Issue LXVII: Frozen in Time- A Theory of National Stagnation

24 Feb

A Polish nurse told me outside of Cleveland that she does not involve herself with the Polish-American community in Ohio.  “They do all this polka music that no one does in Warsaw.  It’s very old fashioned,” she said.

It is not the first time someone commented to me about how America is full of ethnic communities that are more conservative or old-fashioned or antiquated than in their nation of origins.  Cubans in Miami dream of pre-1959 Cuba while Indian-American parents raise their children in the India of the 1970s while Tony Soprano shouts at his daughter, “It’s the 1990s out there, but it is 1954 in here.”

But it isn’t just exiles singing “Guantanamera” on Calle Ocho lost in the world of today, Walt Disney modeled Main Street USA in Disneyland on his Missouri hometown of Marceline…. forever frozen in the year 1905.  Stefan Zweig, an Austrian author, mourned the destruction of Hapsburg-era Vienna after fleeing from Europe during World War II.  An American would not have written a memoir but had Vienna rebuilt it as a theme park of the mythic past.

Walt Disney was on to something though.  Perhaps Disney’s world is indeed our world; the United States is frozen not in 1905 but in the patterns and habits of 1600s England.


Why We Can’t Get Along…. or Evolve

Glance at a map of the 1860 presidential election and a map of the 2004 election.  How can so much have changed in 150 years (trains, plains, automobiles, Internet, highways), but we still have the same two archaic parties?  The Republicans morphed into the party of the South and Mountain West and the Democrats replaced them as the party of New England, the Great Lakes States, and the West Coast.

Mapping elections onto a map of tribal cultural boundaries (and not artificial state borders) excavates the political nostalgia to its roots.  Roughly, the Puritan culture of New England which spread west to the northern cities of the Great Lakes to the northern parts of the West Coast allies with the Quaker culture of Pennsylvania which spreads west through the central portions of the Great Lakes states.  The Puritan and Quaker regions approximated the Republicans and now vote Democratic.  The Cavalier culture of Virginia spread across the deep South and typically allies with the Borderlands culture of Appalachia and the upper South; once Democratic it has been electing Republicans federally for years.

The continuation of the Civil War via the two-party system has led to paralysis of any initiative at the federal level.  And I argue, it has led to a paralysis at the social level in our diverse American regional cultures; encased in amber in the 1600s as seeds from Albion.  In the absence of a positive national agenda, we mostly vote against the regions we dislike and babble about freedom, a word that has completely different meanings for each community.  We have federal elections talking who we are when we aren’t really one thing

What would evolution look like?

If American cultural regions had been split up into different nations or under a loose confederation like Canada or Switzerland, the cultures and politics could have evolved instead of just our technology and businesses.

Canadians understand they are quite different from each other and unite only for national goals of defense, foreign policy, and immigration.  Canadian Medicare is run separately by each province with some federal rules.  Correspondingly, their knowledge of their provincial governments activities is far greater than American knowledge of state government.

Regions have changed dramatically politically and socially, even in our own lifetimes.

Quebec for decades was in a conservative Catholic Dark Age until the Quiet Revolution of the 1960s.  Liberal Party rule switched to the independence minded Parti Québécois which dramatically lost power in the 2010s.  Alberta, a kind of cross between Texas and Colorado, has had five fascinating shifts in party control with the most recent in 2015.

The United States above the Ohio River could have become a more normal Western nation combining lumberjack radicalism of the Northwest with the intellectual brainpower of New England with the industrial might of the Great Lakes States.  It would be a greedier or more individualistic Canada, but it would be politically liberated.  The Minnesota Farmer-Labor Party and the North Dakota Non-Partisan League allied with New York and Milwaukee Socialists could have formed an alternative to the Democrats and the Republicans.  Without having to make electoral pacts with Southern slavery and Jim Crow like Franklin Roosevelt did, there would probably be universal health care, maternity leave, and guaranteed paid vacation.  The Quaker-Puritan regions could have dropped the navel gazing and dour provincialism as a nation or sub-nation.  And you couldn’t blame the filibuster and Dixie for a lack of progress.

Southern politics wouldn’t get to blame those far away New York and Hollywood elites for all their problems.  Instead the eyes would be trained on our modernized planter class, a class as vicious and anti-democratic as it was in the antebellum era.  Untethered from northern industry, the agricultural elites would have to decide how to develop without the Yankees footing the defense budget. Perhaps the South could have modernized via caudillo style politics like Huey Long and Big Jim Folsom.  The Populist Party might have won an election separate from the Democrats… or gone into an insurgency.  Populist or popular-left nationalists like Chavez, Aristide, Lula da Silva, and Michael Manley all seem possible in a post-slavery Southern society.  Instead we have the patently ridiculous picture of Ted Cruz looking for votes in the Bronx in a Republican primary.

Instead, we live like a gerrymandered African nation that forgot about the gerrymandering or our tribe of birth.  Amnestic to ancestry, we can only hark back to World War II to find a time when all of the states did something together.  Like Benjamin Button, history moves forward but we go backwards in time.

Issue LXVI: The Fall in Life Expectancy is a Fall in Expectations

19 Dec

American life expectancy has fallen for the third year in a row.  The Centers for Disease Control and Prevention has reported that life expectancy fell in 2015, 2016, and 2017.  That is two years of President Obama’s time in office and one year of President Trump’s time in office.  This is a bipartisan crisis.

This is an indictment of our political, media, and health care systems.  People are dying who shouldn’t be dying.

This simple fact should be repeated in the news day in and day out.  Local reporting and national media outlets should be targeting and following up on the hot spots of this crisis.

Absent a civil war or the AIDS pandemic in Africa, this has not been seen in international health.  The last time life expectancy fell in the United States it was 1993 during the height of the HIV epidemic.  That decline lasted a single year.  Three years in a row of declining American life expectancy has not occurred since World War I.

Only honest, independent criticism will fix this problem after a cold hard look at the facts.  We cannot treat unless we diagnose.

Since 2000, suicide has risen 18% in the United States while it has fallen 29% across the rest of the world according to The Economist.  The suicide rate (13.4 per 100,000 people) was below the world average and now it is above the world average.  It is now inching towards the high but declining rate of Japan, a nation once famous for seppuku suicide rituals among samurai.

Much of this is due to much laxer gun laws in the United States than other nations since firearms are a common method of reducing suicide.  Australia famously saw a large drop in murders when it passed gun control laws in the 1990s, but the effect on suicides was even larger.  Suicide rates vary between states but are high in states with high gun ownership rates (Alaska) and lower in states with fewer guns (New Jersey).

But the gun issue would be misleading in the American context as the percentage of households owning guns has been declining or at least stagnant since the 1990s.  The rise in gun sales is going to existing gun owners (more guns in fewer households) not to families who never owned guns in general.

What instead is occurring are “deaths of despair” as Nobel Prizing-winning Princeton economist Angus Deaton put it.  The rising gap between rich, poor, and middle class is also killing people on a grand scale according to the Dr. Michael Marmot at University College London.  Inequality is bad for your health.

The striking increase in death rates in the United States is driven by whites without college degrees.  One would first think that this is related to the opiate crisis of the last few years, and one would be partially right.  However, drug, alcohol, and suicide deaths have been rising since approximately 1990.  It is thought to be linked to the lack of steady, well-paying jobs which began to disappear for the high school-educated in the 1990s.  The increase in the Hispanic population (which paradoxically has lower mortality rates than whites) may have masked these life expectancy declines because they live three years longer than non-Hispanic whites.

The closest international analogy to the United States is the former Communist bloc nations of Eastern Europe and Russia in the 1990s.  The economic collapse of Russia after the fall of the Soviet Union led to millions losing their guaranteed jobs for life.  The government privatized state-owned companies and cut back massively on the public health system.  Joblessness skyrocketed and suicides and alcohol abuse did too.  Male life expectancy fell almost a decade to 57 years.  People stopped having children too.

Obviously, the health and economic situation is not nearly as dire in the United States today but there are parallels such as the dramatic drop in young people having children since the recession.  Companies who provided jobs for life such as General Motors and IBM with generous pensions benefits did not go out of business like in Russia but began to end those guarantees for new employees while downsizing the overall headcount.  Public spending cuts supervised by the International Monetary Fund increased tuberculosis deaths in Eastern Europe.  American budget austerity has likewise contributed to the dramatic increase in STDs including gonorrhea and syphilis after reaching record lows.

At the end of the day, the blame for the three-year fall in American life expectancy despite the increase in the percentage of people with health insurance points to the importance of the social determinants of health.  A health care system focused completely health insurance payment models than actual people’s health is a product of a political system focused completely on campaign profits than actual voter’s social, job, and health needs.  America’s politics is actually making us sick.


The Economist –Suicide is declining almost everywhere

National Public Radio – “Deaths of Despair



Issue LXV: Myths and Lies of the Quality Industrial Complex

16 Dec

The Cost Conundrum Re-visited

A pediatric pulmonologist at a prominent Midwestern children’s hospital told me a story about a conversation he had in Iowa City. When he was in training, a faculty member bragged about how he had the best asthma outcomes in the nation. He felt like the medical school, support staff, and community were doing better than anyone else. A visiting pediatrician from Georgia laughed, “Guys!  You are in I-O-W-A. I am in Atlanta. Of course, you have the best results. It’s completely different here.”

Anyone who has been to Iowa and Atlanta would easily notice the difference. I have not been to either, but I have practiced medicine in three different states in many different clinics and hospitals. It is very obvious that geography, poverty, economics, and insurance plans matter more than what the physician or hospital does for any given outcome.

This basic truism is not remarkable except when you realize that the entire health care debate of the Obama era consisted of ignoring these basic facts. If you follow the elite popularizers of health policy amongst the neoliberal press, you may believe that the United States faces an epidemic of unnecessary care by greedy physicians. This creates some regions with high spending and poor health, some regions with low spending and great health, or a mixed picture. Why would that be true?

Dr. Atul Gawande’s famous 2009 article about excessive Medicare spending in McAllen, Texas in the New Yorker revolutionized the conversation. He argued that the very high Medicare spending in McAllen must be due to greedy hospitals and physicians bilking insurance for more services (hospital days, office visits, scans, procedures, and prescriptions) than anywhere else in the United States. The volume of patient services must not be justifiable.

President Obama recommended his Cabinet to read it. According to Gawande, 30% of health care spending in the United States was “of no obvious clinical benefit” (aka waste). Peter Orszag, Obama’s budget director, evangelized these results to Congress and the media. To make the Affordable Care Act affordable, federal health policy should begin to equalize spending between high and low spending regions while maintaining quality.

Based on a once obscure dataset called the Dartmouth Atlas, federal health policy shifted towards justifying and measuring “quality” to prove effective care throughout the nation. Accountable Care Organizations, Big Data, and integrated care delivered via electronic medical records became the mechanisms to do this. Medicare introduced free market correctives such as non-payment for medical errors and “excessive” readmissions and rewards for patient satisfaction and electronic medical records.

The problem is the diagnosis is wrong; therefore, the carrot and stick solutions will fail too. American health spending is high not primarily due to waste or widely different practice patterns that can be easily quantified and equalized. It is a lie on the level of Bush’s missing weapons of mass destruction but with more annual American (not Iraqi) casualties and financial havoc on the lives of physicians and patients. Just as members of the congressional committee on intelligence did not know the difference between Sunni and Shi’ite groups in the Middle East, the federal bureaucracy cannot spot the difference between low spending Utah and Dubuque, Iowa and high spending Miami and Los Angeles.

These lies need to be exposed and fought the way CNN’s Jake Tapper’s misleading comments about Medicare for All were. Here is a short rebuttal of the Quality Industrial Complex’s insistence that American spending is high because of unnecessary health care usage.

Costs = Prices x Volume

Revenue in any business or organization is equal to price multiplied by volume of units sold or used. Businesses can have large revenues selling many items cheaply (Wal-Mart) or few units expensively (Luis Vuitton). Which company is the U.S. health system?

Well, neither. It’s more like a Marc’s or Ohio Discount Drug Mart with Luis Vuitton prices. The late Princeton economist Uwe Reinhardt analyzed prices and volumes throughout developed nations and concluded in 2003, “It’s the Prices Stupid.” The United States had astoundingly high prices but average volumes compared to other OECD nations. A complex analysis performed in the March 13, 2018 issue of the Journal of the American Medical Association concluded again that the United States had very high prices and quadruple the administration costs but normal to below average volumes in most services: hospital visits, office visits, and drug prescriptions.

The United States stands out with its fragmented health financing, health spending, complicated tax breaks, and multiple public and private insurers. But one factor that stands out above all is the lack of standardized prices for hospital stays, office visits, surgeries, and prescription drugs. Not using monopsony power (purchasing monopoly via negotiations) to counteract physician, hospital, and drug monopolies, higher prices prevail.

Indeed, since the Affordable Care Act was signed and Trump’s inauguration, the biggest scandals have all been price related. There have been outrageous increases in antibiotic prices, murderous raises in EpiPen prices, large deductible and premium hikes, and ludicrous shortages of generic medications, and even IV fluids. The government has been powerless to do anything as there are no price controls in the Affordable Care Act.

High Volumes, High Poverty

What about high spending regions that have worse outcomes? Is that all a myth? No, not exactly. But it only puzzles someone who ignores another American exceptionalism: poverty. No other developed nation has such high levels of income inequality, concentrated poverty, residential segregation, and a meager welfare state, particularly for children and mothers.

Why would Miami, Los Angeles, McAllen, or New York have high health spending while Iowa and Utah and Grand Teton, Colorado have “low” spending? It’s obvious: the former have many neighborhoods of concentrated poverty, low education, and high income inequality while the latter do not. The late Dr. Richard Cooper, an oncologist and Wisconsinite, emphasized this difference in his posthumous book Poverty and the Myths of Health Care Reform. And since prices are high throughout the U.S., only volume can explain the differences in health spending.

Surprised to see his hometown of Milwaukee spending 35% more than the rest of Wisconsin, he performed ZIP code level analysis of the region and found that high utilization was occurring in a specific high poverty corridor. Indeed, Milwaukee is the most segregated city in the United States. Excluding the high poverty corridor showed usage in the Milwaukee region to be no different than the rest of Wisconsin, a state with less inequality and more education than the rest of the United States. He performed the same analysis and found the same results in New York City and Los Angeles. In one memorable chapter titled “Riding the A Train”, he demonstrated how life expectancies increased as one went from Harlem to lower Manhattan then went down again after entering Brooklyn.

This fact should not be surprising at all, as it is known to occur in all nations. Poor people are less healthy than middle income people who are less healthy than high income people. Michael Marmot demonstrated this with his famous Whitehall Study on the social determinants of health of civil service workers in Britain. Many mental and physical health problems have been shown to be affected by one’s job rank, education, and even type of contract (temporary or long term) internationally.

Ironically, the one American population that consistently gets medical and social welfare spending is the elderly. And the American health system, shockingly, has the highest life expectancy for those who make it to 65 in the OECD. If we had a similar investment in child and parental welfare, we might see the same results in infant and maternal mortality.

This insight makes the strategy of ignoring prices and poverty and focusing on patient volumes even more dangerous.

Perils of a Volume First Strategy

A volume first strategy focuses on the appropriate utilization of care in hospitals, clinics, and operating rooms. This would involve “integration,” “accountable care,” or “clinical coordination.” In actual practice, it just means mergers.

Solo physicians who made partnerships and then large physician groups are now selling these groups to hospitals. Community hospitals have become part of larger hospital chains.  The point of the mergers is to increase negotiating power with insurance companies, to force them to pay the highest rates. Physicians’ practices (now under hospital ownership) become much more expensive, with the same visit being billed with more expensive codes and with “facility fees”. While the doctors and procedure haven’t moved an inch, the charges have increased dramatically.

Typically, the largest of chain hospitals in any given region introduce their own insurance products, which restrict a customer’s ability to use any facility or physician that they do not control. Networks of “preferred providers” create confusing and costly “in network” and “out of network” charges for patients. Patient satisfaction scores, unwieldy EMRs, and clinical documentation initiatives have created a new tier of administrative employees to manage and monitor physicians’ behaviors.

The quality industrial complex has attacked physician’s autonomy and done nothing to reduce the unquestionably unusual part of the American health system by international standards– high prices and high overhead costs. The “P” of Prices is only getting worse. Instead of a few simple macro-regulations of price setting and global budgeting, hundreds of micro-regulations have been unleashed to control physician behavior and patient utilization. The following is a dramatic example.

Many people know about how patient satisfaction scores may have fueled the opiate crisis (leading to the deaths of thousands annually), but few may know about the Hospital Readmissions Reduction Program (HRRP). Heart failure patients are infamous for returning to the hospital soon after being treated for heart failure exacerbations. Medicare thought that reducing readmissions would save the health care system money. This program to reduce heart failure readmissions (volume control) at 30 days and 1 year was successful. The problem? Patients were not being readmitted because they were dying at home. This volume control program potentially killed 5,000 to 10,000 people as volumes decreased and mortality rates increased over 8 years.

The myth that a third of health care spending is wasted due to unnecessary usage as opposed to high prices, high administration costs and high poverty rates in the United States is probably just that, a political myth. The Darmouth-Orszag-Gawande gang have committed malpractice by perpetuating this fable across the political media. It is a fable popular in a Washington eager to justify spending cuts, attacks on clinical autonomy, and ignoring the real work of bringing hospitals, insurers, and pharmaceutical companies to heel.

November 7, 2018 – Texas Elections

16 Dec

Well Texas…. I know it hurts to see Lyin’ Ted win again, indicted Ken Paxton squeak by, and Dan “Bathroom Bill” Patrick close the door on us.

You know us, the open-minded and open-hearted, diverse and multilingual Texas. We who may not be wearing the cowboy garb of legendary lore, but we are legendary in our own way too. Legends in the frontier of human existence, science, art, and writing. Ideally as cosmopolitan as New Yorkers without the attitude and as relaxed as Californians without the brittleness. We who still go big like the old timers do but in the new economy and old. Cognizant of who we were and pushing toward who we should be.

Our time will come.  For in their grasp of victory drops the seeds of their destruction.  And we grow from this seed and rise to bring forth that future where we live large, dream large, and do large in all things for the world but not against it.

We are not a small, fearful people.  And for that reason our Texas – from Galveston to El Paso – will win.

Good night Texas. We’ll make it there one day.

Beto-casting the Election

3 Nov

I did the needful and stayed away from predicting the presidential election in 2016, but I cannot help but write about  my home state of Texas in this year’s hottest Senate election in the nation.

More money has been raised by Robert Francis “Beto” O’Rourke (D-El Paso) on his quixotic quest to unseat Senator Rafael Edward “Ted” Cruz (R-Katy) than in any other election in the history of the United States Senate.  Out of staters ask, “Does he have a chance?  Texas is so Republican anyway.  It’s just a pipe dream.”    Can Princeton graduate and former presidential candidate Ted Cruz really blow the first election for the Republicans in Texas since 1994?  No Democrat has won a statewide election since the George W. Bush re-election landslide of 1998.

Beto O’Rourke faces an even tougher climb.  No El Pasoan has ever won a statewide office (governor, senator, attorney general, etc.) since Texas became a state in 1845.  What’s the chance?  What can I possibly add to all the digital ink being spilt about this race?  I’d like to introduce the numbers.

Lowest Voting Star State

Texas has the lowest voter turnout of any state in the United States.  The Republicans took over Texas in 1978 when they began to appeal to young urban whites who had moved from out of state.  The bedrock of the Democratic Party was white rural old voters.  Houston and Dallas were the epicenters of the party when Bill Clements squeaked a win out in the 1978 (the map for that election is fascinating) to become the first Republican governor since the Civil War and Reconstruction.  As a child in Southeast Texas, I remember all the older white voters always punching their straight ticket Democratic vote and going home.

Forty years later we have a situation where older, rural and white voters are overwhelmingly Republican and the urban and young populations are the Democratic hot spots.  Only the Mexican border region has remained Democratic in the shift from 1978 to 2018.  In this new world, Beto O’Rourke’s Democratic base is going to be the same areas  as Bill Clements.  However, he has the advantage of the Democratic base vote on the border and being from El Paso which should drive up turnout.  The problem is the border region has some of the lowest turnout in the state and nation, especially south of San Antonio in the Rio Grande Valley.  All Ted Cruz has to do is rely on dependable voters who are above 50 to win and expect low youth and minority turnout to win.  Good turnout outside of the big cities helps as the suburban counties (especially around Houston) are all solidly Republican since the 1978-2018 transition.

FiveThirtyEight (which infamously predicted a win for Hillary Clinton) says there is an 79.1% chance for Ted Cruz to win and says the election will be about 52-47 for Ted Cruz.  The weird thing was that they predicted 6.9 million voters in Texas and now recently 7.1 million voters in this election.  Here is my feeling why the numbers are off and we are much, much closer to a 50-50 race than anyone realizes.

How many voters are there?

Not many.  Although, 15.6 million Texans are registered to vote, the average governor’s election has less than 5 million voters.  Turnout for U.S. Senate is about 4.8 million in non-presidential years sometimes less than 4.5 million.  The Republican usually gets 2.8 million at best but often even less.  The Democrat will earn 1.5 million votes usually.  The last even slightly competitive race for U.S. Senate in Texas was in 2002 where John Cornyn (R-San Antonio) beat Ron Kirk (D-Dallas) by about 500,000 votes (2.49 million to 1.95 million).  That’s not a lot of votes in a state that has around ten million non-voters.  Beto O’Rourke’s stated election plan was to bring 1 million nonvoting Democrats to vote in a midterm to win.  The numbers show that that would be more than enough to win a typical Texas race in a non-presidential year using the 2002 numbers.

But that’s not what has happened.  Turnout has skyrocketed in the early vote. Turnout as of Thursday night in the early vote is already 4.33 million in the 30 largest counties.  That excludes votes in 224 counties with 22% of registered voters and excludes votes from the last day of early voting and Election Day next week.  It’s highly likely 5.5 million people have already voted by today.  Millions will vote on Election Day as well.

If the early vote represents 53-55% of the early vote in a midterm, that is 10 million total voters.  That would be double any governor’s race in history.  If the early vote is 70% of the total vote, that would be 7.85 million total voters which is even higher than the revised FiveThirtyEight numbers of 7.1 million voters.

How Many Republicans are There in Texas?

Actually not that many for a state with 28 million people and growing fast.  Texas does not have party registration.  If voting is going to be at presidential elections, then we need to look at presidential votes.  There at best have been 8 to 9 million voters in Texas presidential elections this century.  Often less.

The Republican presidential candidate gets only 4.5 to 4.6 million votes.  Ted Cruz got 100,000 less votes than Mitt Romney in 2012 in his only statewide election (4.4 million).  More or less the best Ted Cruz (or any Republican) can hope for is to get every single Trump vote in 2016 and that would be 4.68 million.  Trump only won by 805,000 against Hillary Clinton.   The Democrats usually get 3.3-3.5 million with a peak of 3.8 million for Hillary Clinton who lost by the smallest margin in many years.

Again, Beto O’Rourke’s stated election plan is to get 1 million more Democratic non-voters to vote.  If he does that and has all of the Hillary Clinton votes and Ted Cruz keeps every single vote he got in 2012,  Beto O’Rourke will win by 4.8 million to 4.4 million.  If Ted Cruz gets every single Trump voter, he will still lose if O’Rourke’s stated plan works out by 100,000 votes.

I am not convinced every single 2016 Trump voter is going to vote for Ted Cruz, and I am not convinced every single 2012 Cruz voter is going to vote for Ted Cruz.  I find it hard to imagine that turnout could get into the 9-10 million range, and Senator Cruz still winning given the demographics and geography of non-voters in Texas.  Sen. Cruz will win millions of votes, but I am doubtful that there are many more Republicans left in Texas to get to vote.   If Congressman O’Rourke does everything Democrats have been saying they need to do in Texas, then he will win.

So what is my call?  I will still say it is 50-50 at this point and a toss up just like Cook’s Political Report says, and no one else does.   I also think this UT poll of Texas voters shows far more anti-immigrant sentiment (even in minorities) than I think is likely.  The same group at UT says that Cruz is up by 6 points.

Don’t believe the polls.  Go vote.  Anything can happen.







Health Reform Won’t Come from Boston or Buffet

27 Aug

The following is an op-ed that I submitted to a few daily newspapers about the hiring of Harvard’s Atul Gawande to reduce health care costs for three large companies.  No one accepted it so it now goes on the Bhatany Report.


The splashy venture to reduce health care costs by Warren Buffett, Jamie Dimon, and Jeff Bezos has now found their splashy new CEO, surgical oncologist Dr. Atul Gawande.  Their efforts will fail as will any private sector effort to reform our immoral, dysfunctional, for-profit health system.

The Harvard physician, New Yorker writer, and author of The Checklist Manifesto will find that he has bitten off more than he can chew.  Having spent his career blaming greedy doctors, end of life care, and “diagnostic complexity” for the exponential increase in US health care costs, he has studiously ignored the role of price fixing, bloated administration, and hospital mergers (including his own employer, Brigham and Women’s Hospital) in ballooning health care costs.  He has instead consistently advocated for a patchwork of local reforms and band-aids for our health system, but no systemic solutions.

The gradualist Dr. Gawande, working for three large employers, won’t be able to address much for the 1 million employees.  Without controlling a health system, he cannot control the urban, suburban, and rural distribution of health care workers and resources nor unify EMRs for all his workers everywhere.  Without that, he cannot improve coordination of care in a useful manner.  Nor can he address the prescription drug crisis of costs; that can only be addressed by a national drug price negotiation.

I do not think nothing will be done in the venture.  What will likely happen is the companies will improve the health of their employees to the extent that improves their productivity and reduces sick days.  Expect free FitBits, weight loss programs, wellness days, non-hiring and firing of smokers, and health insurance discounts for employees seeking preventive care.

But occupational medicine has always had a classic conflict of interest.  What happens when the health of the worker conflicts with the needs of the employers?  Berkshire-owned railroad drivers spend a majority of the time on the road, leading to poor diets and unpredictable hours (I should know, I have treated them).  JP Morgan traders work around the clock making mergers and acquisitions, infamously leading to the death of one overworked banker in 2015.  Amazon warehouses infamously lack air conditioning and treat passed out workers with fans.  Will a more relaxing schedule, air conditioning, or hiring more workers be permitted if it cuts profits?

The only solution has always been a single payer national health plan that eliminates the employer’s role in health insurance.  Only with a Medicare for all plan can we reduce administrative complexity, negotiate hospital and drug prices, and re-orient health spending towards socially useful spending instead of health care that turns a profit.  Dr. Gawande will not push for that, as it will put him and all private sector health bureaucrats out of a job.  But it is exactly what we need.

There will be little to show for the effort except publicity, profit, and nothing for the health of the public.  We do not look to Amazon, Chase, and Berkshire Hathaway for our health now and we should not in the future either.

Issue LXIV: American Hypothesis -Prohibitionism and the Pro-Life Movement

28 Mar

On my flight to Kansas City, a Kansan explained to me some of the essential differences between Kansas and Missouri.  “You see, all the bars are on the Missouri side because Kansas for years did not allow liquor by the drink.  Also, all the beer had be diluted three-two beer until recently.  There will be old signs right on the Missouri side of the street advertising full-strength beer.  And the Attorney General of Kansas used to fine airlines serving alcohol over Kansas air space,” she said. 

Given that Missouri’s most famous export is Budweiser and a corrupt bootlegger made Harry S. Truman into a U.S. senator, the contrast strikes any driver going down State Line Road. 

But is alcohol Prohibition just a strange relic from the 1920s that does not have any relevance to the present?  Americans think of it as this weird experiment that failed but made cool clothes, jazz music, Al Capone, and the FBI.  As a historical antecedent, it has no meaning for today’s politics.

I think the politics and morality of Prohibition have continued in a different form in the United States; after a few decades dormant they erupted into the pro-life abortion prohibition movement.  In the process of exploring these prohibitions, I will come across some hypotheses as to why we are in the present moment and how to fix it. 

From anti-drink to anti-choice to the politics of women

The first woman elected mayor in the United States was in Kansas.  It was a joke, but it still counts.  In fact, the states that have had women governors you notice that most of the states are in the western United States (especially if you exclude acting governors that were never elected in Massachusetts and Ohio).  Women also got the right to vote in western states before many eastern states.

But what did women want the right to vote for?  Anyone who has watched Boardwalk Empire would notice that many of the suffragettes are pushing for Prohibition as well.  More women voting would make the nation more Christian because men did not think of the home and God in the voting booth.

More explicitly, Kansas-Missouri prohibitionist Carry A. Nation used to chop up saloons with her axe and fight for the women’s voting rights.  She also complained about women wearing tight clothing for a good measure as well.

A ban on alcohol was seen as a national good in and off itself.  All social problems like family violence, child abandonment, education problems, unemployment, vice and sin all stemmed from alcohol.  Evidence for or against this idea did not matter.  Directly funding or attacking these social problems did not matter either.  This single policy would erase these problems.  It is a very narrow morality that focuses on the sin while doing nothing concrete about the (often alleged) consequences.

The point is that the link between women’s suffrage and liberalism or feminism is actually quite tenuous in most of the nation.  The link between elected women politicians and progressive politics is probably thin as well.  Are most elected Republican women legislators any more pro-choice, pro-gay rights, pro-sex education, or even pro-public education than the men today?  A different sort of women’s leadership developed with very different politics in most of the United States.  Why else did white women overwhelmingly vote for Trump instead of Hillary Clinton?  It is not something that happened by accident with no historical roots.

A fascinating article in Kansas History explored how certain fundamentalist churches in Wichita fought modernization of Christianity in the region (aka accepting evolution and science).  Monkey-baiting preachers fought for Biblical literalism and against the trend of northern churches accepting evolution.

The churches were mostly peopled by migrants from Southern states who came to work in the airplane factories that popped up during World War II.  They also fought against alcohol legalization in Kansas which did not end Prohibition until an election in 1948, long after the rest of the nation ended Prohibition.  These churches went on to become backbones of the pro-life movement which in 1991 erupted in Operation Rescue’s “Summer of Mercy” in Wichita.  2,600 people were arrested over 6 weeks during blockades of abortion clinics.  These activists went on to seize control of the Republican Party from the moderate, pro-choice wing of Kansas Republican Party and turn it almost uniformly into a pro-life party by the end of the decade.

Again, the narrow moralism of pro-life politics is just as narrow as the old prohibition politics were for alcohol.  It focuses entirely on the act of abortion and not at all about making a society which is good for children and families.  Unlike the Catholic pro-life worldview which encompasses anti-capital punishment principles and concern for the poor and families, the American Protestant pro-life seems to focus on the sin of abortion only.  Last year, Kansas Governor Brownback (a pro-life hero) had a major scandal when the privatized foster care system lost 74 children.  The idea that a pro-life governor had a privatized foster care system that lost children left and right is proof positive that pro-life politics is not really about the life of children.

The Way Out

This article may have been going out on a limb to mark the connections and continuities between  Prohibition and the pro-life movement.  But the solution to this problem will have a much greater evidence base.

Alcohol Prohibition died when the voters decided to democratically destroy it. The Eighteenth Amendment was repealed when 36 states amended their constitutions with the same repeal amendment, bypassing Congress.  Some states carried on for longer like Kansas and Mississippi but eventually even they by vote or by law ended the policy.  Why can’t we do the same for abortion?

Abortion has been legalized in many nations of the world by act of Parliament or by referenda.  Catholic nations like Italy, for example, legalized abortion by Parliament (1978) and ratified them in a referendum (1981).  Canada and the United Kingdom legalized abortion by national law in the 1960s.  Ireland, which has a constitutional ban on abortion, will soon have a vote on it and likely will end the ban on abortion according to polling.

The United States is standing more and more alone among developed nations (totally alone among Protestant developed nations) as even Catholic countries start to move legalize abortion (Mexico City, Argentina).  The problem is that the United States Congress never legalized abortion.  It was all decided by the Supreme Court in Roe vs Wade to throw out state abortion restriction laws all at once in 1973.  Some states had like New York and Washington had legalized abortion and many states had some limited right to abortion (see this map) and the rest had complete prohibition.  Had the Supreme Court not ruled on abortion at all, many states would have continued to legalize or liberalize abortion laws over time.  Moving too early to legalize abortion before a consensus had been formed in a majority of states or even the larger states has paralyzed the pro-choice movement to be perpetually be in defense of a policy that was undemocratically decided and unlike abortion legalization anywhere else in the world.

Had the Supreme Court waited more states could have legalized abortion or liberalized it and then they could make a ruling that would have thrown out the laws in the recalcitrant states.  This would be similar to what happened with state sodomy laws (widely considered a joke and rarely a legal threat to anyone in 2003) or gay marriage laws (widely accepted and legal in many states by legislation).  Or like Prohibition laws, they could have slowly died out state by state, extinguished by their own voters and not by a federal court.

The solution?  The pro-choice movement should push for Congress to pass a federal law legalizing abortion and limiting interference and regulations designed to prevent access to abortion.  Until that happens, locally the movement needs to push for every state to pass a law or referendum legalizing abortion and limiting restrictions to access.  That way if Roe v. Wade is ever overturned, state laws will already be ready.  When George W. Bush became president in 2001, California passed a law to do just this.

The costs of this defensive strategy are huge.  By arguing continually about abortion’s basic legality we are ignoring the even larger problem of access and affordability and funding in one of the largest nations in the world.  Harper’s poignant article about the difficulties of getting an abortion in South Dakota shows how this defensive focus forgets how abortion may as well be illegal for the poor and rural women of the nation.  A grassroots mobilization for state legalization the way other nations have decriminalized abortion is the only way forward.

No one thinks any state will bring back alcohol prohibition.  Why can we not do the same for abortion prohibition?  Only if you dream of it can you do it.


Harper’s –  Letter from South Dakota

Issue LXIII: American Hypothesis – The Death of the North

15 Feb

This year, I am going to try making a stab at making some hypotheses about the United States and the world.  These have been based on conversations, travels, and readings I have made.  Random facts have come to me from places off the beaten path that I think lend themselves to a pattern.  This issue, I will elucidate my first theory towards American mass identity confusion lays in the death of a regional culture.

The Death of the North

Growing up in the South, I felt a kinship and understanding of places I had never been to in the South.  To Kill A Mockingbird seemed it could have been written in my hometown.  I felt I understood Alabama or Georgia or Tennessee or the Carolinas even though I really hadn’t been to any of these states.

Not too long ago, someone with a thick Southern accent told me about something at work in Ohio and about how someone was coming in from Alabama.  I said, “It sounds like you came from Alabama yourself.”  “Well….” he said, “I am from Arkansas but I have been living in Alabama until this year.”  When I told him I was from Texas, he said, “It is nice to talk to a fellow Southerner.”

He hung up.  I smiled in recognition.

Then I thought, “What the heck?  I have never even BEEN to Alabama or Arkansas.”

In my mind, I thought there must be some sort of inverse in the North.  A “fellow Northerner” feeling or “fellow Northeasterner” or “Midwesterner” feeling.

There really isn’t any such thing.  There is no kinship at all.  No understanding at all.  Within Ohio, people do not have anything in common.  Nor do people in the Great Lakes Region seem to share a certain city they can all claim (to me, it should logically be Chicago).  There is not much interstate or intrastate travel that unites people into a shared consciousness, nor is there any art form or shared metaphor (even as cheesy as a Sweet Home Alabama or Waterboy).  That nod and wink between people of a shared region seems absent.  Was this always so?

How the Northeast Colonized Westwards

A historical first thought would be, what about the Civil War?  What about the Union?  Should that have created a shared memory and mentality that defines them the way the South defines itself (haziness and inaccurate nostalgia notwithstanding).

Well, it seems to me that at least once a upon a time the Yankee moved west from Boston and spread his culture across a large swathe of land.  As they traveled they founded universities like Oberlin, Grinnell, and the University of Kansas.

The New England Colonization Society sent settlers west to fight pro-slavery forces in Kansas.  They were given a Bible and a Beecher Bible (a rifle) to go fight the Missouri ruffians.  John Brown came from Massachusetts lived in Akron and came to Lawrence, Kansas to fight the slavery forces.  Portland, Oregon’s name came from a coin toss between a man from Boston and a man from Portland, Maine.  The Mainer won the coin flip.

This was the social, cultural, and economic geography of the North.  Roughly, interstate-90.

How do you maintain ties to your ancestral land?  You maintain it via education, travel, shared experiences, and marriage with those from your homeland.  When I see the education and travel patterns of President McKinley (R-OH), educated in Pennsylvania and New York, I see that at that time northern states traveled east for education and moved west for business.  Southern contemporaries often did the same, travel to the eastern Southern states for education.

At the Woodrow Wilson’s home tour in Washington D.C., I was told that it was very important for Wilson to have only married Southerners.  He was born in Virginia.  Despite being known as the governor of New Jersey when becoming president, his second wife tried to insist that his portrait in the White House upon retiring label him being from Georgia not New Jersey.

How and why did the northern unity fall apart?  Was it ever that strong?  I do not know.  But the collapse of the historic links between New England and the people of the Great Lakes and the Plains States may explain the vast identity crisis felt in the industrial Midwest.  This identity crisis has been filled currently with authentic anger and vague displacement as reality and prosperity fall apart around them.  This void has been filled by retrograde (often Southern-inflected) religiosity, intolerance, and Tea Party hysteria.

New England’s civilizing educational mission (their “City on a Hill” in Puritan times) has been a historic boon for the social development of the United States.  It was crucial in the struggle to end slavery, labor abuse, and voter disenfranchisement.  This mission has been replaced with fleecing the world with expensive private education to produce a homogenously mediocre “cosmopolitan” class of occasionally second rate writers, third rate politicians, and even worse philosophers and economists and media personalities.  Their obligation to their northern brothers seems dead.

How did northern unity fall apart?  I leave that up to you readers to give me ideas.  But why is a place a place and a region a region?  One thing is for sure for this Texan, the South is a place and the North is decidedly not.

Unless Minnesota decides to run off with the term.


KCUR – “Why Minnesota Should Break up with the Midwest



Issue LXII: The Neoliberal’s Health “Reformer”

7 Oct

Few people’s reputations are so sancrosanct in my field as the reputation of the surgical oncologist and New Yorker health policy journalist, Dr. Atul Gawande.  Nary a criticism of him gets published in either the popular or medical press (Russell Mokhiber’s one article is all I can find). But behind his strangely class-free, race-free, and context-free view of the history of American medicine lays the worst instincts of technocratic market liberalism. An avatar of progress he is not.

This week Dr. Gawande, in an echo of Hillbilly Elegy, decides to wander around his hometown in Ohio (my current state of residence) looking for a consensus on health care as a human right. Being from Texas, I have come to violently disagree with his much-hailed 2009 New Yorker article about McAllen, Texas. His naive traipse through southeast Ohio talking to people is just that: naive.

He finds that, golly gee, health care is expensive, and even conservatives cannot pay their $6000 deductibles, immunosuppressant medications are outrageously costly, and surgery bills keep people up at night. In this region where people repair their own cars and shoot their own deer (a symbol for real America), people can’t repair their own appendix! And they hate freeloaders.

Liberal or conservative, everyone agrees there has to be some sort of level playing field where everyone contributes, costs are controlled, and people will have the freedom to work or start businesses as they please without worrying about insurance. Just like how we do not worry about police and fire protection. Despite his Rhodes Scholarship in Philosophy, Politics, and Economics at Oxford, Dr. Gawande just now seems to be coming around the concept of positive rights and how these guarantees enhance liberty. But then he goes backwards and ponders if Americans have a right to garbage pickup… and then declares the idea irrelevant.

The muddled thinking of the Harvard doctor extends to his use of region and history. It may shock Bostonians, but Athens County is actually the most consistently Democratic county in Ohio. Historically, Appalachian Ohio has allied with Northeast Ohio (Cleveland) to form the bulwark of the Democratic Party in opposition to Southwest Ohio (Cincinnati). The last Democratic governor of Ohio, Ted Strickland, hails from the region and progressive Senator Sherrod Brown still wins in the region.

This coal and union region is economically liberal and socially conservative like its neighbor West Virginia but (as documented brilliantly by this magazine) has rapidly been shifting to the Republicans since 1992.

While he writes about the irrelevant Vaccine Act of 1813 to prove the point that Jefferson and Madison supported some concept of public health (as if that evidence will convert the Right!), he avoids discussing class or race as potential reasons why a logical health system never developed in the United States. When he notes that Athenians love Medicare but hate unemployed, idle people on Medicaid, he neglects look at the relevant legislative history of Medicare and Medicaid. Congressman Wilbur Mills (D-AR), chairman of the Ways and Means Committee, deliberately separated Medicare and Medicaid to create a two tier system in 1965. The elderly would get a national Medicare program while the poor (often black and minority) would get an inferior, unequally implemented, joint state-federal program called Medicaid. De-linking the poor from the elderly has cost Medicaid politically for decades, and it was deliberate strategy.

Elitism In, Elitism Out

What do we expect from a man who took time away from medical school to campaign for Bill Clinton in 1992, who proudly worked for Blue Dog Congressman Jim Cooper, and supported Al Gore in 1988? His national profile ignores his essentially conservative and elitist politics.

Dr. Gawande (who gained fame nationally bashing greedy doctors in South Texas) has never mentioned how regional hospital monopolies result in higher prices for all, including his employer Partners HealthCare. The 2000 merger of Massachusetts General and Brigham & Women’s Hospitals into Partners HealthCare, as noted by the Boston Globe’s Spotlight team, led to bullying of insurance companies to pay them much more per visit and procedure than local non-chain hospitals. Elite hospitals’ price-gouging is fine, but these unscrupulous border physicians and hospitals are just so gauche. Robbery and health care profiteering has to have a proper pedigree. In one ludicrous article, Dr. Gawande extolled hedge fund takeovers of Catholic hospital chains and how they should make hospitals more like the Cheesecake Factory. Seriously.

Stumbling on Solutions

Based on his on the ground conversations in Athens, Ohio, the logical political, moral, and marketable answer to the health care crisis would be Medicare for all. The simple appeal of everyone in and nobody out with direct tax contributions would seem to pass the moral and practical conditions of all these victims of the American health care system.

But Dr. Gawande, perish the thought, cannot make that clean leap in logic.

Instead he buries the idea in fatuous maxims about tradeoffs and the social compact. He does not even seem to answer the question of health care (or even garbage pickup) being a right. He thinks Medicare for all, Medicaid buy in by state, and even health savings accounts are all equally morally acceptable solutions. His bias, as always, is towards a hodgepodge of regional incremental solutions.

And he seems to fear a transition more than any lasting, political solution. And he never mentions Bernie Sanders’s new Medicare for all bill or the collapse of the private insurance system or non-profit hospital price gouging and mergers.

If we are to have Medicare for all and a not for profit health system, we will need to abandon “thought leaders” like Dr. Atul Gawande. They hold us back with their faith in MBA-style management of health care from above and small, incremental, unscaleable experiments in health delivery from below.

We will need a dedicated cadre of physician and public health leaders who understand the role of the public sector in finally providing and implementing the Alma Ata Declaration’s promise of Health for All in the United States. It is only with such dedicated leaders who know that only by confronting the inequalities in wealth, power, geography, and race directly, we can produce a healthy society and finally join the civilized world in guaranteeing health care as a human right.

Issue LXI: A British History of Game of Thrones

6 Aug

Upon meeting His Catholic Majesty Felipe VI, King of Spain, Castile, Léon, and Aragorn, Professor Pablo Iglesias presented him with a modest gift.  A DVD box set of Game of Thrones.

The leftist lecturer of political science and leader of the political party Podemos, professed his love for the show in 2015.  He would, like Khaleesi, ride the dragons of political power to the summit of the state.

Now what could he be talking about when ranting about Weber, Machiavelli, and Gramsci in an HBO serial?  Professor Iglesias is not off the mark at all, dear readers, and I will show you how Game of Thrones explains the creation of the modern world via British history.  But with dragons.

 From Antiquity to Modernity

George R.R. Martin has explicitly stated that Game of Thrones most resembles the War of the Roses.  The War of the Roses was an insanely complicated civil war between 1455 and 1485 for control of the British throne.  As a war between dueling relatives of House Plantagenet, there were many alliances and betrayals and short-term kings that in turn got overthrown by another.  Fighting over hereditary “legitimacy” really was a fig leaf for different groups to support different sides.

The House of York (white rose) fought with the House of Lancaster (red rose) until it ended with the Battle of Bosworth Field in 1485.  The Lancastrians defeated the Yorkists and Henry Tudor became King Henry VII.  To wrap it all up he married Elizabeth of York to unite the two families and thus claims for the throne.  The Tudors ruled until 1603.

What makes the Battle of Bosworth Field more important than other fights over kingship is that this was really the last time inheritance had to be decided by war in Britain.  We can really say that British dynastic stability begins from then until now (notwithstanding complications like Cromwell and the Glorious Revolution).

Stability is the key word in this.  A stable realm with stable rules and rulers can lead to people planning for the future.  They will not have to worry about soldiers wrecking their farm, their apprentices being drafted by the local aristocrat, and changes of religion that lead to religious persecution.  What George R.R. Martin shows, but does not tell, is how political stability will be created in Westeros by the (likely) victory of Daenarys Targaryen.

Origins of Political Order

 It all goes back to German sociologist Max Weber.  The state, in political science, is the only institution allowed to commit legal violence in a modern society in a defined geographic area.  This violence encompasses the police, prison and court system, the death penalty, or (in olden stays) corporal punishment and torture.  We are shocked at the violent actions of terrorists, criminals, or militias because, unconsciously, we believe that only the government is allowed to use violence legitimately.

This was not always the case.  In the New World, it took centuries to develop a political culture in which cowboys can’t just shoot Indians or the Hatfields shoot the McCoys and get away with it.  Being civilized means settling disputes non-violently and using the court system if disputes cannot be settled.

In the Old World, monarchs could not directly control their entire nation and had to rely on local nobles to collect taxes and draft men for their army for centuries.  These nobles could also commit violence and keep some of the tax money they collected for their estates.  They may have additional mandates to protect certain bridges, rivers, mountain passes, or borders from the king.  This is the world of Game of Thrones.

The Birth and Death of the Seven Kingdoms

A brief recap of Westerosi history draws out the parallels with British history.  The original people of the continent were the Children and the First Men.  These natives (equivalent: Celtic tribes) were disrupted by the Andal invasion of Westeros.  They are pushed to the margins of continent just as the Celts were pushed towards Wales, Scotland, and Ireland.  The First Men become the Wildings and are pushed beyond the Wall.

The Andals form the Seven Kingdoms and most likely represent the Angles, Saxons, and Jutes who invaded Britain from Northwestern Europe in 410 AD.  These Germanic tribes form the English people who are the Anglo-Saxons.  The majority of people in Westeros descend from the Andals.  The exception are the Starks in Winterfell (which most likely represents York, England) who are mixed with Andal and First Men blood and follow the religion of the First Men and the Children.

The Seven Kingdoms were all dramatically conquered by Aegon the Conquerer who invaded from Dragonstone three hundred years before the show begins.  Aegon the Conqueror, undoubtedly represents William the Conqueror.  William the Conquerer and his Norman invasion from France conquered Britain at the Battle of Hastings in 1066 AD.  William the Conqueror began much of the current British state including Parliament and government records (the Domesday Book).  One can say the British monarchy as an institution began with his rule.

Like the Normans, the Targaryens are not native to Westeros but come from Essos.  They also do not speak the Common Tongue at home (aka English) but speak Valerian (French/Latin).  In some of the backstory videos on the DVDs (you can find them on YouTube), it is made clear that the Targaryens reduced the amount of warring between the different kingdoms.  By being foreigners, they could stand above any of the individual Seven Kingdoms.  By having dragons, they have the overwhelming monopoly on violence and the ultimate weapon.  You can view the dragons symbolically as the supreme power of state violence, like nuclear weapons or a very strong army, and these dragons make lesser kings submit to the Iron Throne in Kings Landing.

The Seeds of Modernity

Unification and centralization of political power into a single state is an essential precursor for advanced civilization.  The Chinese achieved this thousands of years ago under the emperors of yore while Spain, Portugal, France, and England achieved the nation state centuries later.  What George R.R. Martin’s stories metaphorically reveal are the seeds that will lead to the destruction of the Middle Ages and the beginning of Enlightenment and modernity.

In terms of learning, the Citadel clearly represents the origins of universities and knowledge that will lead to science.  Universities descend from medieval monasteries dedicated to training priests and studying religion.  Samwell Tarley’s apprenticeship (an ancient grad school if you will) shows how medicine is developing from their studies both new and old.

In terms of technology, Cersei contracts the Alchemists’ Guild to develop technology like wildfire and the dragon-slaying ballista.  Medieval alchemy tried to convert common substances into gold.  The knowledge of these thousands of failed attempts led to a body of knowledge about substances which led to modern chemistry.  Once cannon technology began to destroy medieval fortress walls, the point of using castles for defense ended and so too did the Middle Ages.

In terms of statecraft, Lord Varys represents English philospher Thomas Hobbes and his book Leviathan.  Lord Varys, uniquely, defines the goal of governance to be the good of the common people.  Unlike the other advisors, he is a commoner.  Furthermore, he sees stability and peace in the realm to be the primary goal of politics, not who sits on the throne.  His loyalty is not to the ruler but the realm…. or as we would call it, the nation.  His switching from supporting one ruler to the next makes no sense to the others except as a way to get or keep power.  They do not understand his goal of a commonwealth.

In terms of political power, Daenrys Targaryen represents Henry VII. Raised in exile in Essos (France), she will return to her native land to end the family feuds.  She understands that the back and forth between the different families is ruining Westeros.  When Tyrion describes it as a wheel where families rise and fall with the turn of the wheel, Khaleesi responds that she does not want to stop the wheel but to break it.  Her ultimate goal will be the disestablishment of feudalism.  It helps that the families are killing each other off anyway.

An astute marriage, like the marriage of Ferdinand and Isabella in Spain in 1469, could consolidate the territorial gains (Cersei Lannister and Euron Greyjoy?  Jon Snow and Khaleesi?).  A foreign invasion by White Walkers will help consolidate her authority the way the invasions of the Moors helped unify Spain and Portugal in the 1400s.

A single, unified monarchy will rule Westeros without any challengers from below.  In essence, it will be the end of the Seven Kingdoms and the beginning of the modern nation-state of Westeros.


YouTube – Complete History of Westeros

Atlantic Monthly – “Political Order and Political Decay