It's all over

There's no question now but that Donald Trump will be President through 2024. That really doesn't have much to do with the voters, or how they will react to whomever the eventual Democratic candidate is. It has everything to do with the man himself, and how he conducts his affairs.

To begin, try this: Close your eyes, and imagine that it's January 20, 2021. Inauguration Day. Donald Trump sits idly by, watching Joe Biden take the oath of office. He then congratulates President Biden, and hops on Marine 1 to start back to New York City.

Can't imagine that? Then you're beginning to get a grip on why Trump will still be our President for another term.

Through gaslighting, lying, false accusations, and hate-based rhetoric, President Trump has managed to convince a large segment of the American voting public that
(a) Hillary Clinton conspired with the Russians during the 2016 campaign
(b) The Obama administration organized a spying effort against the 2016 Trump campaign
(c) The nefarious 'deep state' actors who perpetrated these crimes are still in place in many areas of the Intelligence Community
(d) The Department of Justice in general and the FBI in particular are political bodies, and cannot be trusted to investigate anything about the President or his family

Additionally, he has installed an obvious shill at the head of the Department of Justice, and has removed every law enforcement official who has shown any inclination to stand up to him. And the Department of Homeland Security, who is supposed to be helping state and local officials protect their election systems, is now being run directly from the Whiter House. The Federal Court system, which is one of the expected avenues of relief for the citizens, has been packed with Trump sycophants who in many cases are questionably competent to be in the job. And the Supreme Court has a strong majority of conservative ideologues, more committed to the agenda of the extreme right than justice in our nation. The Senate is actually a body of Trump enablers, who will find every excuse possible to support the President and make sure his wishes are met.

In short, there is no body of the U.S. Government who will stand up to the President if he hijacks the next election. And hijack it he will. He has already begun. And we can already see a lot of his tactics being rolled out.

- The administration will not cooperate with the House of Representatives on any matter. In many cases, they have told House committees to go pound sand. In other cases, they have simply refused to comply with legal, legitimate requests from the House (Mnuchin / Tax Returns). There is no reason to think this behavior will change when those committees start looking into Russian interference in the 2020 election. Trump himself has never acknowledged that the Russians had any role in the 2016 election, and that will be his position regardless of what happens going forward. So if you thought the House was going to be the check on the President, you obviously assumed that the President was going to follow the law. He won't.

- The Department of Justice will not pursue any new investigation of Trump, his family, or his administration. The talking heads have been suggesting that Trump can't do anything about the Southern District of New York, but it's not clear why they think that. SDNY is as much a part of the Justice Department as any other Federal Prosecutor's office. If Trump tells Barr to shut down an investigation, the legality of the request will not be an issue.

- DHS is doing essentially nothing about election security. To her credit, Kjerstin Nielsen tried several times to organize a cross-agency response to election hacking, but was always stymied by, among others, White House staff. There is absolutely no reason to think any of that will change. Russia will enjoy a free hand to manipulate our elections and there will be no official response. The Intelligence Community may try to wave their arms, but they really don't have any ability to do anything about it (legally).

When Trump eventually loses at the ballot box, an entire army of lawyers working for the administration and for Trump personally will be loosed on the Federal Courts to challenge everything - big or small, important or unimportant. Remember that Trump has shown us that the real value in legal action is time. And if he can stir up enough legal trouble post-election, it will become difficult for the Electoral College to meet and do its work.  Remember that there are dozens (98 as of this writing) of new Federal Judges that were nominated by Trump and approved through Mitch McConnell's kangaroo Senate. They are all on standby, waiting to repay the favor.

Finally, in the midst of all the legal wrangling, Trump and his minions will take to the airwaves to sell the story that it's really the Democrats who tried to steal the election. They will make absurd accusations, bolstered by ridiculous lies, but there will be enough acceptance of that, and enough Trump supporters, to put the entire succession process into disarray.

So if you think Trump will participate in some sort of peaceful transition in 2021, think again. The fix is in.

The Search for Peace in the Middle East

In September 2000, Ariel Sharon, head of the Likud Party in Israel and nemesis of Palestinians, paid a visit to the Temple Mount in Jerusalem, including the environs of the Al-Aqsa Mosque. That mosque is considered one of Islam's holiest sites (following Mecca and Medina). Muslims around the world were outraged by what they considered as a direct provocation, and an effort to desecrate or at least lay claim to their important shrine.
The Palestinians responded with what they had - stones on a good day, suicide bombers on tragic days. And the Israelis defended themselves with tanks, airplanes, and artillery. By the end of the uprising, it had a name - the Second Intifada. It also had a toll: an estimated 3,000 Palestinian lives, 1,000 Israeli lives, and 64 foreigners.

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Today, Donald Trump did his best to emulate Ariel Sharon's actions. His best was pretty weak, because Sharon actually was a proven warrior and commander of armed forces. Trump is, at best, a drive-by shooter. But in one of his drive-bys, he has taken a great leap toward the Third Intifada. There are few things the U.S. could do to add extra instability in the Middle East, but he did it today. By recognizing Jerusalem as the capital of Israel, and pledging to move our embassy there, he has essentially shoved aside any claims the Palestinians may have had to parts of Jerusalem where they have lived for thousands of years.

Trump followed his announcement with what sounds like great words about the commitment to the peace process, and the dedication of the U.S. to finding a peaceful solution to the Israel / Palestine standoff. Early readings on the celebrations in Israel and the disturbances in Palestine would indicate that the people on the ground don't place high value on Trump's neutrality and commitment to peace.


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In 1969, I took a college course called "The Search for Peace in the Middle East". We took an in-depth look at the various claims, insults, frictions, historical complications, and religious misunderstandings that shaped the Levant at that time. Of course, the Palestinian issue was on the back burner at the time - The refugees were lodged in slums in Lebanon, and all the Arab / Palestinian participants assumed that a solution would be found that would allow them to return home. (They're still there - at least the ones that Ariel Sharon, the Israeli Army, and Christian Falangists didn't eradicate.) I've been following the trajectory of the situation since then. One thing that amazes me is that, even though there have been incremental steps forward in the last 50 years, nothing fundamental has changed.

Many, many people in the Middle East, Europe, and the U.S. have made a herculean effort to affect a real change in the relationships there. The successful efforts are named after places - Camp David, Oslo, etc. As a matter of fact, the unsuccessful points in history are named after places also - Munich, Beirut, and others. But despite the steps forward and the steps back, nothing has really changed. Jewish people in Israel are still locked in a to-the-death struggle with Palestinian Muslims over who owns the land, who has rights to various sites, who has freedom of travel, and who can develop economic institutions and business. Nothing has really fundamentally changed,

To compound the situation, various neighbors of Israel and Palestine have become less reliable, rather than more reliable, over the years. We can still count on Jordan; The Hashemite Kingdom has been on the road to peace since the first Arab failure to eradicate Israel. They are our strongest partner in the neighborhood, and in a quiet moment, the Israelis will admit to being comforted by their efforts.

Egypt, at one time the flag-bearer for Arab / Israeli cooperation, has become a less democratic and less stable regime over time. Their inability to control the Sinai has had a direct, negative effect on Israel, by giving a refuge to violent people who hate the very notion of Israel. Syria, of course, is not really even a country any more. The government that is left, centered in Damascus and propped up by the Russians, has enough problems of their own. That's good news and bad news: they aren't (probably) going to stir up trouble with Israel, but they also aren't going to do anything to help - like controlling the flow of arms from Iran to Hezbollah.

The Saudis also have problems of their own, in Yemen, the Wahhabis, and the Royal Palace. Kushner's and Trump's fawning over the Crown Prince will help, but it's likely to be a long time before the Saudis can truly engage in any peace process.


In the face of all this instability and chaos, Trump has chosen a path which can only add to the critical mass of outright human catastrophe. There can be no positive purpose served by his plan to move the embassy. Much like his tweets of hateful anti-Muslim #FakeNews, today's action can only be viewed as a provocation. We are isolated on this, without perhaps even Russian support. To their credit, they are trying to bring stability to region that knows almost none.

Despite his actions, Trump sounds the cry for peace, to be pursued aggressively. There is no real peace process right now because

• Israel insists on talks with no pre-conditions, which sounds pretty good
  
• The Palestinians insist that the talks include discussions of the settlements, which in Palestinian terms means "settlements are going away"
  
• Israel repeats that they will only enter discussion with no pre-conditions, which in Israeli-speak means "no, we aren't going to discuss settlements".
   

This leads us to a maintenance of the status quo, which serves every purpose of the Israelis and particularly the Zionists. They will continue to confiscate Palestinian land, and build new settlements, in the name of "security". They will consolidate those settlements behind "Israeli only, no Palestinians may cross" highways and walls. And they will continue to enjoy the patronage of the Trump regime, which even before they took office were trying to manipulate an anti-settlement vote in the U.N.

The lights got darker in the Middle East today. Nobody knows when they will get brighter again.

Treat Mental Illness With Respect

Mental illness, in all it's varied forms, is a horrible disease. It brings at least discomfort, and in many cases actual danger, to both the diseased persons and those around them. In modern societies we have for the most part learned to treat the afflicted with respect; we don't mock them, or tease them, or poke fun at them or their families. We try to be quietly supportive, lending whatever help we can with our very limited understanding.

In the past months, there have been an increasing number of commentators suggesting that our President, Donald Trump, is either mentally ill or is at least a borderline case. This diagnosis has been offered by all sorts of people who don't really have any qualifications; Senators, TV and radio pundits, social media raiders, and even some qualified psychiatrists. The most frequently offered diagnosis is "malignant narcissism", which itself is a little-understood syndrome. The four elements of this disease are  narcissism, paranoia, antisocial personality and sadism. We can clearly see that President Trump exhibits all four of those. (Note that there are professionals who also say that, while Trump certainly shows those characteristics, they don't rise to the level of mental illness)

But what are we to do? My first (and only) recommendation is that we all quit talking about it, and quit talking about Donald Trump in general. Ever since he entered the Presidential race in June of 2015, we have been obsessed with every word, every tweet, ever imagined slight, and every piece of evidence of his imbalance. This is harmful for two reasons:

First, all the attention we are giving Trump is simply feeding the beast. To a narcissist, even criticism is joy. As long as he can focus the nation's attention on anything he does, there's little reason for him to change any of his behaviors regardless of how toxic they may be.

Second, in fairness, mental illness should not be our daily entertainment. When someone is cracking up before our eyes, we shouldn't be riveted to our TVs and computer screens feeding our dark places with the by-products of a terrible disease.

Let's all go on a Trump fast. His cabinet and associates will provide us plenty of interesting stories of corruption and poor policies for the next several months. Let's let Donald and his family have some peace.

(Full disclosure: I am one of the worst offenders. This is as much my confession and contrition as it is a call for decency.)

Image  Johann Anwander [Public domain], via Wikimedia Commons

Confusion in the Buckeye State - So What?

This brings us to the question of "so what"? The idea behind Issue 2 is admirable - to lower prescription drug costs. And the method, to do it through legislation, appears to be the only path. The Pharmaceutical companies are not going to lower U.S. drug prices until they are forced to by some legal effort. Meantime, U.S. Citizens will continue to pay astronomical prices for key prescriptions.

How much do we pay? Let's look at one example (unnamed, but you can find this information yourself).
Using GoodRX.com, we can find the prevailing 'retail' prices for a drug. The V.A. prices are published at their website, as are the Ohio Medicaid prices.

Retail Price                  $4,500
V.A. Price                      1,383
Ohio Medicaid price      4,294

So, you can see that there is a huge difference in prices from Medicaid to the V.A. If Ohio paid the V.A. price, Ohio Medicaid would save 67%. For this particular medication Ohio paid a little over $80 million in 2016, so the saving to Ohio would be $54 million. An impressive amount for just one drug.

But what happens then? As the system is currently structured, the patient is on the hook for the difference between the retail price and the Medicaid reimbursement. Just like regular insurance. So the Mediciad subscriber (who is presumably struggling financially) would suddenly be faced with paying an extra $2,900 for the same prescription. This is probably not the outcome we are looking for.

In case you wondered, the National Health Service in the U.K. pays $944 for the same medication (current exchange rates). The cost across most EU nations seems to be about that - around $1,000 USD for the 2-pen package.

So, I think it can be said that Issue 2, while well-intentioned, is not ready for prime time. There are simply too many questions about where the money comes from and goes to, how it would be administered, and  how the rebates would be affected.

At the same time, the conversation has been started. Now it's time to get serious about managing drug prices in the U.S. Canada, Great Britain, and the E.U. are not third world countries; they've got as much money as we do, but pay only a fraction of the amount for the very same medicines. There are a lot of possible solutions to this, but we need to keep the pressure on our legislatures to actually confront the issue.


Prev: The Bottom Line

Confusion In The Buckeye State - Part 2

So what's the bottom line?

The State of Ohio paid a little over $3 billion for medications through Medicaid in 2016. If they paid V.A. prices for those medications, my estimate is that they would save about 10-15% of that. Why is it an estimate, and not a hard number? Well, there a lot of reasons, but there's two big ones.

First, the list of drugs available from the V.A. is much smaller than the list available from Medicaid. This is generally not because the drugs are different, but because Medicaid pays for a much wider variety of packaging than the V.A. does. Medicaid prescriptions are fulfilled through commercial pharmacies, so there are a lot of different options for how a particular prescription gets filled. V.A. medications, on the other hand, go through a relatively small number of outlets (V.A. Hospitals and clinics) so they can use a much smaller number of packages. (Incidentally, this smaller list gives the V.A. advantages in dealing with the drug companies, and efficiency in handling their stock of medications.)

Because of these differences, it simply isn't possible to get a one-to-one match between a Medicaid prescription and a corresponding V.A. prescription. My estimate includes an estimate of what the pricing would be, if in fact the V.A. actually had a price for all those packages. That's my estimate only.

"Nobody knew that health care could be so complicated". . . Donald Trump

But the bigger challenge is called the Medicaid Drug Rebate Program. This is a program under which the individual state Medicaid agencies get rebates from the Pharmaceutical Companies based on the amount of their drugs the state Medicaid program pays for. Essentially an earned-discount program. The Federal Medicaid folks calculate a baseline rebate amount, which is set by law. The individual states then negotiate their actual rebates with the drug companies. The actual rebate amounts are confidential. This gives the states negotiating leverage with the Pharma companies, but prevents us, the private citizens, from knowing what exactly the state pays for any particular drug.

The Ohio Office of Health Transformation has published an Executive Budget document which indicates that the total rebate to the state is over 50% of the total expenditure for Medicaid drugs. Because the rebate is confidential and negotiated on a company-by-company basis, it is highly likely that the pharma companies will simply take any reduced drug costs out of the rebates. It seems unlikely that they will continue to rebate over 50% of the old cost, when the new cost has reduced their revenues by 10%-15%.

So the Bottom Line? Who knows? There is certainly some potential that the State of Ohio could save money on Medicaid prescriptions. But, to this researcher, it's impossible to tell where or how much.

Prev:  Confusion - Issue 2 Next: So What?

Confusion In The Buckeye State - Issue 2

Where to begin . . .

I first became aware of, and interested in, Ohio Issue 2 when I began seeing negative ads about it in May of this year. Usually, ballot issues get some play in October if they're contested, maybe September if people are really hot about them. But May? Really? So I dove in.

Ohio Issue 2 is a ballot initiative that would say that the State of Ohio would never pay more for medications than the V.A. pays for them. From a superficial standpoint, that makes perfect sense. The V.A. is reputed to get very good drug prices through strong negotiations, so why wouldn't other government agencies want to take advantage of that? For all the negative advertising, including character assassination, there must be some serious dollars involved.

Using only publicly available data, I tried to find out what the dollar amounts involved actually were. At the start, it looked easy - The V.A. publishes the prices they actually pay for their medicines. These can be matched to a State of Ohio Medicaid website that gives the corresponding price, to the Medicaid patient, for exactly the same medicine. It's a little confusing because Ohio gives their prices in 'units', while the V.A. prices the entire package. But with enough perseverance, you can figure it out.

And the answer is a resounding "yes". The V.A. pays less, in about 90% of the cases, than the Ohio Medicaid price. In some cases, it's a LOT less, in others it's just a little less. In a handful of instances, they pay slightly more.

Simply knowing that some drugs are less expensive at the V.A. doesn't tell you a lot. You need to also know how much those drugs are actually being used. For that, we can go to a third agency, the U.S. Medicaid administration, which conveniently tells us how much of each drug was prescribed and paid for by Ohio Medicare. And that's where the fun starts.

It quickly became clear to me that there are three types of drugs on these lists. The first group is generics. Across the board, these are relatively inexpensive and the differences in V.A. and Medicaid prices are generally fairly small.

The second class of drugs is the patented, proprietary drugs. These are newer and more revolutionary, and include the ones you see advertised on TV. These drugs are amazingly expensive. Just amazing. But, the results they claim are also extraordinary, so I'm not going to make any judgments about 'value'.

The third class of drugs are those that are priced so astronomically, for no apparent reason, that Medicaid doesn't even list them. You can see one example of these in the Issue 2 advertising - where a family has no choice but to pay the several hundred dollar price increase to protect their children's lives. That's because Medicaid won't pay anything for that particular medicine.

Next up: What's the bottom line?

Throughout this set of articles, I'm going to try to avoid naming any particular medicine by generic or brand name. There's two reasons for that. One is that I'm not trying to pick a fight with any particular drug company or group. The second is that I have absolutely no expertise in medications or the practice of medicine in general. I do not want to leave the impression I'm trying to make any statement about the value of a particular statement.
I will be happy to share my data and analysis with anyone who wants to see the actual names and numbers.  

From 2012, but more relevant than ever.