Spreading the Wealth?

It brought back memories of Joe the Plumber.  That was the fellow who had a campaign-stop conversation with presidential candidate Barack Obama in Ohio in 2008 about tax policy.  Joe, a Republican, didn't like the idea that Obama thought it was a good idea to "spread the wealth around."

This time it wasn't Joe, and the candidate wasn't Obama. Two friends of mine, both in EMS, were commenting (on Facebook) about the idea that Bernie Sanders is a "socialist."  One of them, Ken, said Sanders "wants to share my money with people who work less."  I promised Ken I'd write back later to explain why that isn't really so.

A little more than a century ago (February 1913) we amended the US Constitution to allow for a federal income tax.  Many Americans look at their paychecks or their tax returns every year and wish we had never done that.  But there are a lot of things we expect the government to do, and they all cost money.  The consequence of that is that we have enacted a dizzying array of taxes.  It seems as though any time money changes hands the government wants a cut.

When people are asked about taxes, most say they don't have a problem with paying money into the federal treasury so long as they can be confident that it is being spent wisely.  And there's the rub, to borrow an expression from Hamlet. The late Senator William Proxmire of Wisconsin created the Golden Fleece Award, presented monthly from 1975-1988, to call attention to examples of what the senator considered wasteful public spending.  In the 1820s and '30s famous frontiersman Davy Crockett served two terms in Congress and was noted for his belief that members of the House - where bills related to raising revenue and spending it are supposed to originate, according to the Constitution - should be as careful with the people's money as they were with their own.

We do not, in general, believe that our elected representatives are careful with our money.  English Prime Minister Margaret Thatcher said, "The trouble with socialism is that eventually you run out of other people's money."  As a matter of fiscal policy, of course, that's complete nonsense, because the stream of revenue flowing from the people into the treasury is continuous.  But Thatcher's quotation does make the point that if public officials don't spend public dollars wisely, the money does run out, and that leads to deficit spending and ever-growing public debt.

But we don't have socialism in the United States, so this isn't a problem, right?

The idea that socialists are spendthrifts and capitalists are frugal is, to be charitable, comical.  Dwight Eisenhower warned us about the "military-industrial complex," and if you look back over the last century, we have done an astonishing amount of deficit spending and creation of debt to engage in wars of dubious merit (to say the least), and capitalists running companies with fat defense contracts have vigorously promoted all of that.

That brings us back to Ken's worry that Bernie Sanders wants to share some of his money with people who work less.  What Ken should understand is that his money is not being funneled directly to some lazy bum sitting at home collecting a welfare check and other benefits of social programs.  No, if you take one of the dollars Ken sends to the federal treasury and divide it up according to the federal budget, that's a pretty small fraction.

But Ken's remark does highlight something that is a striking feature of the national conversation, to the extent that we have one, about spending on social programs.  People with moderate incomes are having their opinions shaped by the very successful efforts of the wealthy to focus our attention on how our tax dollars are spent to help the poor - specifically the undeserving poor.

Traditionally, for many centuries, there has been "class warfare" that has pitted the poor against the rich, from the peasants of Europe versus the noble aristocracy before democratic governments began to replace monarchies, to the working classes of the modern industrial age against the capitalist robber barons.

The wealthy are keenly aware that this kind of class warfare is bad for them. And they have succeeded in using the corporate media to help them mold public opinion, so that now class warfare is between the struggling working-class folks - who often live paycheck to paycheck but get by without any help from government social welfare programs - and those who have it even rougher and rely on some of those programs for subsistence.

How do they do this?  After all, while we are in many ways a nation of rugged individualists, we also believe in helping the less fortunate.  So they do it by finding examples of the undeserving poor, the small fraction of people getting stuff from social programs by working the system, people whose problems stem more from being lazy and shiftless than from misfortune or disability.

Remember the California surfer dude using his SNAP card (what used to be called food stamps) to buy sushi and lobster?  It doesn't take many stories like that to make the working class feel as though the poor are the enemy, at least economically.

The trouble with those stories is that there is just a little bit of truth to them - after all, no "entitlement" program is going to be completely successful in screening out the people who really aren't entitled to any help - but they fail to mention that the percentage of the dollars going to people who don't deserve them is very small.

So what about Bernie?  What is he going to try to do if he gets elected?

For one thing, he would like to see far less money spent on an astonishingly bloated defense budget that often has far more dollars in it than our military leaders ever requested.  While I am no expert on defense policy, I am skeptical of the need for the American taxpayer to spend more on defense than all of the other First World nations combined.

More directly to Ken's point, though, is where the money will come from (besides a shrinking military budget) to pay for the things Bernie believes are worthwhile, like rebuilding our crumbling infrastructure and funding education so the US can reclaim its position as having the world's best-educated workforce. (We were once #1, and we are now #12.)

That income tax I mentioned earlier is supposed to be "progressive."  That means that, as you earn more money, and the amount you earn rises ever higher above what one needs to live on, the percentage you pay in federal income tax rises, too.  As a high-income-earning professional (a physician), I am in the top marginal tax bracket.  What does that mean?  Well, on the calendar, before we've gone too far past the midpoint of the year, about 40¢ of every dollar I earn is going to the US Treasury.  The top marginal tax rate used to be much higher.  I'm old enough to remember when it was 70%.

What about Social Security?  That is a very different situation.  The tax on that stops - that's right, stops - before I reach the midpoint of the year, because there is a cap on the amount of my income that is subject to the tax.  What that means is that the more I earn, the smaller the percentage of the total goes to pay that tax.  That is what an economist would call a regressive tax.

So, does Bernie want me to pay higher taxes?  Yes, he does.  He wants to lift the cap on my Social Security tax.  Am I happy about that?  No, of course not. But in another ten years I may start to collect Social Security, and I might actually need the money to avoid a dramatic decline in my standard of living, so the adequacy of the revenue stream that funds the system is important to me.

What about Ken's taxes?  Would they go up?  I'm not Ken's accountant, so it's hard to be sure.  But look at the overall picture.  Ken is not a front-line medic. He's a small businessman - like Joe the Plumber.  If Bernie gets the single payer health care financing system he wants, Ken and his employees, in the aggregate, might pay a little more in taxes, but that would be far more than offset by the fact that they wouldn't be paying eye-popping health insurance premiums.  If Ken and his employees have kids, and Bernie gets the funding he wants for higher education, the parents won't be struggling to pay for college, and their kids won't be graduating with educational debt the size of a mortgage on the house that they might then actually be able to buy.

So is that enough money?  Savings on a bloated defense budget and taxes a little higher on average folks but way more than offset by what they'll get back?

Nope.  It's not.  It will also take higher taxes on what Al Gore called - in his sing-song, whiney drone that made me want to find the mute button as quickly as possible - the wealthiest one percent.

Who are they?  Well, the bottom half of that top one percent includes some high-income-earning professionals.  Not emergency physicians, but probably some surgical specialists - who get paid a lot because of the high value of their work.  But the top half of that one percent is where the real money is.  The folks up there make most of their money in capital gains: interest, dividends, proceeds from investments.  And that money is taxed at a lower rate!  Does that make sense to you?  The rationale for taxing capital gains at a lower rate, as it might be explained to the working class, is to encourage savings and investment.  But tell me, does someone making over a million dollars a year really need an incentive to save and invest?  For Pete's sake, many of these folks don't even want to pay the capital gains tax as it is, and move their assets overseas to try to avoid it.

This is the kind of outrage that must stop.  The wealthiest people in this country, the ones who can most afford to pay higher taxes, are paying a lower percentage of their income in taxes than anybody else.  And large corporations are getting all manner of subsidies, from the oil industry to agribusiness, and we - the regular folks - are paying for all that.

So before we have a conversation about whether it makes sense to give the single mom more money if she has yet another child out of wedlock to a father who will take no responsibility, let's have a conversation about how Walmart has $75 billion in assets overseas, in countries where the company doesn't even operate any stores, just to avoid US taxes.  I'm pretty sure the taxes that we should be collecting on that would pay for daycare, K-12, and college for every one of those children of deadbeat dads in the entire country, with plenty of money left over.

So, Ken, the answer is no.  Bernie doesn't want your money to give to people who work less.  He wants the wealthy and powerful to start participating the way they should be, in the American society that has been so good to them, by paying taxes instead of using every imaginable dodge to avoid them.  Oh, and one more thing.  Yeah, those tax dodges (loopholes) are legal.  How did they get there?  They were enacted into law by politicians bought and paid for by the wealthy.

Look at Bernie's campaign financing.  His money comes from folks like you and me.  No big corporations.  No fat cats.  No super-PACS.  He wants to give the government of this nation back to you and me.  I don't know about you, but I think that's a great idea, and it's high time.

Time to Ban Guns?

Last week the New Republic published a piece by Phoebe Maltz Bovy, a regular columnist for that publication, that makes the argument for banning all guns from American society. Interestingly, the writer isn't talking only about civilian gun ownership, as she advocates disarming the police as well.

It's been a while since I last saw something in print that staked out this position, and so I found myself thinking that it might be time to ban guns, or it might be time to review the reasons why we should not do so.  Further, the columnist sets forth her reasons for making the argument, explaining that she believes it is necessary to make the case for elimination of guns from our society in order to bring the possibility into the public mind.  And that got me to thinking about the other side of the coin: reasons why, instead, it might actually be counterproductive to do this.

First, a little background for those who may not be familiar with the publication. The New Republic is a "progressive/liberal" magazine with a focus on politics and public policy.  It has been around for over a century, and its founders included that luminary of American journalism named Walter Lippmann.  (For those with an interest in the history of American journalism, I highly recommend Ronald Steel's book Walter Lippmann and the American Century, a superb biography that was published in 1981 and won the Bancroft Prize.)  So this is not some millennial left-wing blog site.

Let us first consider the case for banning guns.  In its most elemental form, it is starkly simple.  Guns are used for things other than killing people, to be sure, but Maltz Bovy does not address that, so I will set that aside for the moment and focus on this particular use.  Guns are used to kill people.  Yes, we know that "guns don't kill people; people kill people."  And we know there are other ways of killing people, as people killed each other, sometimes in large numbers, for millennia before the invention of the firearm, which historians place in the 12th or 13th Century.  So the gun is simply a tool, an inanimate object without autonomy.  Thus, as a careful user of English, I am constantly irritated by news accounts that someone was killed by (rather than with) a gun, just as I am when there is a report that someone was "killed by an SUV."  But guns are used to kill people, and it is argued that they afford more of what the New York Times called "brutal speed and efficiency" in a recent editorial advocating a new ban on semiautomatic rifles.

So let us imagine 21st-Century American society without guns.  To be sure, that does require some imagination.  We cannot assume it will be like more primitive societies that didn't have guns because they hadn't been invented yet, because at the same time they didn't have guns, they also didn't have modern social institutions that provide stability and make violent behavior generally unacceptable.  In other words, we have made much progress toward creating a "civil society" in the last half millennium, so if we could just eliminate guns, that would be a great leap forward, with apologies to Chairman Mao for appropriating the phrase.  Of course we also cannot assume an American society from which we magically removed all guns would be suddenly transformed into a North American version of Japan, where guns in the hands of civilians are rare.  There are vast sociocultural differences between Japan and the US.  To offer just one example, many of the shootings occurring in the US each year are related to the urban subculture involved in illegal drugs and gang activities, and Japan doesn't have anything quite analogous to that.

But let us imagine that we could eliminate all guns, and thus all shootings, from American society.  Would that eliminate all crime?  Well, no, obviously not.  It would not eliminate crime, it would not eliminate violent crime, and it would not end homicide.  It would reduce the number of killings - both homicides and suicides (the latter of which typically outnumber the former) in which guns are used, necessarily to zero, because this is an absolutist hypothetical.  But there are other ways of killing; they simply tend to be more difficult and may require more skill or planning.

In general violent crime, to be successful, requires the same things that are required for success in war: careful planning or some other approach that results in the victim being surprised or unprepared to put up a defense; disparity of force; or both.  Firearms are not required.

Now let's look at things from the intended victim's viewpoint.  How does one avoid becoming a victim?  Well, take the elements required to make you a victim and hold them up to a mirror, and you see that you must be prepared to put up a defense and must be able to avoid being on the wrong end of disparity of force. So the keys are education and training, mental preparation, and possession of a tool that can serve as an equalizer if the person(s) intent on victimizing you are bigger, stronger, faster.  This is the rationale for the possession of a gun for personal defense.  Note the importance of education, training, mental preparation, and practice.  Without these, the gun is unlikely to serve its purpose.  It is not a talisman.

At this point it is tempting to go off on a tangent about whether private ownership of guns increases or decreases the risk to one's personal safety. The published literature is replete with "evidence" pointing in opposite directions.  If there is a gun in the household it is more likely to be used to injure or kill a member of the household than against a criminal intruder, says one side.  Oh, no, says the other side, the number of times guns are successfully used for self defense is greater by an order of magnitude, if you look at data collected and reported by criminologists.

So, rather than going off on that tangent, I'll just opine that the private citizen who does the "right things" mentioned above (education, training, mental preparation, practice) along with other "right things" such as safe storage, is going to be one for whom the risks of ownership are low and the value of possession for personal protection has obvious appeal.  In a household with children or other irresponsible people and adults lacking the good sense to secure firearms effectively; or a history of domestic violence; or people who are depressed and think the world would be better off without them ... yes, clearly, there are households where guns don't belong.

But when the advocate for a total ban is talking to a gun rights advocate and it gets down to brass tacks, one believes in the right to armed self defense and the use of lethal force in defense of life, and the other does not.  Once the discussion arrives at that point, there isn't really anything more to talk about.

So now let us imagine that we would like to see fewer guns in American society. Maybe our idea of "fewer" is zero, but let's leave it imprecise for the moment. We could say we'd like to keep guns out of "the wrong hands."  We could say we'd like to ban "weapons of war" (even though we mean the AR-15, when it's actually the M-16 that is a weapon of war).

So we press for universal background checks, and we say no one "needs" an AR-15, and we can find millions of gun owners to agree with us.  After all, the number of gun owners is about ten times as large as the number of owners of the AR-15 and similar rifles, and it's easy to compromise on what the other fellow has.  The large majority of members of the NRA are OK with universal background checks, although the percentage might drop a little if you remind them that if Uncle John is going to buy a new hunting rifle and decides he'll give his old .30-06 to Bobby, who is ready for his first deer season, that transfer has to go through a dealer.

Now, hold on, say the hardliners to their brethren inclined toward a softer position.  This is only the beginning.  This is a slippery slope.  Give 'em an inch and they'll take a mile.  Every time they say "common sense gun control" remember it's always the first step toward something you won't like.

And that brings us to the question raised by Maltz Bovy's essay.  Not the first one: is it time to ban guns?  The rationales for and against could fill a book (and they have, many books), and I've given you the highlights.  No, the second one: is it time to make the case for this and try to bring it front and center in the public mind?

On the pro side, Maltz Bovy is right, if you tacitly accept that something is not possible, then it is not possible.  If you start talking about it like it is not only possible but clearly the right thing to do, then you can work on shifting public opinion your way.

On the con side, if you make a forceful public argument that unequivocally states your endgame, the very first move of the very first pawn will be resisted.

If you are a gun control advocate, Maltz Bovy is not helping your cause.  If you are a gun rights advocate urging the compromisers to take a harder line, Maltz Bovy has just made your case for you.

Muting the "Trump-Et?"

The other day Donald J. Trump, who is seeking the Republican nomination in the 2016 presidential contest, issued a public statement in the aftermath of a shooting in San Bernardino, California.

Tafsheen Malik and Syed Farook, a Pakistani immigrant and her husband, the Illinois-born son of Pakistani immigrants, attacked a large holiday gathering of Farook's coworkers, reportedly using semiautomatic rifles to kill 14 people and injure 21 more.  The pair were married, and early details of an ongoing investigation suggested both were "radicalized" Muslims who had embraced the concept of jihad as an Islamic fundamentalist war with Western society.

This mass shooting occurred as the federal government is grappling with decisions about admitting to the United States thousands of refugees from strife-ridden Syria, where the Islamic extremist group ISIS controls large areas of the country, now engulfed in civil war.

Mr. Trump called for a ban on any further immigration of Muslims into the United States until the federal government can "figure out what the hell is going on."

This was just the latest in a series of provocative statements from the candidate during a months-long campaign in which he has distinguished himself from others seeking the office in many ways, perhaps most notably a complete rejection of any notions of political correctness.  Trump has shown that he is ready, willing, and able to offend absolutely everyone.

In other parts of cyberspace, although not yet in the blogosphere, I have characterized Trump as jingoistic, xenophobic, nativistic, racist, and homophobic.  I have said he appeals to the basest impulses and the ugliest prejudices to be found in the American psyche.  His attractiveness as a candidate, I believe, relates to the fact that there is a segment of the electorate that is incoherently angry about many changes going on in the world around them.

[No, I am not a fan.]

His demand for a suspension, as he later qualified his call for a ban, of immigration by any and all Muslims until our government figures out "what the hell is going on" stems, I believe, from the simple fact that Mr. Trump himself does not know what the hell is going on.  Geopolitics and foreign policy are, and will likely remain, well beyond his ken.  What he sees is that there are Islamic extremists whose intentions toward Western society in general and the US in particular are malevolent.  Therefore, he insists, until some foolproof test is devised whereby it can be determined whether an individual Muslim who wishes to come to the US is, and will remain, no threat to Americans, we should allow absolutely no Muslims to enter the country.

Anti-immigrant sentiment has been with us for a very long time.  Before the Civil War, these tendencies were already very much with us.  American society went from 1.6% foreign born in 1830 to 9.7% in 1850, and the us-versus-them view of immigrants by the native-born was sufficient to provide the foundation for a strong nativist current in US politics in the second quarter of the 19th century.

That this phenomenon is not new, however, makes it no less repulsive. America has always been a beacon of freedom - political, religious, economic, social - to the rest of the world, and that necessarily attracts immigrants.  That is a fact of which we are justifiably proud.  We are inspired by "The New Colossus," the famous poem by Emma Lazarus that is inscribed in a place of honor at the base of the Statue of Liberty, a poem that concludes with the words

Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door! 

Mr. Trump has declared that ISIS, and Islamic extremists like Malik and Farook, along with the terrorists who killed over 120 people in Paris last month and others who have carried out attacks around the globe, have proven that all of the world's billion or so Muslims are suspect and must be viewed through a prism of presumptive guilt.

Words such as repugnant, appalling, reprehensible, and disgraceful can only begin to describe this kind of public pronouncement and the rationale that underlies it.

So what? you may be asking.  We live in a country in which freedom of expression is guaranteed.  People can think and say whatever they want, with few exceptions: no shouting "Fire!" in a crowded theatre or making other utterances that could pose an immediate danger to the public safety, for example.

Yes, freedom of expression is guaranteed - against abridgment by government. If someone who finds Trump's public utterances opprobrious punches him in the nose, that person has not violated the candidate's First Amendment rights, although he will likely be charged with battery.

This also means that the press has no obligation to report Mr. Trump's declarations.  They may do so if they think what he has to say is newsworthy. They are equally free to choose not to report, although they risk losing audience share if they don't report a story that is sure to interest the public.

What would Trump have to say to get the news media to decide it doesn't bear repeating?  Can we assume that no matter what he might say, no matter how outrageous, they will tell us, because it's news?  Probably so.

Then, at what point is there an obligation on the part of the press to say, here is what this fellow said, and these are the ravings of a madman?

Oh, no, they can't do that.  That would be interpreting.  They mustn't do that. They can only report the interpretations of others.  So they can tell us other Republican candidates have condemned what Trump said.

Let me tell what I think of that: Baloney!

The news media have a great deal of control over what and how much we learn about candidates.

Here is an example.  You've all seen how news organizations commission polls because of the public interest in the "horse race" aspect of the presidential campaign.  Within the last week, three polls were commissioned by news organizations: CNN, MSNBC, and USAToday.  All three looked at how Hillary Clinton matched up against Republican candidates in hypothetical general-election pairings, Clinton versus Trump, or Cruz, or Rubio, or Carson.  (MSNBC included Bush; the others did not.)

Missing from these polls, as reported by the superb political website realclearpolitics.com, was any match-up between the Republican candidates and Bernie Sanders.  Oh, well, that must be because Sanders doesn't match up anywhere nearly as well as Clinton.  After all, the conventional wisdom is that he's unelectable because his image is that of a crazy left-wing socialist.

Not so fast.  A poll conducted last week by Quinnipiac University (not on behalf of a news organization) looked at exactly those Sanders-versus-Republican-candidate match-ups, and ... well, waddya know?  Bernie does even better than Hillary, leading against Trump, Carson, Rubio, or Cruz.

The media have reported this campaign season's news as if Bernie Sanders is barely worth a mention.

Well, let me tell you something.  There is a candidate in this race who is barely worth a mention, and his name is Donald Trump.  Trump is a disgrace to this great nation.  Remember Ronald Reagan, who famously said Republicans should never speak ill of each other?  This was known as Reagan's "Eleventh Commandment."  Now consider this: Senator Lindsay Graham and former Governor Jeb Bush, two other Republican candidates, described Trump as "dangerous" (Graham) and "unhinged" (Bush) in the wake of The Donald's call for a "total and complete shutdown" of Muslim immigration.

The news media do not have an obligation to report, breathlessly, the ravings of a madman who has been characterized by his fellow Republicans as "dangerous" and "unhinged."

Not when they have clearly made a deliberate decision to minimize their coverage of the campaign of Bernie Sanders, whose career and whose candidacy have been the most positive and principled this pundit has ever seen in American politics.

Is it newsworthy that we have a candidate who taps into deep-rooted American prejudices and ugly, base, xenophobic instincts?  Perhaps.  Should that be reported?  Before we can answer that question, we must ask another.  Does Trump merely tap into those ugly features of the American psyche?  Or does he encourage, ignite, inflame them?

I think you know my answer.

Shame on you, Donald Trump.  And shame on you, complicit journalists.
  

Research on Gun Violence Banned? Not Exactly.

Churchill, Thompson submachine gun, 1940

As a physician specializing in emergency medicine, I have a keen interest in areas of research that are related to my practice.  This includes public health and injury prevention.

Much medical research is funded with public dollars.  In fact, most medical research is funded either with public dollars or by industry, meaning the pharmaceutical industry and the manufacturers of medical devices. Among folks in academic medicine, it is considered a truism that publicly funded research is much more likely to be of high quality, whereas industry-funded research is much more likely to be biased, with problems ranging from study design intended to produce certain results, through dubious statistical methods, to spinning results to draw conclusions that aren't really justified.

Many years ago my colleagues in public health came up with the idea that violence is a public health problem.  This led to an interest in all sorts of research into the nature and causes of interpersonal violence.  One area of this research involves violent acts committed with firearms.

Early on some of the researchers adopted a metaphor from the discipline of infection control in which guns are viewed as "vectors" of "disease," rather like the way in which the female anopheles mosquito is a vector for malaria.

And here you can see where some trouble might begin.  You see, there are people - many Americans among them - who like guns.  And so, if you adopt a viewpoint that guns are a vector of disease, you will inevitably find yourself in conflict with those people.  If you want to control malaria, you are likely to decide an effective approach is to wipe out the population of mosquitos that transmit the parasite that causes the disease.  If you view guns as a vector, according to this metaphor, you are likely to think that eliminating guns from human societies may be the solution to the problem.

The reaction from gun rights advocates was predictable.  Maybe violence is a public health problem, they said, but guns are not a vector of disease, and this is an essentially flawed metaphor - a metaphor that biases the research done by the medical scientists working in this field, nearly all of which seems to begin with some sort of hypothesis that guns are bad and that wherever you look at the role of guns in human societies you will find trouble that would go away if we just took guns out of the picture.

At the same time that public health researchers were publishing one study after another that concluded guns are a problem (if not the problem), social scientists (especially criminologists) were doing research that seemed to reach very different conclusions, often finding that guns are used at least as much - maybe much more, according to some - to deter or stop crime than to injure or kill innocents.

It would be easy to conclude that researchers examining the same questions and reaching essentially opposite conclusions probably are all biased, and their opposite conclusions reflect opposite biases.  And that may be the case.  If you are reading this essay, that suggests you are interested in my opinion, so I'll tell you I have read most of this research, and it is pretty clear to me that there is plenty of bias to go around, and it is quite difficult to tell how much the results are influenced by it.  This much, however, I can tell you: the truth is not entirely on one side of this question.

One cannot reach any other conclusion than this: more research would be a good thing, and the less biased that research is by preconceived ideas on the part of researchers, the better.

Where should the funding for that research come from?

Well, public dollars seem a sensible choice, given that gun violence is a public health problem (in the view of medical scientists) or a social problem (in the view of social scientists).  (It is obviously both.)  Besides, what sort of private funding might there be?  You can imagine the potential source of bias if the money came from the firearm manufacturing industry, on one side, or billionaires (such as Michael Bloomberg or George Soros) who ardently support pro-gun-control advocacy groups, on the other.

And that takes us back to 1996, when the National Rifle Association was fed up with the public health research that pretty uniformly concluded guns are bad and we should get rid of them.  The NRA lobbied Congress, with the result that an omnibus appropriations bill prohibited the flow through the CDC of research funding that would "advocate or promote gun control."  (Those are the actual words in the legislation.)  Notice that this is not a prohibition on federal funding for research into the problem of gun violence.  But an article in the New York Times explains how it effectively became that, mostly because the CDC became "squeamish" about funding research in this area.

This puts a little bit different spin on the subject than what we have repeatedly been reading and hearing in the news lately, which is that the NRA succeeded in putting an end to research into this problem.  Two quotations from the Times article offer insight into two quite different perspectives on what the NRA asked the Congress to do:

 “We’ve been stopped from answering the basic questions,” said Mark Rosenberg, former director of the National Center for Injury Control and Prevention, part of the CDC-P, which was for about a decade the leading source of financing for firearms research.

 and

Chris Cox, the NRA’s chief lobbyist, said his group had not tried to squelch genuine scientific inquiries, just politically slanted ones.  “Our concern is not with legitimate medical science,” Mr. Cox said. “Our concern is they were promoting the idea that gun ownership was a disease that needed to be eradicated.”

In 2011 further congressional action extended this restriction on the flow of research dollars so that it affected all other agencies funded through the Department of Health and Human Services.

It seems clear that more research is needed.  It is not clear that congressional action is needed to reverse the actions taken in 1996 and 2011.  I may be extremely naive, but if were in charge of these dollars at the CDC, I would look for opportunities to fund research on gun violence that appeared to lack obvious bias in either direction, and consider the burden of proof to rest upon anyone who objected to convince my congressional overseers that the research was intended "to advocate or promote gun control."

And what sort of research might be funded?  Perhaps you've heard of the National Academy of Sciences.  One of the institutes under its umbrella is the Institute of Medicine (IOM).  The IOM's Division of Behavioral and Social Sciences and Education has a Committee on Law and Justice that published an excellent report addressing this question two years ago: Priorities for Research to Reduce the Threat of Firearm-Related Violence.  (If you follow the link you will see that you can buy a paperback copy of the report, but you can also read it online or download it as a pdf, free of charge.)  If you wonder about bias in this IOM report, I would draw to your attention that two of the reviewers of the report were Paul Blackman, a criminologist and political scientist who is regarded by his detractors as a shill for the NRA, and Arthur Kellermann, a distinguished medical professor and public health researcher whose work is harshly criticized by gun rights advocates.  The IOM does an excellent job of pulling in diverse viewpoints on controversial subjects.

When we see and hear in the news that more than 30,000 people are killed with firearms each year, and many more injured, a small fraction of these in horrific mass shootings that grab the headlines, we all want somebody to do something about it.  The question is what.

And the answer is not whatever seems to you or me to make sense.  I can tell you from my experience of 37 years studying medicine (beginning with medical school) that what makes sense often turns out to be completely wrong when subjected to scientific study.  We need more research.

Thanks to the IOM, we have an agenda.  It is possible to approach this research with an open mind and without bias.  That kind of research has not been prohibited by Congress.  So let's get moving!

Socialized Medicine: Utopia or Dystopia?

Rep. Utt (R-CA) said this about Medicare in 1965.

First, what is it?  That's right, do you know what socialized medicine is?

A better question, perhaps, is what people mean when they use the phrase.  The simplest definition is a system of health care for all paid for with public funds.  Providers (which means doctors, hospitals, and everyone else who renders health care to patients within the system) provide the care, and it is paid for with money that comes from taxes.  In its pure form, then, there is no health insurance, there are no bills, and there are no deductibles or copays.  You, as a human being in need of health care, consult me, a physician; I take care of you; no money changes hands; the government pays me, using public dollars (tax revenues) for what I do.

There is a lot more information on what people use, and have used, this term to mean, including complete control by the state (meaning the government) of the health care system.  Depending on how you view the government - is it competent, reliable, trustworthy? - the thought of a government-run health care system may hold more or less (maybe even zero) appeal for you.  But in its most basic sense, the essence of what I'm writing about here is public financing of health care, which can occur within but does not require a health care system that is operated by the government.  So, for example, the Medicare and Medicaid systems are financed with public dollars, and the Veterans Health Administration is operated by the government.  Right there you can see how a broad spectrum of opinion might be generated on the idea of the government doing things.  The VA has its admirers and critics - recently mostly critics, because of failings in looking after the health care needs of veterans, and Medicaid has more critics than there are crystals of salt in the ocean, it seems, while Medicare gets pretty high satisfaction ratings from seniors.

The USA is, in many ways, fundamentally opposed philosophically to the very idea of socialism, because it seems to require Big Government.  Most (but certainly not all) of our Founding Fathers were mistrustful of the idea of a powerful central government.  During the 19th Century there was vigorous public debate over whether the government should be involved in, and spend public dollars on, "internal improvements" such as roads and canals.  After the development of an Interstate Highway System in the 1950s it may seem odd to us that in the first half of the 19th Century many were opposed to giving this sort of power to the federal government, and foremost among the opponents, perhaps, was President Andrew Jackson.  Some of my readers may recall that Jackson was also the last president during whose administration the national debt was paid off, so support for or opposition to public spending has obvious potential implications.

Aside from basic mistrust of Big Government by some, there is concern about Big Waste by the feds.  After all, can we trust public financing of health care by the same government that paid $600 for a hammer?  (By the way, the $600 hammer is a myth.)  Well, Medicare is, by any measure, less wasteful than just about any private health insurance enterprise, in that it spends a higher proportion of every dollar on health care, with less going toward administration and zero going to profit.  The role, or lack thereof, of profit in the health care system and the way we finance it is an important part of the consideration of "socialized medicine."  That could be the subject of a very lengthy essay all by itself, but if you believe the profit motive is bad in this context, I submit that socialized medicine is the only way to eliminate it.

Physician satisfaction with Medicare is another matter altogether, and many doctors are opposed to socialized medicine largely because of their frustrations with Medicare.  Medicare, they believe, pays too little for their services and requires them to do a great deal of useless clerical work to collect what they do get.  Ironically, that should be part of the attraction - not the repulsion - of socialized medicine.  Medicare irritates me as much as it does any other doctor, mostly because I'm a pretty irritable fellow (also known as a crank).  But if we have a system in which all health care is financed with public dollars, the reasons for most of what Medicare does that annoys doctors could (and should) disappear.  In the system I envision, I could be paid for taking care of patients in a way that wouldn't require me to provide documentation of everything that was done or doing all sorts of clerical work (or paying others to do all that) to submit claims to an administrator.  I could go back to putting information about my caring for the patient in the medical record for its original purpose: communicating with other people who are also caring for that patient or who will in the future.

Now wait a minute, I can hear my physician readers saying.  The only way that could happen would be if I become a government employee.  That isn't necessarily so, but it does require a system in which money is allocated for the health care of the general public and is paid to the providers of that health care without being based explicitly on the exact services provided.  That doesn't require that doctors be government employees, although that is one approach. What it does require is a fundamentally different approach to financing health care from what we have now.

Doctors aren't necessarily the only ones leery of physicians being employed by the government.  Many of us like to quote, derisively, the imaginary expression, "I'm from the government and I'm here to help you," as if those two things couldn't possibly go together, and anyone who says such a thing should be viewed with a mixture of amusement and paranoia.

But we don't have a problem with firefighters being government employees.  Or the Coast Guard.  Or air traffic controllers.  Or any number of other people we trust with our lives.  So we certainly shouldn't assume that doctors who are government employees would be in any way inferior.  The patients in the VA system do not, as a rule, have a problem with the quality of the doctors but with the system that lacks the capacity to care for them.  As a nation we recognize that shortfall, and we are demanding it be remedied.  If we had a system for everyone that had inadequate capacity, how quickly do you think we would demand - and get - action to remedy that?

Many who deride socialized medicine look to the United Kingdom's National Health Service and say people wait weeks or months for elective surgery, and Americans won't tolerate that.  Three things you should know about that.  First, Americans with no health insurance don't wait weeks or months for elective surgery.  They wait forever.  And that is unacceptable in the wealthiest nation in the history of the world.

Second, the satisfaction of the Brits with the NHS is higher than our satisfaction with our non-system, regardless of any of the (exaggerated) claims about their waits for elective surgery.  Third, per capita spending on health care in the UK is half what it is in the US.  I am entirely unwilling to believe we couldn't create a system that covers everyone with what we're spending, with high quality and no long waits for anything.

[What we have now, instead, covers 85% of our population, many with woefully inadequate health insurance that has ridiculously high copays and deductibles, and leaves 15% (perhaps a bit less now with expansion of Medicaid under "Obamacare") with nothing.]

If you think we can't do that, I must ask you why.

There are two possible answers that come immediately to mind.  The first is that we are a lot dumber than the Brits, and although that is possible, I don't think so. The second is that we cannot do that without eliminating all of the waste associated with having a for-profit health insurance industry, in which many dollars intended to be spent on health care are, instead, spent on administration (twice what the government spends for Medicare administration), and profit, and seven-figure executive salaries.  If you guessed that the second possibility may really be a big part of the problem, go to the head of the class.

I must now ask you to consider a simple question.  If you work for a living and have employment-based health insurance, it's called a benefit of employment. That means you worked for it.  You earned it.  And every dollar that you earned that is spent on health insurance premiums is, in principle, a dollar that should be spent on health care.  Looked at the other way, every such dollar that is not spent on health care is a dollar wasted.  So, every dollar that a health insurance company diverts to profit, to eye-popping executive salaries, and to excessive administrative costs is a dollar wasted.  Looked at even less charitably, every such dollar spent on those other things is a dollar stolen from you.

The solution?  Eliminate the health insurance industry.  If we do that, we must have a new way to finance health care.  What would that be?  Re-read the first two paragraphs.  And now you know the answer to the question posed in the title of this essay.  Utopia or dystopia?  Neither.  It is, plainly and simply, what we must seriously consider if we hope to have a system for financing and providing health care that works for everyone, rather than the absurdly fragmented and wasteful non-system we have now.

Feel the Bern

Many of you who have been victims of Facebook's facilitation of my political proselytizing are now keenly aware of my support for the candidacy of Vermont Senator Bernie Sanders for president.

What follows are a few thoughts I shared with another FB poster, someone I don't know and have never met and likely never will.

To offer context, much of it is rooted in comparison with Hillary Rodham Clinton.

My correspondent thinks Hillary has a more refined understanding of foreign policy issues than anyone else in the race.

It is possible to have the most refined understanding and still be wrong.  I think my understanding of the Levant (an almost forgotten term resurrected by John Kerry) is more "refined" than that of most Americans, and I thought the invasion of Iraq might actually accomplish something useful.  I thought the long-term outcome could be a stable democracy in Iraq that would help the entire region move forward toward peace and security.

I was, I now believe, flat wrong.

I'm not sure we know what Hillary thought about it over the last dozen years, or even what she truly believes now.

Sanders, on the other hand, thought it was a mistake even when Iraq was still called Mesopotamia, and he has (wisely) seen no reason to change his mind.

I like a man who chooses positions on issues wisely.  Is he a foreign policy geek?  Perhaps not.  Can he be trusted to make sound foreign policy decisions, faced with an array of complex options?  I believe so.

Then I was reminded of the undeniable advantage of the experience of having served as secretary of state when a foreign policy crisis arises.  So here we are at the campaign commercial about the 3 AM phone call again, only then (2008) Hillary's experience didn't yet include service as a member of the cabinet.

There were plenty of people who thought the peanut farmer from Georgia would be clueless about foreign policy, and many people still blame him for some of the mess that developed in Iran with the overthrow of the Shah.  But that was only the first draft of history, and he is now getting credit for the lack of US involvement in war during those years, so perspective is an ever-changing thing.

My partner in this discourse then wondered "what this wonderfully principled man (Sanders) would be able to accomplish with a Congress full of loons."

I like a man who can be described as "wonderfully principled," I think he can get elected if people will step out of their echo chambers, or take their fingers out of their ears and stop saying "LA-LA-LA-LA" and just listen, and I think a Congress full of loons can be bent to the will of a president who gets the people behind him.

Were you listening when Sanders reminded us that the Walton (Walmart) family has more wealth than the "bottom" 140 million Americans?  What about when he talked about how it is unconscionable that the average American college graduate has to work many years to be free of the burden of educational debt? (So, don't go to college?  Not everyone is cut out to be a plumber or an electrician.)  Were you plugging your ears, because you have a job with health insurance as a benefit - although you have to pick up the lance and the shield to get them to pay for stuff - when Bernie called us out as the only First World nation without universal access to health care and a rational mechanism for funding it?

Perhaps inevitable is the skepticism about whether Sanders could accomplish much of anything as president, given the dominance of the Republican obstructionists in Congress.  Seriously, have you been paying attention to the monkey-wrench-in-the-works approach of the House Freedom Caucus, that group of 40-odd far-right congressmen prepared to shut down government to prevent continued funding for Planned Parenthood, settling instead for the resignation of John Boehner as speaker?

Well, the same question could be asked about any Democrat, although one might imagine Hillary learned something from Bill's experience in working with Newt Gingrich.  But this is not 1994.  It's far worse.  And my correspondent noted that the current occupant of the Oval Office campaigned on a theme of change and has been stymied more often than not.

That is a fair point.  But Obama disappointed me by putting his oratorical skills on the shelf after he won the election in '08 instead of using them to shape public opinion and get the people to turn the flames up high under the derrieres of Members of Congress.

No, instead he chose to try to work with a Congress that is controlled by the wealthy, the powerful, and the multinational corporations.

Obama knew when he took office that pursuing his agenda would take a revolution.  Sanders knows that, too.  Barack didn't follow through.  I'm convinced Bernie would.

Realizing that the perspective of the "opposing" argument must seem awfully gloomy, my debate partner then simply admitted inability to share my optimism. I was ready with a reply to that:

You can share my optimism.  I have plenty, and would be more than happy to spare some for you. You may have some difficulty sharing my vision, but when I look at Bernie, I see a man with integrity, high principle, and the courage of his convictions.  I see a man who is willing to be the TR of the third millennium, to launch peals of thunder from the bully pulpit and stir the masses to demand reform, to bring low the high and mighty who use their wealth and power for nothing but the accumulation of more wealth and power.

It is time to use the federal government for something important and worthwhile: to rebuild the middle class and to bring many of the poor up into that middle class.

Today's corporate robber barons don't even have the redeeming virtues of Rockefeller or Mellon or Carnegie, who realized they had an obligation to use a substantial chunk of their amassed wealth for philanthropy, building institutes and universities and endowing museums, even if it may have been partly to get their names all over them.

No, now it is all about wholly unrestrained greed, accumulating wealth for its own sake.  It is inviting revolution.  That revolution needs a leader.

HRC might be a good president.  She will never lead a revolution.

Bernie Sanders, that Brooklyn-born independent thinker from Vermont, is the man for the times. 

Is Law Enforcement Racist?

A teenager named Michael Brown was shot dead by a police officer in Missouri last summer.  He was black.  The officer was white.  The youth was unarmed. Conclusions were drawn that were likely inevitable in a country in which race relations have their roots in the enslavement of Africans, brought to the New World to perform hard, forced labor.

Was this really about skin color?

Rewind to the early 1970s.

I was a teenager in Philadelphia, a student at an academic high school then considered one of the best in the country.  One day after school I was waiting at the bus stop on the edge of the school's grounds.  Some time in the last day or so a car had struck the pole holding the bus stop sign, which was now bent over to an angle of about sixty degrees with the pavement.  I straddled the pole and leaned back against it, there reclining while awaiting the bus.

A police cruiser stopped, and the officer, disturbing my reverie, barked, "Get off that pole!"  I looked in his direction, perplexed and a bit annoyed.  "What?"

"Get off that pole!  That's destruction of public property!"

I said the '70s equivalent of "Dude?  Seriously?" - explaining that the pole had obviously been hit by a car, and it was ridiculous to think that I had the strength to bend this solid metal cylinder.

The officer was disinclined to engage in thoughtful discussion.  I had questioned his authority.  He ordered me into the cruiser and drove to a police station, where I was placed in a holding cell.  A few hours later my mother appeared to pick me up and take me home.

I was not arrested or charged, and I acquired no record of violating the law.  I did, however, learn a valuable lesson about what is, and what is not, a sensible way of responding to an order from a police officer.  Questioning authority is risky.

A young man in Missouri last summer was told by a police officer to get off the street and walk on the sidewalk instead.  His response, like mine, was to question authority.  I could have told him that was a bad idea.

The sequence of events that followed was tragic - and resulted in the young man's death.  A grand jury spent many hours hearing testimony and reviewing physical evidence and drew the conclusion that there was insufficient evidence to indict the officer.  I have not heard the testimony or reviewed the evidence myself, and so I cannot draw an independent conclusion.  News reports suggest to me, however, that the investigation was thorough, and our legal system must be trusted to reach conclusions that are fair, even if they do not satisfy everyone - indeed, even if they satisfy no one.

The reaction in Missouri to the shooting last summer included looting and rioting.  The reaction to the the grand jury's conclusions has been worse: more rioting, more looting, numerous cars and buildings set ablaze.  The property damage will likely total in the millions of dollars.  The damage to the collective psyche of the community cannot be tallied.

The population of Ferguson, Missouri is about two thirds black.  The police department, nearly all white, has only a small handful of black officers.  The fact that the officer was white and the young man questioning his authority was black was, as a matter of statistical probability, to be expected.  One can argue that a police force should mirror the community it serves.  But often it does not, and yet the police and the citizens must still engage each other in ways that are positive and constructive.

Michael Brown, according to the accounts available to the public, not only questioned authority but responded in a hostile, aggressive manner.  There was a scuffle.  Brown's conduct was described as threatening.  The officer said he feared for his physical safety.  Brown was a big fellow, with an intimidating physique.  His size, and his behavior, were such that the fact that he was unarmed did not figure into the officer's reactions.

Michael Brown has been variously described as a congenial and docile boy and as a thuggish delinquent.  We have all read the news accounts and have drawn at least some tentative conclusions of our own as to what he was really like.  But we did not know him, and we did not know officer Darrin Wilson.

It is easy to believe that what happened between Brown and Wilson was largely determined by the color of their skin, or by the tension between law enforcement and the community when the police department and the citizenry are demographically on opposite sides of a racial divide.

I do not doubt that race can be a factor in such incidents. But this particular incident started with a response by a teenager to a command from an officer of the law.  That response was not one of respectful obedience.  A response by a teenager to a police officer that is not one of respectful obedience is a bad idea.  I learned that the easy way, if spending a few hours in a holding cell and then having to explain oneself to a mother who was every bit as authoritarian as the police officer can be described as easy.

But compared to what happened in Ferguson, Missouri last summer, my lesson came cheap.  Michael Brown is dead.  And last night Ferguson was ablaze.  It may be partly about race - anyone who says race played no role is naive and will be branded a fool.  But it is also about teaching our children that the command, "Question authority" comes with a responsibility to do so prudently. It is not something to do in interactions with police officers to whom we have assigned the responsibility to exercise authority in maintaining order in our communities - and who must spend all day, every day, dealing with persons who question authority, often in belligerent ways, and sometimes in ways that put an officer's personal safety at risk.

We have much to do in this country to bridge the racial divide whose roots go back to the slave trade.  Thomas Jefferson, prescient in his foretelling of the Civil War, said the question of slavery awakened him with terror, "like a fire bell in the night."

A century and a half after the Civil War, that bell is still ringing, and the fires are still blazing, this time in Ferguson, Missouri.  We had better get to work.