We might have hoped that eventually, Congress would understand its mission: To defend and improve the lives of the people.

And we might have hoped that eventually, Congress would understand it has the unlimited ability to create the dollars to defend and improve the lives of the people.

And we might have hoped that we, the public, would learn that our federal taxes do not fund federal spending, so even “wasteful” federal spending costs us nothing, and in fact, benefits us by adding growth dollars to the economy.

Sadly, those hopes, once again, are dashed, as an intentionally ignorant and uncaring Congress and President have found a new way to make our lives worse.

In a six-year experiment that begins Jan. 1, millions of original Medicare beneficiaries in six states could be required to get advance approval, called prior authorization (PA), before certain medical services, procedures or devices are covered.

If successful, the pilot project could lead to wider use of prior authorization in original Medicare, possibly using artificial intelligence (AI). The practice is already widely used in Medicare Advantage, with some plans using AI and algorithmic software to help make coverage decisions.

It’s designed to speed up coverage decisions and cut wasteful spending on at least 16 devices, procedures and services that are “particularly vulnerable to fraud, waste and abuse or inappropriate use,” according to CMS.

There is no way that waiting for prior authorization can “speed up” anything.

Technology companies that participate will be paid based on savings from denied medical claims, which has drawn the ire of the American Medical Association and consumer organizations.

If your pay depends on your denying health care claims, what will you do?

Right. Deny claims. And that is exactly the experience people have had with PA.

The pilot project comes amid concerns from lawmakers, government watchdogs and others that Medicare Advantage plans’ prior authorization procedures can create burdens for caregivers, who have to figure out how to appeal, and risk the health of patients by delaying or denying care that would otherwise be covered under original Medicare.

Prior authorization helps save the federal government money by screwing sick people.

There is no simpler, more accurate way to say it. Under the false banner of cutting “waste,” the government plans to cut services. Remember, because the government is Monetarily Sovereign, “cutting waste” is meaningless.  

The federal government cannot run short of its sovereign currency, the U.S. dollar. Even if the government collected zero taxes, it could not run short of dollars. 

Even if the federal government collected zero taxes and tripled spending, it still could not run short of dollars.

Unlike state and local governments, the federal government creates unlimited dollars by pressing computer keys. In reality, so-called “wasteful” federal spending benefits the economy. It adds to Gross Domestic Product.

GDP = Federal Spending + Nonfederal Spending + Net Exports

The sole purpose and effect of prior authorization is to reduce, delay, and eliminate medical services and to transfer much of the remaining cost to the ill.

It is a program only a right-wing Republican could love — and even that right-winger won’t love it when he/she has payment or procedure denied because some bureaucrat in Washington won’t pay for the procedure your doctor prescribed.

The terrible irony is that while the Republicans, under Trump, tell you that Washington is filled with “useless” people who must be fired randomly, the Republicans want those remaining “useless” people to make your healthcare decisions. 

Here are some examples of what the current administration wants to subject you to:

94% of physicians report care delays due to prior authorization, AMA says

The survey underscores the urgent need for reform and regulation of prior authorization, the AMA said.

In December 2022, the Centers for Medicare and Medicaid Services released a proposed rule to speed up prior authorization approval.

Physicians spend almost two business days each week on prior authorization requests and 35% have had to hire additional staff to exclusively handle the administrative burden, the AMA said.

The AMA said other survey results show that 80% of physicians report that prior authorization can lead to treatment abandonment; 33% of physicians report prior authorization leading to a serious adverse event for a patient in their care – with 9% reporting it’s led to permanent bodily damage, disability or death.

Prior authorization complexity does not eliminate unnecessary treatments, the AMA said. Eighty-six percent of physicians report that prior authorization leads to higher overall utilization of healthcare resources.

Many ophthalmologists have faced – and continue to face – broad prior authorization policies on cataract surgeries from certain insurance giants, the AMA said.

Rheumatologists have long decried prior authorization policies for worsening outcomes for their patients. Many rheumatology patients rely on expensive biologic medication to treat their disease, meaning they are commonly a target of insurers, the AMA said.

And then there’s this evaluation of the “Save the government money by costing people money, their health and their lives program.”

Imagine you have a cancer growing in you, and your doctor tells you that you need treatment right away. Good luck with that:

The Patient Experience of Prior Authorization for Cancer Care

Question What is the patient experience with prior authorization (PA) for cancer-related care?

Findings This cross-sectional study of 178 patients with cancer with experience with PA showed delays to care (with most delays ≥2 weeks), increased anxiety, and patient administrative burden. The PA process was rated bad or horrible by most respondents and was associated with decreased trust in the health care system.

This study suggests that PA for cancer care can have discrete negative associations with outcomes for patients; streamlining the process is key to optimizing the quality of care delivered and improving the patient experience with cancer care.

Prior authorization (PA) requires clinicians and patients to navigate a complex approval pathway. Resultant delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management.

Results:
22% did not receive recommended care due to delays or denials.
69% reported a PA-related delay in care; of those with delayed care,
73% reported a delay of 2 or more weeks.
67% had to personally become involved in the PA process;
20% spent 11 or more hours dealing with PA issues.
The PA experience was rated as bad 40% or horrible 32%
PA-related anxiety was higher than usual anxietyand was correlated with delay length, and time spent
After PA, 89% of patients trusted their insurance company less, and83% trusted the health care system less.
22% of patients did not receive the care recommended by their treatment team because of PA.

PA processes may require clinicians and patients to navigate a complex approval pathway and can lead to delays in receipt of care or denials of recommended
Delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management.

Oncologists have reported suboptimal care and delays in cancer treatment owing to PA’s bureaucratic interference in clinician-patient decision-making; an oncology survey found that payer pressures, including handling PA, ranked as the most pressing practice concern.

An American Medical Association survey found that 90% of respondents reported treatment delays due to PA.
73% of surveyed oncologists reported that patients “routinely” expressed concerns to them about PA-related delays.

About 33% of physicians in the AMA survey said PA criteria are rarely or never evidence based.
62% of physicians reported difficulty in determining whether a service required PA.
Patients described the process as arbitrary, with lack of communication, lack of transparency

Does this really sound like an improvement to Medicare? Does it sound like you will receive better care at less cost?

IN SUMMARY

1. Your federal taxes do not fund government spending. The sole purposes of federal taxes are to regulate the economy and stabilize the dollar, not to provide funding for government spending.
2. The federal government cannot run short of money. It creates dollars simply by voting to fund projects.
3. FICA does not fund Medicare. The federal government has the power to fund a comprehensive, no-deductible Medicare plan for everyone of every age in America, without collecting a penny in taxes.
4. The current administration is in the process of firing hundreds of thousands of federal workers; yet, those remaining workers are expected to administer PA, a complex process that requires medical expertise and handling hundreds of thousands of individual cases. 
5. No one knows your medical needs better than your doctor, yet the government wants a Washington bureaucrat to make your medical decisions and overrule your doctor.
6. Delays or refusals to provide services have cost people’s health and lives.
7. PA does not save you or your doctor time or money. PA does not improve service. On the contrary, PA costs you and your doctor time and money, and worsens medical services.
8. Private insurance companies are dollar-constrained. They use PA so they can deny services. Their people are paid to deny services. The federal government is not dollar-constrained. Its purpose is to protect you and provide service. 

In short, PA is an even worse idea than the notorious “debt ceiling,” and that is really saying something.

Rodger Malcolm Mitchell

Monetary Sovereignty

Twitter: @rodgermitchell

Search #monetarysovereignty

Facebook: Rodger Malcolm Mitchell;

MUCK RACK: https://muckrack.com/rodger-malcolm-mitchell;

https://www.academia.edu/

……………………………………………………………………..

A Government’s Sole Purpose is to Improve and Protect The People’s Lives.

MONETARY SOVEREIGNTY

Official Results of the 2024 Presidential Greatness Project Expert Survey

Brandon Rottinghaus, University of Houston Justin S. Vaughn, Coastal Carolina University

The 2024 Presidential Greatness Project Expert Survey was conducted online via Qualtrics

from November 15 to December 31, 2023.

Respondents included current and recent members of the Presidents & Executive Politics Section of the American Political Science Association, which is the foremost organization of social science experts in presidential politics, as well as scholars who had recently published peer-reviewed academic research in key related scholarly journals or academic presses.

525 respondents were invited to participate, and 154 usable responses were received, yielding a 29.3% response rate.1

Note: Donald Trump’s 2nd term was not included.

The primary purpose of this survey was to create a ranking of presidential greatness that covered all presidents from George Washington to Joe Biden.

To do this, we asked respondents to rate each president on a scale of 0-100 for their overall greatness, with 0=failure, 50=average, and 100=great.

We then averaged the ratings for each president and ranked them from highest average to lowest.

The results of this ranking are quite similar to the results from our previous surveys (released in 2015 and 2018): Abraham Lincoln again tops the list (95.03 average), followed by Franklin Delano Roosevelt (90.83), George Washington (90.32), Teddy Roosevelt (78.58), Thomas Jefferson (77.53), Harry Truman (75.34), Barack Obama (73.8), and Dwight Eisenhower (73.73).

The most notable changes in this ordering are Franklin Delano Roosevelt moving up to #2 from the third spot last year, and Dwight Eisenhower falling back to #8 from #6 last year.

The bottom of the rankings is also relatively stable. Donald Trump rates lowest (10.92), behind James Buchanan
(16.71), Andrew Johnson (21.56), Franklin Pierce (24.6), William Henry Harrison (26.01), and Warren Harding (27.76).

What is most noteworthy about the remaining presidents concerns who has risen and fallen over time. Since our initial survey, several presidents have had significant changes in their rankings.

Barack Obama has risen 9 places (from #16 to #7), as has Ulysses S. Grant (from #26 to #17), while Andrew Jackson has fallen 12 places (from #9 to #21) and Calvin Coolidge has dropped 7 spots (from #27 to #34).

Examining the partisan and ideological differences among our respondents also indicates some interesting dynamics. While partisanship and ideology don’t tend to make a major difference overall, there are a few distinctions worth noting.

For example, Republicans and Conservatives rank George Washington as the greatest president and James Buchanan as the least great.

There are also several presidents where partisan polarization is evident – Reagan, George H.W. Bush, Obama, and Biden – but interestingly not for Bill Clinton. 

 

Why Trump, and why Trump now?

Donald Trump is a demonstrable psychopath. He meets all twenty criteria of the Hare Psychopathy Checklist, an initial diagnostic tool for psychopathy.

See the July 16, 2015, post titled, “Is Your Favorite Candidate a Psychopath,” in which we already identified Trump as a psychopath. Then came the May 12, 2016, post titled, “Will Our Next President Be a Psychopath,” and “A Psychopath Slipped Into the White House,” in which we again told you that Trump is a psychopath. 

More than 10 years ago, it was clear that Trump had severe psychological problems, and since then, they have grown worse. Much worse. He may be one of the least capable people to assume the Presidency.

So why Trump, and why now?

I suspect it began with white resentment of a black president, Barack Obama, and the “replacement” theory that has been the emotional fuel, but those are only part of the important shifts that occurred during the recession of 2008..

That period saw a perfect storm of fear and loss. Several simultaneous changes rattled the American self-image:

1) Demographic reality: 

White Americans went from an overwhelming majority to a plurality heading toward minority status. Immigration, interracial marriage, and non-Christian identity became normal.

That triggered a visceral “status loss” among some whites — not necessarily material loss, but loss of primacy. This status anxiety is the emotional heart of “replacement theory.” It is the basis for the illogical but powerful hatred of immigrants today.

That hatred is illogical from an economic standpoint. (Immigrants are a major benefit to America. They pay taxes, don’t receive social benefits, don’t steal jobs, fill undesirable jobs, are less likely to commit crimes than citizens, and are important consumers for businesses.)

That hatred also is illogical from a moral standpoint. Americans have viewed ourselves as a “shining city on a hill,” an example for the world. “Give me your tired, your poor, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!”

Yet hatred is planted and nurtured by fear, and Trump consistently has played on that fear

2) Economic disillusionment: 

Forty years of wage stagnation, automation, and globalization hollowed out the working and middle classes. People were told “hard work pays off,” but it stopped paying off.

Resentment needed a target; the wealthy cleverly redirected it toward immigrants, minorities, and “liberal elites.”

3) Information collapse: 

Social media algorithms radicalized discourse. Traditional media lost authority, creating epistemic tribalism: “facts vs. alternative facts.”

(On January 22, 2017, Kellyanne Conway used the expression “alternative facts” while defending Sean Spicer’s false statement that Donald Trump’s inauguration crowd was the largest ever; others pointed to photographic and transit evidence to the contrary.)

Outrage became both identity and entertainment. The result: A broad sense that “we are losing our country” — a fertile emotional base for authoritarian politics. Again, fear turned to hatred.

4) The election of a black man, Barack Obama, was a catalyst:

Obama’s election was a psychological earthquake for a segment of white America. A Black president symbolized a reversal of the old hierarchy. For many, that wasn’t progress; it was humiliation — the fear that their America was slipping away.

The right-wing media ecosystem immediately capitalized on that feeling: “He’s not one of us,” “He’s un-American,” “He’s a secret Muslim.” That rhetoric reactivated the oldest American myth — that whiteness and nationhood are synonymous — and made it politically mainstream again. Trump is the perfect authoritarian response

5) Donald Trump didn’t invent this resentment and fear; he channeled it. He offered:

The rich: deregulation, tax cuts, and judicial control.

The poor and anxious: revenge, validation, and a sense of belonging.

He fused those groups into a coalition of resentful masses and self-serving elites under a single emotional banner: Make America Great Again. Translation: Make it white, familiar, and obedient again.

6)Institutional erosion followed:

The judiciary and Congress polarized into obedience camps. 

Truth itself became optional — a sign of late-stage institutional decay.

The old norms (“losers concede,” “laws apply equally”) began to crumble.

That’s the moment when democracies shift toward authoritarian logic:

“If the system won’t protect us, we need a strongman who will.”

Today’s U.S. shows all the classical precursors

Elite cynicism: billionaires and corporations backing populist rhetoric to secure deregulation and tax shelters.

Mass grievance: working-class whites convinced they’re victims of elites and minorities.

Institutional decay: parties acting as tribes, courts politicized, media fractured. Truth derided.

Mythic narrative: “We are being replaced — but our leader will save us.”

That’s textbook pre-authoritarian alignment. The U.S. hasn’t yet become a dictatorship;  it still has strong institutional inertia. But the pattern is unmistakably the same as the early stages seen in other democracies that fell.

Summary

Dictatorships seldom emerge without an elite faction, consisting of the wealthy, military, bureaucratic, or business leaders, seeking either to protect or expand their privileges, alongside a mass faction that desires vengeance, dignity, or the redistribution of wealth.

The dictator brings the two opposing sides together by offering each what they desire. The wealthy gain order, financial benefits, privileges, lucrative contracts, and the suppression of unions, protests, and taxation.

Meanwhile, the poor get a sense of release, a target for their blame, a sense of symbolic justice (“the wealthy will pay”), and a false hope that the nation will reclaim its mythical historical greatness.

This dual alliance is historically visible in Mussolini’s Italy, Hitler’s Germany, Perón’s Argentina, and Putin’s Russia.

The poor are not always motivated solely by material improvement. They may be driven more by:

Status resentment (“we’ve been humiliated”), cultural anxiety (loss of traditional values, foreign influence), ethnonationalism (restoring dominance of a preferred group), or fear of chaos (preferring strongman order to democratic uncertainty).

This emotional substrate lets the dictator convert economic anger into identity loyalty. It’s why propaganda focuses more on who to hate than how to eat.

The elites’ calculations are usually short-term and self-destructive. The rich see a dictatorship as a profit opportunity. But they often misjudge it. 

They assume they’ll control or “ride” the dictator. They believe democracy’s instability poses a greater threat to their holdings. They underestimate how fast the dictator will turn on them.

In most historical cases, the elites who empowered the autocrat lose control quickly — often their assets, sometimes their lives. (E.g., German industrialists in the 1930s, Russian oligarchs post-2000.)

Dictatorships need institutional decay to take root. Neither mass rage nor elite greed is enough on its own. Dictatorships also need:

Weak political parties (so no one can organize opposition) as demonstrated by the leaderless Democrats and the cowardly Republicans

Distrusted media (so truth collapses into tribal belief), as demonstrated by feckless Fox News and the success of so many conspiracy theorists 

Judicial erosion (so laws become discretionary), as demonstrated by the “politicians in black robes” of the Supreme Court

Obedient security forces willing to obey illegal orders, implemented by Trump’s firing of career generals and other officers.

That decay allows a demagogue to present himself as the only source of unity or salvation. The promise is always the same: revenge + redemption.

Nationalist form: “We’ll restore our greatness.” (Make America Great Again)

Religious form: “We’ll restore moral purity.” (Book burning, censorship, anti “woke”)

Populist form: “We’ll take back what was stolen from you.” (anti-union, anti-rich, anti-immigrant)

It always is about undoing humiliation and promising simple certainty in a complex world.

Is America a dictatorship? We’re not quite there yet, but getting close. We may be saved by Trump’s age and his obvious lack of intelligence and overall mental capacity. But we are teetering.

If a man as weak as Trump can bring us to the brink, that is evidence we need a reassessment of our political, financial, economic, and moral structure. Otherwise, the next moral midgit will bring us crashing down.

I suggest we begin (not end, but begin) with federal spending and legislation to narrow the income/wealth/power Gap between the rich and the rest of America.

Data from a Milken Institute report shows that in recent years, the top 10% of households hold about 72% of the wealth in America.

This is a recipe for dictatorship.

Rodger Malcolm Mitchell

Monetary Sovereignty

Twitter: @rodgermitchell

Search #monetarysovereignty

Facebook: Rodger Malcolm Mitchell;

MUCK RACK: https://muckrack.com/rodger-malcolm-mitchell;

https://www.academia.edu/

……………………………………………………………………..

A Government’s Sole Purpose is to Improve and Protect The People’s Lives.

MONETARY SOVEREIGNTY