors have been carrying U.S. flags and singing the National Anthem as part of their protests.

Credit: AP Photo/Vincent Yu via Deseret News

What a world we live in.

People in Hong Kong waving the Stars and Stripes, standing and singing the National Anthem.

At the same time, we see another American athlete kneeling with bowed head while the National Anthem is played in an award ceremony at the Pan American Games.

Race Imbdoden of USA Fencing team kneels during playing of National Anthem after he and teammates won the
Men's Team Foil Gold Medal at Pan Am Games in Lima, Peru last week.
Credit: Lima 2019 News Services

Who really understands and appreciates freedom?

What I thought was really interesting about the image above is that the fencers from second place Brazil are saluting the American flag while the United States national anthem is played while Race Imboden of the gold medal USA team is kneeling.

I guess there are some that have to lose freedom before they appreciate what freedom really is.

Keep your eyes on Hong Kong.

Friction Is Not Your Friend

Friction is not your friend.

Most people understand friction to be defined as the following.

I am talking about financial friction. That friction is defined this way by Investopedia.

Friction cost is the total direct and indirect costs associated with the execution of a financial transaction. The friction cost comprehensively takes into consideration all of the costs associated with a transaction. Calculating the friction cost provides an investor with a full range of expected costs they can expect to incur.

It is hard to become wealthy if you don't understand and appreciate friction costs. I am applying the concept of friction costs more broadly here than you might find in a textbook on finance. However, I think it is useful to think about friction costs as they might apply in some of the more common financial decisions an individual makes.

My experience is that most people do not pay enough attention to the friction costs in common financial decisions they make like buying a car, a house, investing in rental real estate or in their 401(k) plan.

Take the simple case of purchasing a personal vehicle. Sales taxes alone will add a fairly large sum to the final purchase price. That is friction. That is one of the reasons that I drive my cars for 10 years or more. Gasoline, insurance and repairs while you own the vehicle are also friction costs. That is why you should understand the "total cost to own" of any vehicle you are thinking of purchasing. Both Edmunds. com and Kelley Blue Book provide this information on their web sites.

Buying or selling a house brings a lot of friction costs. Real estate commissions, title insurance, transfer taxes and other closing costs are examples of these costs. That is why I generally tell young people to be certain of your situation before you buy a house. It is hard to overcome the friction costs in real estate if you are only going to stay in the house for a few years. Don't buy if you think you might want to move or the house will not meet your requirements in a few years. Rent and avoid the friction costs.

Friction costs also come into play during the time you own a house. Real estate taxes, insurance, HOA fees, maintenance, repairs. All of these costs gnaw, grind and wear away the actual return you will eventually receive from the "investment" in your house.

My experience is also that these friction costs are also easily forgotten when you calculate your return on an investment. You buy a house for $300,000 and sell it ten years later for $400,000. It is easy to think you made $100,000. Of course, the purchase and sales price don't take account of the transaction costs when you bought and sold the house. You don't think about the new carpeting and roof you replaced, the exterior painting you did, the hot water heater you replaced or the $1,000 you spent annually to have someone cut the grass while you lived there. Did you really make $100,000 on the house?

The same thing occurs when you buy rental investment property. There are a lot of friction costs and these might also include the time you spend between renters when you have no rental cash flow as well as your time in managing the property and your labor involved in any maintenance or repair issues. There is a reason it is called sweat equity and we often don't include these as friction costs.

The annual fees on the funds in your 401(k) or IRA are also friction costs. Pay attention to the amount you are paying to those who are managing your money. You don't consider those costs very closely if your portfolio is up 20% for the year. It seems a small price to pay. However, how will you feel if your portfolio is down 20% and the fees make it 21%?

You don't know for certain whether your investment will be up or down during the year. The only thing that is certain are the fees you will pay to manage that investment. Understand that and pay attention to these friction costs.

Friction costs add up. You may think you are only talking about pennies on the dollar. However, those pennies on the dollar add up.

You understand this when you see what a penny's difference can make when it is compounded over time.

Take the example of a graduating college student who receives a $2,000 gift at graduation from her grandparents. Her grandparents tell her to invest it in a retirement account and to add $2,000 to the fund each year for the next 45 years as a tribute to them. She does just that.

That money, compounded monthly at an 8% annual return, will give her almost $1 million at age 67. However, if she only earns 7% (a mere penny on the dollar less per year), she accumulates only $682,000. If she earns 9%, her retirement nest egg becomes $1,356,475.

An extra 1% in extra investment return per year makes a huge difference over a lifetime. That additional penny provides a lot of grease to assist in making your wealth wheel turn faster.

On the other hand, an extra 1% in friction costs to pay for higher investment management or advisor fees slows down that wealth wheel and erodes your return on that investment.

Those fees can be well worth the money if Warren Buffett is picking stocks for you or managing your investments. However, the fact is that only 19% of active investment fund managers around the world are doing better than their benchmark index according to a study by Bank of America.  Beware of active fund managers who are charging premium fees even though they may be delivering sub-par returns.

Remember that friction is not your friend when it comes to money.

See to it that your pennies do not get ground, gnawed or worn away by friction costs.

Diversity at the University

What is the most powerful word in higher education today?

DIVERSITY.

Is it not interesting that at a university (which in Latin literally means "turned into one") today the highest order is to place the most focus on those things that divide people rather than bringing them together in a common cause---the pursuit of knowledge and truth.

Anthony Kronman, who is a Professor of Law and the former Dean of Yale University Law School, recently wrote about "The Downside of Diversity" in an essay in The Wall Street Journal in which he made the point about diversity I made above.

“Diversity” is the most powerful word in higher education today. No other has so much authority. Older words, like “excellence” and “originality,” remain in circulation, but even they have been redefined in terms of diversity.

At Yale, where I have taught for 40 years, a large bureaucracy exists to ensure that the university’s commitment to diversity is rigorously enforced—in student admissions, faculty hiring and curricular design. Yale has an Office of Diversity and Inclusion, a Dean of Diversity and Faculty Development, an Office of Gender and Campus Culture and a dizzying array of similar positions and programs. At present, more than 150 full-time staff and student representatives serve in some pro-diversity role.

Yale’s situation is far from exceptional. “Diversity and inclusion” is a dogma repeated with uniform piety in the official pronouncements of nearly every college and university. At Dartmouth, the Office of Pluralism and Leadership “engages students in identity, community and leadership development, advancing Dartmouth’s commitment to academic success, diversity, inclusion and wellness.” The University of Michigan proclaims that “diversity is key to individual flourishing, educational excellence and the advancement of knowledge.” At the University of Oklahoma, students are required to complete a mandatory “Freshman Diversity Experience” by the end of their first semester.

If you wonder about the cost of all this consider that the University of Michigan spends $11 million per year on "Diversity Administrators" alone. That is enough to pay for 700 students to attend the university on a full ride.

There is little question that diversity is a noble value. This is especially true on a college campus where you want a range of backgrounds, beliefs and experiences to influence and inform debate and inquiry.

However, this is not how diversity is being used in university settings today.

But diversity, as it is understood today, means something different. It means diversity of race, ethnicity, gender and sexual orientation. Diversity in this sense is not an academic value. Its origin and aspiration are political. The demand for ever-greater diversity in higher education is a political campaign masquerading as an educational ideal.

That diversity seems to be centered primarily around political grievances where various groups argue about injustice, disrespect or abuse.

The life of the classroom is transformed as a result. It is common to hear complaints that an assigned text is disrespectful of women, blacks, the gender-fluid or some other oppressed or marginalized group. White, male, heterosexual students are often attacked on the grounds that their comments reflect a smug and privileged view of the world. Such complaints are hardly new. I have heard versions of them at Yale for the past 40 years.

What is new and discouraging about today’s academic culture is the unprecedented weight that these grievances are given by teachers, students and administrators alike. Even to raise them puts one on a high moral ground that requires all other considerations to be put aside until the grievance has been assuaged by an appropriate act of apology or reform. Raising it amounts to a demand. It brings the conversation to a halt. It converts the classroom from an open space for the free exchange of ideas into a political battleground.

I recently read a great novel that paints a wonderful (but terribly troubling) view of what all of this diversity and political correctness have done to our universities. The book is written as a satire. However, doesn't the best satire have an enormous amount of truth to it?

The book is Campusland by Scott Johnston. Scott is a BeeLine follower and was nice enough to send me an advance copy of the book. It is set at the fictional Devon University which is an Ivy League school in the New England town of Havenport. The fact that Scott is a Yale grad probably did not have anything to do with the things he writes about as occurring at Devon. It is Scott's first novel but you would never know it reading the rich descriptions and the colorful characters that come to life through his written words.

The main character in the book is Ephraim Russell who is an Assistant Professor at Devon and is competing with another assistant professor for a sole tenure position in the English Department.

Everything was looking good for Eph (he even has a beautiful African American girlfriend who he met at a climate rally and who is the assistant to the University President) until he assigns The Adventures of Huckleberry Finn by Mark Twain in his American Literature class.

Why would he have anyone read such a racist book?

Why would he assign a book that makes many students feel unsafe by the language in the book?

Why would he not assign books by African-American or Native American authors from the 19th century American literature rather than Twain's book?

Why would Devon allow a racist like Eph to teach its students?

This is just the beginning of Eph's problems as he has to confront the modern university framework that values diversity more than anything else. The fact that Eph is a progressive politically, along with everyone else at Devon, does matter one wit.

Campusland is well worth the read to better understand how far afield higher education has gone in putting the politics of diversity above all else.

It goes on sale next week.

Reading the book you might also better appreciate these two pull quotes from Kronman's essay that I thought were particularly on point.

Diversity is supposed to elevate the college experience. Why is higher education allowing it to diminish it? Why have universities stopped trying to be places where students are "turned into one" seeking objectivity and "the truth" and instead have become giant bureaucracies encouraging divisions and defending people who see only "their truth'?

You also have to ask what the effect of having students spend four years or more in this type of environment are having on the overall level of political discourse in the nation? The evidence suggests that it has been far from helpful.

Trump's Tariffs

President Trump announced last week that he was instituting a 10% tariff on an additional $300 billion on imports from China effective September 1.

This is in addition to a 25% tariff on another $250 billion of Chinese goods that has been in effect since May. This levy started at 10% in July, 2018 and was increased to the higher level several months ago after China allegedly reneged on a proposed trade agreement between the two countries .

This effectively means that all imports from China will now be subject to some amount of tariff.

The 25% tariff is being applied to foods, chemicals, minerals, clothing, textiles and machinery items.

The new tariff will be applied to items like cell phones, laptops, footwear and toys.

As expected, China has retaliated with its own tariffs but the wide trade deficit between the two countries makes this a losing proposition for China. China also announced that it was allowing its currency to fall which spooked stock markets causing the Dow in the U.S to drop 750 points on Monday.

The United States imports over $550 billion of Chinese goods. China imports only a little more than $100 billion of U.S. goods. This results in a $450 billion annual trade deficit for the U.S.

China's economic power has grown over the years with its one-sided trade views. China effectively closed off imports of U.S. goods for decades. To do business and get access to its huge consumer market the Chinese government forced many U.S. companies to commit to manufacturing sites there. In addition, China required them to provide their most valuable intellectual properties in order to have an entry into the Chinese market. What intellectual property China did not obtain legally they stole illegally.

At the same time, China began flooding the U.S. with imported products fueled by cheap labor, lax environmental and labor standards.

Republicans and Democrats alike did nothing about the inequity or the illegality. Our elected representatives literally gave away substantial portions of our domestic economy by thinking short-term rather than long-term. They had the advantage of having the most attractive market in the world and yet they gave it away and did not get anything in return.

China grew and got richer with each passing year. At the same time, the United States saw millions of high paying middle class manufacturing jobs lost. This change also caused a further worsening of the social and economic divide between the college-educated service class and the high school educated worker class.

China has been taking advantage of the trade situation for years and years and no one did anything. China has also been manipulating its currency to their advantage. All the while they also have blatantly stolen intellectual property from U.S. companies for decades without being held accountable. This is particularly dangerous as innovation has become the primary product of the United States. Having it stolen and getting nothing in return is a recipe for long term economic disaster since manufacturing base of the United States has been hollowed out.

Only one man stood up and questioned the wisdom and fairness of it all. That man was Donald J. Trump.

It is not easy negotiating with the Chinese on trade because they have had it so good for so long. No one wants to give up an extremely advantageous situation easily. The Chinese are no different.

The mainstream media seems to be portraying these tariffs on China as another example of an unhinged Donald Trump who is going to do great damage to the American economy and consumer. You will undoubtedly see this view played up in the mainstream media and by Democrats.

You will see stories of how the tariffs will be passed through to the American consumer as a hidden "tax" as prices of products from China will rise. Kamala Harris repeated this line at the Democrat debate last week.

My advice is don't believe everything you hear. China is a master manipulator of its currency. China also needs the U.S. market. They do not have ready alternatives for the exports required to keep their manufacturing plants running. Japan only imports $150 billion of Chinese goods. Germany $110 billion. Together these two large economies import less than half of what the U.S. does.

Consider as well that the tariffs on almost half of China's imports have been in effect for nearly a year. Where is the inflation effect in prices from the tariffs?

Inflation is lower over the last 12 months with tariffs in effect than they were in 2017 and 2018 when there were no tariffs on China imports.

I don't know anyone who thinks these tariffs are a great idea for the long term. Free and fair trade has proven to be the best formula for improving global wealth and well-being.

However, things have not been fair with China for a long, long time. How else do we get China to play fair unless they get hurt in the pocketbook?

You get a better perspective of how unbalanced our trade situation is when you look at this list that compares the U.S. companies that are the biggest importers from China and the companies that are the biggest exporters to China.

Our exports are dominated by companies in the paper and plastic recyclable industries.

Our imports are dominated by consumer companies like Walmart, Target, Home Depot and Lowe's.

We have been importing masses of manufactured consumer goods from China which also effectively wiped out a great deal of middle class manufacturing jobs in the process.

What did China take in return? Our trash. It begins to give you a better idea of why something has to be done.

However, as I pointed out in a blog post last year, China does not want our trash any more. Therefore, unless we can get China to level the playing field a little we are facing even bigger problems in the future.

Keep all of this in mind as you see news reports that try to paint Trump as unbalanced or unreasonable. They will say he is sticking it to U.S. consumers. Or farmers. Or the stock market.

When you hear this ask yourself is there another way to make China play fair? If there is, why hasn't someone else done something about China before?

Does it look like the United States is playing on level playing field in trade?

Fortunately, we have a President that understands all of this and is willing to hold those to account who don't want to play fair.

I can safely say that there is no other man or woman in either political party who would have had the courage to take on the Chinese on this issue and the commitment to follow it through as Trump has done.

There will be short pain. Trump will take criticism. He will be second guessed. However, short term pain is almost always necessary for long term gain. Fortunately, Donald Trump also understands this.

However, it is important to remember that no matter how strongly Trump feels about the issue he will only succeed if he has the support of the American people. Understand what he is doing and what the long term stakes are. There may be some pain. However, I can assure you that any pain now will be nothing compared to where we end up if we don't confront China on this issue now.

Are We Looking At The Right Target (Redux)?

The last few days have seen several more horrific mass killings.

It is so sad and such a waste of life.

Unfortunately, we have seen this movie too many times before. What is it with disaffected single white men in their 20's who so often are guilty of these heinous acts of violence?

Predictably, many immediately want to politicize the tragedies for political purposes.

The smoke had barely cleared from the Walmart in El Paso and the mainstream media and Democrats were claiming that the perpetrator was a white nationalist who had a vendetta against Hispanics and was a follower of Donald Trump.

Several hours later another white man in his 20's was killing nine people in a bar area in Dayton, Ohio. The dead included his sister. However, it is being reported that he was a "pro-Satan leftist and Elizabeth Warren supporter" who hated President Trump.

Of course, all of that carnage made the earlier shootings at the Garlic Festival in Gilroy, California almost an afterthought that were also perpetrated by another young disaffected white man in his 20's.

How do you make sense of it?

The Editorial Board of The Wall Street Journal does a good a job as any of trying to identify the root cause. It is not guns. It is not politics. We are talking about disturbed young men who are alienated from society.

The mass shootings in El Paso and Dayton over the weekend are horrifying assaults on peaceful communities by disturbed young men. American politics will try to simplify these events into a debate about guns or political rhetoric, but the common theme of these killings is the social alienation of young men that will be harder to address.

Take the El Paso shooter, who is suspected of writing a manifesto posted on the 8chan website before the rampage. He expressed sympathy for the racial motivations of the Christchurch killer and denounced Hispanic immigration, but he also raged against “unchecked corporations” who support immigration and pollute the land.

This is the rant of someone angry about a society he doesn’t feel a part of and doesn’t comprehend. It is all-too-typical of most of these young male killers who tend to be loners and marinate in notions they absorb in the hours they spend online. They are usually disconnected to family, neighborhood, church, colleagues at work, or anything apart from their online universe.

These men may draw inspiration from one another online, and any communication or common connection needs to be investigated. The FBI says it has made 100 arrests related to domestic terrorism in the last nine months. But blaming all this on one politician or ideology, left or right, without evidence of such a connection is disingenuous and counterproductive.

The Wall Street Journal suggests that we need to put renewed focus on mental health to combat this problem. However, it is not so much an issue of money as one of policy. There needs to be more resolve to get troubled people out of our midst.

The problem is identifying those with mental illness who are a threat, and then allowing society to intervene to prevent violence. Overwhelming evidence suggests that the de-institutionalization of the seriously mentally ill has had tragic results. Libertarians and mental-health advocates who resist such intervention need to do some soul-searching.

If you don't think this is an issue consider this chart that shows the gigantic reduction in the number of mentally ill people who used to be housed in inpatient institutions and have been released into the general population since the 1950's.

Credit: PBSFrontline

Bear in mind that the total population of the United States in the 1950's was only half of what it is today!

This is not to say that there is not a place for more stringent gun control laws. These young men should clearly not have been able to buy a firearm. However, how could they have been stopped unless they were first identified as having a mental issue? The laws should permit family members or the police in these cases to file some type of "red flag" to petition a court to disallow the possession of firearms to someone who might cause harm to themselves or others due to their mental state.

Unfortunately, not much has changed since I wrote the following post in 2013 shortly after the Aurora, Colorado and Sandy Hook killings perpetrated by another couple of disaffected twenty-something white men. Most of the facts and data has not changed materially in six years.

Those shootings resulted in similar outrage and calls to ban or limit the possession of firearms---particularly rifles.

Not much has changed. Consider, for example, that there were only 403 homicides in 2017 (the most recent year data was available ) by rifle. There were four times that many homicides caused by knives or cutting instruments. Is anyone suggesting we ban knives?

Number of murder victims by weapon, 2017
Credit:Statista

Six years later and I am still asking,

"Are we looking at the right target?"


Are We Looking At The Right Target?
(originally published January 17, 2013)

We barely avoided going over the fiscal cliff.

We are now heading straight for a collision with a mountain of federal debt.

However, all we hear the President talking about right now are guns, guns and guns.

Are we looking at the right target in all of this?  What should we really be focusing on?

Credit: AccurateShooter.com

There is little doubt that gun violence is a big problem and an important issue. However, is it the biggest problem we have right now?  After all, we are less than a month from hitting that debt limit ceiling. We continue to spend $1.00 for every .60 in revenues.  We are still looking at $1 trillion annual deficits. We still have a U.S. Senate that has not passed a budget in almost four years.

What will all of the talk, proposals and executive orders on guns actually accomplish?

First of all, I am not a gun nut.  I have used firearms and at one time had obtained the NRA Sharpshooter classification.  I respect guns and what they can do.  More importantly, I respect the U.S. Constitution.  I believe the 2nd Amendment is pretty clear.

A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.

There is no doubt that the people have the right to keep and bear arms and that right is not to be infringed.  At the same type, it seems understood that some type of regulation is permitted with regard to that right.  The difficult question is at what point is the right to keep and bear arms infringed on by regulations?

For example, does an individual have the right to keep and bear arms such as a nuclear weapon, surface to air missile or bazooka?  I have not heard anyone with the NRA or anyone else make that argument.  Machine guns and other military types of automatic weapons are already illegal and have been since the 1930's.  In fact, the use of these weapons by gangsters such as Machine Gun Kelly, Baby Face Nelson and John Dillinger led to the passage of the National Firearms Act in 1934 that made them illegal in the U.S.

If anything is going to be done that might infringe on that right in the Constitution it would seem that it should be clearly demonstrated to be a reasonable regulation.  To meet that standard government should have to show that vast numbers of the public are being killled (or could be killed) to outweigh the individual constitutional right.  This is clear with an atomic weapon, machine gun or SAM.  In other words, the public's interest to safety outweighs the individual rights to keep and bear arms.

Let's look at some surprising statistics that I found in researching this blog.   The following information on gun violence comes from the Brady Campaign to Prevent Gun Violence.  The other data is from research I did to put these deaths in context.

On average, over the three years 2008-2010, 31,537 people in America have died from gun violence. This is a shocking number.  However, over the same time period, an average of 34,651 people died in auto accidents. 25,000 people die annually in accidental falls.  There are 39,000 deaths each year by poisoning, most due to abusing drugs.  There were also almost 800,000 abortions  in the U.S. in 2009 according to the CDC.  120,000 abortions were done in New York alone.

What I found interesting in looking at the gun violence deaths is how they were caused.

Only 11,583 of the total were homicides.  That is only 37%.

18,783 of the total deaths by gun violence were the result of suicides!  That is 60% of total deaths.

Only 334 of all gun deaths were caused by police intervention and 584 were the result of people being killed accidentally by guns.

When you consider that 60% of gun violence deaths are caused by people committing suicide you begin to get an idea of how ridiculous all of this gun talk is.  How many people kill themselves using an assault rifle or with a magazine with over 10 rounds?  Will any of this do anything substantial on curbing gun violence deaths that would justify infringing on the rights of law abiding citizens.  I think not.

Further to this point, John Hinderaker cites another interesting statistic in PowerLine that adds additional context to all of this.  In 2010, there were only 358 homicides that involved rifles (all rifles, not just "assault weapons") in the U.S.  That means that only 1% of all deaths by gun violence involved rifles of any type.  Again, are we looking at the right target?

Handguns are clearly the cause of almost all gun violence in this country. However, standard handguns are not even being discussed. That is because the U.S. Supreme Court in D.C v. Heller ruled in 2008 that banning personal firearms possession is unconstitutional. The District of Columbia had banned the possession of all firearms by anyone but law enforcement officers beginning in 1976.  Of course, there are legitimate questions about how useful the ban on handguns in D.C was anyway as Jeffrey Scott Shapiro points out in this Wall Street Journal op-ed.  Murders in D.C. have actually declined by more than 50% in the four years since the handgun ban was repealed.

When I look at the statistics the obvious answer is that the primary target on gun violence needs to be focused first and foremost on the people firing the weapon. It seems to me we need to be focusing more on the mental health side than on the gun side. You start with the fact that suicides are the cause of 60% of gun deaths.  The recent mass shootings in Aurora, CO and Newtown, CT clearly seem to point to serious mental health issues being the primary reason for the killings.  The same was true with Jared Loughner in the Gabby Giffords shootings in Arizona last year.

Much more of this debate and discussion should be looking at the issue of mental health than the size of the magazines in firearms.  That debate should also include what effects (if any) video games and other entertainment might have on the mental state of mass killers like we saw in Aurora (Batman) and Newtown ("Call of Duty" video game).  It may be coincidental or circumstantial but it bears looking into in some depth.  We have introduced a lot of external factors and influences into our environment that were not present 20, 30, 50 or 200 years ago.

It should not be easy to infringe on individual constitutional rights. Should any of this be done by Executive Orders?  I know that is easy for the President. However, what happened to the idea of passing bills in the legislative branch first and having the President sign them into law?

As for the issue of gun violence, let's start where the numbers tell us the real underlying problem is. Mental health is being talked about but not with the same vigor and rigor that guns are being talked about. As a result, it seems that most of the focus in this debate is on the wrong target.  And we are also spending a lot of time talking about an issue that, while important, is far less critical than the looming debt and budget crisis that should be #1 on every person's mind in Washington right now.

We are not going to solve any part of the gun issue in this country in the next 60 days.  We have to solve some part of our debt and budget crisis in the next two months.  Time is wasting and the President is fiddling.  I just don't want all of us getting burned in the process.

Thoughts on the Democrat Debate

I spent the last two nights watching the Democrat Presidential debates. I missed round one last month when I was traveling so this was my first chance to see all the candidates up close and personal.

One of the remarkable things about the debate is that I don't think jobs or the economy were mentioned one time on either night.

The economy and jobs are usually the number one issue discussed at any Presidential debate I have watched for the last 60 years. What more do you need to know about what President Trump has achieved on this issue over the last two and half years?

In that there was little to talk about on jobs and the economy it seems that the Democrats were mostly focused on promising how much they are going to give everybody and what a racist and reprobate Donald Trump is.

Here are just a few of the Democrat giveaways promised.

Free healthcare coverage (if you don't calculate the large tax increase that will be required to pay for it)

Forgiveness of all student loan debt.

Free college.

Reparations for African Americans.

A $1,000 payment each month for every American (Andrew Yang's proposal).

Free healthcare for illegal aliens.

No longer considering it a crime to enter the United States illegally. At worst, it will only result in a civil penalty. I guess this means the offender might only have to pay a fine and be able to stay.

Of course, while they promise to give you free stuff they also want to take other stuff away.

Your employer-provided health care.

Your 2nd Amendment rights.

Your access to low-cost and convenient fossil fuels for energy needs.

Your job if you are in an industry (oil, gas, coal, insurance, Wall Street) that the Democrats want to demonize or eliminate.

The other remarkable takeaway from the debate is the fact that the Democrats are no longer hiding their agenda. It remains to be seen whether they really believe that the people in this country who vote have veered that far left or the Democrats are simply on a suicide mission.

Bill DeBlasio made it very clear where many of the Democrat candidates are when he said it is time they put their agenda out there for the American people to vote on. In effect, do Americans want socialism or the values and principles that made America the greatest country known to man?

Democrats have been very good in the past at "covering up" their own views in order to get elected. For example, they would say they were personally against abortion but they believed women should have the choice. They would never say they wanted to raise your taxes or take away your private healthcare. They would never tell you they wanted to double the price of gasoline or triple your utility bills.

Of course, that it exactly what they wanted to do. They just knew they could not get elected saying it.

Look no further than how Barack Obama ran for President.

Those days are gone. There is no "cover up" involving what most Democrat candidates want to do and how far left their views are any more. It is all out there for everyone to see.

The Democrats are doubling down on Trump and doubling down on their radical, progressive agenda.

In the process, they spent almost as much time last night criticizing Barack Obama as they did Donald Trump. Obama was too timid and too moderate. As a result, he was responsible for getting Trump elected.

It is a risky strategy. It could result in the end of Trump. However, it could also result in the end of the Democrat party as we know it.

There is only a small remnant left of what we used to understand the Democrat party to be. The party of the working man and woman which also believed in strong borders, a strong defense and a commitment to helping those who could not help themselves.

The only people on that stage who bear any resemblance to that Democrat were Joe Biden, John Delaney, Tim Ryan, John Hickenlooper, Michael Bennet and Steve Bullock. Barack Obama would have been in that group as well based on what he was saying when he ran for President. Make no mistake this entire group is still very liberal but they at least have some grasp of practical realities.

Of these, only Biden appears to have any chance at the nomination. However, he still is a man that will be 78 years old if he were to be elected President. I think there are substantial questions about whether he has the energy and mental fortitude for the rigors of a 16 month Presidential campaign run.

As for the rest, they are all WAY OUT there. I will say that I found both Tulsi Gabbard and Andrew Yang to be refreshing and to possibly have some potential. However, that potential is unlikely to be in 2020 where they will almost certainly have difficulty in separating themselves from the others.

Kamala Harris, who I believe is the candidate the Democrat and media establishment wants, came across to me as very unlikeable. That could prove to be her undoing as the candidate that connects best with voters almost always wins the Presidential race. (Yes, it was a low bar, but Donald Trump connected better than Hillary!)

Things will start to get serious for Democrats beginning with the next debate as the participation rules (based on poll numbers and money raised) will probably mean that half the candidates on the stage this week will not be on the debate stage next time.

If they are not on the debate stage it will be impossible for them to continue as candidates.

We are still in the early stages of this race. Much can happen...and will.

Stay tuned and stay in touch with BeeLine as events unfold.

Being A Smart Patient

Neil Armstrong survived 78 combat missions in the Korean War, was a test pilot for the X-15 and flew to the moon and back as the first man to step on the moon. However, he did not survive a trip to a suburban Cincinnati hospital in 2012 where he had open heart surgery at age 82.

Neil Armstrong and the X-15, circa 1960
Credit: NASA

In the aftermath of the 50th anniversary of the moon landing the New York Times and Cincinnati Enquirer reported that Armstrong's family had gotten a $6 million settlement from Mercy Hospital-Fairfield related to the care that Armstrong received in conjunction with that heart surgery.

That cash settlement had been kept under wraps as part of the legal agreement until a whistle blower recently sent supporting documents to the papers. Armstrong's children and grandchildren received the payments after they threatened a lawsuit alleging that the hospital had not met the standard of care in its treatment of the former astronaut and test pilot.

Armstrong's death appears to have resulted when a nurse at the hospital removed epicardial wires protruding from Armstrong's chest while he was in a step down unit after a temporary pacemaker had been inserted to regulate his heart after the bypass surgery. In doing so the pericardium was torn and the cavity sac around the heart starting filling with blood. That blood choked off the function of the heart before the hospital team could correct the problem and Armstrong suffered irreversible brain damage. It was alleged that the problem could have been corrected if a cardiothoracic surgeon and operating room had been on standby.

What I found baffling in the story is why would Neil Armstrong, one of the most famous people on earth, go to a modest suburban community hospital for open heart surgery?

It is particularly bewildering considering that Armstrong, an aeronautical engineer by training, was someone you would expect to be both analytical and meticulous in his preparation in dealing with risky situations.

Sadly, Armstrong was human and he probably did what most of us do when a decision regarding health care in concerned. He took as gospel what his physician told him. He might have also consulted with his family or a few friends. He probably did not seek a second professional opinion. He likely did not consider getting care at any place other than the Cincinnati area where he lived.

When I was in charge of employee benefits for a Fortune 500 company I spent a lot of time looking at our costs as well as the quality of care that our employees received. We were self-insured for the health care costs of our 10,000+ members so both of these issues were critically important to me.

When you study this issue as closely as I did you quickly discover that health care is one area that high quality care almost always produces the lowest cost care. If you receive the right care, at the right time and at the right place you generally are going to have the lowest costs. You will not overpay for care that you don't need and you will not have to pay again if the original treatment does not solve the problem or complications arise.

The problem is that it is very difficult for any of us to assess the quality that we are going to get in any health care situation. We can judge bedside manner much better than the technical skills of our doctor. We choose the local hospital because it is convenient and we want to feel comfortable in our surroundings and close to our family if we have a health issue. However, bedside manner and a convenient hospital should be far down any list when considering medical treatment.

I think there is much to be learned from the Neil Armstrong experience that may be helpful to you or a loved on.

I developed an educational seminar for our employees in 2007 to help them become a "Smart Patient, Smart Consumer" that was based on the book You: The Smart Patient by Mehmet Oz, M.D. and Michael Roizen, M.D.

United Healthcare subsequently took the basis of this presentation and made it available to all of their business customers with my permission and that of my company.  You can view that presentation here.

I will summarize a few key points that everyone should keep in mind regarding being a smart patient that I included in that seminar based on the excellent book by Oz and Roizen.  I highly recommend it to everyone.

• You need to be your own health advocate. If you don't feel that you can do that for yourself get someone else to be an advocate for you. Don't be afraid to ask questions and get the answers you need.
• Choose your doctor carefully.
• Make sure he or she is board certified.
• A good way to find a great doctor is to ask ER nurses. They usually know who the best doctors are from observing a lot of them.
• Do not be afraid to seek a 2nd or 3rd opinion (a 2nd opinion results in a new diagnosis about 1/3 of the time but only 20% of patients seek one). You should seek a 2nd opinion every time a doctor recommends surgery. You should also seek a second opinion if your doctor is unwilling to discuss alternative treatment options with you.
• If your doctor is going to do any procedure make sure they have a lot of experience doing it. You don't want someone who does a handful of anything. You want them to have seen a lot and done a lot of similar procedures.
• Choose your hospital just as carefully. Realize that the doctor you choose is going to be tied to a hospital through admitting privileges. A great doctor at an average hospital is not good enough. Make sure you have both.
• Make sure that the hospital you choose is also doing lots of the procedures you are in need of. For example, if it is bypass surgery, you want the hospital to be doing a minimum of 500 per year. You want to make sure they have seen everything so they can deal with anything that might come up.
• The last thing you should want is a hospital that is close to home that will be convenient for you, your family and friends. Your sole objective should be to get in and out of the hospital as quickly as you can. In addition, you should try to limit anyone visiting you as much as possible due to the risks of infection. Find the best hospital for what you need, not the closest hospital.
• Although it is still not easy to get quality measures about doctors and hospitals, there are more resources than ever before that are accessible to consumers. Your health insurance company likely has quality and efficiency ratings on many doctors and hospitals. There are companies like Healthgrades and Grandrounds who are in business to see that healthcare consumers are connected with the best care. The internet is a great place to begin your research but it can't take the place of a good medical professional.

Why is all of this important?

Consider the numbers.

98,000 people die each year due to medical mistakes. 

2 million people contract an infection in the hospital each year.

Of course, Neil Armstrong was just not a number. He was the first man to walk on the moon. However, when he walked into that hospital he was no different than you or me. He was just a man, and he was mortal.

I don't know all the reasons Neil Armstrong decided to undergo his heart bypass surgery at the hospital he chose. However, it seems a curious choice considering what I know.

The news reports suggest that he did not seek a 2nd opinion before he had the surgery. At least one expert witness doctor who was consulted after Armstrong's death suggested that he would not have recommended immediate surgery for the 82 year old Armstrong.

It appears that the hospital and staff were not well staffed and equipped to deal with the complications that ensued.

Arguably the #1 ranked hospital in the world for open heart surgery is just a 4 hour drive away from Cincinnati.

US News ranks The Cleveland Clinic as the #1 hospital for cardiology and heart surgery with an overall score of 100/100.

Note that even with the high ranking of the Cleveland Clinic it still has areas that need improvement. That is why the best advice for anyone is to try to live as healthy as you can to avoid having to visit a hospital.

The Mayo Clinic is ranked #2 with a score of 99.6/100 and Cedars-Sinai Medical Center is ranked #3 with a score of 84.3/100.

Only 50 hospitals in each specialty are given a numerical rank by US News. Hospitals near the top 50 are listed as high performing. The remainder of the 550 in which a scorecard is done are ranked from poor to excellent.

Here is the heart bypass surgery scorecard for Mercy Hospital-Fairfield from US News which has an overall rating of average. Was average good enough for Neil Armstrong? Would average be good enough for you?

Mercy-Fairfield gets its highest score on the scorecard for the volume of its heart surgeries. It also gets excellent scores based on patient experience. However, it does not come close to the Cleveland Clinic or the 50 other hospitals that are top ranked by US News.

Remember as well that every time a medical intervention (tests, immunizations, prescription drugs, surgery) is undertaken you are taking a risk. That risk is generally worthwhile because it will make you better in the long run. However, you could end up in worse shape because of the intervention.

To better understand this, consider the research that shows that in every instance in which doctors have gone on strike around the world, death rates have stayed the same or gone down when the doctors were out. There has never been a study that shows the death rate has gone up. Think about that. When the doctors are not involved the death rate actually drops?

This is attributed to the fact that elective or non- emergency surgeries do not get done when doctors are on strike and a surprising amount of mortality occurs following these procedures. Death rates actually rise when elective surgeries begin again.

A 90% success rate sounds good. However, what if you are the ONE in 10 that gets the short end of the stick?

That is why you should do everything you can to make sure the odds are stacked in your favor as much as possible when it comes to healthcare.

Neil Armstrong could have had complications from his surgery or his recovery no matter where he was treated. He could have been hit by a bus or fallen down a flight of stairs.

However, it is hard not to say "what if" in this case.

May God bless the man who made that small step and demonstrated so well what mankind was capable of.

Keep his memory alive by also remembering the advice I have offered about being a smart patient and consumer of healthcare.

Good health to you!