Gaming Our Health-Care System

I turned 80 last month. I’ve been on Medicare, with an “AARP” United Health Care Medicare Supplement, for fourteen years. In my working years, I was a physicist and business lawyer, so I’m not unacquainted with science or business. As a world-class hypochondriac from before puberty, I’ve probably learned more about medicine than most people who never went to medical or nursing school.

During the last twenty years, I’ve given a lot of thought to navigating our rapidly changing, often dysfunctional and sometimes miraculous health-care system. So I thought I’d put my advice, impressions and experiences in writing to help people trying to figure it out. Our system is likely going to continue to offer “miracle” treatments like my two total shoulder replacements, which let me swim and do things most previous generations could not do at my age. But it’s not likely going to get any simpler, cheaper or easier to use. (Everything in this essay is a report of my opinion and experiences and my personal point of view.)

1. When you have something that you think might be serious and/or life threatening, go to the ER, not “Urgent Care.”

A good Emergency Room at a big, properly funded hospital is a microcosm of modern medicine and medical technology. It has much, if not all, of the advanced technology that can peer inside your living body without harming it. Nearly every ER can do ultrasound scans, X-rays, and Computer-Assisted Tomography (CAT) [X-ray] scans. Many also have portable X-ray machines that can be brought to your bedside. Some can also do MRI (Magnetic Resonance Imaging) and PET (Positron Emission Tomography) scans, which can see “soft tissue” inside your body better than X-rays, CAT scans, and ultrasound.

In addition, a good ER has Emergency-Medicine specialists with years of training in precisely the stuff you need when you require rapid help. Some also have other specialists, in such fields as internal medicine, geriatrics or infectious diseases, on call or on tap online. All have on-tap or online radiologists, who can interpret your medical images in hours, rather than days.

In contrast, “Urgent Care” facilities are often under-resourced and under-staffed. IMHO, they are facilities for people with little or no access to any professional medical care. They typically consist of a cadre of nurses or nurse practitioners supervised by one or two general practitioners, who are not generally trained in emergency medicine. And urgent-care facilities may have little or no imaging equipment besides portable ultrasound machines.

A good ER is to an urgent-care facility as the UCLA Medical Center is to a country doctor’s wooden shack in rural Alaska. So if you think you might have something serious, go to the ER. You might be as lucky as I was when I had an inflamed appendix, and the urgent-care center sent me to the ER just in time to have it taken out as it was bursting.

One less pleasant thing you should know about ERs: they reflect modern medicine’s total destruction of human relationships with your providers. If you haven’t noticed your provider staring into a computer screen and typing on a keyboard during most of his/her interaction with you, then surely you have noticed how MyCharts, byzantine telephone queues, and other means of computerized communication have made personal relationships with your providers difficult, if not impossible.

There is not much to be done about this. It’s the price we pay for the vast complexity and extraordinary capability and success of modern health care. The days of my youth, when the family doc came to your bedside at home with the proverbial “little black bag” and kept your and your family’s medical history in his or her head are long gone. In exchange, you have machines that can peer inside your body in multiple ways, antibiotics, antivirals, genomic medicine, a wide range of drug therapies, plus robotic surgery and AI diagnosis. It may not be entirely comfortable for people my age, but I would say that’s a fair tradeoff.

Anyway, the MBAs who control modern medicine have made it impossible to keep your General Practitioner (GP) or family doctor “on tap” in any reasonable way. My GP at a major medical group told me that, for financial and administrative reasons, his bosses make him keep a full daily schedule six weeks in advance. You may think there are a lot of medical issues that fall between going to the ER and waiting six weeks for medical advice. But many business systems in health care simply don’t let you see your family doctor in that gap.

The solution is obvious and inescapable. When something medical that might be serious comes up, go to the ER. It’s where the system pushes you, and it’s where all those advanced technologies come together in one place. Take advantage of it, and don’t be shy. Good modern hospitals are designed to feature it.

2. The second thing to know about ERs is that when you go makes a big difference. There’s a big difference between going in the wee hours of a weekday and coming in on Monday morning or Friday afternoon. Over the last decade or so, I’ve been to ERs, for myself or family members, at least a dozen times. My time to see an ER doctor has varied between less than one-half hour and 3.5 hours. The time to discharge has varied between 1.5 and 5.5 hours. The most important determinant of delay was when I or we arrived at the ER. Sometimes I even called ahead to see how crowded the ER was and delayed my arrival accordingly.

If you have a bleeding gash, a high fever or a broken bone, you obviously have to go to the ER right away. That was the original purpose of ERs, now vastly expanded. But there can be reasons for delay. If you go when the waiting room is crowded, you might be exposed to viruses, bacteria or just some obnoxious and maybe dangerous people. Then you might wonder how important speed is.

If your own lack of medical knowledge leaves you guessing how urgent you problem is, a resort to AI might be in order. According to this review of AIs in the Washington Post, Anthropic’s “Claude” AI was the best at summarizing health research of the AIs tested. I’m appending the prompt I input and Claude’s response, which helped “diagnose” what appeared to be an upper-respiratory infection.

Claude’s response struck me as what a good GP might say. It led me to skip the ER and take a Covid test instead. Of course, an AI is only as good as the data you give it, so you should carefully note all symptoms and any deviation from your normal body temperature, resting heart rate, respiration rate and feelings of well-being.

A big advantage of going to an ER in the wee hours is having good docs and all that marvelous technology at your fingertips. You shouldn’t be shy about using it, even for things other than what you came in for. If no one else is waiting, you are making the hospital’s huge investment in the ER and its staff worthwhile.

Once I got lucky in that regard. I went to the ER at about 4 am with persistent abdominal pain that I thought might be an intestinal obstruction. The imaging showed it to be a false alarm. In retrospect, I should have known that intestinal obstructions produce nausea and vomiting, which I didn’t have.

But my mistake put me in the hands of a brand new, highly qualified, Emergency Medicine resident. He was one of the smartest, most articulate and most helpful docs I’ve ever seen. By the time I left the hospital, I had resolved a short list of put-off medical issues. I had even gotten a follow-up ultrasound scan of a longstanding lump in a testis, which confirmed and updated a years-ago conclusion that it had been benign.

Did I feel guilty about “gaming the system” in this way? Not a whit. The waiting room was empty both when I arrived and when I left. So I didn’t deny or delay anyone else’s care. Anyway, highly qualified professionals like that great doc hate to spin their wheels. By making sure he was not idle, I also lessened the chances that an eager MBA would “downsize” that unit, to the disadvantage of other patients that the same ER serves.

3. Don’t neglect prescribed care if you don’t have insurance or fear it may not cover your care. Instead, price shop and bargain.

With MAGA folk “downsizing” everything about medicine that involves government money, you may fail to seek care that you think might not be covered by insurance. In some cases, perhaps many, that would be a mistake. I’ll give two examples.

With the Covid pandemic declared officially “over,” federal Medicare and my Medicare Supplement have stopped covering Covid tests. But when I got a cough-rich upper respiratory infection recently, I wanted to know. My wife went to the local CVS and picked up a four-pack of tests for about $35.

That’s less than $9 apiece—a price easily affordable by any middle-class family. Why was the price so low, when I expected something closer to $100? I don’t know for sure. When we got the tests home, we noticed that they had just over a year to expire. Maybe there’s some regulation that drugstores can’t sell tests with less than a year before expiration, so those tests were rapidly decreasing in value as they sat on the shelf.

Whatever the reason, we never knew the price until we shopped. Not everything in medicine is priced outrageously. It’s best to find out before foregoing care or testing. And I suspect that, whether for our speculated reason or another, drugstores’ prices for Covid tests and many other things vary widely. Drugstores and chains do, after all, have different suppliers, and they are, after all, in competition for customers.

My second example is something I’ve not done personally but believe is possible. I’m one of those rare Medicare beneficiaries who reads every one of my Medicare Summary Notices. Of course I don’t read all the endless boilerplate, privacy notices and translations into multiple languages. I focus on the little numerical table, usually on the third to fifth page, that reveals the price the provider asked, what Medicare actually paid, and the balance (if any) that my secondary insurer or I would have to pay.

What I’ve learned in my fourteen years of doing this is that the prices for medical services and products are much like the prices of women’s shoes. There is no apparent rhyme or reason to them, and the opening price is just a charade. On average, it seemed to me, the price the provider ended up actually accepting from my insurers was somewhere between one-fifth and one-tenth of the asking or “quoted” price.

So suppose you are completely uninsured, maybe even an undocumented immigrant. What’s to prevent you from asking your family, friends, neighbors and acquaintances to reveal their Medicare Summary Notices to you (or equivalent notices, if any, from Medicaid), so that you can find out what providers in your area actually receive for the care you need? Then what’s to prevent you from contacting your preferred doctor, or even his/her business overlords, and offering to pay the much-lower-than-asking price that insured people pay? Doesn’t it stand to reason that any care center run as a business would rather take that price than leave a care team standing idle and get nothing?

I wonder whether the many nonprofit and charitable organizations that serve marginalized communities could perform this sort of price-investigation and bargaining service for patients in those communities. I can’t imagine why any rational care provider would object to this service. It would fill their schedules, increase their revenue, and give them the same revenue that government insurance provides.

4. Consider traveling for health care. Quality medical caregivers are not evenly distributed nationally. Most are located in or near big cities. This is especially true for emerging technologies such as genomic immunotherapy for cancer and tailored-drug therapies for depression, anxiety and PTSD. If you need standard and well-developed therapy, it makes sense to get it as near where you live as possible. If you need emerging, advanced or exotic technologies or therapy, it makes sense to get it where it is under development.

This approach is especially true for advanced and innovative surgery. These days, the price of travel and a hotel stay, even for a week or so, is far less than half the price of advanced, innovative surgery. And the comparison becomes even more favorable for rural people visiting a nearby prestigious city hospital, who might be able to reduce their expenses by traveling with, and even residing in, a camper or RV.

There’s one other thing that rural residents also should watch like hawks. In recent years, private-equity firms have swooped in to buy rural hospitals, for profit, from charitable, religious and local-government owners who have had trouble sustaining them. The primary goal of these new owners is to make money, not to improve care. Sometimes they find that hard and end up closing the hospitals down.

If I needed surgery and lived in such a rural community, I would avoid these private-equity owned hospitals like a hospital-acquired infection. Instead, I would travel to a hospital with a good reputation, run by a religious organization, charity, or local government. Or I would travel (further, if necessary) to a big-city hospital with a reputation for innovative and high-quality care.

5. Don’t fear scientific and medical innovation. Innovation in health care is one of the last, great triumphs in American science and technology. We Americans have lost the lead in many other fields by ceding our manufacturing base—and also the basic research, science, and advanced engineering that go with it—to China. But in medicine and health care, we have kept our edge and, in some fields, may even be increasing it.

A shining example is our recent development of mRNA vaccines for Covid. These “designer,” “programmable” vaccines are one of the greatest innovations in medical history. They are unique in two respects. First, they train our own cells to make the Covid “spike” protein that allows the Covid virus to attach itself to, and to enter, our own respiratory and other cells.  This process then provokes our immune systems to make antibodies to that “spike” protein.  Second, the vaccines’ method of operation permits “redesigning” them to generate other proteins to which our immune systems then make antibodies.  In theory, it thus can make an mRNA vaccine “programmable” for any new variant of the Covid virus, whether or not it uses the same “spike” protein, and potentially for a totally new virus as well.

A final gigantic benefit of the mRNA vaccines is important. In producing antibodies to the “spike protein, but not to any other feature of the virus, they do not introduce to our own cells any part of the virus that allows it to reproduce itself and thus cause disease. (The “spike” protein is a surface protein that has nothing to do with the virus’ reproductive processes.) Thus, unlike many conventional “inactivated-virus” vaccines, the mRNA vaccines have no risk, even in theory, of causing the disease that the vaccine targets.

Understanding these advantages, I have had nine mRNA vaccines against Covid and am eagerly awaiting my tenth. Every time, I have specifically asked for the mRNA vaccine, in order to realize these advantages. I have had Covid twice, and my wife thrice. Each of us has relied exclusively on the mRNA vaccines and the Paxlovid antiviral treatment to avoid recurrence and reduce the risk of serious consequences of infection, such as “long Covid.” Neither of us has experienced any such consequence.

We cannot understand why some people seem to fear this stunning scientific advance in “programmable” and safer vaccines. The only reason we can conjure is that some people confuse mRNA with DNA and believe there is a risk of the mRNA vaccines changing one’s hereditary machinery.

But that is impossible. DNA and mRNA are different molecules with different structure and functions, and mRNA plays no role in people’s or cells’ hereditary genetics. In contrast, mRNA is the means by which our hereditary DNA-controlled internal machinery in ordinary cells “directs” those cells to manufacture proteins. It has nothing to do with individual or even cellular heredity. If new pandemic viruses emerge during our lifetimes, our family will look for, and will take, mRNA vaccines against them first, because we expect them to be: (1) developed more quickly, (2) less risky overall, (3) more effective, and (4) more easily modified to control genetic variants (mutations) or even new related viruses.

Another innovation to seek and not to avoid is “robotic” surgery. This phrase does NOT mean that little robots will be running around autonomously in your body, controlled by AIs. The most important thing it does mean is what I call “reverse leverage.” When the surgeon moves his or her hand three millimeters, the electronically controlled knife may actually move only three microns, or one-thousandth the distance. This makes a surgeon’s shaking hands and random twitches much less dangerous. “Robotic” surgery also allows the surgeon to see what’s going on through powerful optical and/or electronic magnification, so his/her thinking and decisions are vastly enhanced by clearer, more detailed images of the surgical site. Finally, robotic surgery usually permits a smaller incision and less gory body-entrance procedures than manual surgery, thereby reducing the pain and time for post-operative recovery.

If memory serves, I have had at least six surgical procedures on my prostate. The most recent, nearly five years ago, was by far the most successful, with the greatest increase in flow. It was robotic surgery done in an outpatient surgical center, from which I went home as soon as the procedure was over.

6. One last bit of advice for Seniors: Get a Medicare Supplement or “Medigap” supplemental plan, NOT a Medicare “Advantage” Plan. Not only does Consumer Reports associate the latter with in-network requirements and requirements for pre-approval of spedific treatments. A friend who moonlights as an ER nurse reports that a number of his patients have had trouble and delay getting pre-operative approval for life-saving doctor-prescribed treatments under their “Advantage” plans. In contrast, my Supplement Plan (the big “AARP” Plan from United Health Care) has never denied denied me a provider or treatment prescribed by any doctor, or required special approval, in fourteen years. Apparently the “Advantage” of the plans that carry that name is to the insurer.

Endnote: “Claude” AI’s Prompt and Cough Diagnosis

My prompt:
For two to three days, I have had an intermittent, mostly unproductive, sometimes rasping cough, with some pain in the trachea or esophagus. I picked this up from family, including three young children, recently arrived in Berkeley, CA from Bali Indonesia. I have no or a low-grade fever, at most 0.5 degrees Fahrenheit above my usual body temperature. I have one Covid test left and have not used it yet. What is the most likely diagnosis? (Please do not assume any facts not stated.)

Claude’s Response:
Based on your symptoms - intermittent, mostly unproductive cough with occasional rasping, tracheal/esophageal pain, minimal fever, and recent exposure to family members including young children from international travel - the most likely diagnosis is a viral upper respiratory infection.

Here's why this fits best:

Viral respiratory infections commonly cause:
Dry, irritating coughs that can become rasping
Throat and upper airway discomfort/pain
Minimal or low-grade fever (especially in adults)
Easy transmission within families, particularly from children who are frequent vectors
The international travel context (Bali to Berkeley) increases exposure risk, and young children are notorious for picking up and spreading respiratory viruses during travel and in new environments.

Other possibilities to consider:
COVID-19 remains possible, which is why using your test would be valuable
Bacterial infection is less likely given the minimal fever and symptom pattern
Irritant exposure (air quality, allergens) could contribute but wouldn't explain the family cluster

Recommendations:
Use your COVID test, especially given the family exposure pattern
Stay hydrated and rest
Monitor for worsening symptoms (high fever, difficulty breathing, persistent pain)
Consider isolating until you know what you have, given the contagious nature

The combination of family cluster, travel history, and your specific symptoms strongly suggests a viral respiratory infection, but testing will help confirm whether it's COVID-19 or another virus.
[End AI output.]

In my view, the most important part of the AI’s analysis, which led me to skip the ER, was ruling out a bacterial infection, for which early use of a powerful antibiotic (which I might get most quickly from an ER) might have been useful.  Also, an ER could send the bacteria to a lab for a culture, in order to determine precisely which antibiotic would best work against it; nothing similar can be done with viral infections.  BTW, the Covid tests—three of them over three days—three of them over three days were all negative.

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Our Worst Generation

We all know what our “Greatest Generation” was. They rose up from farms, fields, towns and cities, put on uniforms, took up arms, traveled halfway around the world, and saved humanity from German Nazism and Imperial Japanese militarism. They followed up with the Marshall Plan and the enlightened Occupation of conquered Japan. They thus converted our most fearsome enemies into our strongest and wisest allies and the globe’s third and fourth largest economies (after us and China).

Our Greatest Generation won the most terrible war in human history in a mere four years. They rose from a standing start, untrained, undisciplined, and from a slumbering peacetime economy. Women joined the military effort directly, and millions went to work in war factories as “Rosie the Riveter.”

When the war ended, the US economy was by far the world’s largest. Not only that. It had built mighty factories for warplanes, warships and armaments that had supplied the winning arms caches for the Soviets, who did most of the dying. Under enlightened US leadership, the UN, the General Agreement on Tariffs and Trade (“GATT”), which eventually morphed into the WTO, and the Geneva Conventions (the first-ever attempt to make war “civilized”) all came into play. All these achievements truly deserve the monicker “Greatest Generation.”

But what was our worst generation? It’s never been named specifically. Yet I submit that it’s the very one that followed, the one now passing from the scene, the so-called “Baby Boomers.” Let’s analyze.

Let’s look first at war, our species’ most horrific self-imposed calamity. The US’ direct involvement in WWII lasted less than four years, from December 8, 1941 (the day after Pearl Harbor) to Japan's unconditional surrender on September 2, 1945. Our longest previous war, the Revolutionary War that gave us our independence from England, had lasted 8.4 years.

Before the Boomers took the helm, we had never had another war that lasted so long. The Boomers broke that record, big time. They waged three unnecessary “wars of choice”: in Vietnam (19.4 years), Iraq (eight years, nine months) and Afghanistan (twenty years). The first and last ended in ignominious debacles—complete routs of American forces. George W. Bush’s reckless Iraq War produced an uneasy stalemate, a divided country, and the rise of organized Islamic extremism and terrorism.

As in war, so in peacetime wisdom. When WWII ended, our Greatest Generation had been fed up to the teeth with war.

They converted the factories that had made tanks and warplanes back to civilian transport. They sold off the great wartime aluminum factories, which the government had built to make warplanes, to private investors such as Kaiser and Reynolds Aluminum. The physicists and engineers that had staffed the Manhattan Project and invented nuclear weapons dispersed into private industry and government basic-research laboratories. Their research produced the greatest flowering of real, tangible new technology in human history: television, transistors, integrated circuits containing thousands of transistors (computer “chips”), medical MRI and CAT scans, space travel, and the digital computer and personal computer, from which the iPhone sprang. (In contrast, much of today’s Boomer “technology” involves writing software to exploit market imperfections, to oppress as “independent contractors” workers who are really employees, or to get rid of personal labor altogether.)

The open secret once driving this world-historical rush of progress and enlightenment was intelligent pragmatism. Smart leaders did what worked. They didn’t dwell on who was right or wrong in the abstract. They didn’t build abstract, theoretical castles in the sand. If something didn’t work and work well, they tried something else. They didn’t rely on simplistic abstract ideologies.

As our Greatest Generation knew, clashes of simplistic ideology had produced unimaginable horrors. First came the two Russian Revolutions—the second the bloodiest in human history. Next came the catastrophic war between Russian/Soviet Communism and German Nazism/fascism, which left the flower of German and Russian youth decimated and most of Western Russia burnt and broken. Our Greatest Generation lived these horrors and so despised ideology as the last refuge of scoundrels. Our immediate postwar leaders refused to reduce the complexity of human life and history to childish, simplistic mantras.

All that changed with the Boomers. They became the most pampered, coddled, privileged yet minutely supervised and least personally challenged generation in human history. How it happened is a complex and intricate sociopolitical story, in which miseducation plays a leading role. It’s worthy of a book of several volumes, not just this short essay. But the outlines by now seem clear enough. I would note three turning points.

The first is the pampering. The Ancient Greeks said it best: “The suffered is the learned.” There is no learning without risk.

The grammar school that I had attended, the teaching-training school at UCLA, once had a huge grass field with a tall, multi-branched pine tree. We kids spent many a recess hour climbing its generous limbs, sometimes falling and getting scrapes, bumps and cuts. Yet when I revisited that magnificent tree in high school, it had had its great branches pared from ground level up as high as an adult could reach. The magnificent natural jungle gym had been neutered and pillaged in the name of “safety.”

This story is but a parable of how the Baby Boomers raised their children as “helicopter parents” with supervised “play dates,” constant, oppressive adult supervision, and absolute prohibitions on wandering around the neighborhood alone or with other kids. In contrast, from the time I learned to ride a bike, my parents didn’t know where I was from the end of the school day until it got dark and I came home for dinner. I believe that unsupervised, self-directed learning set my course of discovery and exploration for the rest of my life.

As in physical wandering, so in intellectual life. The Boomers had to have a theory for everything. And because it had to be easy for all to grasp, it had to be simplistic. Communism bad, capitalism good. Socialism seems like Communism, so it must be bad. Capitalism exploits greed as a powerful motivation, so greed must be good. Government exists in part to suppress and channel greed, so government must be bad.

There you have the “philosophy” of Ronald Reagan in a nutshell. His first inaugural became famous for the mantra: “Government is not the solution. Government is the problem.” That has remained the central tenet of Republicanism to this day. And the untutored still adore him for it.

This sort of patently simplistic ideology permeated the highest reaches of academia. Milton Friedman, who won a Nobel Prize in economics for his abstruse work on monetary policy, became famous for another proposition entirely, an absurdly simplistic one. In his telling, the notion of “shareholder value,” all by itself, was the driver of corporate capitalism, responsible for all the discoveries and riches of American industry.

Never mind that greed has been anathema to every organized religion, and to our most thoughtful philosophers, throughout human history. Never mind that a moment’s thought reveals multifarious human motivations having nothing to do with greed. Sportsmen and women, for example, give their all to beat their rivals and improve their performance, regardless of how much they are paid. (You have only to review the history of the Women’s Professional Basketball League to get this point.)

Doctors seek to heal and reduce human suffering. They crave the gratitude and admiration that results. Engineers try to build things that work higher, faster, better and smarter, just for the sake of doing so, with monetary rewards an “extra.” Scientists seek to discover new truths; mathematicians new proofs. (The latter bent their brains for three and a half centuries, for example, finally proving Fermat’s Last Theorem conclusively in 1995. Did they do so for greed?)

Priests, nuns, rabbis, imams and other religious leaders exhort their flocks to suppress greed and help their fellow men and women, thereby magnifying our species’ key evolutionary advantage: the ability to communicate in detail and cooperate fully. And what about mothers, fathers and grandparents? Do they save, sacrifice and spend for their progeny out of greed?

As Mark Twain once remarked about premature reports of his own death, the idea of greed as the fount of all human motivation is greatly exaggerated. So the abstract notion of “pure” capitalism, or “shareholder value” as the best or most perfect economic system is fundamentally flawed. Ask the surviving participants in the Manhattan Project what motivated their work on the greatest, most secret and successful crash technological project in human history, and greed will not even make the list.

And so we come to the last, perhaps most important point: corruption. Our English language uses the very same word for economic corruption and the biological kind, the rotting of corpses. (Compare the line from the Bible, about Jesus, quoted in Handel’s Messiah: “Thou didst not suffer thy Holy One to see corruption” but resurrected him.) Greed-driven economic corruption destroys a society the same way rot destroys a corpse: individual organisms bent on their own ends decompose and destroy the whole. Somehow, the apostles of a greed-based capitalism never came to grips with this essential truth of biology and history, which is now proving itself daily in our corrupt, divisive and faltering economy.

There is something truly pathological about the mechanistic and simplistic abstract ideology that gripped our nation in the decades following our greatest national triumph, in WWII and its aftermath. As Milton Friedman’s sick history shows, it has permeated our highest intellectual citadels, our great universities.

I had the displeasure of observing its destructive power personally while a Fulbright Fellow in Moscow in 1993. At the time, Russia was led by the drunken but democratic and well-meaning President Yeltsin. He had, two years before, withstood a right-wing Putsch against the Russian Parliament by standing on a tank in front of the Parliament Building. Russia’s leadership and academic elite were then all agog at the prospect of Russia becoming a “normal” country, with normal economic and external relations.

At the end of my four months in Moscow, I was invited to a conference of Russian and German journalists discussing the subject of state secrets. Its Russian participants were eager to learn the American point of view. This was the “window to the West” that Putin slammed shut at the end of the decade, when he dropped his clever deception and revealed himself as the incarnation of the sixteenth-century Czar Ivan the Terrible.

During and after my fellowship, reform-minded Russia’s chief concern was what to do with its industry. All of it had been government owned and run, in keeping with the old Soviet Communist system of wholly nationalized production. Somehow, a then-little-known Harvard economist named Jeffrey Sachs captured the apparatus of USAID, insofar as Russia was concerned. I never met the man, but it soon became clear that he had a mechanistic and simplistic view of “converting” Russia’s state-owned industries to capitalism. He advocated a form of “shock therapy,” in which shares of these firms would be put on the market to the highest bidder(s), financed in part by American capitalists.

Never mind that, under Communism, it had been over seventy years since any of Russia’s ordinary citizens had owned any stock or share in anything. Never mind that, for all the intervening time, Russia’s media had propagandized capitalists, including share owners, as evil exploiters of the working classes. The “shock therapy” and stock-and-asset sales went forward, with significant American financing. Unsurprisingly, the buyers all turned out to be insiders, i.e., the very Soviet Commissars who had run the companies by Soviet fiat during the preceding decades.

In other words, Jeffrey Sachs’ simplistic and mechanistic approach to economics created the Russian Oligarchs out of whole cloth. They included the oligarchs who now meekly follow Putin’s imperial dictates and run his businesses, cementing his economic and political power. They also included the few, like Mikhail Khodorkovsky, who supported truly free markets, resisted Putin’s control and were jailed and ultimately exiled. To my knowledge, after an AI search, Professor Sachs knew and knows nothing of Russian history and speaks no Russian.

Let us give this dismal tale its coup de grace with the story of Joseph R. Biden. By now, the recent book of reporting has revealed all: Original Sin: President Biden’s Decline, Its Cover-Up, and His Disastrous Choice to Run Again, by CNN’s Jake Tapper and Axios’ Alex Thompson.

During his last year in office, President Biden’s staff and his wife Jill conspired to keep the public from knowing and reacting naturally to his increasing mental and physical decline. Then they let Kamala Harris loose with too little leeway and no practical power to address the one issue amenable to a quick fix: the public perception of open-door immigration.

I need not outline the ensuing history. It’s too recent and too painfully embedded in progressives’ memories to erase. I would only add that it mirrors the similar history of President Woodrow Wilson’s massive stroke while in office. After that stroke, his wife, aided by his staff, reportedly served, for over a year, “essentially, [as] the nation’s chief executive until her husband’s second term concluded[.]”

After this hidden debacle, Wilson’s Republican successor, Warren G. Harding, won by a landslide. He became noted for the Teapot Dome corruption scandal that occurred on his watch. He led the nation headlong into the Great Depression with all the wrong economic policies, including the leadup to the disastrous Smoot-Hawley Tariffs, which passed in his Republican successor’s very first year.

Technically, President Biden is not a Boomer, whom the US Census Bureau defines as someone born between mid-1946 and mid-1964. He was born during WWII, not after it. But he was three when it ended. In my view, he partook, like all born in the era, of all that uniquely characterize that dismal cohort.

So let me get to the bottom line. The Boomers took a nation that the Greatest Generation had preserved and advanced, against incredible adversity, by being smart and doing what works. The coddled Boomers on the right gave it a simplistic, counterfactual, fairy-tale ideology that ignores all the complexity and glories of our species and presumes to turn greed and corruption into advantages. The coddled Boomers on the left and in the center failed to counter this nonsense narrative effectively. Instead, they apparently relied on their fellow travelers of their own generation, without any effective effort to educate and attract the young. They let the greed-is-good narrative survive, if not thrive, by negligence and inaction. (To see this narrative in all its modern glory, take a look at how many readers’ comments to this op-ed, apparently submitted by people of all ages, assume without questioning that running corporations for the sole benefit of their shareholders is the best way to maximize human welfare.)

Despite all this nonsense, the Boomers on both sides have held on to power, apparently out of sheer ego, for far too long, well into their senile declines. Although vastly different in policies, intelligence and practical impact, both Biden and Trump fit this dismal description.

So it’s now long past time to take away the keys. If it were up to me, I would have the Democratic Party purge from leadership everyone over 65, and specifically every member of Biden’s cabinet and campaign team, regardless of age. Only then will it have a chance of preserving, let alone advancing, what remains of our nation’s greatness. Restoring that greatness requires a new intellectual approach and an enthusiasm and vitality that few, if any, entrenched and grizzled elders possess. Most of all, it requires an innate sense, foreign to the aged, that youth really matter.

Legions of Zohran Mamdanis can’t rise to replace our Boomers quickly enough. Sure, they will make mistakes and have to change course as they see what works and what doesn’t. But, so far, they show no sign of trying to stuff our nation’s greatness, and its future, into a box of simplistic nonsense that treats greed as good. Nor do they suggest, like both Biden and Trump, that only their dismal experience, including three needless and useless wars, can fix what’s broken. In that regard alone, our youthful contenders already surpass many of our Boomers, let alone the two, long-past-their-primes, who dominated our last several years.

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Contempt for Truth and the Law

During Trump’s first term as president, the Washington Post found that he lied or made misleading statements 30,573 times. The Post apparently is not keeping the same tally for his second term, but Trump’s contempt for the truth seems to have persisted. For example, he steadfastly maintains that the 2020 election was “stolen” from him, and that tariffs are paid by the country on whose goods they are imposed, not by the businesses and consumers that buy those goods after import. For a cogent and incisive analysis of just how big a lie that second one is, click here and set the timer at 2:28.

There are those—perhaps many—who think that all pols lie. But insofar as Trump is concerned, it doesn’t matter now. Our Supreme Court, in its infinite wisdom, has ruled that a president cannot be held criminally liable for “official” acts, presumably including the most bald and outrageous lies. And earlier legal analysis says much the same for civil suits. So there is, at the moment, no sanction whatsoever for a president lying in the course of arguably “official” duties: not civil, not criminal, not administrative, not even customary. Like emperors of old, our president can make things up as he goes along. The people can believe and knuckle under, or protest at their peril.

Even in John Roberts’ miserable understanding of democracy, there is some incentive for truthful talk and lawful behavior. No one else in our system enjoys the same near-absolute immunity for deliberate dissemination of falsehoods. In his celestial immunity from ordinary human morality, the president is alone.

That simple fact opens the door, perhaps, to the salvation of our Constitution and our Republic. However much a misguided Supreme Court might wish to make him so, the President is not actually omnipotent. He has the nuclear codes, but he cannot personally launch the missiles that might spell the end of our species. He’s not at the controls, and he doesn’t now how. Only the dedicated men and women in the nuclear silos or submarines can. He can’t even send a telegram or a secure message without the help of those who know how to work the machines. In a nation, an age and a government of unprecedented technical and organizational complexity, the president must act through others.

Does this simple, practical fact allow purveyors of human morality—truth and law—to put a foot in the door of the Oval office? I think maybe so. Here’s how.

Viewed broadly and fairly, the Trump presidency is the result of a long-developing popular rebellion against the rule of law and its inevitable complexity. Its origins long antedate Trump’s entry into politics. I dimly remember a Time magazine cover from the eighties, showing a statue of Lady Justice, with her characteristic blindfold, frowning deeply over the caption “Too Much Law?”

That cover reflected a general angst among the population about the prevalence of law and lawyers in every field of human endeavor. It also reflected a reality at that time: the vast majority of legislators, both state and federal, were lawyers, as were the vast majority of officers and higher-level administrators of state and federal agencies.

Most were graduates of a four-year college and a three-year law-school. Each thus had had at least seven years of higher education, culminating in three years of exclusive study of law. And each graduate typically specialized in a particular field of law—for example, civil, criminal or administrative—in the last one or two of those years. It took that much education to steep these civil leaders in the long history of law and the Enlightenment that underlies our democracy.

Besides all these years of training, lawyers in government have two other unique characteristics. First, they have a license to practice law in one or more states. Second, that license (and thus their right to practice their profession) depends on their continuing compliance with the rules and standards of their profession and of the courts before which they practice law. Notably among them are two fundamental norms: (1) respect for the truth; and (2) respect for and obeisance to the courts before which they practice.

Rules requiring truth in the courtroom are incumbent on every member of the bar. Most states’ rules reflect the substance of Rule 3.3 of the Rules of Professional Responsibility of the American Bar Association (“ABA Rules”), which are quoted in full in a footnote below. Their essence lies in ABA Rule 3.3(a), which reads in part: “A lawyer shall not knowingly . . . (a) (1) make a false statement of fact or law to a tribunal or fail to correct a false statement of material fact or law previously made to the tribunal by the lawyer[.]” (emphasis added)

In other words, a lawyer may not lie or knowingly mislead a court, ever. Other rules, quoted below, expand on this notion, requiring a lawyer to correct even inadvertent misrepresentations of which he or she is aware.

Anyone who has attended a year of law school—let alone who has graduated and become a member of a state bar—knows and understands these obligations. They are the essence of the practice of law. Anyone so trained also understands that practicing law is not just a business run for profit: lawyers are by profession “officers of the court or courts” before which they practice, and responsible, along with the court itself, for maintaining respect and for and obeisance to the rule of law.

All lawyers, upon being sworn into a state or federal bar association, take an oath to respect, obey and maintain these professional rules. If they fail to do so, their licenses to practice law can be suspended or revoked. Or they can be reprimanded and/or sanctioned by tribunals of their state bar association(s). (Many lawyers are licensed in more than one state; during my practice years, I was licensed in three.)

The point here is simple but profound. The “morals of business” and “public relations”—including such touching rules as “let the buyer beware” and “say what sells”—just don’t apply to lawyers. The courts before which they practice impose a higher standard. And so, traditionally, have legislatures, administrative agencies and other organs of government whose workers have, throughout our history, been mostly licensed lawyers.

So when a lawyer representing the federal government tells a court that an illegally deported person like Kilmar Ábrego Armando García is on a plane that cannot be reached by radio and cannot turn back, he damn well better be right. There better be no way of communicating with the pilot, and no way of turning the plane back or diverting it to a third country, if only to fuel and return. Otherwise, that lawyer has violated Rule 3.3 and is liable for censure, sanction, suspension or disbarment, depending on how a bar tribunal views the severity of the untruths.

Another lame excuse for continuing to send García to the vile Salvadoran gulag CECOT was that the court’s order to return him was rendered by the judge orally, and not in writing. But there is no rule to that effect in any court that I know of. A judge’s order rendered in open court in proper session must be obeyed, especially by the lawyers in his/her court. Otherwise, the administration of justice would break down.

In any event, most courtroom sessions are transcribed in real time by a court reporter sitting in close proximity to the judge. So most likely the judge’s order to return García was being reduced to writing even even as it was delivered orally. It likely was, a few minutes or at most an hour later, part of the written record of the proceedings.

The point here is again absurdly simple. The “no written order was served” excuse sounds plausible to the average Joe or Mary who has never spent a day in law school and who has no lawyer relation to consult. To any lawyer it is absolute nonsense: the sort of lame excuse that one would expect a naughty six-year-old to make and quickly regret making.

No government—let alone one based on intricate laws derived from centuries of history, science and technology—can function if legal duties yield to lame excuses of the type made by naughty six-year olds. Unfortunately, our Supreme Court has rendered our Chief Executive mostly immune from the laws that apply to the rest of society.

But the President is only one man. He has no training in the law, and he has taken extraordinary steps to keep his college grades and test scores secret, undoubtedly for a reason. He has demonstrated little technological, organization and practical skill, except perhaps in distracting, deluding and deceiving.

As a practical matter, he therefore must act through others, many of whom are lawyers and are held to a higher standard of honesty, candor and duty. Isn’t is about time to start holding some of those lawyers to the standards of their profession, by the usual procedures, before our entire government degenerates to the morals of the bazaar?

Endnote: ABA Rule 3.3

(a) A lawyer shall not knowingly:

(1) make a false statement of fact or law to a tribunal or fail to correct a false statement of material fact or law previously made to the tribunal by the lawyer;

(2) fail to disclose to the tribunal legal authority in the controlling jurisdiction known to the lawyer to be directly adverse to the position of the client and not disclosed by opposing counsel; or

(3) offer evidence that the lawyer knows to be false. If a lawyer, the lawyer’s client, or a witness called by the lawyer, has offered material evidence and the lawyer comes to know of its falsity, the lawyer shall take reasonable remedial measures, including, if necessary, disclosure to the tribunal. A lawyer may refuse to offer evidence, other than the testimony of a defendant in a criminal matter, that the lawyer reasonably believes is false.

(b) A lawyer who represents a client in an adjudicative proceeding and who knows that a person intends to engage, is engaging or has engaged in criminal or fraudulent conduct related to the proceeding shall take reasonable remedial measures, including, if necessary, disclosure to the tribunal.

(c) The duties stated in paragraphs (a) and (b) continue to the conclusion of the proceeding, and apply even if compliance requires disclosure of information otherwise protected by Rule 1.6.

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