Motivation

Just received this from my daughter Maren, a day after completing her first triathlon.

Post by Josiah Mizukami.

Hiding in Plain Sight

One day you finally knew

what you had to do, and began,

though the voices around you

kept shouting

their bad advice – – -

though the whole house

began to tremble

and you felt the old tug

at your ankles.

‘Mend my life!’

each voice cried.

But you didn’t stop.

You knew what you had to do...

From The Journey by Mary Oliver

I honestly think the healthcare system knows what it has to do to deliver quality care at a sustainable cost: replace the fee-for-service payment model with partial and total capitation; use Electronic Health Records throughout the system; coordinate care; make decisions using evidence-based medicine; and always reward quality of treatment, not quantity of procedures performed. Parts of the system are doing all of this, with terrific results: Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Intermountain Health, Geisinger, to name a few. But much of the work these fine organizations do, plus all the work of just about everybody else, is based on fee-for-service, rewarding quantity, not quality.

What to do? As we all know, there are plenty of voices around us shouting their bad advice, and folks tugging at our ankles, saying "Don't go. Don't change." Inertial resistance to change in a system is a huge force. And if change doesn't in some way originate within the system, it will most likely not stick. That's why most of the cost-containing changes to Medicare  the ACA introduced are exploratory, not prescriptive. In other words, the Act proposes and supports multiple tests, to see what works, what the system will adopt. There are some prescriptions: reduced payments to Medicare Advantage; reducing the annual Market Basket Pricing Update by a multi factor productivity measure (usually from .6 to 1.0%) each year; putting in place a penalty for Hospital Readmissions. But most initiatives are designed for testing, to see what works, to see what will support the system in moving away from fee-for-service, and towards better care coordination and payment for quality.

Based on trends in per Medicare beneficiary spending since the ACA was approved in 2010, it looks like it might be working:

As I pointed out in a recent post, if per capita spending is held flat (i.e., 0% growth), and Medicare (and Medicaid) spending growth is based on enrollment (Baby Boomers turning 65), then the country's budget/entitlement problems are solved, and going forward Debt as a % of GDP will gradually decline:

The problem is that no one has come up with a research-grounded explanation of why per capita Medicare cost growth has flattened. What's worse, almost all of the solid research has focused on the private insurance market, not Medicare or Medicaid, and the generally accepted expert point of view is that most of the slowdown is recession-driven, and cost growth will return (after a lag time) as economic growth picks up (see here). The CBO did a terrific Working Paper in August, 2013, that looked squarely at Medicare, concluded that the recession had nothing to do with the slowdown, and then said that most of the slowdown could not be explained and more research was needed. Here's the  key chart:

Bringing this chart forward to include more recent data simply increases the Unexplained Contribution to Growth. Average Spending Growth 2010-2014 is .6% (vs. 3.8% above); putting this number in, and leaving other adjustments the same (obviously not accurate/needing further work), widens the unexplained gap to 4.7%. So if it's not the economy, not inflation, and not demographics, what is it? Is structural reform underway? Will this slowdown last?

How can we know if the healthcare system has, as the poet would say it, finally figured out what needed to be done, and has begun doing it?  Answer: we can't know for sure; but there is some extremely interesting data indicating that at least part of the Medicare system has figured it out, and is doing the necessary work to keep costs under control. And that data comes from a surprising place: Medicare Advantage.

Until very recently, I knew next to nothing about Medicare Advantage, and what little I knew wasn't very positive. I thought it was an insurance company boondoggle, where they convinced Congress to give a chunk of the Medicare business to private industry, saying they could do it more efficiently than Big Government, but that over the years, with intense lobbying, the benchmark bid targets kept moving up and away from actual Medicare Fee-for-Service per beneficiary costs, with the results that MA was now costing more than normal Medicare.

I knew that the ACA had cut back the bid benchmarks over time, bringing them back much closer to regular Medicare, and generating substantial savings to fund the Bill, with ongoing complaints from MA providers.

What I had not known was that MA is a managed care with capitation model; that the geographic-specific bid price per beneficiary was an "all-in" number (all Part A and B medical costs (Prescription Drugs handled separately), admin expenses and profits included); that the famous rebates were awarded as a percentage of the difference between the bid price and the reference price for that geographic area; that the rebate percent was awarded on a Five Star Provider quality measurement system, with larger rebates going to those with higher rankings; and that rebates had to be used to help beneficiaries lower their premium payments or to give them additional benefits (drug, vision, dental, etc.). 

I also had no idea what the per beneficiary cost trends had been, since the information is almost completely hidden. Don't really think CMS is trying to fool or deceive us; I have concluded that the individual claims are not reported with other Part A or Part B spending because MA claims are paid by the MA Plan Payers, not Medicare central.

I searched and googled for a long time. Finally I hit pay dirt: on page 157 of the 2014 CMS Trustees Report, a section began labeled Private Health Plans, and there was the history and all the data, with the key page being 168, reproduced here:

Using info from this Table; focusing only on "Local CCP (Coordinated Care Plan)" which covers the vast bulk of the enrollees; and excluding rebates (marketing, not health dollars), I came up with the following chart showing trends in per beneficiary bids to trends in Part A/B in FFS Medicare:

The above tells me that MA delivered all Part A and Part B care in 2014 for an average bid of $8,671 per beneficiary, 16% below the $10,339 average for FFS Medicare; and even adding the $799 MA rebate back in, gives only a $9,470 total, still 8% below Medicare. Per beneficiary MA costs have been gradually declining since 2009, opening up the gap with FFS Medicare - MA 9.5% lower in 2009; now 16% lower.

Remember when Managed Care drove healthcare costs down in the mid-90s', until people rebelled against the "Only Say No" rationing mentality of the HMO providers, and the business dried up. Not so now. Take a look at this enrollment chart:

How about quality of care? Take a look at this Boston Consulting Group study, a long, but extraordinary read. BCG analyzed 3 million claims, roughly split between normal FFS Medicare and Medicare Advantage: in almost every example the MA model delivered better quality with less utilization. It certainly looks to me like MA, with its Managed Care delivery system, is consistently giving high quality care at a predictable and managed cost.

And if I'm right about this, then the following chart showing CMS' forward projections (much like CBO's) simply doesn't make sense:

Why will the MA costs move up sharply in 2017? CMS/CBO will say they are tied to the FFS numbers; but MA has already demonstrated an ability to open the gap with FFS spending. The above chart simply doesn't make sense. The flattening of the FFS Medicare numbers from 2010-2014 might be said to be a fluke, a move away from the mean. You cannot say that about MA, where the Bid Offered reflects a commitment to manage their part of the system to that number. It is not a happy accident. It's a Managed Plan.

Medicare Advantage is, I believe, the miracle hiding in plain sight that should give us confidence that the overall Medicare system will slowly work its way to the efficiencies MA has found, and that we have a good chance of holding per beneficiary costs flat, thus accomplishing an extraordinary reversal of our healthcare cost and budget trends.

The Budget Game Has Changed

Evidence is mounting that per beneficiary Medicare costs are flattening or dropping. The chart above shows the trend in per beneficiary cost growth since 1980. Before now, the only "off trend" period was 1998-1999. Turns out this short drop in cost growth was caused by the 1997 Balanced Budget Act, which significantly adjusted and cut payment rates. Providers complained loudly, and the Balanced Budget Refinement Act of 1999 reduced many of these cuts and put Medicare back on its strong annual growth in spending per beneficiary.

Beginning roughly in 2010, another slowdown began, this time with no immediate adjustment in Medicare payment rates: the ACA was passed in March, 2010, but the first payment rate adjustment didn't occur until 2012, when the annual market basket inflation adjustment was reduced from 3% to 2%.

Sarah Kliff of Vox was digging through the most recent CMS Trustees' Report, and she was stunned to come across this "deep data chart" on page 283:

From this she put together the following chart, showing how per beneficiary spending has flatlined in the Hospital Insurance portion of Medicare:

The charts above deal with Medicare per beneficiary cost growth. Information is less plentiful for Medicaid per capita spending, due to high turnover in the membership base, but here is a chart put together from a number of CBO Medicaid Focus Briefs put out before the annual 10 year Budget Outlook, generally published in March each year. Here we see per beneficiary Medicaid costs declining:

What would happen if this trend continued? What would our budget picture look like if Medicare and Medicaid per beneficiary costs stayed constant? In particular, what would happen to the critical Debt to GDP ration? I downloaded the CBO 2014-2024 Budget Outlook model, then adjusted it to hold per beneficiary cost growth for Medicare and Medicaid at zero. Here are the results for the ratio of combined Medicare/Medicaid spending to GDP and the Debt/GDP levels for two scenarios - current CBO forecast and that forecast revised to hold per beneficiary spending constant:

Because Medicare and Medicaid take a decreasing share of our resources, deficits gradually decline, moving below the rate of GDP growth (and staying there), thus allowing the Debt/GDP ratio to decline.

With zero per capita spending growth - in other words, with Medicare and Medicaid spending growing only with enrollment - Debt to GDP ratios drop gradually over the 10 year period. Budget deficits stay below GDP growth, allowing the debt ratio to improve.

But this is a far cry from what CMS and the CBO are forecasting. Here's CMS' forecast for per capita Hospital Spending:

And here's the CBO:

How do they support this resumption in per beneficiary cost growth in 2016, after a five year hiatus? Nothing much is said: CMS is silent; CBO presents some discussion of competing research viewpoints on overall economy-wide healthcare cost trends; mentions one of its own papers (here) saying the Medicare cost slowdown is most likely not recession related; then presumptively uses a 3% per beneficiary annual cost growth average, plus the anticipated 3% annual growth in enrollment as the baby boom is absorbed into Medicare. The result is the same it seems to have always been: we're OK for now, but we're in trouble in the long term, as we watch Medicare/Medicaid take an ever-increasing share of our national resources, leaving the country with an untenable long term structural budget problem.

The "healthcare cost slowdown is recession-related and therefore temporary" school got a big boost last week with the Health Affairs publication of a peer-reviewed research report showing how markets that were the hardest hit by the recession (Las Vegas, Birmingham, AL), measured in local/regional employment trends, showed the biggest healthcare cost slowdown, versus markets (Trenton, Dallas) that were relatively unscathed by the Great Recession. In fact,the hard hit Las Vegas and Birmingham markets showed private insurance-based healthcare costs growing from 5.4-7.2% per annum, where similar costs in the less affected Trenton and Dallas markets grew from 28 to 29%. The research concluded that: the recession/economy/income accounts for 70% of the healthcare cost slowdown; systemic changes in healthcare delivery are not that important, and we can expect cost growth to resume (with a lag effect) as the economy picks up steam.

I'm not equipped to argue the case with regards to the private market, but I will claim that the research results simply don't apply to the public, Medicare/Medicaid markets. Enrollees in these programs have minimal out of pocket costs. In fact, for Medicare those already low costs have been coming down: premiums held flat and closing the Part D Prescription Drug Care donut hole. Recession and the resultant changing income levels should have no effect on utilization in either program. Turns out the CBO publishes amazing county-level Medicare per beneficiary spending trends(here). I decided to check the same four counties the Health Affairs researchers had reviewed. Here are per beneficiary Medicare spending results for the two "hard hit" counties (Las Vegas and Birmingham) and the two that came out of the Recession "relatively unscathed" (Trenton and Dallas). As you can see: no difference - the per beneficiary spending slowdown showed almost identical trends in all four counties:

So what IS going on? If the Recession is not the slowdown's cause, and enrollee out-of-pockets are actually coming down (as opposed to going up markedly in the private insurance marketplace), why are per person costs flattening? The fair answer is that I don't really know; but there are things the evidence points to.

First, it's essential to understand what we're looking at (and here, I will focus on Medicare): when reviewing Medicare "spending trends", you are not really looking at spending; rather you are seeing provider billing information. Providers treat patients, then bill Medicare per a preset pricing list according to diagnostic related groups, or DRG's. Medicare spending is a country-wide buildup, provider by provider, of DRG's billed for services provided. The actual costs of providing those particular mix of services are nowhere reflected in Medicare billing. Spending over the allowed DRG limit is simply shifted  to other patient categories (private insurance, private pay, charity). Almost all providers bill above the allowed per-DRG Medicare rate; but costs for the more efficient providers can line up with these DRG rates.

So Medicare spending trends over time are an unusually clean and precise look at trends in patient utilization (both usage and mix of services, or complexity of usage). In this light, since we are in a billing, not a spending model, inflation doesn't happen all the time, at different rates throughout the year; it happens once a year, with a different "market basket rate adjustment" depending on service category. For example, the Part A/Hospital Insurance market basket up date for 2012 was 2%, after taking off (for the first time, per ACA) 1% for the multi- factor, economy-wide, 10 year average productivity adjustment.

Billing, not spending. And therefore an unusually good approximation of system utilization for our prototypical average, or composite patient. What's happening here? Some will argue that with the arrival of the Baby Boomers beginning in 2010, the Medicare pool is getting younger, therefore healthier. This is most likely true, though the impact of moving annual enrollment growth from 2-3% to 3-4% is likely quite modest, though certainly helpful.  Speaking quite broadly, I think evidence will start to show that the healthcare provider system is getting more efficient - less utilization/complexity to support our "average/composite" patient. We can begin to see this clearly in Medicare (and probably Medicaid); it will take more time in the private insurance sector.

There are two huge and converging trends in healthcare that I believe are causing the entire system to become self-organizing around the desire to reach these difficult, yet attainable objectives: Electronic Health Records (EHR) and the movement away from fee-for-service. There are other initiatives (penalties for hospital readmissions, for example), but these two hold the key. Providers want to achieve both; they are, I believe, convinced that they must achieve both, and quickly, in order to be successful in the evolving healthcare order of things.

Each initiative requires big provider investments and transformational changes in culture. Many providers will fail. Many more will be gobbled up as providers seek scale and more forward, cross-functional integration.The examples of giant organizations like The Mayo Clinic are powerful: where all services are under one ownership/organizational roof,and there is no, or little quantity incentive. Mayo is the quintessential accountable care organization, where patient costs are low, in large part because patient care is brilliantly coordinated, EHR is (and has been) largely in place, and quality care is the obsessive focus, not quantity of procedures performed (often the fee-for-service incentive results).

No one can predict exactly what this will all look like in 5 to 10 years. But what we can say with confidence is that these two powerful trends are happening: the movement to EHR and the shift away from fee-for-service. Just last week, Health Affairs reported on the extraordinary progress the system is making towards EHR: 59% of hospitals now have basic EHR in place, up from 15% in 2010. There are, and will be problems on the way to full adoption, but this train is moving fast.

So moving back into the Medicare/Medicaid cost forecasting arena, do you agree withCMS and the CBO that per beneficiary costs will restart their historical 3-5% growth trend? I don't. If I'm right, how long will it take the system to catch up and adjust their forecasts? I can't say, but my guess is: 2-3 years at a minimum. Democrats will, quite rightly, push this in the 2016 election, if per capita costs stay flat for Medicare and Medicaid. Conservatives will trumpet the news loudly when overall healthcare spending moves up, due to the large ACA coverage expansion . Progressives will need to work hard to keep the focus on per capita costs, not total spending.

As a progressive, feel we are moving into very rich terrain: the healthcare system has been transformed, and now is taking on the job of transforming itself, which all systems will do, when they select a new identity, as long as the system remains open, sufficient information is provided to all relevant players, and relationships between players are well coordinated.  Probably the most important policy change needed to speed this change is to find more ways to reward providers for not performing services, in other words by not spending/billing for added procedures because you (the provider) have found a better way to treat the patient and thereby eliminate procedures done in the past.

A system that rewards for services performed (FFS) needs, dare I say, a way to "reward abstinence," if that abstinence is congruent with the best healthcare practices and supports/nurtures the patient. Peter Orzag, formerly CBO Director, now at Citibank, and on the Board of Mt. Sinai Hospital in New York, is a clear voice calling for CMS to find ways to pay for quality, including rewarding providers for not doing procedures in certain circumstances. He tells us that Mt. Sinai is "bleeding money" by finding more and more ways to keep patients out of the OR and out of their hospital, believing that fee for service is on its way out, and the system will start paying for quality, and for doing a better job of keeping patients healthy.

The politics of this is something else. The Right will resist this for as long as possible, because it means they can't scream for budget cuts or the dismantling of entitlements. The CMS and CBO will be typically slow to change their fundamental assumptions about the healthcare future.

But it's happening. We need to get ourselves together to magnify the power of this crucial transformation of our collective healthcare and therefore overall budget future.

The Obama Doctrine

Nancy LeTourneau was the first to frame what the President said in this big policy speech last Wednesday in Brussels, Belgium as an Obama Doctrine. I believe this framing is very appropriate. Nancy identifies three central elements of this emergent Doctrine:

• establishing and defending international norms - In the current case of Crimea and the Ukraine, the norms are self-determination, the integrity of national borders, and the prohibition against a stronger country changing a weaker country's borders by force.
• operating through partnership, not power, to discipline norm-breakers - Here, with Russia's annexation of the Crimea, there is no military response to Russia's actions. Rather a partnership of concerned nations will work together to fashion a series of non-military responses: diplomatic isolation; expulsion from the G8;  economic sanctions (as much as possible, directed against the ruling oligarchs, not the Russian people); facing the Russian Security Council veto, secure an overwhelming condemnation of the Crimean referendum in a General Assembly vote (100 voted to condemn, where Bush got only 14 in the 2008 Russian incursion into Georgia); invite and support a rapid (90 day) review, country by country, of alternatives to Gazprom/Russian gas; provide very substantial, multilateral economic support to the Ukraine; work to split Russia from its traditional ally (China) with some success already (China abstained and did not vote with Russia in the Security Council).
• when conflicts arise, keep a clear diplomatic off-ramp open - With every pronouncement, the President has been clear that this problem can only be solved diplomatically, that we are not trying to put Russia down - rather we are trying to support and enforce international norms which have benefitted all of us. Friday, Putin called the President. Today Kerry and Lavrov are meeting in Paris. It's quite likely this will not prove the end of this crisis; but it does clearly establish the process that needs to be followed when resolution does occur.

Will this work? Ian Bremmer, in his New York Times oped, thinks not. In fact he is certain any attempt at sanctions will fail. He (along with many other very smart analysts) thinks we need to more fully understand the Russian perspective - that the Crimea belonged to them, and that the West has been relentlessly trying to encircle them since the Fall of the Wall, and that as our understanding deepens, we will lighten up on the critique. Roger Cohen, in his Thursday New York Times oped, having listened to Obama's Brussels' speech, seems to metaphorically throw in the towel, saying how can the US or Europe engage in elevated appeals to principle, when our own houses are so out of order.

Ambassador Michael McFaul (until mid-February, our Ambassador to Russia) and Fareed Zakaria have completely different takes. One of my favorite analysts, Ambrose Evans-Pritchard, penned his op-ed in Britain's The Telegraph on Wednesday - "Putin's Russia Caught in US and Chinese Double-Pincer". From my perspective, the smart money is on Obama.

The stakes are high here. Can we have a world where the leading powers follow an agreed set of rules - rules which can guarantee that smaller nations don't have to always look over their shoulder to see which great power might gobble them up. Will the rules of the jungle apply, where the mighty can feast on the midgets to their heart's delight; or can we, as an international community, agree on a different set of rules, ones that protect both the meek and the mighty?

And how do you enforce these rules? In a nuclear age, military conflict between the great powers is unthinkable. So what happens when a great power wants to eat up its neighbor? Are we pretty much helpless? Until now, the answer was pretty much - Yes. Nobody could stop us from invading Iraq, and nobody did. Nobody could stop NATO from bombing Kosovo, and nobody did. So Putin says to himself, "Since the US won't use military force, no one can stop us from invading the Crimea, and probably the Ukraine, and nobody will." Until Obama did.

Will it stick? I think so, over time. Mostly because I think Obama looks at this episode of unacceptable Russian norm-breaking, as very similar to what the GOP tried to do with the Government shutdown, and their requirement that Obama negotiate over the national debt. Obama said no to the GOP and meant it. Everybody knew he would cave. He didn't. The stakes were too high. And that's right where I think we are today - the stakes are too high to just back off and give the Crimea to Russia. Bad precedent. Big countries must follow the rules, just like the small ones. If they don't, chaos follows.

But being determined might not be enough if our President did not know how to genuinely ask others to help. It's hard for us to understand what a big deal this is: Obama is telling everyone that he cannot do this alone, that he needs help from every country that recognizes the value of defending international norms - whether that help comes in the form of a UN General Assembly vote, or hard-nosed economic sanctions. US Presidents never ask for help, at least not publicly. And that's precisely what Obama did in his Brussels speech. Simply extraordinary.

This may take a week, a month, a year, or more. But starting with Wednesday's speech (above), we are watching our President lead us, and whatever other countries will join to help, in a non-violent war against the old paradigm that says, "Might makes right." Or "He who has the gold, rules."

He is leading the world in establishing certain norms that say all of us have value; that we all deserve to be heard; and that the more powerful should not be allowed to run roughshod over us.

These are norms worth fighting for.

I Am My Brother's Keeper

(from theobamadiary.com-President with Christian Campagne from BAM)

A gathering and presentation like this shows the astonishing authenticity of this man. These can be tricky waters for him, as his early Beer Summit and his more recent comments on Trayvon Martin have shown. Adversaries are always waiting for him to "play the race card": They want to hear him complain about institutional racism and how it prevents minority progress (presumably due to white prejudice and dominance); and they especially want to find ways he is trying to provide special programs and privileges for the "victimized" minorities, at the expense (presumptively) of whites. And we shouldn't forget the GOP trope that being your "Brother's Keeper" leads you into the dreaded territory of communalism and away from the sacred ground of becoming a "job creator". And, finally, there's the always lurking possibility that this will be one more Obama effort to enlarge the domain of Big Government at the expense of individual and family.

All of these needle eyes were "seamlessly" threaded. A bravura performance, and even Bill O'Reilly rose at the end to shake the President's hand.

But I want to highlight something else: the tangible, visible-while-invisible connection he establishes and demonstrates with Christian from BAM (Becoming A Man), and with all the boys/young men gathered behind him. Watch how the President listens to Christian's introduction of him, making occasional gestures or expressions, but mostly holding himself quietly, so the attention wouldn't shift from young Christian to him. Notice both of their movements and expressions when Christian tells the audience what the President had shared a year ago "in Circle" with the young men from BAM - that he had, in fact, goofed off from time to time in school. Notice the quiet dignity and diligence with which the President connects with each young man, including a touchingly long head-on-the-President's-shoulder hug with one boy, before he leaves the room.

This is pure Presence - being right here, right now, and nowhere else, with a Beginner's Mind and an Open Heart, focusing so completely that the small "s" self (the Ego, the Busy Mind) drops away, and Big Mind/Big Heart is what is there. The pure and utter Mastery of the Peaceful Warrior. Our President as Integral Leader.

And I haven't even talked about the program itself! Wonderful public-private partnership with multiple, and varying players, depending on the location (city by city). $200MM in new Foundation support, over and above the initial $150MM commitment. A great call to minority families, particularly fathers. And a powerful call to each young man present (and those watching at a distance) to personal responsibility and hard work.

In and through it all, we see and experience our President demonstrating great personal mastery.

I am Privileged, So Some Learning is Hard

That's my picture. Pretty well sums it up. More precisely, it sums up a certain dimension of "me": white, male, physically large and strong, probably affluent and well-educated (sort of looks that way and it's true) - in short, privileged. I have never faced "negative" discrimination, where I was treated badly because of what my outside appearance "said" to people I would meet. Lots of "positive" discrimination - special preferential treatment, most likely because the experience of power, of being powerful, becomes a habit, an assumption, that is somehow carried in the body, and people recognize it. Also, I look like an overweight, but still passable linebacker - someone you don't mess with if you don't have to. And yes, I have resources. I am part of the 1%.

I simply have no idea what it's like to be looked at and immediately disliked, despised or merely diminished because of what my appearance communicated to the onlooker about my status, my relevance, my power. In business deals through the years, I have experienced being looked at as an object, with certain measurable assets those I was negotiating with wanted; but this was a game, a ritual that had a beginning, middle and end - and I was doing some of the same myself. I really have no idea what it is like to be looked at as an object all the time, an object with presumably desired functions (sexual pleasure - a woman; physical or mental output - workers as mere inputs to production; and the like).

It's not that I haven't experienced vulnerability and, from that place, fear: My Mom was ambivalent about herself, and therefore me. My Dad always was, and remains (as an active, still curious 97 year old) like a god. I grew up suspecting Mom was right and I would never measure up. Failing terrified me and was not an option; so I did what I was good at (academics) and avoided what I wasn't so good at (sports, social life/friends). Girls were difficult, but sex was terrifying, and remained so for a long time. So I have experience of vulnerability, but none of discrimination based on "outside stuff".

So learning to enter the mind-space of people who face discrimination as part of their daily life is hard. And that's why this article in yesterday's Atlantic.com by Ta-Nehisi Coates is so important. TNC is talking with Lucia McBath, the mother of Jordan Davis, who was gunned down by Michael Dunn because his music was too loud. TNC, using his own words and those of Jordan's mother, recreates for us the mind-space of the black, male teenager with language and images that first bring me into his head, then Lucia McBath's, then Jordan Davis' , then TNC's own 13 year old son who came with his Dad to the interview, and then into the lovely and mysterious mind recesses of our own children and grandchildren - those spaces we take and have some responsibility in forming, defining, and inspiring. Reading TNC's article I was at once a bit ashamed, in awe, and deeply grateful; because we one per centers have a lot of work to do, and we cannot easily do it by ourselves. We need the firm hand and inspired guidance of Ta-Nehisi Coates and those amazing soul teachers like him. Excerpts:

Last Thursday, I took my son to meet Lucia McBath, because he is 13, about the age when a black boy begins to directly understand what his country thinks of him. His parents cannot save him. His parents cannot save both his person and his humanity. At 13, I learned that whole streets were prohibited to me, that ways of speaking, walking, and laughing made me a target. That is because within the relative peace of America, great violence—institutional, interpersonal, existential—marks the black experience...

She stood. It was time to go. I am not objective. I gave her a hug. I told her I wanted the world to see her, and to see Jordan. She said she thinks I want the world to see "him." She was nodding to my son. She added, "And him representing all of us." He was sitting there just as I have taught him—listening, not talking. 

Now she addressed him, "You exist," she told him. "You matter. You have value. You have every right to wear your hoodie, to play your music as loud as you want. You have every right to be you. And no one should deter you from being you. You have to be you. And you can never be afraid of being you."


She gave my son a hug and then went upstairs to pack.

I have Tears in my Eyes

(from theobamadiary.com)

Watching Michelle Obama talk to the cast of "The Trip to Bountiful" and to the assembled young college students, moved me to tears. What is it about the "zone" in which the First Lady spoke, and that same zone she easily evoked in me, that moves me so? Such hope. Such confidence that this will all work out. Her energy. Her call to action to the students: (more or less, she says) "To carry on the work (of Cicely Tyson and Carrie Underwood), you must get right. You must get right in the head (pointing to her left temple). You've got to be clear, solid, centered. And you will be. You will take up this banner, taking the mantle from us, and carry this work forward..."

How utterly marvelous!

Obamacare: The Central Objective

(from acasignups.net)

This is the most recent enrollment status from the remarkable Charles Gaba, who appears to have put his entire life on hold for 6 months to provide really good reporting of the ACA numbers. We are all blessed indeed that Charles has made such a generous commitment. Today I want to focus on the Medicaid numbers - the big purple section in the middle of the graph.

Conservative pundits have attacked the gross Medicaid enrollment numbers (reduced only by renewals, which Charles has been able to separate out) - 7.16MM shown above - saying much of the volume comes from already eligible people signing up, not the newly eligible under the ACA Medicaid expansion. So he strips out all enrollment in the non-expansion states plus numbers of those enrolling in expansion states who were already eligible before ACA, and simply "came out of the woodwork", and gets a rock bottom number of 2.60MM. For a number of reasons, I think something closer to the 7.16MM is closer to the mark. Take a look at this chart from Kaiser:

Looking at this, I would have predicted a 55.5-56.0MM forecast for 2014, based on extending past trends. So anything over, say, a 1MM increase in enrollment for 2014 must be due to the ACA's impact: some people signing up will be newly eligible under the new ACA eligibility rules; but many will be listening to the national debate, paying attention, and finally signing up, though they had already been eligible.

So let's take 1.0MM off Charles upper range number, and we get 6.16MM for Medicaid through mid-February and 3.31 on the Exchanges (excluding unpaid and off-exchange). Where will that leave us by March 31? My guess: Exchanges - 5.5-6.0MM, Medicaid - 8.5-9.0MM (after deducting 1.0MM for normal growth). In other words - short of target on the Exchanges (7MM target) and pretty close on Medicaid (9.0MM target).

But here's what I learned today: Medicaid enrollment continues throughout the year through the Exchanges and direct to state Medicaid offices. Larry Levitt at Kaiser said a drop off in monthly enrollment is expected for Medicaid, but that the signup process will continue through the year.

So how many will signup by year end? Very hard to tell, but how big would that number have to be to make the original goal of reducing the number of uninsured in 2014 by 14MM? If 5.5MM is the Exchange result, and 2.0MM of these were previously insured on the individual market, then this is a 3.5MM reduction in uninsured. To hit the 14MM original target, Medicaid would need to generate 10.5MM new signups by year end. And this looks to me to be very achievable.

This is a big deal and my guess is that very few people know about it: Medicaid enrollment numbers will keep coming in after 3/31, and we may well be hitting the original overall target of reducing the uninsured by 14MM in 2014 around the November election day.

This should help Democrats in the coming midterms.

Is the Light Breaking Through?

I must say that Avik Roy's Forbes article surprised me a bit. I am so used to conservative pundits not engaging the facts honestly, so when one of the ACA's most severe and continuing critics puts out the above, I stop and take notice.

Now that the GOP has failed to stop or significantly change the ACA legislatively, there are only a few ways the law could be thwarted:

• If nobody signs up.
• The howl from those hurt by the bill ratchets up big time.
• A premium "death spiral" - premiums continuing up and enrollment down.

Enrollment looks solid. We will probably top 6.0MM, which is the CBO's revised forecast. Right now 20% haven't paid month one's premium. Suspect we'll be in the 5-10% unpaid range by the end of April. So we'll end Open Enrollment with solid numbers, a bit behind forecast, with no reason to change the forecast for 2015. At least that's the CBO's determination.

Medicaid numbers are confusing: How do you count new enrollees in non-expansion states? How about people who enroll in expansion states but were actually already eligible? Should the ACA get credit for raising awareness such that already eligible folks finally come in and sign up? These are good and legitimate questions. The way acasignups.net is doing it is to show a range, which right now goes from 2.5MM up to 7.7MM. I end up about splitting the difference, saying 5.4MM signups (expansion states only, includes enrollees who were already eligible). Original CBO forecast was 9.0MM, now revised to 8.0MM. We should hit this number, though conservatives will argue loudly for a lower number, stripping out the already eligibles. For Mediacid as for the Exchanges, the CBO has not adjusted forecasts for 2015 and beyond.

So enrollment looks fine. How about the complaint level? Conservatives have been waiting for another shoe to drop when small businesses have to renew their coverage for 2015, moving up to the often stiffer requirements of the ACA. They have also been expecting blowback when the employer mandate goes into effect for 2015 and employers have to "face the music". So when the Administration recently delayed the employer mandate for companies with under 100 employees for another year, conservatives were beside themselves. Given all that, here's my best guess:

• The small business move to ACA compliant plans will cause some problems, but no significant disruption. Unlike the individual market where people receive cancellations directly, for small businesses there will be some HR individual who will plan for and mediate this change. Employees will often have to pay somewhat more but this bump will be absorbed.
• Delaying the medium-sizes employer mandate was good strategy - spread out the sometimes painful ruffles and give companies more time to plan and adjust.
• Large companies will not make substantial changes with their mandate kicking in for 2015. Almost 95% of these firms are already offering ACA-compliant plans; so no need for wholesale changes. Company costs will go up and part of this will be passed on to employees; but this is nothing new. And when Home Depot or Target cut some of their part-time workforce loose, it's because they know that with subsidies, the Exchanges will provide a better deal for their people.

So what about the dreaded premium/enrollment "death spiral"? As I've been saying for some time, and now Roy is agreeing, it won't happen. Since there are 50 different state marketplaces, we will most likely see some places where premiums spike, or insurers pull out of the market. But it seems that most of the insurance industry agrees with the Wellpoint CEO, who told a recent conference that he was pleased with the numbers coming in, that pools seem pretty balanced versus their estimates, and that they believe these Exchanges represent a great opportunity for the future. My guess (unchanged): 2015 premiums will be up 5% or less as an overall average.

Will the GOP come together on a plan and push it out as an ACA replacement as Roy advocates? The Coburn-Burr-Hatch plan in the Senate is a possibility; but I don't think they'll organize behind it - they just don't want to give Dems a way to shift the conversation away from the ACA.

Will this work? It might and it might not. The real question for the midterms is who will show up? The normal midterm skews older with fewer minorities, a mix that is favorable to Republicans. In 2010 this is the electorate that showed up, with a fired up and angry white working class base, leading to the GOP wave victory. What if the ACA is generally thought to be working by summer, and no one is really being pummeled, and the economy is improving - might the "angry base" stay home? Could Dems convince more Hispanics, other minorities and single women to show up more than they normally do?

It's possible - not likely, but possible; which is why I forecast the Dems to hold the Senate and gain a few in the House.

Faith and the Integral Leader

Be sure to read Nancy's post first.  A wonderful look into our President's faith life. The question I think Nancy is asking is: "How does Obama's description of his interior faith life align (or not) with your understanding of how other integral leaders describe their faith?" In other words, are there characteristics of faith that integral leaders have in common and does Obama "fit the model"?

My answer to both questions is: Yes - there are ways of being in faith that integral leaders share, and President Obama is clearly an exemplar. But before going to Nancy's question, I want to put down some basics of integral developmental theory. For a much better view, read Ken Wilber, particularly (to begin) his A Brief History of Everything; or visit his website, and/or spend some time browsing at the extraordinary integrallife.com: 

The idea of levels of development comes from the fields of developmental psychology and education. 

To summarize briefly:

• There are stages/levels of consciousness development that are potentials for everyone, related to but not synonymous with the stages of life (infancy, childhood, adolescence, adulthood, older age).
• The stage/level names vary somewhat from one theorist to another, but there is broad agreement on the following six developmental levels: 

1. archaic (the infant; self/reality fused; no differentiation); 
2. egocentric (the child; self is differentiated but world is self-centric; can't take perspective of another; pre-operational, often magical thinking; tribal social structure; gangs); 
3. traditional (the adolescent; can take another's perspective;  group membership is central; black and white/concrete thinking; authoritarian/hierarchical structures; the time of myth in religion; truth is "revealed" and absolute; low tolerance for deviance from the true faith; witches and heretics are burned; Europe's dominant mode of thinking before the Enlightenment; American exceptionalism as absolute (no bowing to dictators); fascism; terrorism; fundamentalism; Tea Party) ; 
4. modern (the adult; formal operational/what if-as if/reason-based thinking; can take multiple perspectives; one's role is key to self concept; the Enlightenment perspective; universal rights/the Rights of Man; democracy; the scientific method; "Does it work?" is the value test; interiors are split off and diminished; systems are seen and studied; the "Invisible Hand"/free market capitalism; competition; Darwin/Social Darwinism; American exceptionalism (based on US as Superpower); winning matters; Wall Street; Republican Establishment; some/many Democrats);
5. plural/postmodern (cultural creatives; holding many perspectives but privileging none; aperspectival; interiors are back; the sensitive/spiritual self; "I am spiritual but not religious"; hierarchy detested; organizations distrusted;  marginalized groups are seen/supported; civil rights; feminism; environmentalism; LGBT rights; deconstruction of universal truths and meta-narratives; rewriting "Eurocentric" history to focus on groups marginalized by the "dominant" power structures; all truth is relative (except the rule that truth is relative; that rule is absolutely true); anti-war; anti-surveillance; world centric with no enforcement-capable governance structure;  America is not exceptional (we have much to apologize for);  many Democrats; all strong liberals); and 
6. integral (vision/logic as mode of thinking; searching for patterns and emerging wholes; the Deep Currents/not the Surface Storms; the "parts" (blown apart in the prior period) cohere again and now form "emerging wholes" this level can discern (not invariably, but consistently); truth returns - not as static absolute, but as evolutionary process; evolution is "going somewhere" - towards higher levels of complexity, broader and deeper levels of awareness, greater human interconnection; strange attractors (the Good, the Beautiful, the True), lying in our future - not in an archetypal past, call/urge us forward; for the first time, evolution becomes aware of itself and participates consciously in cocreating the emerging future; deep acceptance of transcendence, of Spirit/God as both Source and Destination; the mystical level of all the world's religions (little dogma, many spiritual disciplines and practices, focus on values - but as a way of being, not merely rules); complexity is welcomed; paradoxes are not solved - they are embraced as spaces of interior tension where new insights can emerge; the Warrior returns as Master Peacemaker who desires Peace and understands that War is sometimes necessary to ensure it; a self-enforcing world governance structure is now possible).

CBO Report - Budget Outlook 2014-2024

This is the Cover Page of the recently released CBO 10 year Budget Outlook. Most of the talk you have heard has focused on the effects the ACA might have on jobs. Conservatives claimed the CBO Report documents that Obamacare is a job-killer. Progressives quickly, and accurately responded that giving hard-working folks a chance to work less, because their healthcare is no longer tied to their work, does not represent any reduction in jobs. It signifies a voluntary decrease in the labor supply, which might even tighten that supply in some markets, and improve wages for those staying in the market to work. The Conservative case is very weak, which many now admit. So will not comment further on this. The CBO did reaffirm its earlier enrollment forecasts, while acknowledging that Year One might be a little short:

• 6MM Exchange and 8MM Medicaid enrollees expected in 2014 down 1MM in each category.
• Years 2 and 3 will see the shortfalls made up with total Exchange enrollment reaching 25 million and new Medicaid hitting 13MM.
• As originally forecasted, employers over time will reduce insurance coverage for 7MM workers and the Non-Group market will shrink by 5MM.
• The pool of Uninsured will shrink from 55MM to 31MM, a 24MM drop.

So nothing in the CBO forecasts has changed, except for timing. This is great news.

What I want to focus on now is the 2014-2024 forecasts and what they say about the country's economic health and financial stability. Here are some summary comments.

• As the above cover image shows, deficits will drop in 2014 and again in 2015, before starting to move back up.
• Mandatory expenses (Social Security, Medicare, Medicaid) go up as a percentage of GDP. Discretionary spending goes down as a percentage an equivalent amount. What causes the deficit to start growing again in 2018 are interest costs, which are returned to their "normal" levels of 3-4% on 90 day Treasury Notes and 5% on 10 year Bonds. I think the CBO is probably wrong here, and will show you what happens if we cap the average rate Treasury pays at 3% (mix of short notes and long bonds).
• Believe CBO has accepted the fact that a transformation of the healthcare delivery system is well underway and that it will continue for the foreseeable future. Real healthcare costs per capita are forecasted to grow at just 1.5%, well below the growth of real GDP per capita. This is great news, and should result in a solid improvement in the deficit and debt picture, when the CBO publishes their Long Term Outlook, most likely in June.

Warriors-in-Training: Study This

Warriors need to be unflappable. If they do demonstrate anger, it's their choice. They are never triggered by events (including aggressive interviewers) outside themselves.

I am 72 years old and retired. I have studied the Warrior's Path of mindfulness and presence for more than 20 years. In many respects, I have achieved a certain mastery. But watching the President stay inside his center of silence and peace, I know I still have a long way to go. This is Mastery. Not a type of personality given at birth. Self awareness. Non attachment. Beginner's mind. Holding the paradox that there is no enemy and I am facing a dedicated adversary. Remembering Jesus; "Be gentle as a dove and shrewd as a serpent." Both - at the same time. 

Staying fully present within the embrace of your larger commitment, your North Star. Can you feel the internal power of the President's words, saying (more or less), when stuff happens, I/we stay focused on doing what I/we can to help the average person do a little better? His mantra. It's what he would say under truth serum. It's the central beat of his mental and spiritual heart. This North Star of his organizes even his internal spaces, and provides an energy shield or buffer when missiles are incoming. Yet "shield" is the wrong image. Nothing is defended. What happens is you become transparent, frictionless, and the arrows pass right through you. You don't contract around the arrow, so it doesn't dig in and impale you. You are fearless. Fully and always present. You see the arrow coming. And you relax, open yourself even further up. No tightening. No contraction. And the bad stuff passes right through you.

Mastery, as the President demonstrates it, is what poet Jack Gilbert called "...the edited conclusion of being, the normal excellence of long accomplishment."

Mastery is earned, not given. Ever.

Beautiful Indeed!

Our ability to celebrate diversity is America's greatest asset. Now and for the long term.

Morning Notes to Myself

I just finished writing these down in Notes, then concluded that they are reasonably intelligible, so here they are:

What’s Going On?

1. Economy is strengthening: removal (relative basis) of fiscal drag (4th qtr showed .98 % Governmentt drag - this will go to 0); good consumer spending; continued improvement in Net Exports, based partly on falling oil imports; fair investment levels (slowdown in housing), plus ACA. GDP growth in the 4th quarter was 3.2%; 2014 could average 4%. This will have the US as the fastest growing developed economy (China, an emerging market, will slow down to 5-6% range).
2. Obamacare-Announcement from US’ largest insurer-Wellpoint: enrollment good, pool as expected, holding earnings forecast-takes most of the uncertainty out-ACA is on track.Ezra Klein’s point this am in Bloomberg: many signups from folks who had insurance; the big deal, not yet focused on, is that our total healthcare delivery system is moving from “quantity to quality, coordinated care vs. isolated procedures, and data driven, evidence-based medicine vs. intuition and individual experience only”. Part of the conversation may shift to this larger perspective. Just released Health Affairs/CUNY study of red state/no Medicaid expansion showing 7-17,000 increased deaths, hundreds of thousands of increased depression cases, missed diabetes treatment, missed pap smears/mammograms, missed cholesterol screenings, missed blood pressure tests. Plus ACA cuts uncompensated care payments to hospitals in these states; hospitals must cover uninsured in ER; lower uncompensated care reimbursement puts pressure on hospitals. This could be an election issue in red states.
3. GOP P CARE: No Medicaid expansion, so poor (<100% FPL) adults w/o kids have no coverage. Subsidies to cover catastrophic events for 100-300% FPL offered to small business employees and people w/o employer coverage; presume this will change to all folks w/o employer coverage, but perhaps not. Auto enroll ensures big signup. No preexisting conditions if continuous coverage maintained. Uninsured will have one time open-enrollment period where they will get this benefit. ESI exclusion capped at 65% of cost of Cadillac plans: this will either be a tax increase on workers with big plans, or those plans will be cut way back. If a tax increase, this means middle class is funding the plan (not wealthy or business); if no tax increase results, no funding. No coverage for poor adults w/o kids. Near poor only get catastrophic coverage, w/o prevention services. Middle class is funding the uninsured through tax hikes. If not, plans reduced and no funding. Medicaid shifted to defined contribution/block grant program. Preexisting gets handled only through continuous coverage. If this is seriously pursued by GOP, will give Dems big ammo:”Which do you want, our plan or the GOP’s? You must make a choice.” Will GOP push this? Don’t know. Possible.
4. Immigration-Everyone will describe GOP plan as just a slower path to citizenship (legalization). That’s why Dems might accept it. This could pass the House with a lot of Dem votes. If Boehner rules out going to Conference with the existing Senate Bill, then Senate could take up a version of the House Bill, presumably closer to their own, and Conference on that. I’ll go 60-40 that this happens before November. What election impact? Primaries will be more divisive. And this might cause primary losers to stay home.
5. GOP will back down on debt ceiling. Compromise will be reached on UI. Dems will launch state-by-state effort on Minimum Wage.
6. Election forecast: Same. Dems will hold the Senate; pick up 3-5 in the House.
7. Iran - there will be a deal.
8. Syria - discussions will continue sporadically. CW will eventually be removed. Some agreement by year end.
9. Israel-Palestinians - 50-50 for a deal by year end
10. Polls - Obama-back to 50% approval by election; Obamacare - 50% approval by election.

This is not a Loyal Opposition

Letter to a Thoughtful Conservative on Healthcare

A very thoughtful, economically conservative, socially moderate friend of mine asked me to put down some thoughts about how I would improve Healthcare, with attention paid to the problem of young, middle-class, upwardly-moving folks; who are out on their own; who probably had their individual policies cancelled; who are above $40,000 in income and therefore don't get subsidy support; and who find the new ACA policies asking them to pay for more insurance than they want or can afford. He asked me to try and suspend my desire to support Obama and his policies. Here is what I wrote:

In September, CDC will publish Early Release data from its National Health Interview Survey. It will cover Jan-Mar 2014. This will be the best data on how many are uninsured/insured and trends in those numbers. They don't appear to have a question that would show stats for people who were insured but now are not (the 6MM cancellation group), and data is collected all through the quarter; but we should get a good indication of how the level of uninsured is dropping.

Kaiser and others will do insurance company surveys that will show coverage trends in the individual market: What's happened to total market? ACA vs. non-ACA compliant policies, on or off-Exchange. By September, we should know how many in the non-group market are opting out for 2014. 

Hypothetically, let's say Kaiser estimates that 1MM individuals have chosen to opt out. Presumably they will have done so because the ACA-compliant policies were too expensive for what they felt they needed or could afford. As I understand your thoughtful comments, these are the folks you are most concerned about: the up-and-coming, young middle class who are trying to build a personal economic base and can't afford to put 10% or more of their income into health insurance they don't think they need.

It's just that I'm not sure they've been hurt that much: Inconvenienced, frustrated, pissed off...yes, for sure. But they can pay the penalty and be way ahead economically. Then if they get sick, they quickly buy coverage and not too much will have been lost. This is the argument used by a host of conservative analysts arguing that because of this, the young and healthy won't sign up, and the system won't work. No harm, no foul, I might say. Since the penalties are so low, they can free-ride until sick, then signup with little lost. Pretty good deal, if you don't need the mental reassurance that you are already/always covered.

So if no one is really hurt economically (they surely have been inconvenienced, and may well express their frustrations in how they vote), then the ACA needs to be judged on whether it works, measured by enrollment, reduction in the numbers of uninsured, pool balance, premium trends, insurance company state-by-state participation and degree of financial success in Exchange markets, levels of reinsurance activity, and customer satisfaction with the often narrow networks. By October, we'll know a lot of this; and we'll be able to project pretty well for 2015.

I think the program will work well. And because I think this will be reasonably clear before the mid-terms, I'm predicting a modest election uptick for Dems (+3-5 in the House; hold the Senate). I am confident about ACA's coming scorecard; I'm much less confident this will be seen and rewarded by voters. Specifically: I give 80% odds to my ACA forecast (6-7MM Exchange signups, 10-12MM Medicaid enrollment, 14-16MM reduction in unemployed by end of 2014 (not sure about the Jan-Mar NHIS data), reasonable pool balance, only small premium increases for 2015, increased insurance company involvement in 2015, and continued healthcare cost slowdown despite a growing 2014 economy). I only give 50-50 odds, however, to my political forecast (Dems holding Senate; small pickup in House).

I don't say this because I'm an Obama fan. These conclusions don't come from a desire to beat up on Repubs. This is what I see happening. And because these conclusions have been well researched over time, the new system I might design would not vary much from what we have. Tort reform would make sense; but letting the young/healthy carve themselves out of the central risk pool with narrower policies does not, in my opinion. Possibly the subsidies should be beefed up in the 250-400% FPL levels. We should consider raising the top end to 500% of poverty for a family of four (approx. $115M). Otherwise, assuming I'm right that it will work as defined above, there's not much to change.

Two more points:

First, the cost curve has been bent downwards. Healthcare providers are moving away from fee-for-service towards just emerging new service and payment forms that will reward quality, coordination of care, and new delivery methods that reduce system utilization. They are moving to EHR aggressively, which will enable this productivity improving, cost-curve bending, system-wide change. In fact, I believe this highly complex system (medical care delivery) is beginning to self-organize around a new productivity improvement identity;that the cost curve bending is taking on a life of its own, and that the "half-life" of this system change will be long. This is the complete opposite of top-down, command-and-control org change. This is almost the only kind of big org change that works. I predict that the CBO wonks will have figured this out by  the time they issue their 2016 Long Range Budget Outlook in June, 2016. At this point they will drop the tried-and-true excess cost growth out of their forward calculations, and their forecast will show stable debt/GDP levels looking out, which means Medicare is sustainable and the US is on solid economic footing for the long haul.

Second, the trend to consolidation in the hospital/doctor space will accelerate. If coordinated care works best in Mayo or Cleveland Clinic formats, and those are the low-cost/high productivity models that work, the industry will move away from fragmentation towards "smokestack/silo function" coordination. It's already happening, as you know. But this will be a full sea change.

That's my forecast. And I'm excited about gathering the data as it comes in.

Why are the One Percent So Thin Skinned?

(AP Photo-Tom Margot)

From The Wall Street Journal, Letters to the Editor, last Friday:

Regarding your editorial "Censors on Campus" (Jan. 18): Writing from the epicenter of progressive thought, San Francisco, I would call attention to the parallels of fascist Nazi Germany to its war on its "one percent," namely its Jews, to the progressive war on the American one percent, namely the "rich."

From the Occupy movement to the demonization of the rich embedded in virtually every word of our local newspaper, the San Francisco Chronicle, I perceive a rising tide of hatred of the successful one percent. There is outraged public reaction to the Google buses carrying technology workers from the city to the peninsula high-tech companies which employ them. We have outrage over the rising real-estate prices which these "techno geeks" can pay. We have, for example, libelous and cruel attacks in the Chronicle on our number-one celebrity, the author Danielle Steel, alleging that she is a "snob" despite the millions she has spent on our city's homeless and mentally ill over the past decades.

This is a very dangerous drift in our American thinking. Kristallnacht was unthinkable in 1930; is its descendent "progressive" radicalism unthinkable now?

Tom Perkins

San Francisco

Mr. Perkins is a founder of Kleiner Perkins Caufield & Byers

 I find Perkins' letter utterly stunning.  Josh Marshall at TPM is startled as well. He does a great analysis and puts it this way:

It is the mix of insecurity, a sense of the brittleness of one's hold on wealth, power, privileges, combined with the reality of great wealth and power, that breeds a mix of aggressiveness and perceived embattlement.

In the Review Section of last Sunday's New York Times Sam Polk adds an important perspective from his own, quite brief, hugely financially rewarding career on Wall Street: It's greed, he says. Pure and simple. As obsessive and as difficult an addiction to kick as alcoholism. Polk titled his article "For the Love of Money".

As Progressives, we need to understand the psychology of the One Percent. We need to be much smarter than the Neocons and the Right generally have been in their simplistic views of Iran. As best we can, we need to understand these One Percent folks at a visceral level.