The Long Telegram

This post is about what Russia is currently up to and why.  The way I going to go about doing this is to use a popular narrative device, starting in the middle of the story.  And the middle of this story is a famous diplomatic cable that garnered the nickname, the "Long Telegram".  It was close to 6,000 words long.  That is far longer than the usual diplomatic cable.  So how did it come to be sent?

In early 1946, a man named George F. Kennan found himself in temporary charge of the US Embassy in Moscow.  He would later be officially appointed to the job.  But this time around he was in temporary charge while the process of appointing, confirming, and installing a new Ambassador played out.

Kennan was one of a small group of Russia experts in the US government at that time.  Walter Isaacson and Evan Thomas grouped the more prominent members of this group together as "The Wise Men" in their book of the same name.

Kennan had studied Russia extensively.  He had also spent many years serving in the US Embassy in Moscow.  Both his study and his on the ground experience drove him to the conclusion that US policy toward Russia (then officially known as the Union of Soviet Socialist Republics or USSR, but which I will uniformly call Russia in the interests of simplicity) was seriously in error.

Then someone made the mistake of asking his opinion.  He felt compelled to answer at length because

[the] [a]nswer . . . involves questions so intricate, so delicate, so strange to our forms of thought, and so important to analysis of our international environment that I cannot compress [my] answers into [a series of] single brief messages without yielding to what I feel would be dangerous degree of oversimplification.  I hope, therefore, [that the State] Dept. will bear with me if I submit in answer to this question five parts . . .

[In fairness, Mr. Kennan is an excellent writer.  But it was common practice at the time to leave out the odd extraneous word to minimize length in diplomatic cables.  I have added these words back in to improve clarity and readability.  You can read the full and unmodified "Long Telegram" for yourself here:  http://www.ntanet.net/KENNAN.html.  Also, I later make reference to the "X Article".  You can read it here:  https://en.wikisource.org/wiki/The_Sources_of_Soviet_Conduct.]

Before getting into what he had to say I need to provide some context.  For centuries Russia relied on the Tsarist form of government.  It was a minor variation on the then common monarchial system that had long been the preferred form of government all over Europe.

As a side effect of the upheaval attendant to World War I, the Tsars were thrown out and the Communist Revolution installed a nominally Marxist government in its place.  They renamed Russia to the Union of Soviet Socialist Republics. (The country's name eventually reverted back to "Russia" in 1989 when all the countries that had been swept up into the "Union" were allowed to revert back to being independent countries.)

As soon as the dust settled in the aftermath of World War I, various European powers sponsored a counter-revolution that was supposed to toss the Communists out.  (The Europeans supported the "White" Russians who opposed the Marxist "Red" Russians.)  The US joined in on the European side of the conflict.  The counter-revolution was unsuccessful.

In the run up to World War II the maxim that "the enemy of my enemy is my friend" became applicable.  As a result, Russia eventually became an ally of the British, (and eventually) the US, and others, in the fight to defeat the "Axis" powers of Germany, Japan, and (at times) Italy..

At the end of the War there was real interest in the US in keeping the alliance intact.  So, a serious effort was made to remain on friendly terms with Russia but Russia wasn't interested in cooperating with that plan.  In early '46 the official policy of the US government was still to try to hold things together.

Kennan thought that effort was doomed to failure.  He wrote his Long Telegram to explain why.  It was broken down into five sections:

1. Basic features of [the] postwar Soviet [Russian] outlook
2. Background of this outlook
3. Its projection in practical policy on [an] official level
4. Its projection on [an] unofficial level
5. Practical deductions from [the] standpoint of US policy

It covers a lot of material that is not germane to what I want to talk about.  What I am interested in is the parallels Kennan makes between the Tsarist outlook and methods and the ones Kennan attributed to Russian leaders of that time.  Let me quote Kennan at some length

At bottom the Kremlin's [Russia's] neurotic view of world affairs is traditional and instinctive [to a] Russian sense of insecurity.  Originally, this was [the] insecurity of a peaceful agricultural people trying to live on [a] vast exposed plain in [the] neighborhood of fierce nomadic peoples.  To this was added, as Russia came into contact with [the] economically advanced West, fear of more competent, more powerful, more highly organized societies in that area.  But this latter type of insecurity was one which afflicted Russian rulers rather than Russian people; for Russian rulers have invariably sensed that their rule was relatively archaic in form, fragile and artificial in its psychological foundations, [and, therefore,] unable to stand comparison [to] or contact with [the] political systems of Western countries.  For this reason[,] they have always feared foreign penetration, feared direct contact between [the] Western world and their own, [and] feared what would happen if [ordinary] Russians learned [the] truth about [the] world without [the world outside Russia][,] or if foreigners learned about [the] world within [Russia].  And they have learned to seek security only in [the] patient but deadly struggle for [the] total destruction of [a] rival power, [and to] never [engage] in compacts and compromises with it.

Later in the Telegram he wrote

This thesis provides justification for that increase in military and police powers of [the] Russian state, for that isolation of [the] Russian population from [the] outside world, and for that fluid and constant pressure to extend [the] limits of Russian police power[,] which are together the natural and instinctive urges of Russian rulers.  Basically[,] this is only the steady advance of uneasy Russian nationalism, a centuries old movement in which [the] conceptions of offense and defense are inextricably confused.

Kennan is not attributing these concepts to the Marxists that were running Russia at the time.  He says that's how Russians have always operated.  In fact, he explicitly makes reference to "a centuries old movement".  At the time of the Telegram, the Marxists had been in control for less than thirty years.

Kennan's thesis was that there was a commonality and continuity of behavior that extended from the Tsarists to the Marxists.  So, if your understanding of Russian behavior and attitudes in a contemporary context required them to differ markedly from the well established Russian norm, then either you needed to come up with a strong justification for the change, or you were likely wrong.

Kennan had been dealing with various Russian government officials, all the way up to Stalin, the leader at the time, and had seen no justification at all for a belief in a change either in attitude or in behavior.  In fact, he had seen a lot of first hand evidence to support a belief that it was "same old, same old".  So, in Kennan's mind, you could delete the word "likely" from the phrase and just go with "wrong".

Kennan's Long Telegram quickly received wide circulation within upper echelons of the US Government.   It turns out that others had also come to the conclusion that Russian thinking just did not run along the lines of alliances and cooperation.  They realized that Kennan had said what they were thinking.  He had just done so far more articulately than they could have done so.  So, rather than muddying things up, they just endorsed the Telegram.

Kennan reworked his Long Telegram, added some additional material, and published it in the July, 1947 issue of Foreign Affairs, a highly respected journal.  The author was initially only identified as "X", so the article became known as the "X Article".  But Kennan was quickly identified as its author.  This article was the first one to characterize the US Anti-Russian strategy as the "containment" strategy.  (The word "containment" appears several times in the piece.)

So the attitude of the US toward Russia went from friendly and accommodating to hostile during this period.  You can pick various events and use them to mark the start of the Cold War.  Churchill's "Iron Curtain" speech, for instance, happened in this time period.  But, starting shortly after the Long Telegram was sent, "containment" and "Cold War" came to dominate international politics.  It was many decades before that changed.

Before continuing, I want to take a moment to acknowledge that there was considerable justification for Russian paranoia.  First of all, Russia does not have the kind of natural barriers to hide behind that the US has.  Instead of wide oceans Russia has wide flat plains that can easily be marched across while simultaneously feeding the invading army.

And the idea of invasion was not a theoretical concept for them.  Besides the "fierce nomadic peoples" alluded to above, we have the fact that both Napoleon (France) and Hitler (Germany) invaded Russia from the West.  The greatest power in the world for many centuries (China) was located to the South.  And again, there was no natural barrier to protect Russia from a Chinese invasion.

Beyond that, there was the experience of the Marxist government in charge at the time of the Telegram.  The western powers had joined together to support the "White" Russians in their efforts use military force to kick the Marxists out less than twenty years previously.  Sure, all these attempts had failed.  And lots of countries have done lots of nice things for Russia over the centuries and decades.  But the case for paranoia remains a strong one.

So paranoia has been a feature of pretty much every Russian government going back centuries.  Unfortunately, so has repression and a large and generously supported secret police operation.  The justification for this has been far less clear.  The only thing I can come up with is economics.  Russia has not seen a lot of economic success.  But what little economic success it has seen has, for the most part, come while authoritarian governments were running things.

But non-authoritarian governments have not had much time to get themselves sorted out and, presumably, work their economic magic.  The Tsars got Russia into World War I.  That was an unmitigated disaster for Russian.  Under Lenin things at least stopped getting worse.  And he could blame a lot of economic troubles that happened on his watch on the war with the White Russians.

Stalin came in and started collectivizing everything.  This was a disaster in the agricultural segment of the economy.  But by then he had complete control of the reigns of power so there was no way to oppose him effectively.  And there was little outside information people could use for comparison purposes.  And what outside information there was, could be easily spun.  At the time the rest of the world was working its way through the Great Depression.

Kennan cautiously predicts that the Marxist's days might just be numbered.  He was completely wrong about that.  Russia suffered terrible devastation as a result of World War II.  But they were able to leverage the economic resources of all the territory they gained control of (Eastern Europe) to rebuild quickly.  Then Russia went through a period of economic growth that lasted for decades.

One thing Kennan got right was his discussion of "the succession problem".  He says it took 13 years to transition from Lenin to Stalin.  That seems like a bit of an exaggeration to me.  Russia did not come to a dead stop for anything like 13 years.  The succession that started with Stalin's death was another matter, however.

It took several years after Stalin's death for Khrushchev to emerge.  But then he didn't last long.  He was kicked out of the top job (and managed to not get killed in the process) after only a few years.  It then took several years for Brezhnev to consolidate power.  And he was ultimately a disaster.

Lenin seems to have had some real faith in Marxist principles.  But Stalin was just your basic dictator.  He did make a lot of noise about Marxism.  But it was just window dressing to disguise his political maneuvering.  His collectivization of agriculture and industry can be justified using Marxist doctrine.  But his real reason for collectivizing was simply to increase his own power and control.

His use of "show trials" (and other actions he took) actually ran counter to Marxist ideology.  Stalin needed to eliminate his enemies and this was often the tool he chose to use.  In many cases the people on trial for being "enemies of Marxism" were actually people who carefully adhered to Marxist doctrine.  The "Marxist deviation" they were accused of having participated in was entirely fictitious.  Stalin, on the other hand, frequently engaged in Marxist deviation.  But he had the power so there was no one to challenge him.

Khrushchev was not much of a Marxist.  But he was a far better one than Brezhnev.  All Brezhnev cared about was staying in power and keeping his cronies in power.  Everything else was left to rot.  When he finally died Russia was in bad shape.  But by this time he had systematically eliminated anyone he perceived as a threat.  The only people left were a bunch of his cronies.  They were both old and incompetent so Russia drifted for several more years.

By the time the dust settled it was too late.  We got the fall of the Berlin Wall and the end of the USSR.  Russia was back to being just Russia.  But by now no one knew how to run a democratic country.  And anyone who had any belief in things like honesty and the rule of law had been eliminated by Brezhnev and his cronies.  Things went badly and an opening emerged for Putin.

Putin spend a long time in the Russian intelligence service before he moved over to politics.  And there was a lot of continuity dating all the way back to the Tsars in how Russian intelligence people operated.  Putin is a capitalist and a democrat in the same way that Brezhnev was a Communist.  Putin has a strong interest in getting and keeping power.  Everything else comes in a distant second.

Unlike Brezhnev, Putin is relatively young and in good health.  So he has the energy necessary to get and keep power.  And, since he doesn't know any other way, he uses the intelligence services the same way Russia has always used its intelligence services.  And he executes foreign policy the same way Russia has traditionally executed foreign policy.

Again, quoting the Long Telegram, Russian foreign policy is designed

[t]o undermine [the] general political and strategic potential of major Western Powers[.] Efforts will be made in such countries to disrupt [their] national self-confidence, to hamstring measures of national defense, to increase social and industrial unrest, to stimulate all forms of disunity.  All persons with grievances, whether economic or racial, will be urged to seek redress[,] not in mediation and compromise, but in defiant, violent struggle for [the] destruction of other elements of society.  Here poor will be set against rich, black against white, young against old, newcomers against established residents, etc.

And, going back to the five point summary, both "official" (item #3) and "unofficial" (item #4) techniques will be used.  Official techniques comprise the public and acknowledged actions of the government.  This includes things like official pronouncements, treaties and other agreements, policy statements, etc.  Unofficial techniques include any action the government attempts to keep hidden.  This includes efforts by the intelligence services, secret treaties and agreements, government actions that are denied, etc.

Remember, the section I quoted above was written in 1946.  But it is an accurate description of what is going on today.  The more things change, the more they stay the same.

The only people who don't have a clear picture of what is going on are those that are ignorant of history and those who are willfully ignorant.  Unfortunately, there are far too many people that fall into one or both of those categories.

Medicare for All

I am returning to a subject I haven't addressed for a long time.  Back in 2013 I wrote:  http://sigma5.blogspot.com/2013/02/medical-costs.html.  About a year later I sort of addressed the same subject with:  http://sigma5.blogspot.com/2014/03/fixing-healthcaregov.html.  But this latter post was more about politics and technology than it was about medicine.

A lot has changed since then, right?  The first post was written in the middle of the Obamacare fight and that was ages ago.  Obamacare has been the law of the land for several years now, which actually has improved things.  Even so, remarkably little has changed.

"Medicare for All" is an eye catcher when it comes to a subject line.  But it  is misleading as I am not going to confine myself to just it.  Instead, in this post I am going to take a broad look at health care as a whole.  And one reason is that so little has changed is that there is so much noise and BS surrounding the subject.  And I like to write posts where I cut through noise and baloney and get to the real story.

And it turns out we can now start with a simple question for which we now know the answer.  The question is:

Is it okay for many people in the US to have poor to non-existent health care?

Republicans say "yes" and Democrats say "no".  This conclusion is borne out by the debate that surrounded Obamacare and the actions subsequent to its passage and implementation.  An argument can be made that Obamacare is flawed and needs fixing.   Republicans have made that argument all along the line from then to now.  It is a reasonable position.  After all, I agree with it.  Pretty much everybody agrees with it.  There is literally nobody, from Obama on down that thinks it can't be improved.

And we can divide the way it should be improved into two general approaches.  The first approach is espoused by the group that thinks it is a good foundation but various fixes and improvements should be implemented on top of it.  Vice President Biden and lots of others support this approach.  Then there is another group who start with the position that it has major problems.  This group says it should be scrapped and replaced with something else.  President Trump says he is in this group.  He is joined by a large majority of Republicans.

So where's the problem?  Republicans have been advocating for a "repeal and replace" strategy all along the line.  The problem is that in the entire time since President Obama proposed the plan that eventually became Obamacare, and right up to the present day, no Republican replacement plan has been brought forward.  None!  On the other hand, several serious attempts have been made to repeal Obamacare without including a replacement.

And it is instructive to review the history of where Obamacare came from.  Early in the Clinton Administration, a proposal was brought forward and championed by then First Lady Hillary Clinton.  It was a pretty good proposal.  And all along Mrs. Clinton said "if you have ideas for improvements, bring them forward".  For a long time Republicans engaged in a "death by a thousand cuts" strategy where they said "we don't like this" and "we don't like that".  However, they never proposed an alternative or a fix.

Late in the process they finally rolled out the outline of a plan to replace Mrs. Clinton's plan wholesale with a plan of their own..  It was produced by the Heritage Foundation, a conservative think tank.  It was introduced at the last minute and, frankly, was not a serious proposal.  But afterward, whenever anyone got serious about a major change to health care they would trot it out and say "this is our plan"..

Then a Republican Governor, Mitt Romney, got serious about health care.  He dusted off the Heritage Foundation plan, fleshed, it out, and tuned it up.  Then he got it implemented in the state of Massachusetts.  A Republican Governor implemented a Republican healthcare plan.  President Obama was serious about doing something about healthcare.  He figured that if he took Romneycare, tweaked it slightly, and proposed it as his healthcare initiatives, Republicans would embrace it.  It was, after all, a Republican plan through and through.  That plan is what is now generally referred to as Obamacare.

He expected it to be embraced by Republicans.  That was a reasonable expectation.  After all, it was their plan.  He probably thought resistance would come from Democrats.  But not one Republican voted for Romneycare/Obamacare.  Nor did Republicans make a serious effort to engage with it.  They instead engaged in a "resist everything, block everything" campaign, even though it was their plan.  Their strategy came very close to being successful in blocking President Obama's efforts to pass it into law.

Since then Republicans have made countless efforts to "repeal and replace" Obamacare.  Except they haven't proposed a replacement.  The reason for this is simple.  Any proposal they made would be less popular with their base than Obamacare.  The only conclusion that can be drawn from all this is that Republicans are okay with many Americans having poor to nonexistent health care.  That's what the current system delivers and they have made no effort to change it so that coverage is broadened.

So that leaves the Democrats.  One complaint, then and now, is that Obamacare does not cover everyone.  This was because his team made the calculation that any "universal coverage" version couldn't get passed.  Given how close Obamacare came to not passing this is a reasonable position.  None of the "no" voters voted "no" because it did not include universal coverage.  And, as a side note, Romneycare provides near universal coverage in Massachusetts.  The provisions of Roimneycare that would make Obamacare near universal, were left out in the first place, repealed later, or struck down in the courts by Republican judges.

It is possible to provide universal or near universal health care.  Lots of countries have done it.  And it can be done in several different ways.  In my 2013 post I mentioned a book called "The Healing of America" by T. R. Reid.  Amazon sells a Kindle copy for $13 and a paperback copy for a little over $16.  In it he examines the health care systems in use in 6 countries.  Some of the six plans he reviewed are cheaper.  Some are more expensive.  Some countries run the whole thing as a government operation.  Some countries insert insurance companies into the middle.  No two countries do it exactly the same way.

But in all of the cases Mr. Reid examined, everybody is covered, it is cheaper than the US system, and it doesn't matter whether you look at the pre-Obamacare US or the post-Obamacare US.  And, most critically, citizens of all six countries like their system better than Americans like ours, and citizens in all six countries are healthier and live longer than Americans.

What Mr. Reid did is what's called in business circles, "going to school on the competition".  You study what others are doing, you see how their system works, you see what it does well and what it does badly, and you go from there.  This works best for systems that have been up and running for a while.  That way you can see how well they work, not just in the beginning, but over time.  All the health care systems Mr. Reid studied have been in place in their present form for many years.

The smartest thing the US could do would be to adopt a system that is based on parts that are found in the systems of these other countries that look like they would work well in the US.  This process should result in looking at ideas that otherwise don't get discussed in the US.  Studying the strengths and weaknesses of each system, which Mr. Reid did in his book, would allow us to implement proven "best practices" while simultaneously avoiding common mistakes others have made.  The reason we don't do this is politics, pure and simple.

What we have is a bunch of people of power and influence who have adopted a position and are not interested in learning why it might be wrong.  So they do the political equivalent of putting their fingers in their ears and shouting "la, la, la, la, la" loudly, any time somebody tries to inject anything sensible into the debate.

This, in a nutshell, is the strategy Republicans have adopted on the subject.  They have had quite a bit of success with it.  At no time did Republicans admit that Obamacare was a Republican plan originally created by a conservative think tank, for instance.

Now, there's lot of nonsense on the other side of the aisle.  And I am now going to get into some of it.  Let's start with the most fundamental truth about healthcare:

Health care inevitably eventually puts a price on life.  Further, it puts a price on quality of life.

I have seen this time and time again in my lifetime.  When I was a kid, health care was cheap.  It isn't any more.  What has happened in the interim is that a whole bunch of people have come up with a whole lot of ways to improve health.  But, on average, these improvements and innovations keep getting more and more expensive.

Everybody was poor during the Great Depression.  If you were in the medicine business and you were pushing an expensive treatment, people would chose to die.  In many cases the decision was forced on them because they literally didn't have the money.

I grew up some time later.  But the overhang of that behavior was still around.  Medicine was plain and cheap back then.  But the "plain and cheap" medicine of the time produced a lot of people dying who wouldn't today.  Or they were sick a lot of the time from things we can now prevent or cure.

We now have a vaccine that prevents people from getting Polio, a disease that killed some people and left lots of others confined to something called an "iron lung" for the rest of their lives..  We also have ways to treat things like infectious diseases that used to sicken almost everybody and kill far too many.  The Polio vaccine was introduced when I was a kid.  It was cheap.  Many of the medical innovations of the time were cheap.

But people found more and more ways to spend more and more money to develop the next medical improvement.  So, soon you had the thousand dollar drug.  That led over time to drugs that can cost a million or more dollars.  After all, you can't put a price on life, right?  It turns out, however, that people are very reluctant to fork over their hard earned tax dollars or insurance dollars, to pay for an expensive cure for somebody they don't know or don't like.

There are some good reasons for the steady increase in the cost of health care, and some bad ones.  But the trend has so far proved unstoppable.  Someone can always come up with a new treatment that saves live or improves quality of life but costs more, often much more, than the old treatment.  At some point someone has got to sweep in and say "no".  We are going to let that person die.  Or we aren't going to improve the quality of life for that person.

No one wants to make these kinds of decisions.  We as a society have figured out dozens of ways to avoid having to directly answer the question of who should live and who should die.  And then there is the "bright line" problem.  There is no bright line between things that are too expensive and things that, while expensive, seem worth the cost.

There are always procedures that are a little more expensive or a little less expensive than other procedures.  But one way or another something draws the line and some things fall below the line and are provided and other things are deemed to be above the line and are not.  And "not paid for" means someone dies or suffers an impaired quality of life.  So,

Medicine is always rationed.  The only thing we are really arguing about is who sets the rationing rules and what they are.

Someone, who opposes some change to health policy will say "that's rationing -- we can't do that".  If the person saying it is knowledgeable on the subject, then they know it is a lie.  Any "expert" who is unwilling to say "there will always be rationing" is purposefully conning the less well informed.  Con men (and women) should not be listened to.

Get over it.  If we are honest, we are never arguing between a "rationing" system and a "not rationing" system.  We are instead arguing either about who does the rationing or about what the rationing rules are, or possibly about both.

Obamacare put in rules requiring insurance policies to cover certain situations.  The most famous example of this is "pre-existing conditions", but there are many others.  Generally speaking, these changes improved the quality of the insurance coverage.  But they also increased costs.  (SPOILER ALERT:  Health care is not free.)  What this did was "ration less but pay more".  It did NOT eliminate rationing.  It just changed the rationing rules.

The primary rationing mechanism used in the US is bureaucrats working for insurance companies.  There was an argument in opposition to Obamacare that went "it will put government bureaucrats in charge of your medical care".  First of all, that wasn't true.  Second of all, if it was true what we were actually doing was shifting the decision from insurance company bureaucrats to government bureaucrats.

In that context, lots of people would have seen the shift from using insurance company bureaucrats to using government bureaucrats as an improvement.  Finally, many of the people pushing this line knew it wasn't true.  Obamacare has taken some discretion out of the hands of insurance company bureaucrats.  But the Insurance people are still the ones making the decisions that deny some people life saving treatment.

Reid in his book makes it clear that a number of systems would result in a system that was cheaper and worked better.  And he is not alone.  That is a broadly shared consensus among those who have studied the health care systems used in other countries.  And, based on the experience of many countries around the world, people would like the new system better than the current one.  So what's the holdup?

Let's start with money.  It seems obvious that cutting red tape and bureaucracy is a good idea.  It should save money.  Okay.  That means you want a British style system where the government does everything.  All the doctors, etc. are government employees.  They have no financial incentive to run you through expensive procedures so they can get a kickback.  And they don't waste their time on forms and paperwork.

Every doctor office dentist office, etc. in the US has at least one person whose full time job is to shuffle paper.  The US system demands vast quantities of paper.  Those paper shufflers are running up costs and not improving the quality of the medical care you get.  But medical offices literally can't stay in business without them.  So now you're sold on the British system, right?  I'm guessing you are adamantly against a government run medical system in spite of the fact that it would be cheaper and work better.

So how about the French system?  Hospitals, doctors, etc. are independent.  There are even insurance companies.  The government provides an "audit" function but doesn't provide any of the actual care.  Well, in France the whole process is strictly regulated.  There are so many regulations that everybody might as well work for the government.  In spite of this, French health care is far better than that found in the US and it's cheaper.  That should give you an idea just how wildly inefficient the US system is.  Pretty much any other system works better and is cheaper.

The Canadian system has gotten some coverage here and there.  It delivers a better quality of service, on average, than the US system.  This is reflected in many ways.  But a simple example is it's popularity.  Most Canadians live near the border.  So they are pretty familiar with the US system.  They are uniform in preferring their system to the US one.

They have good reason for this.  Everyone is covered.  And routine procedures are covered.  So people don't get sick as often.  And when the do get sick, the problem is caught and cured more quickly.  But the Canadians have not figured how to avoid rationing.

Their system covers all reasonably inexpensive and common procedures.  It covers many expensive procedures too.  But one of the ways they keep costs down is by being slow to provide non-life-threatening expensive procedures.  You get them for free but you have to wait.

The US medical system is the best in the world, if you are rich.  If you have money to throw around, the US system will take great care of you.  Some relatively well off Canadians run into this expensive-but-not-life-threatening situation.  Some of them come down to the US where they can get the procedure immediately.  They just have to pay a lot of money.  But if you have the money then it often seems worth it.

So, the US system is the best system, if you are rich.  The Canadian system is better if you are in the middle, financially.  The Canadian system is far superior if you are poor.

So why can't we fix our system.  Well, here's one reason:

People don't like their medical plans.  It doesn't matter if it is an employer provided plan, a union provided plan, a plan from the Obamacare Exchange, or whatever.  What they do like is the team at the doctor's office, clinic, etc., that they have been using for the last few years.  They have built up a level of trust with this particular group of people.  So, they very much want to stick with them.

The thing that scares people about various proposals is that they fear that something MIGHT get in the way of them sticking with the medical professionals that they know.  It's not a chance they want to take.

I'm convinced that if this last issue is addressed in a way that people are convinced will work then they will support the plan, whatever it is.  But doing so is complicated.  And the devil is in the details.

And there are lots of people that want to mess with the details.  They want to make some "minor" tweak so that one group or another ends up making a whole lot of money out of the deal.  And that makes this almost impossible to pull off in a political context.

People know there is a problem.  They just look at any specific "solution" and find reasons to distrust it.  Senator Warren has run into this recently.  She rightly calculates that a fast transition saves money.  So she initially wanted to do it very quickly.

She recently put out an updated plan that stretches things out to three years.  But it also had a lot more detail.  And that additional detail caused a lot of people to conclude that her plan MIGHT get between consumers and their medical team.

The short term concern about having to change doctors, etc. overrode the potential long term benefit of better service at a lower cost (and likely the ability to keep their current doctor).  And that put a lot of people off her plan.  And that caused her standing in the polls to take a big drop.

There are several ways to go that I think would work well in the long run.  But, due to the problem I have just been discussing, I don't see how we get from where we are to one of these plans.  So, is there a way forward?  Yes!

Moving toward the French plan could be done in such a way as to allow people to keep their current medical team.  So that eliminates one roadblock.  All we have to do to get there is to pile enough regulations on top of the current system.  Done correctly, we will end up with something very similar to the French system in the end.

But the whole process (except possibly when we are close to the finish) will be horribly inefficient.  Most of the intermediate steps will increase overall health care costs.  And I don't know how the French fund their current system.

In the US pretty much every company or union is a separate path along which the money flows.  One of the things that is really disruptive about the US system is that changing jobs almost always involves changing health plans and that threatens the connection to the health team.

France, and the other countries have fixed this problem by getting businesses and unions out of the health care business.  When you change employers your health plan doesn't change.  And, therefore, your health team doesn't change.  They do this by using a single payment path that runs through the government.  There would be a lot of resistance by Republicans to this.  Currently, companies and unions oppose it too.

But I think the company/union resistance can be handled by coming up with a good transition method.  For both companies and unions, the health plan is part of the compensation package.  Let's say that the company/union contribution can be zeroed out.  Then if all the money saved went directly to the employee in the form of increased compensation, I think the change could be sold.  If employees are sold on the change then I think both companies and unions would be happy to get out of the health care business.

But, of course, this change would not free any money up to pay for a presumably more expensive (in the short run) health care system.  If nothing else, a new money stream would have to replace the old money stream of company (possibly to union) to insurance company to health care provider path.  The health care people need to get paid somehow.

If we use a government system then inevitably, taxes would have to go up.  Theoretically, the taxes of the employees and union members could go up the same amount as their increased take-home pay without harming them.  But that is hard to do and even harder to sell.  The Warren wealth tax represents an alternative source.  She is already planning on dedicating a large amount from it to cover health care costs.

And I'm sure many of you can lay out your own objections to what I have just laid out.  And the fact that it is so easy to come up with objections to changes in health care is why it has been so hard to improve the system.  But it is important to note that health care costs are going to go up if we do nothing.

They will go up because people will find new, expensive ways to improve one or another aspect of health care.  They will then proceed to find a way to get paid.  But the current system compounds the problem by piling all the inefficiencies and inconsistencies of our current system on top.  The current system magnifies cost increases.

An option that is getting talked up a lot is "Medicare for All".  Now, you need to be 65 or disabled to qualify for Medicare.  And, in theory, it is paid for by Social Security taxes.  The whole thing is calculated so that, on average, a senior citizen has contributed enough over the years to cover the cost of Medicare in his/hers golden years.

But the "Medicare Trust Fund" will run out of money in about a decade, according to most estimates.  So there really isn't enough money to fund the current system.  Medicare expansion proposals vary from lowering the eligibility age by a modest amount to, in the most extreme proposals, opening Medicare up to literally everybody.  Some proposals let people voluntarily opt in to Medicare.  Others make it mandatory.

It is important to understand that Medicare is just a big, government run, insurance plan.  There are no executives pulling in millions but, in terms of analysis, it's an insurance plan.  So it's like France.  So, if we were sensible about these sorts of things, which we are not, we could look to France for ideas about what to do and what not to do.

The reason that people talk about Medicare is that it has a good reputation.  It provides a good quality product with far less overhead than insurance plans.  But there is lots of bureaucracy/paperwork involved.  Those paper shufflers in doctor's offices spend a lot of time dealing with Medicare.  And it is important to understand that Medicare is not the whole solution.

I am on Medicare.  But I also have a "Medicare Supplemental" plan.  Medicare doesn't cover everything.  It just covers a lot of things.  That leaves a lot of gaps.  The combination of Medicare and my supplemental plan provides me with a level of coverage that I am happy with.  Just plain Medicare would fall far short.

The supplemental plan costs money.  I can afford it so I pay.  But what about people who can't pay.  Mostly, the "Medicare for All" people don't talk about this problem.  It's not their fault. There is so much BS and noise being thrown around there really isn't room for a discussion of this issue.

If we could get to a point where the BS and noise people shut up or were shut up then a discussion of this and many other topics would be possible.  (One reason they throw up the BS and noise is because they don't want these subjects discussed sensibly.)  But far too many people powerful people benefit from injecting BS and noise into the discussion of subject after subject for me to believe that is a problem that will be solved soon.

If at this point you are saying to yourself "I hate all the options, even the option of doing nothing" then you have been paying attention.  (And I hope you can now engage with the subject with a clearer understanding.)  But it is important to understand that it is possible to make the current system worse.  A repeal of Obamacare without replacing it with something that is as good or better is just the most obvious example.

But this is a subject, like climate change, where doing nothing is not really an option.  So I applaud all of the people who I think seriously want to improve the situation.  Even if I don't think a plan has much of a chance, just thinking about that plan make a change for the better more likely.

Finally, if you want a "glass half full" way to look at this, here's one.  If you are going to do something about one problem and ignore another one, do something about climate change and ignore health care.  If you think things look bad when you look at the health care landscape, trust me, things look far worse when you look at the climate change landscape.