TCS Daily


Medicare Rationing Begins in 2011

By Richard Amerling - January 12, 2010 12:00 AM

House and Senate Democrat leaders, and President Obama, argue that they can "pay for" health insurance "reform" by cutting $500 billion from Medicare spending over the next decade—largely through arbitrary reimbursement cuts,— without reducing the quality of care delivered to beneficiaries.

Yet, in January, 2011, Medicare will implement a new payment system for patients receiving dialysis for end stage kidney disease that will severely ration care to this vulnerable (and largely minority) population based on equally arbitrary payment reductions. These patients will be the unfortunate canary in the Medicare coal mine: "reform" legislation will expose millions of Medicare patients to rationing and reduced quality of care.

In 1972, Congress passed legislation creating an entitlement to Medicare for patients diagnosed with end stage renal disease. The bill allocated about $140 per treatment (or $1820 per month) per patient. This facility fee was large enough to incentivize the creation of dialysis centers, the expansion of dialysis treatment to all patients, and an end to what were very real "death panels." The ESRD program became a model for what good government could accomplish. There was broad consensus that payment for this catastrophic illness was a legitimate federal function and use of taxpayer funds. Unfortunately, Congress neglected to index the payment for inflation, leading the constant-dollar value to dwindle to around $14 per treatment. Dialysis units were able to survive, and even prosper, by aggressive cost-cutting (substituting technicians for nurses), consolidation into ever-larger chains, boosting efficiency (sometimes by cutting treatment times with a negative impact on outcomes), and by generating revenue from sales of drugs used during dialysis.

In the late 1980s and early 1990s, recombinant erythropoietin (Epogen®, manufactured by Amgen) was introduced to treat the anemia associated with chronic kidney failure. An active vitamin D analog (Calcijex®, by Abbott) was also synthesized to replace deficiencies associated with kidney disease. Both drugs were administered during each dialysis session intravenously, and were paid for separately by Medicare. Medicare paid dialysis units 95% of the average wholesale price for these drugs. The units, especially the large chains, were able to buy at deep discounts below the AWP, generating significant margins. These margins became the major source of profit for dialysis units over time. A debate of the scientific merit of using these agents and their clinical outcome benchmarks is beyond the scope of this article. But clearly the payment model that had evolved led to incentives to prescribe that were potentially hazardous, and needed reform.

Evidence that treatment of anemia might not be beneficial or benign emerged in 2006, and this led to partial payment reform. Congress, in 2003, also instructed the Center for Medicare and Medicaid Services to come up with a "bundled" payment system for dialysis in which one payment per treatment would cover these additional medications. Under contract with CMS, the University of Michigan Kidney Epidemiology and Cost Center provided early in 2008 a detailed report on how this could be instituted. Congress then mandated implementation of a bundled payment system by 2011.

The UM-KECC model proposed payment of roughly $235 per treatment, with some adjustment for local wages and patient case-mix variables. Using this methodology, small dialysis providers Premila and Ganesh Bhat modeled their patient population in an article published in Nephrology News and Issues in June, 2009. They estimated losses in excess of $100,000 per year.

Last month CMS shocked the nephrology and dialysis community when they issued the final rule: Payment would be $198 per treatment. In addition, oral drugs typically used by dialysis patients were to be included in the bundle, with only an extra $14 per treatment thrown in to cover this added burden.

Nephrologists prescribe medications to dialysis patients to limit absorption of phosphorous from foods, and other drugs to treat the bone disease that accompanies kidney failure. Some of these are expensive, but are often covered under private insurance, Medicaid, or Medicare Part D (Full disclosure: I have received honoraria from companies that manufacture several of these drugs). Again, this is not the forum to debate the relative merits of these medications. However, no one in the medical community thinks they should be banned, or their use severely curtailed.

Yet that is what will almost certainly happen if the current scenario is enacted (The official comment period ended on December 16). Dialysis providers have already been looking at different strategies to lower the use of epogen and vitamin D analogs to minimize the financial impact of bundling. There is no question that similar cost-saving strategies will be used for these outpatient drugs. Formularies will almost certainly be introduced that will make it difficult for physicians to prescribe expensive oral medications since these will now be coming out of the dialysis unit budget.

The new rule contains even more disincentives for high quality dialysis care, including higher levels of federal micromanagement, lack of incentives for home dialysis, pressure to limit laboratory testing and hospitalizations, and increased staffing that would be required to administer outpatient medications. The end result is a highly restrictive practice environment that imposes de facto rationing of care to the most vulnerable population of Medicare patients.

Remember that the current payment structure is a result of congressional mismanagement of the basic dialysis payment. The "solution" now being proposed will greatly increase financial pressure on the dialysis industry and will very likely lead to bankruptcies and closures of many independent units, further limiting the availability of dialysis. Even the large dialysis chains will struggle to remain afloat. Their situation will worsen dramatically if private insurance (which covers dialysis at rates well above Medicare) disappears as a result of the added costs and regulatory burdens imposed on them by ObamaCare. In effect, this legislation sets the stage for an eventual nationalization of the dialysis industry.

The dialysis community has been under the heavy hand of federal regulation since the beginning. We are the first victims of Congress' misguided price control schemes. Whatever happens to us will eventually be extended to other segments of health care that come under government control. Medicare rationing is well under way.


This article first appeared on Medical Progress Today.

Dr. Richard Amerling is Director of Outpatient Dialysis at Beth Israel Medical Center in New York, Associate Professor of Clinical Medicine at Albert Einstein College of Medicine, and a Director of the Association of American Physicians and Surgeons. He writes and lectures regularly on health issues.

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222 Comments

another example
That's right Joanie, and here's another example.
Many liberals think that Medicare is a wonder example of socialized medicine, and that it should be exanded to include everyone(although it's not clear if they mean everyone in the country including illegals, or everone in the world).
But if it's so wonderful why would there be a need for: Medi-gap, the supplemental insurace scheme? It's another kind of ration too since coverage is different for those who have it, and those who don't.

Let's keep the examples coming.

I just keep laughing
Now, the unions are on the warpath because they won't be exempt on the 40% tax on 'cadillac' employer-provided health plans.

Meanwhile, they think it is a great idea for the rest of us.

Of course, the government will collect very little revenue from such a tax, as employers will just offer 'pontiac' plans instead. Of course, the union thugs have that figured out too.

Liberals could be such idiots.

What a coincidence...
...I just got a lot of flack from a liberal friend of mine when I asked those kind of questions.

I also asked:
How is it ok that we can build schools in Haiti (you know that is coming next) but not in Iraq?

If the UN isn't the hotbed of Third World corruption I keep telling you it is, then why did the UN HQ building there totally collapse, eh? Seems like some featherbedding went on...

I was told that my 'cruel disposition' was not tolerated.

What you believe?
What 150 military bases?

You agree with North Korea.
"Pyongyang, March 27 (KCNA) -- It is an important task facing the world peace-loving people at present to check and foil the imperialists' moves for reinforcing their overseas military bases for aggression and get them dismantled.

Rodong Sinmun Friday observes this in a by-lined article.

The imperialists' overseas military bases are operating as military strategic strongholds for implementing their policy of strength and the forces stationed there are playing the role of a shock brigade for aggression, the article notes, and says:"
http://www.globalsecurity.org/wmd/library/news/dprk/2009/dprk-090327-kcna05.htm

You mean; if NK says the earth is round you would doubt it? Can’t you argue from fundamentals?
..

The spending problem is NOT with national defense.
I agree other countries should pony up for their defense.
However, the bottom-line adult response is that the USA must not depend upon any other nation for its defense.
And a defense is certainly required from China, Russia, Iran, DPRK and every other socialist state that does not like our liberty.
If you want a repeat of the 1930s when the USA attempted the isolation you want, the war following such isolation will be significantly more destructive and COSTLY. Or the USA will join the socialist, which BHO is trying to do right now.
I know you don't care about the liberty of others, but a strong defense IS the most cost effective alternative to a hot war or to socialism in the USA.

This is good:
"# The Libertarian Party’s platform essentially would sustain and rebuild the freedom the Constitution gave us, but it would then do nothing to defend that Constitution or freedom from aggresors.
# The Libertarian Party doesn’t care when idividual freedom is infringed somewhere else in the world. Yet they complain of the U.S. infringing freedom across the world when we intervene, we are at a loss with this stance. Do they care about the freedom of hummanity or don’t they?
# The Libertarian Party does not represent what libertarianism was intended for, nor does it represent the broad libertarian movement at all, this needs to change.
# The Libertarian Party does not represent the Constitution, the Founders, the Republic, freedom, liberty, John Locke, Thomas Paine nor any other undeniable virtue or patriot. We draft this declaration in order to bring them back to true freedom, liberty, and justice."

Do you agree with these?

"The government has no right to infringe or constrain the economic freedom of law-abiding individuals nor the free market in this country."
"The central right of humanity is the right to resist an aggressor, even if you aren’t the victim."
"We advocate a constitutional federal republic that has very large, innovative, capable and robust military, homeland security, and intelligence forces at its disposal for defense, reactive and pro-active actions against threats to said republic’s citizens, its interests, or foreign allies and civilians. It also encourages its citizens to help in their overall individual defense. As the armed republic, she should be bound by the same moral rules as individuals, and the Constitution."
"We, the Libertarian Defense Caucus, are made up libertarians and Libertarians, and we declare these tenets to be the Better Libertarian Platform for the Libertarian Party of the United States of America. It shall be the only platform we rcognize as Libertarian. All other platforms are recognized as “un-Libertarian”."

http://defendliberty.net/2009/07/04/declaration-of-the-better-libertarian-platform/

Since you started the personal attacks...
You are selfish and naive.

Then start attacking all the unconstitutional spending.
You 'Libertarians' remind me of today's news 'reporters' who pick the low hanging fruit.
National defense IS an enumerated power of the federal government .
How many other government programs can justify their existence in the Constitution?

defense against socialism
You seem to say that a strong denfense establishment is the most cost effective alternative to socialism in the US.
How did that work out so far considering that the US has had a very strong military for many decades, yet still the country goes more and more socialistic?
We also can't assume that it would have been even more socialistic than it already is, because the military doesn't really control internal politics.

I agree with it
I do agree with the anti-imperialist stance. The US should not have all those bases, only 150, but perhaps 700+ overseas. And I think it's really insensitive to expect your grandchildren to have to pay for them sinc the US is broke.

P.S. To agree with somebody on one issue does not mean that you agree with their entire program. For example, a person could also agree with Hitler than building autobahns is a good idea, yet the person might be totally anti-nazi on every other issue. I feel I always have to ad such disclaimers because people often illogically accuse me of adhereing to a whole package of items unrelated to the issue.

But you'll go never with that disclaimer with Marjon, Colonel. He will continue to insist that you
agree with everything the other guy said. That’s his modus operandi.

I don’t know what (psychological) reason he has for extracting sanction for his views from strangers.

Merely asserting “More of that if NOT for this” is how the Marjons of the world argue Colonel
That’s how the GOVAGs have been arguing ever since the crisis they helped create unfolded and they started flooding the economy with more fiat money. We hear that refrain daily; but for such actions of the Fed, we would’ve been in deeper trouble, the unemployment rate would’ve been higher etc.

The only difference between different people is; what is THAT and what is THIS.

But you'll go nowhere with that disclaimer with Marjon, Colonel; he will continue to insist that you
agree with everything the other guy said. That’s his modus operandi.

I don’t know what (psychological) reason he has for extracting sanction for his views from strangers.

to Joanie re overseas
Yeah, that's what I meant too. I don't think the US needs to maintain the prestense of defending everybody else in the world.
The US would be better off if they tried to concentrate on their own liberty.

That there are such ignort people in your area is just another indication of the dreadful state of the government run schools in the US. Apparently before there were all those gulag propaganda schools forcing kids to say the pledge of allegiance and all that jingoistic nonsense, Americans weren't so anxious to go about waring all over the world.

I know a guy who told me about that Dietmar, but he never wrote in here himself. He figures the guy is probably dead already since he was real old I guess, and also still suffered from war wounds. To criticize him would be like bad-mouthing japanese kids who were also brainwashed and forced into service. I wonder what happened to any kamikazee pilot who refused service.

my disclaimer
Not just him, but many people are like that. Here's another example; on another forum I specifically mentioned, in the first sentence of my paragraph that I was not a fan of S. Palin, but just asked a guy for the specifics of why he had called her a facsisstt.

Instead of answering he simply called me a Palin supporter, in spite of my proviso.

libertarian and low hanging fruit
When you bad-mouth libertarians, you make it sound like the are affilitated to the Libertarian Party, but that would be wrong. There are many libertarians out there who have quite different stances on many issues. So you can only respond to individual issues not libertarian as a class.

Here's one example where many of them differ; some libertarians advocate strong border controls, whearas others don't think that there should be any at all. Indeed, some of them don't even use the word, 'immigration', legal or other wise, they just call it 'moving'. Nobody makes any issue of half of Detroits population moving to some other place, yet if people come from some other country, they think it's some sort of disaster.

Defend against socialist dictators.
The rest of the world has become less socialistic after the collapse of the USSR. Estonia and the Czech Republic are two great examples of socialist states becoming less socialist.
France, Netherlands and Ireland are discovering the benefits of markets.
If the USA had no capability of defending against an Iranian or DPRK nuke on a ship off the coast of DC, why wouldn't they or Russian or Venezuela or Cuba commit such blackmail?

Isolationism was tried, twice.
The results were WWII and a Cold War.

This was and article about unconstitutional medical spending.
Why did you feel the need to inject any comment about national defense spending, which is constitutional?

So I don't believe you when you claim to have been attacking unconstitutional spending such as social security, medicare, medicaid, education, etc.

that wasn't isolationism

The US was meddling greatly what with embargoes and ulimatums against Japan way before Peal Harbour. They were also heavily involved with supporting England in europe before the US finally entered formally.

Even the idea that it caused the cold war is not right. Had the US not gone to war over there, maybe the nazziis would have wiped out the USSR.

The US could have had a policy of free trade with everyone, no entanglements with any. They could have been nuetral like Portugal, Sweden, and Switzerland.

Even if the naazis had beaten england and russia, it doesn't follow that they could have beaten the US. They were already overstretched over there and it would have fallen in a few years anyway.

You have bought into the mainstream propaganda.

defense
Some go more, some have gone less as with the east euro examples. The US is one that is going MORE socialistic IN SPITE OF having a huge military. It's not from external sources that the movement comes, but internally, and the military is not doing anything to stop it. They take their orders from their socialistic and imperialistic political masters.

You also make the mistake of saying that if someone is against all those foreign bases, it must follow that they don't believe in any dense; that is false.
I believe non in initiating violence, but that self defense is quite OK.

I don't think the dictatorship of north korea would want to nuke a ship off the coast of America any more than it would do so off the coast of Brazil, or Ireland. You might remember that it is the US that has all those forces in neighbouring south korea.

Indeed I also don't think the jihadis would terrorise the US any more than they do Peru or Mexico or Portugal. The Us shouldn't be sticking its nose in everybody else's business all over the world.

I recomment they have a foreign policy simialar to say Luxemburg, or maybe Chile.

Don't know much about defense.
Logistics won WWII for the allies.

Logistics hinders efforts in Afghanistan. When the USA has accesses to large air bases north of Afghanistan, more resources could be applied.
In Asia, Kadena and Tokyo provides critical support to the Air Force and Navy after the PI bases were closed. Now Guam is being beefed up.
Materiel is prepositioned in Diego Garcia.
The alternative is building more long range B2 bombers, more cruise missiles, more ballistic missiles, to project force from US territory or from ships at sea.
Clinton demonstrated the 'effectiveness' of lobbing cruise missiles at Iraq and Afghanistan.
UAVs are very effective, but require close support on the ground, from bases.
As mentioned, the USA did have a non-interventionist policy in the 20s and 30s. See who well that worked?

What should Chile do when Venezuela decides to start invading neighbors? Or if China attacks Taiwan and Japan?
Libertarians shouldn't care if their neighbors are attacked and subjegated?

Look, you started it.
But like so many women, you get mad and walk off in a huff.

UK 'propaganda'
"believed that the sacrifices they had made in the Great War had been a waste of money and men. They were opposed to anything that might drag America into another European war. So the USA did not ratify the Treaty of Versailles (officially accept it), nor did she join the League of Nations or the International Court of Justice. Many Americans simply wanted to enjoy the prosperity that had developed in the previous decade and felt that foreign entanglements would threaten it.
During the 1920's and 1930's, America was in isolation, i.e. she kept I herself to herself and took little part in international relations I (conferences and treaties between the nations) .In addition America, isolated herself in terms of trade. Tariffs (import duties) were put on foreign goods to protect American industry. (Because they could not sell their goods to America, European countries could not afford to buy agricultural goods (farm produce) from the USA. This was one of the causes of the Depression.) "
http://www.schoolshistory.org.uk/america/isolationism.htm

Neutrality Acts
"By the mid-1930s, events in Europe and Asia indicated that a new world war might soon erupt and the U.S. Congress took action to enforce U.S. neutrality. On August 31, 1935, Congress passed the first Neutrality Act prohibiting the export of ?arms, ammunition, and implements of war? from the United States to foreign nations at war and requiring arms manufacturers in the United States to apply for an export license. American citizens traveling in war zones were also advised that they did so at their own risk. President Franklin D. Roosevelt originally opposed the legislation, but relented in the face of strong Congressional and public opinion. On February 29, 1936, Congress renewed the Act until May of 1937 and prohibited Americans from extending any loans to belligerent nations.

The outbreak of the Spanish Civil War in 1936 and the rising tide of fascism in Europe increased support for extending and expanding the Neutrality Act of 1937. Under this law, U.S.citizens were forbidden from traveling on belligerent ships, and American merchant ships were prevented from transporting arms to belligerents even if those arms were produced outside of the United States. The Act gave the President the authority to bar all belligerent ships from U.S. waters, and to extend the export embargo to any additional ?articles or materials.? Finally, civil wars would also fall under the terms of the Act. "
http://www.state.gov/r/pa/ho/time/id/99849.htm

As usual, you’ve evaded the most important point of a post; in this case, letting Germany and USSR
fight it out among themselves.

You were the one who introduced me – in this forum - to the thought that the Union should’ve let go the South instead of fighting the Civil War.

So, why are you reluctant to even discuss the point raised by Colonel?

The ***** wipe out USSR?
They tried. It was called the battle of Stalingrad.

"In early September 1942, the German Army advanced to the city. The Russians, already devastated by the power of Blitzkrieg during Operation Barbarossa, had to make a stand especially as the city was named after the Russian leader, Joseph Stalin. For simple reasons of morale, the Russians could not let this city fall. Likewise, the Russians could not let the Germans get hold of the oil fields in the Caucasus. Stalin’s order was "Not a step backwards"."
http://www.historylearningsite.co.uk/battle_of_stalingrad.htm
The USA was doing very little at that time to annoy the Germans.

What if USSR won?
Assuming the Germans would have lost to the Soviets, opposite of what you suggest, without USA involvement, the Soviets would have had to deal with Japan in the east as they invaded China.
In the 30s atomic energy was being investigated for weapons use. Certainly the Soviets new this as well as the Japanese.
Assuming the USA stayed 'neutral', and the USSR controlled most of Europe, Japan controlled China and they started developing atomic weapons because attacking the USA directly would be logistically challenging. Why not threaten the USA with atomic weapons?
The neutral USA would have to either fight back or bend over and grab its ankles, no more neutrality.

Why do you assume that US can't develop nuclear weapons for defense, WITHOUT joining the war?
..

That was because the US gave the USSR hundreds of billions in lend-lease. Read your history
Would USSR be able to defeat Germany without the help of US?

Would USSR even be a viable nation had the US not sent it millions of tons of wheat when Hoover was the Agri. Secy.?

neutrality, my foot
The support given to the UK and Russia was not 'neutral'.

Nor was my point that you ignored about the ultimatum and embargo against japan.

I said the US should have been as neutral as Switzerland and Portugal and Sweden.

lots about defense
And I know that your point about logistics had nothing to do with my comments. I also know all about logistics, but that doesn't counter my point of not being involved with those countries in the first place.

I said I do believe in self-defense, and gave examples of how I thought that north korea, and others, did not attack the US.

If Venezuelza would invade it's neighbours, which I don't think they would ever do, I think that Chile should heartily condemn the move, as should New Zealand, Slovenia and Albania.

As a libertarian sort of guy I was totally against Japan occupying Taiwan and all of Korea. I felt sad, and sickened also that England occupied Malaysia, and I felt that Hong Kong should have been let free as a city state like singapore instead of being ruled by red china.
I felt like puking when Napolean marched across europe raping and pillaging, and am glad that the US didn't declare war against him and send US forces over to fight that dictator either.

nukes for defense
Good point, you don't have to go to war to make nukes, as has been shown by several countries already.

In fact, some guys think that it would be a good idea for peace if MORE countries had nukes in stead of less.

Part of that case is that they wouldn't even need to waste so much resources and people on standing militaries. It's rather cheap and easy with little manpower to maintain a few nukes ready for the most likely targets.

Strong evidence in favor of this line is that no beligerant countries have used nukes against the other. Even those bitterest of enemies India and Pakistan haven't; do you really think say England and France will ever bother going to war again when both have nukes?

USSR won
Even in the unlikely scenario where the USSR won, if the US had been really neutral, it doesn't follow that they would automatically have wanted to nuke the US.

If the US had been neutral it would have been the same as all the other neutral countries all over the world.

And, as pointed out, that still wouldn't have precluded the US developing its own nukes just in case the USSR and China wanted to make war against such a non-threatening country. Sure the US was bigger, but it would have been basically the same as Brazil or Canada or Mexico threat wise.

North Korean forces launched a massive surprise attack and invaded South Korea on June 25, 1950.
The US Army was in ROK at the time. Therefore, DPRK attacked the USA just as if USSR would have attacked West Germany.

Now you’re entering grey & potentially dangerous area Colonel. I’m referring to, more nukes less war
Let’s not forget – if my recall of history is any good – that the US guy who sold the nuke secrets to USSR did so under the same assumption. He felt that there must be balance of nuclear power for peace to prevail. But, in EACH decade after acquiring THE weapon, USSR invaded other countries. It’s Czechoslovakia in the 50’s, Hungary in the 60’s, and Afghanistan in the 70’s. Sure, they didn’t invade US. But that doesn’t mean that the world became any peaceful. Of course, I’m NOT saying that USSR wouldn’t have developed a nuclear arsenal on its own; they DID have some very good brains.

Even in the case of India and Pakistan, while neither country declared war on the other after getting THE weapon, do you think India would’ve tolerated Pakistan’s support to attacks on its soil if it (Pakistan) didn’t have the nuke? I don’t think so. They would’ve gone to a “conventional” war with it long time back.

In the ultimate analysis, a nuke is like any other weapon. A society’s use of it depends on its dominant philosophy. They may use it overtly, if they don’t care about retaliatory damage. Or, they may leverage it to create havoc in other countries by other means. Or, they may GIVE UP real estate – instead of acquiring new territory - as the US did (with Philippines).

Again, YOU starated taling about national defense.
I call you on it and you get mad.

Be ready to support your assertions or don't make them.

Nuclear weapons == extortion
USA forced Japan to surrender with atomic weapons.

That is why Iran wants nuclear weapons, extortion.

Then heed your own advice, Marjon; NEVER again bring up your faith into political discussions
..

"Germania"
"This retro-futuristic adventure depicts a 1964 in which Hitler won the war and Joe Kennedy Sr. is U.S. president. Europe is known as Germania and opens its borders to American journalists, hoping to line up the U.S. as an ally against Russia."

http://www.amazon.com/Fatherland-VHS-Rutger-Hauer/dp/B00000EZTR/ref=wl_it_dp_o?ie=UTF8&coliid=I1GLQ00LADRODD&colid=OQIHZ7EN1J0O

What disturbs me most about 'libertarians' like you and Joanie is your philosophy of 'liberty for me, but not for thee'.
Certainly there are limits to what can be done to liberate people in China, Cuba, DPRK, etc., but how can those who claim to support liberty stay neutral about concentrations camps that murdered millions in Germany, USSR, China, etc?
China ostensibly practices 'neutrality' regarding the internal affairs of other countries.

Napolean tried to conquer Russia, once.
His efforts resulted in the best example of a chart ever made, according the expert Tufte.
http://www.edwardtufte.com/tufte/posters

BTW, the USA did NOT help Russia defeat Napoleon.

Germania
I don't know about Joanie, but I wish everybody would have liberty. But that does not mean that I expect that I could liberate everybody in the world, certainly the US can't. Indeed it would be ridiculous to expect the US to do that since America itself does not have too much liberty left.

The term, 'neutral' I meant in the political sense of not intitiating force against other countries even if you disapprove of how they behave. But I'm not neutral in my desire that the Fulong Gang in china be free to practice their weird religion. I just can't do anything about it.

I am ready, willing and able to discuss the importance of faith in politics.
If you or Joanie don't want to discuss national defence, don't raise the issue in a post about Medicare.
But then you refuse to discuss anything.

extortion
If one has nukes it's easy to extort, but if your neighbour also has nukes then it means 'mutually assured destruction'.

So Iran couldn't extort anything from Israel even if both have nukes. I also don't see Russia and China extorting each other, or paki and India, or England and France.

You can't or won't do anything about it?
There are many ways to support liberty around the world.
Some distribute Bibles in DPRK and are willing to be arrested for such 'crimes'.
Do you have such courage to visit China and practice 'civil disobedience' for liberty?

more nukes less war
Because of MAD there was the 'balance of power', but your mention of russia invading chech and hungary does not play, because they did NOT have nukes. If say hungary would have been able to to deliver a measly couple of nukes on moscow or a few main cities, russia would have had to think twice, and I maintain that they wouldn't have invaded hungary any more than they would have thought of invading france.

I don't believe nukes are like any other weapon because politicians don't want to be anihilated, or even if they can hide away, they don't want to preside over a charred ruin of a country.

north korea.2
I thought that US shouldn't even have been there at the time. They should have been in the same place the forces of Mexico, Italy, South Africa and Paraguay were; at home.

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