The Individual Mind

COVID-19 hysteria is in full swing. In the interest of “flattening the curve” of peak cases that might stress hospitals with a rush of capacity-exceeding, ventilator-dependent patients, have we created a greater societal crisis with a much larger and wider peaked curve? In an attempt to avoid certain costs and strain in one aspect of the economy, have even greater ones been caused throughout many sectors of the economy and life, in general? Are all costs and benefits being considered? Do we have a broad and long enough perspective to temper the narrow public health focus?

Yesterday, apparently following the strictest recommendations of CDC guidelines, an affiliate hospital declared that any employee or physician that travels outside of THIS PART OF THE STATE will not be permitted back into the hospital for 14 days. There are staff members returning from vacation who will not be able to report to work on Monday. Staffing, call and vacation schedules are significantly disrupted. In this small realm, what are those losses and costs, both personal and financial? And what if the hospital does become stressed with increased patient loads, now with reduced staff?

In the US, store shelves are being emptied of toilet paper, water and foodstuff. Travel is restricted. Quarantines are in place. Sports at all levels, in general, are cancelled. The effects are everywhere: concerts, Disney World, airlines, schools, work places, basic human endeavors of everyday life. Is there an aspect of the economy that remains unaffected? There is massive financial market upheaval. Trillions of dollars are to be injected into the economy by the Fed to stave off a worsening crash. Bailouts for affected industries and small business are being discussed. A bill is before Congress to give everyone free virus testing, free medical leave, free family leave. What are these costs and consequences, and who will pay for it all? At baseline, the US government spends about a trillion dollars a year more than it takes in,… and has for multiple past presidential cycles. How is your 401K? How is your work affected? What are the effects on individual families, especially the poor? To be clear, a Coronavirus did not cause any of the events in this paragraph. This is all the result of the response to the virus, not its effects. We are still early in the viral cycle and the reactions to it. Subsequent costs and fallout will not be known for months.

Maybe the public health response is appropriate. I’m arguing that it’s excessive. We’ll never really know. Later, most people will just say, “if we hadn’t been aggressive in flattening the curve, more people would have died.” How do you prove a negative? The precedent has been set. True COVID incidence will never be known because testing cannot be performed appropriately now or in the near future. Therefore, true mortality rates cannot be accurately calculated. COVID may be a ubiquitous virus that is mostly unrecognized among the population, leaving only the most symptomatic to be tested, thus skewing mortality rates. Regardless, we have data from the World Health Organization dashboard that shows cases in China and South Korea to have peaked within a matter of weeks and then decline thereafter. Of those tested, the Chinese may have a mortality rate as high as 4%, and South Koreans of about 0.9%. A lesson may be that this is a self-limited illness for almost everyone and that population incidence peaks and declines relatively rapidly.

I’ll argue for caution, voluntary social distancing, good hygiene, prudent travel. I argue against controls, mandates, restrictions, quarantines. The politicians are scared and do not want to be blamed for failures to act. It is an election year, after all. They also tend to see every crisis as an opportunity to expand legislation, oversight, spending and the pleasing of their lobbies and voter base. As a counter balance to that force, healthy skepticism seems appropriate. As we saw 9/11 open wide the doors of state surveillance, COVID will set the precedent for physical controls on citizen movement,… if not a mild introduction to martial law and lockdown, as China and Italy have pursued recently.

What are you trading for the promise of health and safety? How much true risk is there to that health and safety for which you make these trades? Now that precedents are being set, where will the limits be placed? And how will it expand once accepted? What happens with the next bad flu season? Who gets the bailouts, the paid leaves, the quarantines, the closures? What will be voluntary, and what mandated? What are the penalties? Who are the enforcers? When does the National Guard get called in? At what Dow Jones Index level does the central bank take over the stock market? How are the infected tracked and surveilled? These are all issues of degree. To some, they may seem extreme questions, but we are far along that continuum of trades at this point.

Perhaps the country has purchased a small scale curve flattening, but in exchange created a large scale peak across the economic and political landscape of the United States. Tempering the response, and in some cases the hysteria and over-reaction, may help flatten the broader curve of societal damage and costs.

I recently wrote about my new Type 1 Diabetes diagnosis, the quest for affordable meds and supplies, and the subsequent financial savings found through transparent pricing outside of my insurance plan. I summarized that health care “coverage” is very expensive, whereas medical services may be found much more affordably.

My next step was to establish an ongoing primary care physician relationship. I contacted one of the large medical groups that my insurance plan covers and found that before meeting with the internal medicine physician, I would be required to have two visits with a physician assistant first. In regarding this option, I considered: (1) it is not unreasonable for me to seek direct access to a physician rather than being filtered through a physician extender, (2) especially in light of a new and significant medical diagnosis, (3) it is reasonable to anticipate having a personal relationship with my PCP, which would be hampered if I can’t meet him or her for another 6 months or more, (4) I am paying significant premiums for insurance “coverage” that I expect to purchase me access to physician services, and (5) being a physician myself, I want the expertise of a fully-trained, board-certified specialist that exceeds my level of training in general adult medicine. None of this is to denigrate our PA or NP colleagues who are integral to the team approach of medical service provision, but that is not the level of care that I choose to purchase as my initial consultation. (I’m sure that some would disagree with my opinion, but that topic is a debate for another time.)

Having previously visited a specialist in the above-mentioned medical group, I knew that new-patient and follow-up visits would likely approximate the specialist bills that I’d received: $285 and $127, respectively. After insurance “adjustments,” my out-of-pocket co-payments had been $166 and $87, respectively. Now, able to judge costs and service level of that PCP option, I compared these to a Direct Primary Care (DPC) practice that my daughter, Aubrey, had recently joined: Gentile Family Direct Primary Care (pronounced Jin-TIL-ee), in Pittsburgh, PA. I have keenly followed the DPC trend for several years, but this would be my first foray into the field as a patient.

Dr. Natalie Gentile’s initial fee is $100, followed by a $70/month membership fee. Some of the benefits of joining her DPC practice include: same or next day appointments of no less than 30-minutes duration; unlimited office visits with her; direct phone, text and email communication; and wholesale pricing for lab work, medications and many diagnostic tests. I ran the numbers, then emailed her for an appointment.

My first visit with Dr. Gentile lasted an entire hour as she not only focused on my medical issues, but on broader lifestyle, diet and family details. She subsequently researched and emailed me options for wholesale insulins and medical supplies. She saved me several hundred dollars over average retail pharmacy pricing on medications that were not covered by my insurance. Even had my insurance covered those meds, the “discount” would not kick in until I met my $3,000 deductible.

Given my busy work schedule during the week, I was not available to pick up my medications and supplies during office hours, and did not want them mailed to my home to sit on my front porch. Dr. Gentile stayed in frequent email contact with me, and offered to meet me on a Sunday afternoon so I could retrieve my meds! Needless to say, I have found my Primary Care Home.

As I’ve promoted the idea of DPC, one of the concerns that I hear, and have had myself, is that the monthly membership fee might make the economics of the model unsustainable for patients. I calculated my own recent and projected medical expenses to get a comparison between insurance or retail pricing versus Dr. Gentile’s transparent wholesale pricing for visits and services. I project that in a year of quarterly “insured” PCP visits, I’d likely spend over $400 out-of-pocket, whereas with Dr. Gentile, I’ll spend over $900. However, comparing my recent lab work costs, I would have saved about $450 had she drawn the labs for me. Her wholesale prescription service will also save me at least $300 over a year compared to average retail prices. All told, I estimate a net savings of over $400 this year through my DPC membership. The potential for additional savings for other services is significant, particularly as I approach the age for screening colonoscopy – which she has coordinated for around $1,000 for her patients.

In summary, despite a monthly fee, DPC pays for itself (and then some) in many forms of savings and benefit. I believe DPC to be economically superior to the current third party payer model of medical practice. This is especially true for primary care and non-emergent outpatient medical services – which are arguably the majority of the demand in health care. I believe that DPC may be medically superior as this model allows physicians the time and flexibility to know their patients and accommodate their needs. DPC may also be superior from inter-personal, personal satisfaction, and humanistic aspects as the rushed, frustrating (for doctor and patient), insurance-restricted, 10-minute visit is replaced with greater availability, depth, flexibility, frequency and duration of interactions. Lastly, I consider the non-transparency of pricing in our profession to be a moral affront against the patient-consumer who has little idea of his financial obligation or exposure until after the fact. I can think of no other service or product line with similarly hidden and confusing costs. I have not found my own path to higher moral ground as a physician provider, yet, but I’m pushing us all towards greater awareness of costs and of systemic obstacles to transparency. For myself, as a patient, Direct Primary Care is a great stride forward.

I’m a healthy 48-year old anesthesiologist. At least I was healthy until an unintentional 20 pound weight loss over the summer, accompanied by unquenchable thirst, insatiable appetite, blurry vision, and the bathroom frequency of an elderly prostatic. My lab workup would reveal a high fasting blood sugar of 310 mg/dL, a very high hemoglobin A1C >14, positive urine ketones (showing that my body was breaking down muscle to use for energy), low levels of C-peptide (a byproduct of natural insulin production, revealing that my pancreas was making little insulin), and a glutamic acid decarboxylase (GAD-65) antibody level that was off the charts (which correlates with Type I diabetes due to autoimmune pancreatic islet cell destruction). So, today, I’m suddenly an insulin-dependent diabetic with a relatively rare case of Late Autoimmune Diabetes of the Adult (LADA). That will definitely alter your daily schedule,… as well as immediately put you in the market for a fair amount of pharmaceuticals and medical supplies.

Now that I have my diet well-controlled with careful carbohydrate intake, resulting in a relatively low insulin requirement, I’ve started to look for ways to improve the diabetic lifestyle impediments that can interfere with a busy O.R. schedule and active life. My initial daily regimen has included four glucose checks a day (involving meters, lancets, test strips, swabs, and cotton balls), and up to four insulin injections: long-lasting NPH insulin twice daily as a base, with a sliding scale of short-acting regular insulin at meals and bedtime – all with syringes and vials. That’s a lot of stuff to manage and carry.

I’m transitioning to a single daily injection of ultra-long lasting Triseba® (insulin degludec), supplemented with a once or twice daily dose of Novolog® regular insulin as needed for fine-tuning: all by easy-to-manage injection pens. The next step is to convert from all the finger stick checks to a more streamlined glucose monitoring system. After looking at the few continuous (and flash) monitoring options out there, I’ve purchased the Freestyle Libre® system. It consists of a small 14-day subcutaneous sensor which attaches to your skin, transmitting your glucose level to a hand-held scanner, or to an app on some cell phones. That can save a lot of finger sticks, as well as reduce the daily bulk and transport of required equipment.

The savvy reader might have already questioned how much all of this stuff costs. The short answer: it ain’t cheap. Goodrx.com will show you that the most basic insulin vials of regular and NPH can cost $150 each on the low end, with other types of insulin running $300 to $1000 each per vial or pen. The other necessary basic supplies can add $100 per month or more. Finding out the costs and insurance coverages, formularies and deductibles, co-pays and participating pharmacies is an exercise in frustration – and for the patient reader, that’s where this article is headed.

When I priced out the Freestyle Libre system with a recommended medical supply company, applying my private insurance coverage with the $3,000 deductible, the costs to me for Year One would have been:

Handheld reader – $300 each, one for work and one for home: $600

14-day sensor – $193 each x 26 (12-month supply): $5,018

So, of the $5,618 subtotal, insurance would pick up the remaining $2,618 after my $3,000 deductible. I believe that my co-pay for the sensors after the deductible was met was quoted around $70 each. That would leave me with another $900 or so for roughly 6-months worth of the “discounted” sensors.

That all seemed a little pricey to me for a technology that cannot be more complicated than my Android cell phone, Chromebook laptop, or Playstation 4 – any of which cost me about the price of one single, quoted glucose reader – in the neighborhood of $300. So, I started looking for direct pricing. Goodrx.com priced me readers and sensors for about $70 and $55 each, respectively. That calculates to a Year One cost of roughly $1,600 – by paying out-of-pocket at Walgreens. Hmmmm… $1,600 versus $5,600. For the exact same products. A FOUR THOUSAND DOLLAR DIFFERENCE! A 350% markup, if my math is correct.

So, it appears that I (coupled with my employer/group contribution) can pay roughly $6,000 per year in insurance premiums for health care “coverage,” then a $3,000 deductible before that coverage takes effect, at which point I may still be liable for co-payments… and then I get the privilege of being in the covered network for which I will pay a markup of unnecessary, additional thousands of dollars. A 350% tax? Again, the savvy reader might question where all that money goes, if just directly paying for a more transparently-priced medical service or supply can be had so much more affordably?

The thoughtful among us might also question:

What services are insurance corporations actually providing today?

Has the catastrophic medical insurance market morphed into an expensive, non-transparent, buyers’ club which surreptitiously raises prices for everyone while financially benefiting a potentially useless class of interlopers by skimming excess profits… perhaps to the tune of many billions of dollars per year?

What are the economic distortions in the medical market when true costs are difficult to acquire?

What is the cost of supporting the streams of third-party individuals, entities, organizations and bureaucracies that stand between a patient-consumer and a physician end-service, medical supply service or drug manufacturer?

What role is the FDA playing in encouraging or inhibiting competition, price transparency, and corporate protectionism?

What if you and your doctor have no idea what anything in the system really costs?

What if your doctor would happily provide you a service at a fraction of what your insurance “coverage” bills you?

What if your insurance company profits more in the health care transaction than does your physician?

What if she would be happy to charge you far less in a direct transaction… rather than participate in an awkward “provider-insurance corporation-subscriber” threesome of purposefully disjointed communication and secrecy?

What does it mean that in order to essentially avoid being defrauded of large sums of money, a patient like myself must spend many hours searching for solutions outside of the accepted “system” which enables that fraud?… And how much more difficult must it be for patients without health care experience to maneuver through that system?… Especially if sick and financially disadvantaged?

This physician-patient, for one, has been awakened to the power of price transparency and interloper-reduction. Health care “coverage” is, admittedly, very expensive. In contrast, what do the actual medical services and supplies cost, absent the interference and markup? What if we could cut the price tag of our health care by 350% just by pulling the costs out into the sunlight and eliminating the unnecessary intermediaries in exchange for direct and transparent care models?

Although a minority of physicians and patients operate in a freer medical market, there are well-established and growing options in play that bypass opaque, expensive and unnecessary obstacles to affordable medical services. Direct Primary Care (DPC) practices like Atlas MD and 1,000 others around the country; transparently-priced surgery centers like Surgery Center of Oklahoma and many others; advocacy groups like the Free Market Medical Association; Liberty and other health shares; laboratory, radiology and pharmacy service companies that offer transparent and discounted prices; and comparison marketplaces like MediBid to help you find them… all are growing service providers responding to a demand for more transparent, understandable and affordable medical services. By putting in a few hours of research as I did, you may be able to save yourself thousands of dollars in unnecessary medical costs. Few would deny that health care “coverage” is expensive, but medical services do not have to be.

Macabre. Morbid. Dark. Taboo. Frightening. Shocking. Impersonal.

That’s how society thinks of Death… when it allows itself to think of Death… when a short exposure to someone’s serious illness or mortality temporarily intrudes into our consciousness. Death is something that happens to others,… or maybe to us, but in an extremely distant, unimaginable future. Meanwhile, in a false sense of immortality, in a state of willed forgetfulness and denial, we push those thoughts out of our minds. We distract ourselves with daily activities and pursuits that fill our lives with things, little pleasures, complicating and obstructive superfluous “necessities,” stuff, poorly-reasoned endeavors requiring high-energy and resources for the micromanagement of that which is potentially low value and difficult or impossible to control. Of that with which we fill our lives, how much just doesn’t matter? Or worse: harms, hinders, costs, indebts, dishonors us, causes regret?

By attempting to avoid reality, nature, and the ultimately inescapable life cycle, we may create for ourselves an erroneous perspective of our lives and of Life – a disorienting filter, or blinders, that mislead us down errant and poorly-reasoned paths. Our views of reality and our place in the universe become a self-deceptive lens through which we see with a skewed perspective, flawed vision, short-term sight. If what lies in the distance ahead of us cannot be imagined and mapped out, if we do not know even vaguely where we must go, how can we choose a path toward a meaningful destination?

How often do we travel a course in life without thought of where it will lead? What if we thoughtlessly (or purposefully) meander so far down a wayward road that there isn’t time left to correct our direction, to make amends, to create meaning and purpose? How often do we make decisions, large and small, with a limited vision, ignoring a longer term perspective, and without considering the consequences?

Recently, a friend gifted me a book on Native American perspectives – The Lakota Way – wherein Joseph M. Marshall, III, describes a seemingly much healthier view of Death with its rightful role in the life cycle of every living being. As such, it is the great equalizer which unifies us all – animal and man. Death comes for everyone, no matter how “powerful, famous, rich, beautiful, influential, irreverent, or lowly we are.” Death isn’t an enemy, but a friend and guide that “connects all living beings.” It is a “standard for truth against which all others are measured…. [N]othing can compare with its honesty and faithfulness.”

An awareness of our mortality is a tool and guide to cut through noise, distractions, and the appeal of short-term diversions at the expense of long-term fulfilment. These insights reinforce to me that the acknowledgement of our own impending deaths (hopefully distant and painless for us all) provides a perspective that helps us to live well, to choose well, to prioritize, to let go of the uncontrollable, to control only ourselves, to de-clutter our lives, to treat others better, to develop meaningful relationships, to stand for something, to create a positive legacy, to leave this place better than we found it.

Of course, anticipating an impending death, some might say, “eat, drink and be merry, for tomorrow we die.” But this is a very short-term view in which one would attempt to avoid the consequences of his actions. For those that desire to live a long life, it is in their best interest to accumulate positive consequences, build long-term successes, minimize enemies and maximize friends, extend health, avoid waste and poverty, and experience joy over fleeting gratifications.

Although not a specific topic covered on this recent Tom Woods podcast, the mindset of mortality seems part of what was discussed by Tom with Michael Edelstein, PhD, in the episode “How to Conquer Self-Destructive Behavior.” Dr. Edelstein repeats throughout the conversation the distinction between our “needs” and our preferences. We tend to confuse the two, which can lead to poor decision making and misspent emotional energy – if not psychopathology. How often have we raised a personal preference to the level of absolute need, assigning it a false value and importance that causes us unnecessary anxiety, worry and perhaps fixation and torment.

Certainly, we need to eat, clothe and shelter ourselves, avoid physical pain, and deter a premature demise. However, we do not need to have a job that we enjoy, or to get along well with our boss. We may not want to lose a job, but we can typically find another. There may be a particular car, house, phone or shoe that we want, but the degree of importance and the level of acceptable expense that we may assign to that preference is not merited. What about the end of a relationship? Or a required move? Despite our strong personal preferences, what is needed to not only subsist but to thrive may be unrelated to our emotion-laden desires. What we often believe are needs, may merely be personal preferences created with a short-term perspective and infused with a high degree of emotional investment. Recognizing imperfect situations as inconvenient rather than catastrophic by employing a realistic and longer-term perspective, helps us make better decisions and prioritize our emotional energy. These views coincide with a mindset of mortality.

As I work on my own mindset of mortality, I hope to cut through the confusion and emotion of my own decision-making and priority-forming processes. I want to minimize my expenditure of energy, time and resources on what may not be of true significance or value. I want to be more self-aware, to create more meaning and purpose, to appreciate nature’s beauty and order, to sit quietly, to reduce consumption, to keep mindless distractions to a minimum, to foster ideas and ideals of justice and fairness and peace, to encourage and uplift and teach, to try to keep in perspective the daily frustrations and annoyances that are of minor importance, to let go more of what doesn’t matter – physically and emotionally, to recognize and better control my own emotions, to mindfully center myself more often, to foster positive relationships with those that I value, to create a legacy of which I can be proud, to leave the place better than I found it.

I invite you to join me in a mindset of mortality as we defy society’s avoidance of the topic. The denial of death, of our own mortality, is perhaps a sign of our personal and societal dysfunction – a divergence from nature, biology, reality, the universe,.. a psychopathology and self-delusion that impede healthy living, function and interaction. We’re all going to die. We’re all terminally ill from the moment of birth. Let us die well. In the meantime, let us live well in preparation for that eventuality.

Updated quote from a few years ago: “Please do not believe the slanderous accusations against me. I am not an anti-government extremist. I merely oppose those aspects of the government which coerce, steal, invade, surveil, threaten, kill, benefit and favor one group of individuals over another, misrepresent, defraud, reduce the individual to peasant status, grant special rights to persons with a government job or badge, mismanage resources and finances which lead to $21 TRILLION in debt, and practice war-based imperialism globally. On the other hand, I am in complete support of all governmental functions which promote the self-ownership, responsibility, independent thinking and function of the individual to pursue any life of choice which does not harm others. I just haven’t yet identified the existence of the latter.” – Todd Rice

Quick book review:

For most Americans, the CIA is a secretive, but seemingly benign, agency of the government that attempts to gather difficult-to-obtain information for political or military use. The reality is that since WWII, the Agency has been an uncontrolled clandestine and paramilitary arm of government which operates with its own foreign policy objectives – not infrequently in direct conflict with and purposeful opposition to that of the President, military, Congress, and the will of the American people.

Since its inception, Presidents have rarely had an idea of the scope, violence, illegal dealings (arms, drugs, bribes, coups), foreign government interventions, foreign civilian deaths, subsequent global antipathy, costs and absolute failures of the Central Intelligence Agency. Congressional Intelligence Committees cannot break into the secrecy. Often, Directors of the CIA, themselves, have been unaware of major operations. Foreign branches and their directors often operate independently, following their own arbitrary and personal agenda.

Author Tim Weiner, is a New York Times reporter who has written on these topics for over 20 years, traveling abroad to pursue his stories where they take place. With 170 pages of notes and references from an assortment of documents, recordings, declassified materials, Congressional testimony, interviews, etc., his best-selling book is well documented. It serves as a rare glimpse into a dark and ugly space.

While intentions may have been very good in the late 1940s and forward to protect the American people, to fight the spread of communism during the Cold War (which was in part an American creation by handing over Eastern Europe to the Soviets at the end of WWII – a debate for another time), and to have a global awareness of threats, the CIA became something very different from an intelligence gathering agency. It became a rogue agency without control or oversight, run by the whims of Allen Dulles, his cronies, his minions, and their successors.

From innumerable coups, to failed spy operations, to illegal financing schemes, to arms/drug running rings, to whimsical murder and assassinations, to the support of tyrannical dictators, to the unintended consequences of the deaths of potentially hundreds of thousands of foreign civilians, political prisons, black site torture centers, the inception of war,…. What has taken place, often behind the scenes and completely unbeknownst to you, has not been intelligence gathering by the CIA, but rather the destruction of your security, foreign disruption and death, the elevation of global anger and resentment against the USA, the creation of terrorists, instability and destabilization of societies around the world.

Legacy of Ashes is an eye-opening opportunity to understand what certain aspects of your government do to harm you, under false pretenses, with your tax dollar, and without your consent. Instead of providing good intelligence, more often than not, the CIA intelligence reports and predictions have been 180 degree misreads of global events. The basic story of the CIA over the past 70 years has been one of “comic book fiaso,” as the author describes the Iran/Contra debacle. Of course, there must be some good that the agency has done. Whatever that might be, the seemingly endless list of harms and costs cannot justify its existence.

Governments around the world (local, state and national) carry debt loads that can never be repaid. These numbers may combine into the $200 Trillion range – levels that cannot even be imagined, much less dealt with economically. (See IMF, McKinsey, and Bloomberg sources.) Per the IMF source, this translates into about $86,000 of debt for every person on the planet. (How many people are there around the globe who will never even make a cumulative $86,000 of income throughout their entire lifetimes, I wonder.) On top of these numbers, governments have made promises to the public for social and welfare spending (like Social Security and health care) that cannot be fulfilled. In the US alone, these unfunded liabilities promised to the public exceed $100T.

To worsen the picture, every year, the annual deficits grow, just adding to the public debt loads as money is borrowed (primarily through various forms of bond sales, e.g. US Treasuries) to keep the lights on, in a sense. There is no hope that even an annual budget could ever break even to pay current liabilities, despite the fact that tax confiscations from the public are ever-increasing and perpetually break previous collections records. Much less is there hope that any real progress could be made to paying down the principal on the many trillions of dollars of debt held by so many individual governments, like that of the US (to the tune of $22 trillion in national debt). City and state governments in the US have their own unsustainable debt paths, unpayable liabilities, bankrupt pension schemes, etc. Additionally, global private debt and derivatives are separate topics that add their own risk to economies.

To keep the shell games going, governments have to find ways to carry the debt year-over-year, convince the taxpayers to keep participating in the Ponzi scheme, and to create new money sources. Of course, the main form of government income is tax takings from the public. These never suffice. They cannot keep up with politicians’ appetites to grow programs, spending and wars – often as a payment to the public for their votes.

Another form of creating money is that of inflation – the hidden tax on the public. This is a very old practice by which governments dilute the money supply. Thousands of years ago, the Roman government did this by cutting corners into round coins, taking the gold and silver shaved corners to melt down into new, smaller coins that held the same face value, but obviously less real value. Thus the money and its value were diluted, and ultimately prices would rise in response. Today, governments do the same thing with the aid of their central banks (e.g. the Federal Reserve in the US). They sell government debt/bonds to the public and to other governments and use that borrowed income to fund current government liabilities. Thus, the money supply is expanded with that infusion into government coffers, the value of the currency is devalued, and ultimately prices increase on goods and services to balance that change. That is inflation. It isn’t natural. Ever-rising prices don’t just occur. It is the direct result of government theft of the value of taxpayers’ money and savings.

A recently published interview with Doug Casey, a contrarian investor and founder of Casey Research, highlighted some aspects of Modern Monetary Theory. He points out that governments are incapable of controlling currencies and points to the illustrative failures of Venezuela, Argentina and Zimbabwe. I would add the Weimar Republic to the list. Neither governments nor any individuals have the capability to understand the billions of moving persons, parts, decisions and interactions that influence economies and determine the values of goods and services. Manipulating values, especially those of currencies and interest rates, has far-reaching and typically unintended consequences. Casey says, “MMT is about radically increased government control. The argument shouldn’t be over whether MMT will ‘work’ or not. (Which he clearly points out multiple times throughout the interview that it does not.) The argument should be about whether it’s moral and proper for people in the government – whether elected or appointed – to print money to change the economy into something that suits them better.”

A few excerpts from Casey’s interview:

“Money represents the hours of your life that you spent earning it. That’s the basic principle here. It represents concentrated life – all the things you want to have and do for yourself, and provide for others in the future. When these people destroy the value of money, they’re destroying part of your life.”

Regarding the broad spectrum of politicians – “They’re all dangerous megalomaniacs. But the chimpanzees listen to them, choose teams, hang on to their every word, support them, and are easily incited to hoot and pant at each other. The American public is going to get exactly what it deserves.”

“They’re going to try every cockamamie idea they can to keep the ball rolling. Lots more controls of all types. More debt. More inflation. MMT is just going to be part of it.”

“I know I’ve been saying this for years. But the idea of America has gradually degraded since about the time of Teddy Roosevelt, and the original Progressives. Then faster with World War I, faster yet with the New Deal, faster yet with World War II, the Great Society, the Nixon devaluation, the Reagan deficits, the War on Drugs, the War on Terror. The only good news – and it’s super good news – is that science and technology have advanced as well. That’s maintained the general standard of living. Unfortunately, the State always gets first dibs on tech developments, and uses them against society. This long-term trend is now going hyperbolic.”

MMT is nothing new that hasn’t been perpetrated on the public countless times before. It’s a newer term for the ancient practice of governments fleecing the citizenry. A slick name aids the deception. As MMT and other forms of economic trickery are promoted by the political and ruling classes as solutions to the ills that they themselves caused, realize that it’s all been done before. And failed. Maybe consider trying something new… like free markets – unencumbered by so many controls, regulations, road blocks, manipulations, thefts, purchased privileges, subsidized failures, and corporo-gov collusions that benefit the few at the expense of the many. Those free markets, they’ve never been tried.

My wife and I both began visiting Spanish speaking countries in our younger days, over 20 years ago, on mission trips. Now, with both of us working in health related fields, we look to continue trips to some of the poorest areas of the western hemisphere in order to potentially support local health initiatives. We also view these under-served parts of the world as frequent vacation destinations – not in the secluded resorts of poor countries, but relatively immersed within the local populations. We enjoy improving our language skills, better understanding local cultures, sharing ideas and observations with native peoples, finding less common paths, dialing down consumption and expense, and ultimately returning home with improved and broadened perspectives.

We had never visited Guatemala nor knew much of its history until recent weeks. As I was searching for potential vacation spots in Central America leading up to this recent vacation, I wanted to explore somewhere we’d never been. (We’ve travelled several times to areas of Mexico, Costa Rica, and Honduras.) Other considerations: (1) cost, (2) with only one week available, airport and road travel needed to be relatively smooth for a same-day arrival to our destination, (3) safety – an admittedly subjective judgment that can be aided with some travel and government websites, (4) points of interest for vistas, learning, hiking, exploring.

Our preference for vacation accommodations is usually a rented house, rather than a hotel. That option tends to be more affordable while offering amenities for cooking at home, as well as being more culturally immersed. I started a few months ago by looking at VRBO.com (vacation rental by owner) offerings in Panama, Nicaragua and Guatemala – countries new to us. While there are many great options (across the gamut of affordable to luxurious), once I hit upon some spots at Lago de Atitlán in western Guatemala, it quickly became a preferred destination. And when we told my Mom about it, she joined up with us for the experience.

We rented a gated home with lake view in Jaibalito for a week at well under $100/day. We flew into Guatemala City (a 3-hour flight from Houston), had reserved a car at US-based Alamo just outside the airport terminal, and started an adventure. Guatemala City has a population of about 3.5 million people, is well-developed, bustling, and traffic-congested. The primary destination for the day was Panajachel (the town on the northeastern shore of the lake, where we would park the car and take a water taxi to Jaibalito). It is about 140 km, less than 90 miles, from Guatemala City. However, with congestion, mountainous roads, meanderings through small towns and construction, that 90 mile trip took 5 hours. (On return, it took six!) NB: if you decide to do something similar, I highly recommend that you arrange a private shuttle/driver. They are apparently plentiful. You do not need a car for this trip.

We arrived to Panajachel after 6pm, and just after dark, but had a destination in mind. Los Cayucos is a marina/parking lot that was recommended by the rental house property manager. With help from a local, self-appointed tour guide on a bicycle (at least his shirt said “tourism”), we found the lot. I had been quoted an approximate price of 30-50 Quetzals ($5-7) per night by the property manager, but on arrival the 24-hour parking attendant wanted 100Q per night. After a little haggling, we settled at 60Q. Then our “tour guide” showed us where to catch a water taxi.

Usually these run pretty frequently between the 5-6 little towns around the lake at 15-25Q ($2-4 per person), but after dark, you need to find a “private” boat. We ended up paying about 10 times that amount because it was after hours,… we were tourists,… and haggling in the dark in an unfamiliar setting in a foreign country with lots of poor locals standing around watching isn’t the wisest move. Fork it over, and keep moving. (My personal opinion: when traveling in unknown and/or potentially dangerous spots, keep as low a profile as possible and always stay in motion.)

Despite some uncertainty (my wife was convinced we were being taken to a drug lord’s house), the 20 minute boat ride was speedy and uneventful. We docked in Jaibalito, found our property manager’s house within 100 yards of the landing, and walked with her to the rental house a few hundred yards away. The house was among the most elaborate structures in the village: 2 story, 3,000 square feet, sitting on about a 1/2 acre of manicured garden, surrounded by a mostly concrete wall, perhaps 20 feet tall at it highest point. Outside the wall were much poorer huts, relatively tightly spaced, made of various makeshift materials, like tin sheets and pieces of wood slab, often with dirt floors and without doors, surrounded by their own fencing of makeshift materials and barbed wire, typically with a constantly-lit wood-burning fire upon which meals are cooked and which at mealtimes can fill the valley with a haze. A minority of the housing in the village looked better established with concrete structures and floors. A few homes looked to be on par with the quality of our rental house: gated, architecturally pleasing, full household amenities (refrigerator, indoor plumbing, gas stove, well-tended yards), tile floors, professionally crafted furniture. These also tended to be owned by ex pats that we met from Germany, Iran and Belgium.

The town of Jaibalito has a population of about 900 people, lies on the northern lake shore, surrounded on all other sides by mountains, and occupies an area of probably 1 square mile total within this small valley. There is no road access to the town whatsoever. The main lane through the village is a roughly 5-feet wide concrete sidewalk with side trenches for runoff (and potentially some human waste). The only vehicles in the village are two small 3-wheeled, motorized carriages, known as tuk-tuks. There are a few small stores (tiendas) that offer some dried goods, fresh food items and select sundries. Also, there are a few open air restaurants – both locally and ex pat owned. There are also some rooms to rent via hostel, a hotel and perhaps other private options (like our VRBO). Just outside of Jaibalito, within 10 minutes walk are a few other tourist hotels and restaurants. Around the lake’s perimeter are small towns, hotels, resorts, restaurants – some of very high quality and price – all accessible by water taxi.

Throughout our week long stay, we ate and shopped locally, cooked at home some, hiked and explored several of the lake’s towns, enjoyed the views, read, took advantage of several of the documentary DVDs at the rental house (see below), spoke to the locals and ex pats, and came away with a better education and perspective regarding Guatemala (especially in comparison/contrast with our own lives, culture, traditions, government,….).

In preparation for our trip, I read Bitter Fruit: The Story of the American Coup in Guatemala in order to better understand that country’s 40-year civil war that ended in the 1990s, its US-supported death squads, the genocide (I don’t think that’s an excessive term) of 200,000+ Mayan natives, and their very tenuous democracy that many have died attempting to establish amidst purposefully destabilizing and powerful external forces. (If you choose to read this well-documented, Harvard University associated book, you will never see your government – or likely any government – in the same light. As a corollary, you might also explore the 1953 CIA-led coup d’etat which overthrew Iranian Prime Minister Mossadegh.)

Additionally, we watched the documentaries: When the Mountains Tremble (excerpted from Wikipedia’s description):  “a 1983 documentary film … about the war between the Guatemalan Military and the Mayan Indigenous population of Guatemala.^[2][3] …Footage from this film was used as forensic evidence in the Guatemalan court for crimes against humanity, in the genocide case against Efraín Ríos Montt.^[4][5] The film centers on the experiences of Nobel Prize winner Rigoberta Menchú, a Quiché indigenous woman who won the Nobel Peace Prize in 1992….”

Another documentary at the house was Haunted Land: “Two paths cross on a descent into Guatemala’s past: that of Mateo Pablo, a Maya survivor of one of many massacres committed by local government troops, and Daniel Hernández-Salazar, a concerned Guatemalan artist and photographer. Together they travel to a remote site in the highlands where the community of Petanac once stood. The bones found there by archaeologists tell a mute story of agony.”

In summary, it was a great vacation: educational, fun, at once exhausting but rejuvenating of mind/spirit/perspective. The big lesson – take the shuttle.

 I came across this presentation that I made a few years ago at the national AAPS conference and wanted to save it for future reference and the interested. For those that are not familiar with Certificate of Need (CON) laws, many states have created legislation which restricts the purchase, ownership or operation of certain medically-related capital goods, services or businesses. This .pdf format of a PowerPoint presentation is a primer.

My interest in CON laws was piqued when I began considering potential future ownership of a surgery center, but realized that depending on the state in which I reside, that may not be my decision. If politicians (and even my established medical competition, like the Big Hospital Corporations in town) decide that there is not a public “need” for my services, then I can be denied permission to purchase, operate, practice, compete.

The general trend has been towards a peeling back of such laws in many states, but in others, you might not be able to buy a simple x-ray machine for your practice without a politicized agreement of public “need.” If approved, THEN you get to jump through the regulatory and licensing hoops involved with the actual purchase and operation of said machine. But without the CON approval, you do not pass “Go.”

CNBC published an article last week: “The Amazon effect could potentially leave all Americans neighborless.”

The author continues the long-lived and broadly-shared concern that online purchasing and social media are gutting traditional American commerce and interpersonal relationships, leaving us socially isolated amidst a ghost town of dead, bankrupted local businesses. It does sound ominous on the surface. What’s to be done with all of the empty malls and store fronts? What replaces those lost jobs? How do we stay connected to live human beings when we don’t get to see them as our sales people, cashiers and fellow neighbors that we bump into at the hardware store down the street?

The online trends are definitely disruptive. In my opinion, those disruptions are cumulatively positive for economy and quality of life. As consumer goods are supplied at lower costs, with lower overhead and greater efficiency, we are generally better off as a society – although there will be individuals and groups who are forced to adapt to the loss of their less efficient or demanded jobs and business models. These trends are deflationary – driving down prices generally (of goods and commercial real estate), which makes more available to those who could not have earlier afforded as much. That increases quality of life.

While many worry that we will become inseparable from a virtual world, stuck in our electronic devices, divorced from reality and personal interaction, I think we may have reached peak social media tolerance, or are near. People tend to be looking for ways to engage socially – some of which are facilitated and vastly expanded via internet tools. These connections are arguably superior to bumping into Bob and Susie at the hardware store, as we all search among a limited selection of goods priced significantly higher than what Amazon or Costco.com or Facebook Neighborhood Market offers.

As a social example, our local brewhouses in St Louis, are at or approach standing room only on busier evenings – filled with hipsters and professionals and families with children. Sociality proceeds, albeit somewhat differently than in decades past,… which was different from centuries past before telephone or telegram or postal services or a written language. I wonder if people in the early 1900s fretted that visits to friends and family would be curtailed because one now merely needed to pick up the phone to stay in touch.