Author: mkbhhw

Mike Koetting’s career has been in health care policy and administration. But it has always been on the fringes of politics. His first job out of graduate school was conducting an evaluation of the Illinois Medicaid program for the Illinois Legislative Budget Office. In the following 40 years, he has been a health care provider, a researcher, a teacher, a regulator, a consultant and a payor. The biggest part of his career was 24 years as Vice President of Planning for the University of Chicago Medical Center. He retired from there in 2008, but in 2010 was asked to implement the ACA Medicaid expansion in Illinois, which kept him busy for another 5 years.

Being an American Right Now

By Mike Koetting July 8, 2025

Another Fourth of July rolled around and there was new grist for the perennial question of how I feel about being an American.

Being an American is, foremost, a legal definition laying out certain rights and responsibilities. Becoming an American was easy for me: I was born here. And since, at least so far, I haven’t wanted to leave, I am still an American. Of course, the legal fact doesn’t shed light on how I feel about this.

At one level, how I feel about being an American is kind of an unconscious, automatic response to being part of a group, a community larger than me. I always cheer for American teams to win in the Olympics. There are also certain patriotic tropes and evocations that never fail to move me. Lincoln’s Second Inaugural address, for example. Or Woody Guthrie’s “This Land Is Your Land.” I suspect this deep-seated sense of “home” will stay with me no matter what.

But these group instincts are nowhere near as important as the more analytical view of what I believe America stands for and how that is being realized, or not, at the moment.

Are Our Responses Matching the Risks?

By Mike Koetting June 24, 2025

Our country is drifting toward an authoritarian state. This is a fact, not a matter of opinion. One might argue about the speed of the drift or, in theory, even whether that’s a good thing or a bad thing. But one can’t really argue in good faith about the direction.

I am guessing most of the readers of this blog are troubled by this. The question that I can’t get out of my head is how should I feelabout it. And, then, what should I do about it. Asking these questions raises a lot of philosophical questions about what does the abstraction of democracy or, even, of country, mean, none of which have simple answers.

But it seems to me that there are fundamental reasons to believe that democracy is superior to authoritarianism, so much so, I would submit that standing up for it is a moral imperative.

Republican Organization Is (Mostly) an Illusion

By Mike Koetting June 10, 2025

How many times have you heard someone say: “Democrats need to get organized like Republicans.” I don’t have any problem with the idea of getting organized. What I find problematic is the idea that the Republicans have some magic template. For the most part, they are as disorganized as Democrats. They have simply hitched their wagons to one of the world’s most accomplished grifters and let him drag them wherever he wants to go. This simplifies organization enormously. To be sure, Trump has accommodated them by making various nods in the directions of long-time Republican goals. But it is erratic, inconsistent, and can be seen as part of an organized plan only through a peculiar lens. See below about Project 2025.

Democrats Real Problem Is a Lack of Options

By Mike Koetting May 27, 2025

I am increasingly skeptical that characterizations of the Democrats as chronically disorganized are useful. Democrats probably are disorganized. But all political parties are…and the more democratic they are, the more that is the case.

No doubt, mistakes were made in the last election. The biggest one was when Biden insisted on running. Maybe you could blame that on the Party. But just ask the (former) Republican establishment how easy is it is control someone who had structural momentum. And, although a year or so later one can spin all kinds of counter-historical scenarios, at the time there were compelling reasons not to pursue various alternatives.

Post-election, options are even more limited. The other party controls the national government and Democrats have no leverage. Republicans would prefer to toss over all reason (not to mention the Constitution) rather than strike any kind of compromise.

How Many Deaths for Congressional Republicans?

By Mike Koetting May 13, 2025

In Julius Caesar, Shakespeare writes: “Cowards die many times before their deaths; The valiant never taste of death but once.”

Republicans in Congress are today playing out their own version. By failing to take on any of the winnable small battles, they are slipping toward a situation where the entire foundation of the country could be up for grabs. Most Congressional Republicans understand that Donald Trump is playing fast and loose with the separation of powers—and in the process taking away Congressional power.

Inequality Is Giving Money to Rich People

Mike Koetting April 22, 2025

Many Americans are white-hot angry at their situation in life. More and more families are having a difficult time making ends meet. The sense that they are no longer fully participating in the promised life can be found everywhere. Two-thirds of middle-class families say they are struggling financially.

It shouldn’t come as a surprise that many families are feeling short-changed since the richest Americans are increasing their share of wealth at the expense of everyone else. This is primarily a result of deliberate policy decisions. The surprise is that so many of the people feeling short-changed voted for an agenda promising more of the same.

In 2023, the total share of income earned by the bottom 90% of workers was less than 50%. In other words, the bottom 90% altogether made less than the top 10%. There is nothing inevitable about such a distribution. Most countries with American standards of living have more equal income distributions. In fact, America used to have a more equal distribution.

Economic Issues by Themselves Will Not Change Democratic Fortunes

By Mike Koetting March 25, 2025

Sociologist Arlie Hochschild, in her recent book, Stolen Pride, observes that in addition to a material economy there is a “pride economy.” I think recent Democratic losses have as much to do with shortages in that economy as with problems in the material economy. It’s not something voters talk about, so it the poll-centric mainstream media misses it. But I submit it is at the heart of why people vote for a person who is a known liar and is unlikely to actually deliver economic improvement for most of his voters. One way or another, he assuages the loss of self-worth that has afflicted a large swath of the population. This is certainly related to the material economy, but is in fact a different dimension and it is losses in that dimension that have made the road so difficult for Democrats.

To be fair, managing what has happened in the pride economy would have been a difficult, maybe even impossible, task for Democrats.

For openers, Democrats became the party of the oppressed as Republicans settled into the party of “let’s keep everything the way it is,” or, better yet, the way it was 50 years ago. From the Sixties on, the Democrats championed changes in society that were necessary to allow more individuals to be more self-actualizing. These changes, appropriate as they were, created major perturbations in the pride economy. Being right is no guarantee you won’t offend people who feel their status has been eroded.

What Are the Republicans Thinking?

By Mike Koetting March 4, 2025

Twice before in my life, I experienced a sensation that our basic political system was in mortal danger. Once in 1970 on the day protestors were killed at Kent State and three years later when Richard Nixon precipitated the Saturday Night Massacre. In both cases, however, the sensation only lasted for a few hours. I found I had a deep-seated conviction that the series of checks and balances would work, even if a bit wobbly for a time.

Today I am finding that confidence waning.

Throughout our history, our system has worked because powerful individuals were willing to be constrained by institutions, by the system of checks and balances that provide some assurance that a small number of individuals can’t ride roughshod over the rest.

It isn’t as if these powerful individuals were all particularly virtuous—some were and others not so much. It was more that they operated in an environment of a shared understanding that if you wrecked the system, what came next would be worse. Democracy is what allows people with differences to work together over time.

So, although there have always been individuals who would have thrown over the institution, other than the Civil War, the broader ethic prevailed. Those who would have done way with these checks and balances have been restrained. A year after the Saturday Night Massacre, a group of Republican Senators told Nixon that he would be impeached if he did not resign.

What is different about today is not so much that Donald Trump would throw over the institutions, but that there are so many people who are willing to let him do so even though they know better.

Many citizens are so deeply alienated by the current moment and feel so powerless they don’t worry about Constitutional considerations. I am disappointed, but I understand.

However, I cannot fathom what is going through the minds of various Republican Representatives and Senators. What is their rationale for allowing Donald Trump so much leeway? It is implausible that they don’t understand they are destroying the checks and balances that have been fundamental to America for 250 years. Do they really believe that putting all the power in the President is a good idea? And while they may be happy that Trump will accomplish some things that they want and whack away at some things they oppose, do they really believe this is a sustainable model for running a country?

Time to Call Out the Immigration Con

By Mike Koetting February 26, 2025

Everyone knows the story of the emperor’s clothing. No one was willing to say the truth until a child blurted it out.

There are parallels in our national discussion of immigration. Republicans, led by Trump, have inflated some real—but manageable issues—into a national panic. The fact that the panic is caused by a con gets lost in the day-to-day coverage.

It is a real problem that our system for managing immigration is broken. It is broken from lack of funding and from incoherence in our rules and laws, in large part due to conflicting interests. There are any number of feasible solutions to those problems. None of them are addressed by deporting people. Fixing the core system requires nuanced, rational political discussions of the various trade-offs—which Republicans have been systematically undercutting for 20 years.

Numbers and Conversations in the Fires’ Aftermath

By Mike Koetting February 11, 2025

The thing about numbers is they are objective. You can fudge them for a while, but eventually their concreteness wins out.

So when the insurance actuaries mull over the Los Angeles wildfires, they will issue verdicts not based on rhetoric or hope or blame, but gimlet-eyed assessments of what makes sense for insurance companies—increase rates, leave or what.

We already have a preview. In the year leading up to the fires, State Farm, the largest homeowners insurance company in California, anticipating the risk, refused to renew thousands of policies there. They had already stopped selling new policies in the state. Other insurers are similarly trimming their sails.