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.

Donald Trump Is an Act of Desperation

By Mike Koetting March 17, 2026

It’s hardly a newsflash that Donald Trump is so singularly focused on his own interests that anything, or anyone, outside those exists only as a potential obstacle.

This is not normal. I can think of no religion or system of philosophy that doesn’t recognize that humans have something in common, have some universal decency and have certain responsibilities to one another. Donald Trump reflects not a shred of these. He over and over reminds us his world is irreconcilably divided between people who are of use to him and people who are “trash.”

At no point in the history of this country has a man so devoid of common decency—or at least so unwilling to even pretend– been elected to the presidency. Maybe it’s worth spending a minute or so thinking about what it tells us about our society.

I reject the idea that there has always been this great, brooding indifference to humanity lurking specifically in our society. I readily acknowledge that Americans have often in the past defined the category of “fellow human” more narrowly than we do today. But this is true of virtually the entire world. I know of no historical record that reflects a society that sprang into existence with a fully extensive notion of who is indeed a fellow human, and, accordingly, demanded some basic respect. Everywhere this has been a gradual evolution. At some points the US led this struggle, at other times was kicking and screaming to avoid such an expansion. But the complete rejection of the idea of a larger human community is an aberration. Period.

So why have so many people come to accept this behavior from the President of the United States?

My own thinking is that it is a desperate response to both the steady loss of personal agency, primarily due to corporate elites, and to the thinning out of social threads that hold people together. This combination of anger and alienation leads people to lash out on an emotional basis, unrelated to any values or policy.

Loss of Personal Agency

Our lives can be viewed through multiple lenses but perhaps the most pervasive is the economic structures of our day-to-day lives. When we find the economy working for us, life seems manageable. But when that turns every day into a struggle, all the other things in our life are impacted. Riffing a bit off a blog by Dick Dowdell, the underlying machinery of our society has changed over the last fifty years. Three key elements in particular have changed in adverse ways—the richest (and their corporations) exercise more power in individual lives by significantly increasing their role in political life; opportunities for meaningful economic and social mobility have diminished; and individual economic life has become less secure. Whether or not people would articulate these concerns in the same way, a large portion of the society feels the room closing in.

Twelve years ago, political scientists showed empirically what most people feel intuitively: the affluent wield outsize power in determining political outcomes. Citizens United actually went so far as to make this a principle and there is every reason to believe their sway has gotten more powerful since. It is less which party rules and much more that the wealthy are able to maintain the fundamental rule that whatever happens, the rich keep reaping a bigger share.

Again, there has been considerable academic work showing that in the middle of the last century, economic mobility was common. As the century went on, mobility declined. Now it’s a coin flip as to whether you will do as well financially as your parents and, insult to injury, the odds are greater that you will if you start relatively affluent. And, in some sense, the issue is even more blunt than whether you make more or less than your parents; the issue is whether you can afford to have your own home

Underlying economic security is similar. If you feel you’re only one accident away from the whole game spinning out of control, you’re much less inclined to think that the existing political order is worth endorsing. Here again, academics provide documentation that when economic uncertainty overwhelms, political values erode. As the authors of one study put it:

“When respondents were financially secure, support for liberal democratic principles increased. When respondents were economically disadvantaged, they became more tolerant of illiberal conditions, including biased media, weakened checks on leaders and unequal treatment under the law.“

As all three of the conditions referenced above—elite control of public life, lack of social mobility and persistent economic insecurity—became worse over many years, those most impacted stop trusting mainstream parties because things keep getting worse regardless of which is in charge. People intuitively understand that these trends are a result of policy choices that could have been made differently, indeed, used to be made differently. Republicans have done more to impact these dynamics but Democrats have contributed—and certainly failed to prevent them. Should we be surprised, then, if people are willing to take a chance on anyone who looks like he will break the existing consensus, particularly if he reflects their own sense of grievance.

Weakening the Ties that Bind

These concerns are even greater when paired with the overall weakening of the social ties that should hold a society together.

America has never been a cohesive social whole because, unlike many other countries that grew organically over a long period of time, it was an “assembled” country with pieces from all over. But, generally, there have been various veins of coherence that made it possible for people to see their common elements, or at least to find a way to work together. The last fifty years have been hard on that.

Part of what has happened is in fact the broadening of who deserves to get full respect as a human. This is a good and necessary thing. But like any other major change, it produces secondary effects. The assaults by those who make profit from stoking division, which includes Donald Trump, are designed specifically to narrow the bonds among people, to draw lines between some group and the “unworthies.” Hate can be used to generate money and profits.

The declining communal nature of our lives makes these divisions easier. The metaphor of Robert Putnam’s book, Bowling Alone, remains powerful—there has been a retreat from activities that bring people together. From civic organizations to bowling leagues, people do fewer things with other people. And this retreat from communal action has gotten worse in the 25 years since Putnam’s book. The decline in church and unions—organizations with specific communal values—has been particularly steep. Also, this disconnectedness affects the working class more significantly.

These Get Us a Psychopath

The growing anger at the powerless of daily life and the loss of personal connection to the broader society deadens people sensitivities to what seem like the most basic requirement to be president of the United States—to be a discernibly normal human being.

For some Trump voters, Trump’s indifference to the norms of the broader society was a positive attraction. But I believe these were the minority. More Trump voters were aware of this and accepted it as a downside of his opposition to Democrats–economically, cultural, or both. With various degrees of awareness, they hoped that his pathologies would not go so far as to completely upset the apple cart. Another large group was people who are disappointed at their lives and Donald Trump was apparently offering quick fixes. At the very least he seemed to reflect their visceral sense that something was robbing them. Whether he had correctly identified the people responsible, let alone whether he had either the requisite psychological underpinnings or motivation to successfully change America in their favor, didn’t seem important.

Only the first group got what they bargained for. Oops.

It’s Ugly but the Answer Is Still “No”

By Mike Koetting March 3, 2026

It’s a well-known legal adage that hard cases make bad law. The current situation of Iran is a classic case.

The existing regime in Iran is a bad actor. Very bad. They are a menace to their own people—never on fuller display than killing thousands of Iranians in the last few weeks—and are a major destabilizing force in the Middle East. It is hard to imagine the world wouldn’t be improved by their removal from power.

On the other side of the equation is the idea that one country should not interfere in the affairs of another country. This idea has much more currency if there is evidence that the affairs of the country reflect some version of the common will. The evidence in Iran runs counter.

So how should we feel about the intervention in Iran?

My answer: potentially favorable consequences aside, this is a bad thing.

A Modest Strategy of Great Ambition

By Mike Koetting February 17, 2026

While the mid-term elections are ten months off, and ten months is a political eternity, polling suggests it is very likely Democrats will gain a majority in the House and might even eke out a tiny Senate margin. Inshallah.

One hopes this would allow the Democrats to serve as a somewhat greater brake on Donald Trump’s worst impulses. The degree to which that will happen is unclear since so much of what he does is, to be generous, extra-legal. Thus, the ability to slow him will play out in real time when we get there.

Still, having a plan might be good. Here are a broad set of strategies that Democrats might use as a framework for the following two years—if they are willing and able to do so. I think the difficulty of following these strategies will be less a function of Trumplican opposition and more a function of the party’s internal workings, which, by the way, are not unique to Dems but are inherent in the way we allowed our pollical and cultural environments to evolve.

Deflating the Future

By Mike Koetting February 3, 2026

This is the third, and for the moment, final post in my series on how we are failing to prepare the next generation for a fulfilling life. The first two posts focused on broad, but tangible issues, the economy facing young people and the confusion of post-secondary education. Today’s post is about something more diffuse but arguably more important—failing to create a sense of a robust future in young people.

Brief History of the Future

The idea of “the future” is a relatively new idea in history. All the ancient religions had some sense of the magic and mystical beyond day to day, mundane life. And all had a broad notion that fate served some people better than others. To create some degree of protection against the fickle fingers of fate, they conjured rituals and rules. But this was not “future” as we think of it; it was simply the awareness of the random distribution of events from a relatively limited set of possibilities.

We’ve Muffed Post-Secondary Education

By Mike Koetting January 18, 2026

This is the second in a series of posts on how we are bungling the preparation of young people for their lives. Today’s post considers post-secondary education. As noted in the previous post, college student debt is one of the most salient features of young adult society in 2026 America. While this is fueled by the precipitous rise in the cost of college, the bigger problem is that as a society we have misunderstood the economic relationship between college and a good life. This is part of a much bigger problem—what gets taught in college and how—but those are for a different day.

How We Got Here

The problem starts with the fact that historically there was a significant “wage premium” (to use economic jargon) for graduating from college. In the great economic expansion following WWII college graduates did much better economically…and were less likely to wind up in Vietnam.

At the same time, the official US, locked in a geopolitical struggle with Russia, began to worry about the efficacy of American scientific and technical training and engaged in many programs to increase the number of people going to college. It was also a period of starting to address historical divisions in society and one of the politically safest ways to do something was to promote increased educational opportunities as a way of equalizing major income discrepancies.

Then, starting during the Reagan administration, income differentials in the US started to take off. This was due to a series of policy decisions that facilitated exactly such differentials. These policies followed from a set of assumptions about the primacy of capital over labor that led to a significant reconceptualization of how corporations should behave in our society. There should have been a much greater fight over the resulting policy changes since they did not necessarily speak to the well-being of the whole society. Unfortunately, the Democratic Party, the logical–indeed only–group capable of forcing such a reconsideration, itself flirted so heavily with that ideology that no effective opposition was raised.

The Economy for Young People

By Mike Koetting January 6, 2026

The question of what one generation owes to the next is a complicated one, but I am struggling to find any register on which American society is doing a good job of giving young people what they need to have good and fulfilling lives.

This and subsequent posts will look at three important areas where as a society we seem to be doing a particularly poor job facilitating the next generation’s route to good lives. Today’s post will focus on young people in the economy. The next two will consider how we are treating post-secondary education, and, finally but more broadly, what view of the future we are giving to the people who will live it.

Widespread Problems Have Disparate Impacts

Many—perhaps most—of the problems in our economy apply to many age groups, not just young people. But, as I will try to show, the damage to young people is particular, mostly because of the way it shapes their outlooks and their life-long trajectories.

The core problem of the American economy is that the benefits of the economy are going disproportionately to capital rather than labor. We’ve all seen the graphs.

U.S. Bureau of Labor Statistics

Which, of course, has led to a serious divergence in income growth among various cohorts of the economy, with after-inflation growth of the top tiers seriously outpacing the rest of society.

Again, while this impacts everyone in the bottom 80% of the income distribution, the impacts on young are magnified. They have no resources on which to fall back. They are seeking for the first time many of the things all adults want to have–their own car, have their own place, be able to imagine starting a family.

One consequence of these immediate difficulties is that a great number of young people can’t understand how they are going to make their way in life. This is a major change in the social framework of our society. From the end of World War II until, somewhat arbitrarily, the 2008 recession, there seemed to be multiple life paths. Not that they were equal and their real-life availability varied across the population. And cracks started showing well before 2008. Still, most people coming of age over that period could readily imagine a track to a good life—professional, white collar, gray collar, or blue collar. All of these tracks, in varying degrees, promised employment at a wage that afforded a house, a car, and a vacation. It was simply assumed that these jobs would offer health insurance and pension. In that context, marriage and kids made sense. The gradual accretion of women into the labor force helped ice the economic cake, even if it created other issues

By contrast, most of today’s young people are deeply skeptical these pathways will be available to them. For many, they are already facing serious headwinds. In a poll of young people by the Harvard Institute of Politics 43% of people in their sample reported struggling or getting by with limited financial security— and this strain is especially pronounced among Black and Hispanic young people and those without a college degree. In another study of young people, nearly 40 percent of survey participants said they were taking on additional jobs to make ends meet.

Bad Job Market

One of the biggest problems for young people is that the job market is inhospitable. Even those who have graduated from college can find the sledding difficult.

The three-month moving average unemployment rate for recent U.S. grads sits around 5.3% versus 4.2% for the overall workforce; on some measures for degree-holders it pushes ~6–7%. This is being driven by a number of factors. In some cases, it is in fact AI, or, more likely, the expectation of AI. It also reflects the economy of not hiring people who will take a while to ramp up their skills. Both of these have become problematic for today’s cohort because it is looking increasingly likely that during the economic “bounce back” from the pandemic many companies over hired on the assumption their growth would continue at that pace. It hasn’t. With insufficient demand, companies would have to lay off workers to make new hires. They don’t want to. And the problem is amplified because consumer confidence is in the toilet and people are unwilling to leave the jobs they already have. When there are fewer voluntary movers, the number of job openings decreases. All of this generates a longer-term problem because when young people don’t get starting jobs, they are blocked from the opportunity of on-the-job learning and run the risk of permanently lower income and skill levels.

The problems for those who would otherwise head into blue collar jobs are different in particulars, but similar in outcome. On balance, manufacturing jobs in the US have declined as a part of the workforce. This has been going on for years but has recently accelerated dramatically, falling by almost 25% since 2020. This is driven by both automation and trade policies. When total jobs in a field disappear, there are inevitably fewer job openings, which of course is disproportionately felt by young people, setting in motion a chain of problems that stretch over a lifetime.

Student Debt

I have heard many adults dismiss the issue of student debt as some version of “entitled young people”. I am not sure they understand the magnitude of the issue. One in four adults under the age of 40 have student loan debt. This totals to about $1.8 trillion held by 42 million different people, most of them between the ages of 20 and 40. In 2025, the average amount of the loan debt is $50,000, And while there are some people in this mix for whom the student loan was the ticket to a very well-off life style, there are many more for whom this was a marginal investment, or, worse yet, yielded no tangible economic advantage.

To be sure, what’s going on with student debt is intractably related to the cost of college and, further, its role in our society. I will return to these in the next post, but here I am simply pointing out that student debt is a major economic fact in the lives of young people. There is evidence that by itself it reduces home ownership and negatively impacts family formation. It can materially impair credit scores, which leads to higher rates for everything from credit cards to mortgages.

It is hard to put these policies into a global perspective because so many aspects of American post-secondary education are unique. But other countries have chosen different approaches that result in little to none of the anxiety that we have created in America. For all the heat the discussion has attracted, neither party has put forth an agenda remotely commensurate with the problem. Impact of recent changes as part of the Trump administration is still being sorted out—and may include some very modestly useful reforms. But the decision to renew garnishing salaries for delinquent student loans will certainly cause some real hardships.

Housing

The increase in housing costs is well discussed as a problem afflicting all portions of the population. Inflation-adjusted housing costs, rent and purchase, have increased almost 25% more than median wages in the last five years. The result is that the entire bottom range of the income distribution is facing increasing difficulties in affording housing.

But, again, the impact on young people is particularly stark. Median age of first time home ownership, for instance, reached 40 this year, an all-time high according to the National Association of Realtors. The following chart is a poster for the problem.

U.S. Census Bureau

In Short

Darren Walker, President of the Ford Foundation, said “Hope is the oxygen of democracy.” But it’s not at all clear that the current economic situation is generating hope in young people. Rather, it is raising concerns as to whether they will find jobs that pay enough for a comfortable life, be able to own their own home, be confident they will have health insurance, be able to afford children or retire at a reasonable age. And while all young people have some degree of apprehension, it would be inexcusable to overlook the greater pessimism about having a good life among those who start out with few advantages. It is no wonder so many feel the game is rigged.

Rather than generating hope, then, I am worried the current situation is generating fear in young people. That is a very bad thing. As Yoda says: “Fear is the path to the dark side. Fear leads to anger. Anger leads to hate.”

And hate, as we have seen, is a threat to democracy.

Progress on Reducing Violence in Chicago

By Mike Koetting November 25, 2025

Today’s post focuses on fighting gun violence in Chicago, although the issues have national resonance.

The good news is that Chicago gun homicides have decreased significantly since their recent peak in 2021. This is true in most of the nation, but Chicago’s rate of decline was greater than the national average. This is not, of course, due to Operation Midway Blitz, as the Trump administration has ridiculously claimed. It was under way well before then and links in part to specific actions taken in the city and state.

It is still too high. The loss of life and disruption to the community is, and should be, unacceptable. It is also a political problem because ”crime” is a major issue for many voters, even if they aren’t keen on the Trump approach

The Reality of a Progressive-Populist Alliance

By Mike Koetting November 11, 2025

In my last post, I suggested that at least one way forward is some kind of populist-progressive alliance. Although more thinking about such an alliance raises some concerns, as last week’s election results illustrate, this is probably the way forward.

Obvious Convergence on Economic Issues

The primary basis for such an alliance is the concern over economic issues. We are currently in an anomalous situation where the stock market continues to boom. And while numerous other macroeconomic indicators are not plunging, the underlying realities are increasingly wobbly and the stress for many individuals and families acute.

The Unnecessary Scarcity We Tolerate Is Tearing Up the Country

By Mike Koetting October 28, 2025

I’ve been thinking that Abundance, the Ezra Klein-Derek Thompson book, has the right idea but the focus is too narrow.

The Klein-Thompson book starts with the observation that scarcity is a choice. It then proceeds to assume that the way out of the scarcity trap is to make it easier to create more stuff so that all may experience the abundance of what our technology can produce. This clearly has an element of truth. They correctly identify bottlenecks in our current production of social goods and they are right that there is no political appetite for “degrowth.” So power to their suggestions.

That said, however, they miss the urgency of the situation. A large chunk of the population is furious. Trying to remove obstacles to creating greater supply of desired goods, while laudable, is simply not a solution commensurate with the degree of anger in the body politic. I think Michael Hirschorn, in a recent New York Times op-ed piece, has a better handle on where we are: “Trumpism is more than politics. It’s an emotional gas-main explosion, from people who felt unheard, patronized, left behind.”

The Moment of Truth

By Mike Koetting October 14, 2025

I believe we are approaching a “make-or-break” point for Trump’s authoritarian impulses.

It’s not a question of what he wants to do. That’s clear. In the last several weeks, he has replaced Federal Attorneys until he found one who would pursue an embarrassingly flimsy indictment against one of his enemies, he signed an executive order that raised the possibility almost any kind of dissent could be treated as “treason,” he posted on Truth Social that Democrats are “THE PARTY OF HATE, EVIL, AND SATAN,” and he lectured the leaders of the Armed Services that their mission included fighting the “enemies within”.

His approach to controlling immigration is increasingly inhumane. His masked marauders have grabbed people off the streets with little regard for their situations or actual legal status. Here in Chicago, along with the wanton cruelty and indifference to legality, there has been a major performance element designed to intimidate: armed border guards patrolling the Chicago River, military marches down Michigan Avenue on a Sunday afternoon and ICE agents rappelling from Blackhawk helicopters into apartments filled with sleeping families—separating children from parents and causing total pandemonium. Now Trump is calling for Governor Pritzker and Mayor Johnson to be jailed.