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Home Defense

I watched a video this morning purporting to cover this burning issue: “What is the best weapon for home defense: pistol, rifle, or shotgun?”

It sucked.

Basically, the video personality guy showed 3 types of weapons, covered a few points about each, used a lot of meaningless terminology (yeah, he pissed me off by using the “center mass” nonsense term… again…), glossed over a bunch of important stuff, and completely failed to discuss some of the most crucial aspects of the question.

I’ve spent a lot of time and effort researching the realities of home defense with firearms. (And no, by “research” I don’t mean I opened a bottle of adult beverage and used my google-fu to read some internet articles by people I don’t know whose opinions may or not be valid.) I have taken courses on tactical defense from accredited and nationally acclaimed instructors. I have taken courses as part of my LE training. I have read books. Many, many books. And I have learned and modified my views as a result of this research.

Here’s a brief summary of what my research has told me about how a sensible person should go about preparing for armed home defense:

Develop a Defensive Mindset

Massad Ayoob, John Farnham, Jeff Hall, Marty Hayes, Clint Smith, Henk Iversen, and many others I have taken training from have all said the same thing: your mind is the most deadly weapon you possess.

So use it. Use your mind, your imagination, your ability to assimilate information and process it to fit your unique home defense situation. After all, it’s your home you’re planning to defend.

Start by trying to visualize how an armed aggressor is going to come at you in your home. Will he come through the door? Through a window? Across the lawn, or from behind the shed? Will he drive his vehicle through the plate-glass entry hall? Will there be more than one attacker? Will they come at you from two different directions? Look at ALL the possibilities. Then start to work on how you would have to defeat each type of attack.

Oh, and by the way, this is really important: be sure you know when and how you are justified in using armed force on an attacker. This isn’t something you can get from surfing the web. You need to take a class on this. I highly recommend Massad Ayoob Group for this: MAG-40 is his extensive entry-level class that covers everything you need to know. I also highly recommend John Farnham’s Defensive Tactics International class on this. Marty Hayes, a MAG staff instructor and highly qualified firearms trainer out in Seattle also teaches this material.

Prepare the Ground

The day before the Battle of Gettysburg, General John Buford was scouting in advance of the Union army. His far-ranging patrols had told him where Lee’s Army of Virginia was, and in what direction it was heading. He plotted these bits of information on his maps, and concluded that Lee’s advance could be stopped if the Army of the Potomac could occupy the high ground above Gettysburg. His eye for ground (something that can’t really be taught, although tactical instructors have been trying for millenia!) led to the catastrophic defeat of Lee at Gettysburg, and the salvation of the United States as a union.

Look at the ground of your imagined battle, people. This is your home we are talking about here. You know it better than any attacker can know it. So use that knowledge to prepare the battlefield before the battle takes place. You can choose where and how the battle–if it ever does take place–will unfold.

You’ve already started on this, by recognizing the likely points of attack. Once you know where attacks are most likely to come from, you can prepare the ground. If it’s gonna be through your front door, prepare the doorway and entry hall. Placing a long table or a couch across from the door will dictate how an attacker can move as he enters the home, so you should place the furnishings so that he is directed in the way that is most favorable to you.

Set up your fields of fire. Where is the best place to set up to shoot at your attacker without revealing your position, or better yet, that gives you actual cover against returning fire? Plan your fields of fire so that you can interdict the attacker at the safest distance… close enough to hit him, far enough to allow you to escape to another position, or preclude him returning fire. And set up your enfilade for outdoors as well as inside your home, if you have a large yard or you live on a farm or ranch. What windows can you fire from on an attacker outside your home, should that prove necessary?

And while you’re at it, why not create some cover? A shelf packed with dense books or a heavy wooden cabinet with sandbags piled inside it will absorb bullets as well as any purpose-built armor, and you can set it up without making your house look like a fortress. If you’re going to fire from a window, is the paneling below that window bullet-resistant? If not, you need to make it so.

And speaking of fortresses, think about ways of “fortifying” your home that will make it as impenetrable as a castle. How good are your doors and locks? How about your windows… are they lockable? Do you use deadbolts? Experts tell me that the most cost-effective improvement you can install as part of your home security plan is good door and window locks.

Then look at construction. Do you have easily-breached entry points? Are your entry doors flimsy? How about the frames they’re mounted in? If you don’t have the construction know-how to assess this, hire a contractor to look at them and give you an opinion, and perhaps an estimate for installing upgraded doors and frames.

Finally, think about electronic security: alarm systems, cameras, and exterior lighting. You can go cheap and still put up a really good defense. Or you can spend a bundle and get a worthless security system. It makes a lot of sense to talk to a security expert who doesn’t sell alarm systems before you commit to an alarm system.

Make a Family Plan

Unless you live alone, your entire family needs to know what the home defense plan is. Each person needs to know where to go, what to do, and when. Someone needs to be on the phone to the police while someone else is shooting (or preparing to shoot). Kids need to move to a safe place, preferably near the defender(s), but behind bullet-stopping cover. All persons capable of handling a firearm need to have one, and know what they are supposed to do with it. Yes, it’s possible that your spouse could panic and shoot you in the back of the head instead of shooting the armed attacker. This has happened.

Choose Your Weapons(s)

You may have noticed I have put this last on my list of priorities. That’s because figuring out what type of firearm you’re going to use is less important than any of the above.

Now, I’m a firearms guy, so I’m obviously gonna tell you to have a gun. Or maybe even lots of guns. But every person who is armed in your home defense plan needs to have training. It’s not good enough to take your spouse to the range and let him/her plink at targets… we are talking about life-and-death situations when we are talking about armed home defense, so let’s train as if it was actual life-and-death stuff, okay?

I personally feel a handgun and a long gun for each trained home defender is the basic firearms equipment package. I know people who have a veritable arsenal in their bedroom, but let’s be honest… you aren’t Buford, and this ain’t gonna be Gettysburg. But the basic rule of “have a gun” does apply.

I firmly believe having a handgun on your person in your home is smart. Concealed carry is the smart way to go about life, in my longstanding considered opinion. Be deadly, but don’t advertise it. I have a handgun on my person at all times. If the doorbell rings and I answer it, my firearm is concealed. That way I don’t alarm the UPS delivery guy or my neighbor stopping by with a piece of misdelivered mail. But if it’s someone about to attempt a home-invasion type robbery, I don’t have to run back to the bedroom and hope I get to my gun before the attacker gets to me.

There’s an old police adage: “My handgun is primarily for fighting back to my squad car, so I can get to my rifle/shotgun.” There’s some merit to this. Any long gun, whether rifle or shotgun, is a better fighting weapon than a handgun. Long guns fire more powerful projectiles, and they are inherently more accurate. So having a dedicated home defense long gun makes sense.

But long guns are hard to carry around all day, every day, which is the primary deficiency of the long gun. Okay, but if we’ve covered that by being sure to carry a handgun all the time, we’re good. So let’s look at the other drawbacks of the long gun.

First, long guns are really, really loud. Muzzle blast is directly proportional to the amount of gunpowder in the cartridge and the chamber pressure of the firearm. The muzzle blast from a handgun is therefore pretty mild, but will still cause hearing damage if you aren’t wearing ear-pro. The muzzle blast from a shotgun is really loud, and when fired indoors will instantly deafen you, at least temporarily. (I have had this experience… firing shotgun inside an abandoned farmhouse while researching bullet penetration through walls for a long-ago magazine article. I only did it once, and then put on extra ear-pro for the rest of the projecat.)The muzzle blast from an AR-15 is REALLY loud, much worse than a shotgun. The hearing damage you sustain from firing one of these in your home may be major and may be permanent.

So if you’re contemplating using your 5.56mm carbine or your 12-gauge for home defense, you need to have a set of ear-pro right next to the long gun. Preferably active-protection earmuffs, so you can hear what’s going on while protecting your ears from damage. While you’re at it, put on some shooting glasses, because there may be a lot of flying debris if you let loose with a long gun in your house.

Which specific firearm(s) do I recommend? I don’t. You need to determine what works best for you. If you live on a farm/ranch or your home is huge, a rifle might be a better choice. Ditto if you are recoil sensitive. An AR-15 or M1 Carbine is a kitten compared to a heavy-loaded 12-gauge.

Personally, I prefer a shotgun loaded with 00 buckshot as a home defense long gun. I have many years of experience in hunting, competition, and police training with shotguns, and I have fired hundreds of thousands of shotshells, so I am very, very familiar with the platform. This is the most important criterion in choosing your weapon: use the type of firearm you are most proficient with, which is usually the gun you have the most experience with.

I have had several good defensive shotguns, but I’m not married to any of them particularly. I prefer 12 gauge, but a 20 gauge is suitable, too. A pump gun is good, but an autoloader is good, too. I prefer autoloaders for this purpose, for two primary reasons: 1) I can put multiple shots downrange with accuracy much faster with an auto than I can with a pump; 2) a gas-operated auto like the Remington 11-87 reduces the recoil of the gun by its design. Put an extended magazine tube on your shotgun so you have at least 5 rounds available without reloading. Then put a butt-sleeve or side-saddle on the shotgun, with another 5 shells.

My experience and research (both personally conducted and that conducted by others) into the question of shotgun ammunition has led me to unequivocally choose 00 buckshot for anti-personnel use. Birdshot is a very poor choice, and the smaller sizes of buckshot aren’t any better, with one exception: Number 1 buckshot–but only the hard-plated kind, which is really hard to come by–will work almost as well as 00 buck. But 00 buckshot is readily available, and it works. Why fix it if it ain’t broken? But whatever type of buckshot you buy for your defense shotgun, make sure you pattern it. I have done so with all my defensive shotguns, and the results have been surprising. You won’t know what ammo makes good patterns in your gun until you test it yourself.

Test your shotgun pattern at realistic defensive distances: 5 through 25 yards. Shoot several patterns at each distance with each load. You’ll know in short order which ammunition does or does not work well enough in your shotgun.

Keep in mind that the shotgun must be aimed. It’s not going to work if you just point it in the general direction of the attacker and pray some of the pellets find the target. At home defense ranges, the pattern of buckshot will be very, very tight… 2 or 3 inches wide at most. So you need to aim your shotgun as carefully as you would aim your rifle or pistol. (But you’ve taken tactical shotgun training, so you know that already, right? No? Well, go take a tactical shotgun class and get back to me if you have questions.)

Now: what about rifles?

OK, I’ll confess to being a fan of the AR-15 platform. I’ve owned a bunch, fired a bunch more, and liked almost all of them. The AR is light, ergonomic, and accurate. The standard 20- and 30-round magazines hold plenty of ammo, certainly more than enough for effective defense against a single attacker, or even a handful of attackers.

The best ammunition choices for anti-personnel work are soft-pointed bullets in the middle range of weights: 60-70 gr. Don’t cheap out and use mil-surp FMJ ammo, and for goodness sake don’t EVER use armor-piercing ammo in your defensive firearms. There are a lot of effective loadings available from the major ammunition companies in this class. These include (but aren’t limited to) Federal Power-Shok 64 gr, Winchester XP 64 gr, and Black Hills 60 gr (Nosler Partition).

I’ve heard supposed authorities state that you need to shoot bad guys 5 times with 5.56/.223 rounds. This intel supposedly comes from warfighters from the Sandbox, which explains a lot. First thing, our military rounds in the Sandbox were all FMJ, which is a really poor choice for shooting people… they don’t expand, so they simply drill a little hole through the subject. Unlike an expanding bullet, either a hollowpoint or a softpoint, FMJ rounds are not designed for maximum tissue destruction. Law enforcement agencies use expanding ammunition, and you should too.

Do you need to shoot a bad guy multiple times? Maybe. I often quote a guy who once told me, “I don’t shoot the bad guy until I think he’s dead. I keep shooting him until he thinks he’s dead.” In more professional lingo, we shoot until the threat is effectively neutralized. Which means until the attacker is no longer able to press his attack. But as I teach in every Tactical Anatomy class, “Effective neutralization by firearm is highly congruent with mortality.” So govern your shooting accordingly.

That’s about all I have to say on home defense with firearms today. To distill it down to its basic elements: get your defensive mindset straight; harden your home so it is harder to attack; get training in effective tactical use of firearms; and lastly, choose your home defense firearms according to your training and proficiency.

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Why the U.S. Medical “System” is Broken in the Year 2020

First thing: I realize most people who bother to read this blog do so because they are interested in things like guns, shooting, ammunition performance, ballistics, tactics, and the like. I get that. But if you’ve read any of my older blogs, you know I occasionally stray on to political topics. This is one of those meanders into the political realm. Don’t worry, I’ll be back onto the blood-guts-and-gunsmoke side of things next column.

I recently quoted an article on my personal Facebook page, an article about the “system” relying upon the work ethic of doctors and nurses to keep running. You can read that article here:

https://www.doximity.com/newsfeed/ebdf1d48-8eec-48bf-9b89-c4fbc2bcc8c6?utm_campaign=marketing_facebook_newsfeed_bdf1d48-8eec-48bf-9b89-c4fbc2bcc8c6_engagement_20200115&utm_source=facebook&utm_medium=cpc

Yes, it says that the health care industry is kept afloat by exploiting doctors (and nurses, too, but this site is a doctor site, so they emphasize that side of the article in the headline). And this is 100% true.

The scary thing is that this exploitation is getting close to squeezing the last drop of blood from the turnip, so to speak, and in many places it’s already happening. Doctors are just flat out refusing to keep running faster and faster on the hamster wheel to please the insurance companies and the corporate medical system.

The result is becoming apparent: as a patient, you can’t find a primary care doctor in your area who is taking new patients. This means you have to go to walk-in clinics or ER’s to get basic medical care, which has a higher co-pay, which penalizes you for something you can’t control.

And it’s going to get worse in the very near future. A lot worse.

American medical schools aren’t producing enough doctors to meet the demand of our growing population. This isn’t a new thing, it’s been going on for decades. As a result, our hospitals and corporate health care entities have been importing foreign doctors to meet the need. Which explains why you often have to see someone who speaks English poorly and has no empathy for the culture in which you live when you “go to the doctor”.

The reasons medical schools aren’t making enough doctors are complex, but essentially it’s because the number of quality applicants to medical schools has declined sharply, and the medical industry has done nothing to incentivize medical school enrollment and output. Why do young people not want to go to medical school, you ask?

Well, they look at the cost and duration of a medical education, and they look at the (relatively) low earnings doctors can expect when they finally start to work, and they realize they can get a better deal by going into a business career track such as law, or an MBA program. Think about it: a board certified family doctor can expect an annual income of about $250,000, after spending 11 years in training (4 years for a bachelor’s degree, 4 years in medical school, and 3 years in residency). Student loan debt at the end of that will be about $300,000 for most kids. On the other hand, if that same college freshman does an MBA, he’ll be out of school in 6 years, with half the debt load.

The big difference no one talks about is this: the kid with the MBA can expect his salary to keep rising at or above the rate of inflation as he gains experience and knowledge. The kid who goes into medicine is a fool if he expects that to happen to him. Medical salaries have not kept up with inflation for decades, and doctors with 30 years’ experience are hired at the same salary as doctors straight out of residency by almost all health care systems.

It’s a mess, isn’t it? We often hear people say they want their doctors to be “the best and the brightest”… but for at least 20 years (by my admittedly biased count) the best and the brightest have been going into other fields than medicine: engineering, computer technology, and business. Because they know their future prospects are much brighter in those mostly non-regulated fields.

How did this happen? How did the “rich” doctor of the 1960’s become the corporate wage slave of 2020? Well, like the frog in the pot of slowly heating water on the stove, it happened so slowly no one realized what was happening until it was too late. Here’s a primer on the history of the corporate takeover of medical care in America:

In the 1950’s, virtually all doctors were in private practice. If you went to the doctor, you paid cash for your visit. If your doctor prescribed medicine, you paid cash at the pharmacy. If you had your appendix taken out at the hospital, you paid the doctors and the hospital cash for your operation. The bill you were given was exactly what you paid. If it was more than you could afford today, they would work out a payment plan for you and in a couple of months you’d have the bill paid off.

But by the 1960’s, medical care had become more complex. We could do more to save lives than we had in the immediate post-war era, which actually saved lives. But these more advanced procedures and medicines were a lot costlier. Soon, enough people had had catastrophic medical problems come along that were so expensive they began searching for a way to defray that cost, and medical insurance companies sprang up to meet that need.

This was a boon for patients who had to have a major operation, or cancer treatment that exhausted their savings. In fact, it was so much of a change to people’s personal finances, people were opting to have medical care that they wouldn’t have done if they were paying for them out of pocket.

As a result, the medical economy began to boom. Doctors and hospitals saw their workload–and their incomes–increase dramatically. Doctors had had decent incomes before this, but with the advent of healthcare insurance, they learned they could move up from a split-level in the ‘burbs to a big two-storey on the fairway at the country club; they could trade in their old Lincoln for a new Mercedes-Benz; instead of sending their kids to college at State, they could send them to Harvard.

And the insurance companies saw this happening. Their profit margins hadn’t exactly suffered, of course. As people used their insurance more, the premiums were increased to keep corporate profits healthy. But the sharp thinkers in Omaha and Akron saw the exponential growth of the medical economy, and they coveted a piece of the action.

So the insurance companies invented a new concept. It took time and effort. They catalogued all the failings of the medical industry, and played them up to the news media and to government. They pointed out how the medical system was so ineffecient, how it was wasting money, how negligent doctors were hurting patients, how greedy hospitals were price-gouging, and so on. It didn’t take much, really… lots of folks are envious by nature, and they were easily led to blame “the doctors” for any an all ills. Once public awareness of the “flaws” of the smoothly running medical economy was high enough, the insurance companies proposed a solution: Managed Care.

They said it was an easy fix, and everyone would love it. Everyone would benefit: patients, doctors, hospitals, everybody. The way it would work was this: you could keep your personal health insurance (but the premiums kept going higher and higher), or you could enroll in a managed care plan. The managed care plan had lower premiums, and you could get coverage for everything: routine doctor visits, prescriptions, medical appliances, the works. “What a great concept!” said just about every healthcare consumer, and they flocked to the new Managed Care plans (called HMO’s, or Health Maintenance Organizations) in droves.

So many people went from regular insurance to HMO’s that doctors and hospitals had no choice but to accept those plans, or face economic ruin. But for doctors and hospitals, the HMO’s were a very mixed blessing. Sure, they got paid promptly, but they got paid less for the same services and there were strings attached… they had to meet certain “performance criteria” set by the medical experts hired by the HMO’s.

The “strings” weren’t onerous, at first. Doctors and hospitals were still getting paid, although they had to work a little harder to make the same profits. But every year the HMO’s paid a few cents on the dollar less, citing high costs, of course; and the “strings”, the restrictions on practice, kept getting more and more restrictive. The panel of labs and other tests a doctor could order for his HMO patients began to shrink. The panel of surgeons he could refer his patients to began to get more restrictive. And so on.

On the patient side, the problems were equally apparent. Your new insurance plan wasn’t yours, any longer. Your insurance had become a part of your employment package. The insurance companies lobbied government to pass laws that made employer-provided health insurance the norm, rather than an exception.

The incentives to move from private health plans to employer plans were great for employers and for patients, initially. But insurance companies made it harder and harder for non-HMO plans to stay affordable. So gradually Managed Care took over the employer-based healthcare market.

By the 1980’s, HMO’s and quasi-HMO’s were the dominant form of health insurance in America, and the problems with HMO’s were manifest. Patients were forced to see new doctors, if their old family doctor wasn’t a part of the HMO plan. They were also starting to have to deal with higher and higher personal costs… their cover-it-all insurance was starting to only cover 90% of it, or 80%, or less. The medicines they had been taking for years were no longer covered (but a cheaper, less effective medicine was covered, so guess what happened?).

As consumer groups shouted in protest to these changes, governments and insurance companies felt the heat and made some changes. Not a lot of changes, but some. Restrictions on patients became a bit less severe, provider panels grew larger and portability from one hospital to another became a bit easier. But the changes were truly very small, even inconsequential.

By this time the “cost savings” of managed care were manifestly a Big Lie. Insurance companies had created an entire new industry, employing millions of office workers, to administer their HMO’s. And government, bumbling along with them, had created multiple new regulatory entities to watch over both the insurance and medical industries, which again required millions of employees to administer.

So by the early 2000’s, our health care system had become an amalgam of two enormous bureaucracies: one private, run by the insurance industry, and one public, run by various levels of government.

The costs and complexity of dealing with these bureaucracies were staggering for private practice doctors and small hospitals. In the 1950’s, a doctor could run his office with a receptionist who did all the filing and billing, handled the phones, and so on. By the 1960’s, that same doctor had to add a billing clerk to deal with insurance claims. And by 1985, the average doctor had to employ 2.5 billing clerks working full time to keep up with insurance paperwork. Moreover, the increased restrictions imposed on the doctor’s medical practice by insurance companies and governent regulators required employing a compliance officer (usually called an office manager) to keep up with the constantly changing rules of the game.

By the early 1990’s most private practice doctors were no longer able to keep up with the increased regulatory load imposed by HMO’s and government. It was simply too costly, both in money and in time. And corporate America was there to take advantage of the situation.

Hospitals had been mostly privately owned up until the 1960’s. Groups of doctors, sometimes with other investors, were often involved. More often, communities owned their hospitals, and a sizable share of the hospital market was owned by charitable organizations (often churches and religious orders). But in the 60’s, private corporations began buying hospitals. A corporation could operate multiple hospitals much more economically than your local hospital board, because they could use their economies of scale and bulk buying power to bring down costs. Corporate hospital ownership had become the norm by the 1980s.

So when private practice doctors in the 80’s began to fail economically, these hospital corporations saw an opportunity: they bought up private practices like hotcakes. The doctors loved it: they were paid good value for their practice (usually around 2X their annual gross billings, a common standard purchase price for decades), but they no longer had to manage their own billings or compliance. The hospital/corporation took that over for them. The corporation also took on all his employees, and absorbed all the employer obligations the doctor had previously had to do (or pay his accountant to do). The doctor stayed in his office, kept his staff, drew a good salary, and had money in the bank. What could possibly go wrong?

What went wrong was that there were strings attached. Just like the deal with insurance companies in the 60’s and HMO’s (which were still the insurance companies) in the 70’s and 80’s, these Physician-Hospital Organizations (PHO’s) proved increasingly restrictive. Corporate profits were now the driving factor in all decisions. Doctors found themselves forced out of their “inefficient” private clinics into large group practice offices. The nurses and receptionists they had employed for years were moved to different locations, or simply laid off in favor of cheaper, less experienced staff who could be easily replaced if need be. Work that had been previously delegated to nurses and medical assistants became the responsibility of the doctor.

And the doctor’s salary no longer reflected the amount of work he was putting in. Instead, it reflected the Corporation’s balance sheet.

The worst was yet to come. First, the federal government mandated implementation of Electronic Medical Records nationwide. This sounded good, but proved to be a millstone around doctors’ and nurses’ necks. Rather than a streamlined and efficient means of recording medical encounters, procedures, and so forth, Corporate medicine designed it as a means of monitoring and controlling “production”, then added the clinical components doctors and nurses need as almost a second thought. Government went along with this philosophy whole hog, of course, because governments are all about monitoring and control.

By the year 2010, the full mess had arrived. Doctors and nurses, being paid far less for their work than they had been in 1970 (in inflation-adjusted dollars) were seeing roughly the same number of patients than they had in 1970, but because EMR’s required so much data input, these front-line, hands-on, hearts-out practitioners of medicine and nursing were spending more time in front of a computer terminal than they did interacting with patients.

The Affordable Care Act, a.k.a. Obamacare, exacerbated the problem. For everybody. Patients immediately noted that their health care plans were costing them a LOT more, and providing a LOT less service, with a MUCH higher co-payment responsibility. Doctors noticed that the regulatory hurdles for prescribing medicines and getting procedures pre-approved had become a LOT more common and a LOT higher and harder to jump over. Insurance company and government bureaucracies thrived, however, as the increased revenues fed both. The reason for these changes, quite simply, was that Congress more or less wrote the ACA at the behest of the health care insurance company lobby… so the insurers got everything they wanted, while patients, doctors, hospitals, and other players in the health care community were allowed little or no input. Obamacare “expanded” the number of patients with healthcare insurance primarily by expanding the Medicaid program, but numerous studies have shown that it: 1) made health care insurance unaffordable for millions who previously had it; 2) increased regulatory restrictions on doctors, nurses, hospitals, labs, and other providers of health care services and increasing their workload without any increase in reimbursement; 3) eliminated “safety net” plans that paid for catastrophic medical care only, but were affordable for even low income folks; 4) forced everyone to buy plans with higher premiums, higher copays, and higher deductibles, thereby decreasing health care insurance companies’ payouts and increasing their revenues simultaneously.

Until the devastating provisions of the ACA are repealed, we will continue to see everyone except the insurance companies struggle under these increased burdens. The net effect on the front line health care workforce has been loss of experienced doctors and nurses due to early retirement, change of careers, or both. These experienced providers are not being replaced by the medical and nursing training systems fast enough, so an influx of foreign medical grads has been allowed to try to meet the demand.

There is some hope, however. A significant change in the makeup of Congress in November (we need removal of the Democratic House majority) could mean the end of the ACA. Whether there is a comprehensive plan to replace it is not relevant; the ACA needs to die. A healthcare insurance reform bill, opening healthcare markets nationwide (in the same manner that auto insurance was opened up a number of years ago), is badly needed, and the insurance companies need to be free to offer low-cost plans that don’t cover every possible medical situation. By opening up competition we will inevitably see some price relief for the medical consumer.

In the meantime, the world of medical practice is changing. In 2020, doctors in private practice are rare birds, but the number is growing. More and more primary care physicians are spurning the government/insurance/hospital-corporation cabal (the healthcare equivalent of what Eisenhower called the Military-Industrial Complex in the 1950’s) and returning to a direct-pay system for their patients. Since patients are essentially paying cash for most primary care services anyway due to high copays and deductibles, they are starting to say they will pay a premium to have a GOOD family doctor or internist work with them and their families. This is taking the shape of things like concierge medical practices, where folks pay a set fee monthly to have access to first-rate personal medical care from a doctor they trust and who will commit to them for the long term.

The government/insurance-company/hospital-corporation cabal is teetering. It is not sustainable. Whether the feds do anything about it or not, the system is going to collapse. Whether that collapse will be a “market adjustment”, or a catastrophe, is all that remains to be seen.