Fixing Healthcare Part 3A: The organization of care

In order to implement the GHE accountable care organizations (ACO’s) would have to be created.  ACO’s are large group of physicians who would be responsible for the complete care of the several 100,000 lives who have enrolled with them. The Mayo clinic and Kaiser Permanente are groups that have already functioned in this way for decades. 

However, medical groups have been moving in this direction for a number of years so new groups could form to function in this coordinated fashion.  As an example in Rhode Island one could conceive of a metro group that would include Rhode Island and Miriam hospitals (med/surg/peds) along with Women and Infant’s (Ob/Gyn) and Butler/Bradley (psych) and all the physicians who admit to those institutions.  Another group might be northern Rhode Island and include Roger Williams, Fatima, and Landmark.

Patients choose the group they wish to belong to and groups are paid on a monthly basis.  If someone moves from Boston to Chicago they can start up with a new group at the first of the month.   If they don’t like the group they are in they can move to the group across town.

Compensation: Groups could design whatever compensation system they deemed appropriate.  However, the fee for service model would be a non-starter so all groups would have some sort of salary model. 

The following is a model I would propose that would quickly mitigate health care expenditures for the group.  Physicians would be compensated with a base salary plus incentives for care outcomes, and patient satisfaction.  There could be additional incentives for providers who create programs or procedures that improve outcomes or efficiency.  Different specialties would have additional incentives.  For instance, the specialty of primary care would have incentives for lifestyle improvements and screening compliance.  Surgeons would be would have incentives for weighted* surgical outcomes and low morbidity.  Furthermore all of these metrics would be public information so patients can make informed judgment about what group they choose to belong to. 

           

Another adjustment that, introduced over time, would create significant savings would be to make the base salary the same for all doctors regardless of specialty.  Specialists are not any more talented or intelligent than primary care physicians.  The only rational reason to compensate them at a higher level is that they have deferred salary by extending their training.  This could be addressed by either paying all doctors in training the base salary or having groups that hire specialist pay them the difference between their training salary and the base for the number of years beyond the minimum (3) they spent in additional training.  The object would not be to increase the pay of primary care but to have specialists regress to that base and thus create savings.

Such a system then shifts the incentive from adding care to optimizing care thus correcting the fundamental underlying problem with the cost of healthcare. All this can be done by restructuring medicine in a direction it is already heading and changing compensation from fee for service to salary plus incentives.

Fixing Healthcare Part 2: The Cure The Guaranteed Healthcare Entitlement.

Virtually every other developed country has a single payer system. Everyone is covered, medical outcomes are at least as good as ours, and it costs per capita half of what we spend. Those who wish to tweak the current system or introduce things like medical savings accounts are traveling in uncharted waters with four decades of mostly failure as a legacy to build on.

That said, if we are to have a single payer system what should it look like? The following is my proposal for such a system, which restructures what we have and would, by design, bring our health care cost into line with other developed countries within a decade.

In 1992 the then commissioner of education for Rhode Island Peter McWalter proposed what he called the Guaranteed Student Entitlement.  In the program the cost of a solid education for each student would be determined.  This would cover basic subjects, electives, arts, and physical education.  The state would guarantee that each student would have this amount spent on him or her throughout the state.  Recognizing that there are students with special need, these students would get an additional stipend above the initial base stipend.  At the time the base stipend was approximately $7000 and additional funding of $1500 went to students who were either low income or had English as a second language.  They would get $3000 if they were identified with a learning disability. 

            Using this program as a model I would propose a Guaranteed Healthcare Entitlement as a comprehensive plan for the complete overhaul of the American health care system.

Coverage:  The government will pay a provider group the insurance premium for everyone living in America.  The coverage will be for a level of service, which most everyone would recognize as complete coverage.  This would include office visits, tests and procedures, hospitalization, prescription drug plan, and mental health.  There may be nominal co-pays as out of pocket expense. 

The premium:  This would be determined based on the actuarial risk of the patient.  The government might pay $1000/year for a healthy 20-year-old male and $25,000 for a blind diabetic on dialysis.

However, the average premium payment would be about $10,200/year. In addition and most importantly this average reimbursement would not increase until we moved to some fixed percentage of the industrialized per capita mean (mean plus 5-10% for instance). The cost of health care would be fixed for at least a decade. Up front then the government would know their annual healthcare costs would be $3.3 trillion which is what we currently spend on health care. Thus, like the GSE, the GHE would vary the payment for the enrollee based on their projected needs. However, despite the fact that the payments would be much more variable because the projected needs would be much more variable, the national annual cost would be known and fixed.

Cost containment:  Such a system would cost essentially the same as it is now which is still twice what other countries pay.  However, we would come into line with other countries over time simply by not increasing the premium.  Initially there would be a health care bonanza for providers.  This would give provider groups time to adapt to the new healthcare order. However, for all the reasons that the cost of health care goes up, provider groups would have to find more and more efficient ways to provide for their patients.  Once we reached our target health care costs (some percent of the OECD mean) the cost of health care could go up at the rate of that target rate.

            An additional source of savings would be to allow the federal government to negotiate drug prices.  We are paying the bill.  If we realized the saving that other developed countries do with this kind of policy we could expect an immediate saving of $130 billion annually[1]. As an offset to the drug makers, the government can help streamline bringing new drugs to market and help fund research as ways of helping such companies to continue to produce new products. 

Such a plan would, in a finite and relatively predictable period of time, bring our health care cost in line with other developed countries. In doing so, it would go a long way toward allaying the anxieties that individuals, businesses, and government all feel about the cost of our medical industrial complex.

---

[1] http://www.ncsl.org/research/health/pharmaceuticals/costs-and-pricing.aspx

Fixing Healthcare in 3 parts: Part 1 the Diagnosis The Medical Industrial Complex

“We don’t have a deficit problem; we have a health care expenditure problem.”

Aaron Carroll*

What’s wrong with American health care?  To paraphrase James Carville, the problem is “the cost stupid”. ** In 2016 we spent $3.3 Trillion on health care. This is twice as much per capita as any other developed country on health care.  In those countries access is not an issue because no one is uninsured.  In those countries medical bills are not the cause of bankruptcy as they are more than half the time in the United States because no one is under insured.  If our health care system were as efficient as any other developed country we would cover everyone and currently be saving $1.6 trillion per year.

If we a spending $1.6 trillion more than we should, where is that money going?  Well, Consumer Reports looked at the growth of health care spending in the United States from 1970 to the 2008.*** (This report is dated but I think the statistics hold up for another decade.) They found that the biggest growth went first to hospitals and then to doctors.  This was followed by pharmaceutical sales.  The lowest increase was in insurance administrative costs.  Therefore, most of the inordinate increase in the cost of health care goes to care.  Since we are not twice as sick or live twice as long as people in other countries why do we spend so much more on care?

The answer is multifactorial but it starts with the perverse fee for service payment system.  The problem with fee for service is not that doctors are rewarded for providing service; it is that they are rewarded for creating service.  From the extra office visit, to the extra test, to the extra procedure or surgery, doctors have an almost limitless capacity to create service and in doing so drive up costs.  The fee for service system rewards providers for the quantity of the service without regard to its utility.  If America is to cure its ailing health care system it must abandon the fee for service system once and for all. 

A second problem coming from providers, that is doctors and hospitals, is that there are no financial consequences for inefficiency.  The following is a trivial example. It had been pro forma to order 2 liver tests when following a patient who had been placed on a statin for high cholesterol.  These tests are usually done semi-annually. About ten years ago the American College of Cardiology determined that these tests were unnecessary after the tests done at the initiation of therapy.  I stopped ordering the test as soon as I read this but virtually every cardiologist with whom I share patients still orders these tests at an average of $64 for the two tests.  If this is the norm throughout the country then tens of thousands of these tests are being performed by professionals whose organization says they are of no value.  I am not sure if this is just force of habit or an “It can’t hurt” mentality but it is unnecessarily wasteful.

While the lion’s share of wasteful spending comes from providers, others share in the problem including . . .

Insurers get a lot of heat for the mess that healthcare is but their contribution to high healthcare costs is indirect. Competition in our “free market” health care system is among insurers. Since they don’t directly control the delivery of care the only things they can do to hold down costs are to limit care and to select for the healthiest panel of patients. This is inefficient and adds to higher administrative costs to providers – the estimate being an additional 10% (remember of a very big number) to the cost of health care.

Pharmaceuticals cost about twice what they do in other developed countries.[i] They spend more on marketing than they do on research which is a complete waste of money (but we all pay for it). More importantly Medicare is blocked by law from negotiating prices as part of the Medicare prescription Drug Law of 2005[ii] (sometimes referred to as the Big Pharma Relief Act of 2005).

There is controversy about how much malpractice laws drive up the cost of medicine. I think malpractice laws significantly impede best medical practices and I will discuss this in a later entry. However, if it is driving up the use of unnecessary medical services as part of defensive medical practice that is still money being spent on providers and is going into their pocket.

As I move in to my later years of practice as a physician, my biggest embarrassment is that I have been a participant in and benefactor of this wildly inefficient system that is a chronically debilitating disease impeding the health and well being of the rest of society and the responsibility for that falls largely on the people (like me), organizations, and institutions providing the care.

That said, there are no bad actors here in the sense that the players in this game are not cheating.  Providers, insurers, pharmaceutical companies, and personal injury lawyers are all doing what the system pays them to do. If you want better outcomes from your system you have to change the system and that is not going to be easy to do. Every one of these players has a huge stake in this very big pie so they have fought and will continue to fight changes that affect their share of this market.

Since the 50’s when President Eisenhower coined the phrase we have talked about the military industrial complex but no one talks about the medical industrial complex even though it is 5 ½ times bigger than the military budget. When I talk to people about this they seem to have a hard time getting their head around this probably because spending on medicine is seen as helping people and that must be a good thing. All I can say in response is, “Trust me. I'm s doctor.”

Next blog I will propose the cure.

* More dogma – not sure if this is his original quote or he is quoting someone else

** https://www.nytimes.com/2018/01/02/upshot/us-health-care-expensive-country-comparison.html?_r=0 This article antedates my comments and corroborates them. However, the article cited in the 4^th paragraph predates my thoughts on this. However, I did not plagiarize the title of the article cited.  I am not that well read to have been aware of it.

---

[i]https://www.aarp.org/health/drugs-supplements/info-2017/rx-prescription-drug-pricing.html

[ii] https://www.aarp.org/health/drugs-supplements/info-2017/lower-rx-prices-drug-costs.html

THE Simple Complete Market-based Solution to Climate Change

The earth is round, it rotates on its axis, it revolves around the sun, it is getting warmer as a result of humans burning fossil fuels, and if we don’t change course the results will range from catastrophic to apocalyptic. This is settled science that can be demonstrated with a 5^th grade experiment[1], and is shown to be reliably predictable by advances in computer modeling[2]. We are well past the point of defending the science of climate change and it is past time to implement solutions.

Responding to an Op-Ed piece that appeared in the Providence Journal (“Fight, Harvard, against global warming” 11/8/2014) I wrote the following response which encapsulates a solution I have been working on as a member of a group referenced below.

Charles Miller is troubled by the fact that his alma mater, Harvard, won’t divest itself of its investments in the fossil fuel industry. While I share his concern over global warming, I think his targets—both Harvard and the fossil fuel industry—are misplaced. Companies like ExxonMobil, Arch Coal, and Chesapeake Energy merely take the carbon out of the ground, but it’s we the people who cause global warming by putting that carbon into our atmosphere. To solve this fundamental problem we must find a way to wean all of us off fossil fuels. There are all sorts of smaller steps we can take to get there, but the urgent fact is we need to start taking bigger ones.

The enormity of the global warming crisis demands common-sense market-based solutions that shift the market itself without critically damaging our economy. Too often we see the path towards independence from fossil fuels and the road to economic prosperity as inevitably divergent. Fortunately, they don’t have to be. Enacting a revenue-neutral carbon fee and a flat-rate dividend program is a market-friendly approach that would help us change course on fossil fuels without placing undo economic burden on consumers. 

A carbon fee works by placing a charge of $15 per ton on carbon at its source. Though the fee is charged to the fossil fuel industry, of course this cost is passed directly on to consumers. To mitigate this added cost, 100% of the collected fees would be rebated back to consumers at a flat rate. In the first year, for example, the fee would generate roughly $81 billion dollars in revenue, and each American could expect an annual dividend of $250. The carbon fee would increase by $10 per ton every year until carbon mitigation targets are met. Therefore, both the amount of the fee and the dividend would grow annually; at the end of 20 years the expected annual dividend paid out to each American would be approximately $1600.

While every individual receives the same dividend, it’s you—the consumer—who determines how much in fees you actually pay out. The dividend is essentially a refund check for the average American consumer’s carbon fee. If you are an above-average consumer of fossil fuels, the $250 only offsets part of your total fees. If you are average in your consumption, you break even. If you are below average in your consumption, you come out ahead. As a result, everyone has an incentive to reduce their carbon footprints, not out of the goodness of their hearts but out of goodness to their wallets.

Citizens Climate Lobby (CCL) has been promoting just such legislation since 2007. We recently commissioned a non-partisan firm, Regional Economic Models Inc., to evaluate our proposed legislation to determine the comprehensive economic impact of such a plan. Regional Economic Models took the CCL’s model legislation and carried it out over a 20-year period, evaluating its economic, environmental, and social impact compared to a business-as-usual model. 

The study found that enacting a carbon fee and flat-rate dividend program would lead to positive effects on GDP throughout the entire span of the study. In particular, for every year of the study, personal income and job growth was projected to outpace the business-as-usual model. At the 10-year mark, an estimated 2 million new jobs would be created, and 2.8 million new jobs were forecast by the 20-year-mark. Meanwhile, the study projected a 33% decrease in carbon emissions at 10 years, and a 52% decrease in emissions at 20 years compared to a relatively flat business-as-usual baseline.

If we take this step toward comprehensively divesting ourselves of fossil fuels in a gradual, steady, and predictable manner, we can take truly consequential steps towards developing cleaner energy sources without throwing our economy into a tailspin. Carbon fees paired with a flat-rate dividend program will create predictable markets for clean, renewable energy and shrink market share for fossil fuels. As that happens, the issue of divestiture in the fossil fuel industry will solve itself.

++++++++++++++++++++++++++++

One final note, if we want America to continue to be great leaving our head in the sands over climate change is the last thing we should be doing.  To begin with the entire world understands that climate change is taking place as witnessed by the fact that every nation on earth signed the Paris Climate Accords except Syria (who tragically are otherwise occupied) and they are looking for solutions.  America has always been at the forefront of new technologies (think automobiles, airplanes, computers) and that has served us well.  We want to be at the forefront not playing catch up.

Furthermore, remaking our entire energy infrastructure based on clean domestically produced energy sources would be a massive job creator for decades to come.

---

[1] https://www.youtube.com/watch?v=3v-w8Cyfoq8

[2] https://www.ted.com/talks/gavin_schmidt_the_emergent_patterns_of_climate_change#

Death and other harmful side effects

Before I move on to my last book report I wanted to offer my views on the topic of death and how to manage what you can of it.

Usually at some point you will have the opportunity to fill out a living will and a durable power of attorney. The living will gives you the opportunity to leave some general instructions for how you want your health to be handled in the case that you become incapacitated.  However, these instructions may be unhelpfully vague (no extraordinary measures) or inappropriately restrictive (no feeding tube, no intubation, no CPR) in many situations that you cannot foresee in your current state of normal health.

With the durable power of attorney you entrust someone with the authority to make medical decisions on your behalf in the event that you become incapacitated and are incapable of making those decisions. This is far and away the more valuable of these documents because here you take the opportunity to clarify the vague and say specifically under what conditions potentially lifesaving measures become unacceptably extraordinary and therefore should be withheld or withdrawn.

The power of attorney goes into effect when you become intellectually impaired to the point that you can’t make or articulate rational decisions.  This incapacity can come in a variety of ways over a variable period of time. The most important question that needs to be asked if that happens is, “Is this incapacity permanent?” The answer to that question can be yes or no but at the outset the answer is usually we don’t know. If the answer to that question is no or we don’t know then life saving procedures should be implemented.

To be clear, there can be a common misconception that once implemented these interventions cannot be withdrawn and the case of Terry Schiavo comes to mind.  However, this case better illustrates what can happen when there is no clear power of attorney and there is a conflict between loved ones over what should be done. Someone with proper power of attorney can withdraw life support at any time.

The second question that needs to be asked and clearly answered is what is the nature of the permanent incapacity that would render lifesaving measures meaningless. 

People become physically incapacitated over time and that in fact is the trajectory of life beyond the age of 25. We soldier through that and carry on until at some point we may decide that the paralysis or the pain or the labor of breathing with recurrent set backs is not worth the effort so any life saving measure would not be worth the effort. However, as long as the individual is not mentally incapacitated this decision is up to the individual. Because they are mentally competent they have agency in this sort of decision. 

However, as is frequently the case, the individual permanently loses their mental capacity along with their physical capacity so the burden for making decisions about life saving measures falls on the person with power of attorney. This is the same decision as above but must be made before the fact and communicated clearly from the individual to the power of attorney designee.

These kinds of decisions are of course highly personal and everyone will have their own take on them but I am going to give you mine.

If I were to become mentally incapacitated I would want all measures implemented until it was established that this incapacity was permanent.  If it were deemed that I was to be permanently mentally incapacitated them I would consider any lifesaving measures extraordinary and I would only wish to have comfort measures.

What defines permanent mental incapacity? For me it would be my permanent inability to make medical decisions for myself. My belief is that I am my rational conscious self and once that no longer exists and cannot be reconstituted I no longer exist even if the body I inhabit continues with its vegetative and impaired cognitive function. 

Again, this incapacity can come in a variety of ways over a variable period of time. It can come suddenly as with a massive cerebral hemorrhage or gradually as with dementia.  In either case at some point the ability to rationally process information is lost and passed on to another and it is at that point that any even life prolonging measures (in addition to lifesaving measures) for me would be inappropriate because it is no longer my life you are prolonging.  I have ceased to exist.

With sudden and severe and permanent incapacity life prolonging measures are not an issue. However, patients with dementia can have other comorbidities such as high blood pressure, diabetes, or high cholesterol.  Treatment of these conditions are life prolonging and for me I would want my power of attorney to withhold these treatments. Vaccinations would be appropriate for their public health benefit, especially if I were institutionalized. Treatment of underlying conditions if that treatment provided comfort (for example, oxygen if I were short of breath or diuretics if I had edema) would be for me appropriate as well. 

This sort of gradual decline can and often does go on for years. Quite often it is more burdensome for the caregiver than the patient. If I were the patient my existence need not be uncomfortable but it need not be prolonged.

Quite frankly, I think this is a relatively radical way to deal with this problem. Therefore it is clearly not for everyone or even anyone but me.  Perhaps that is the most important point.  These are questions are highly personal and you really need to think about them and clearly communicate them with the person who is going to be your power of attorney.  As important as it is to have your wishes carried out the person who is entrusted with the power of attorney carries the burden of responsibility for doing what you think would be best.  If at any time after the fact they think they have had to guess and guessed wrong that can be a burden of guilt they may carry for the rest of their lives.

Thinking Immortal but Being Mortal

Being Mortal by Atul Gawande is an important book for those who have thought about the death of themselves or a loved one; it is an essential book for those who never considered the question.

Although not specifically delineated that way the book can be thought of as divided into three parts.

Part 1: “Life is a non-winning proposition.” Russell Berg

The first part deals with how we die. I tell patients that we peak between 20 and 25 and then it is a down hill course to oblivion*. Gawande discusses how this takes place and uses the aging of teeth as an example.  Even this most inert part of our body is not immune to the ravages of time. He discusses various theories as to why this happens but favors the notion that we are complex self-correcting machines where eventually the mistakes over take the corrections and we end with overall system failure.

For all of previous human history that end was usually fairly sudden and usually the result of an infection.  Pneumonia was referred to as the old person’s friend. The downhill course to oblivion ends at a cliff.

Now, for the most part, the downhill ride is punctuated by a series of events that permanently reduce our capacities but, because of modern medicine, it becomes a drawn out affair. We aren’t dead but we must learn to live with what we have lost.

Part 2: Don’t live free and don’t die

Gawande goes on to discuss how society has had to come to grips with this extended twilight world that the moderately to severely debilitated aged live in.  He traces the history of the development of the nursing home industry as a well-meaning solution for dealing with people who are unable to care for themselves. He notes that the quality of care is orders of magnitude better than the poor houses they replaced but their principle problem is that there, patients lose their autonomy.  He notes that like the military and prisons nursing homes are the institution in which the individual’s schedule – when you get up, when you eat, when you wash, when you socialize - is completely directed by someone else. This loss of autonomy results in a loss of a sense of self.

There are movements afoot that Gawande talks about to give more autonomy to the client.  The assisted living arrangement was started to give individuals the opportunity to decide when they want to get up, eat, socialize, etc. However, many of the questions revolving around autonomy raise questions about safety.  Can an individual live alone, go out by themselves, without a walker or cane, drive? The important point he addresses here is the interpersonal nature of this problem. This is often a point of conflict between the elderly individual and their loved ones.  While these sorts of issues must be dealt with on a case-by-case basis, being able to frame the problem in this way makes it easier for both sides to come up with solutions to their differences.

Part 3: What are your hopes and what are your fears

In the last part of Being Mortal the author talks about what happens when that decades-long downhill course turns into a rapid rush punctuated by modern medicines valiant but ultimately futile attempts to prevent the inevitable. He deals with this issue objectively quoting authorities and citing statistics; professionally how he dealt, both well and badly, with the problem with patients: and personally in dealing with the prolonged illness and death of his father. 

He feels the medical profession is understandably overly directed toward cure and the patient, equally understandably, is overly optimistic for a cure.  The result can be a futile pursuit of doing too much for too long to the detriment of the patient.

He favors taking a step back, realistically assessing a prognosis, and then trying to optimize everyday that the individual has left to them.  Once an estimate of a prognosis has been determined the first and foremost question, which is straight out of hospice care, is:

What are your hopes and what are your fears; what are you willing to do to realize your hopes and avoid your fears? *

The object is to think as clearly as possible about how to optimize the measurably finite time you have left and make each day a blessing. Gawande’s personal and professional recollections give tangible examples as to how this can work out in practice to the benefit of the patient, their family, and even the provider. 

Being Mortal gives the reader an opportunity to think through these issues before they come to the fore so that the individual can be better prepared when the inevitable comes.

It has not only been beneficial for patients but has been widely read in the medical community resulting, at least in the circles I run in, with a more ready embrace of palliative and hospice care.

*I go on to tell patients that there are 3 things and only 3 things you can do to keep the slope as flat as possible.

1.     Don’t put bad things into your body. (Heroin, nicotine, high fructose corn syrup, etc.)

2.     Put good things into your body. (Fruits and vegetables)

3.     Exercise.

** “What are your hopes and what are your fears; what are you willing to do to realize your hopes and avoid your fears? The object is to think as clearly as possible about how to optimize the measurably finite time you have left and make each day a blessing.”

This should probably be the guiding principle of our entire finite life. But for most of us it isn’t and that is probably because while our life is, of course, finite it is not measurably so in any meaningful way for us. We are all going to live forever until we’re not.

Democracy in America I then Everywhere II Illuminated

A few years ago I went on a Brown (University) excursion to Concord Massachusetts led by Brown Professor of history Kenneth Sacks. He trained in the classics but teaches their influence on American history.

In a brief conversation I had with him he said that de Tocqueville was the Thucydides of American history. If you have an argument about Greek history and can defend your position by quoting Thucydides you win the argument. He said that the same can be said of American history with de Tocqueville.

Alexis de Tocqueville’s seminal text is, of course, Democracy in America, which is in fact, like Don Quixote, two books. De Tocqueville was a French aristocrat who in 1831 traveled to the United States ostensibly to study the American prison system. He was here for 9 months and took extensive notes.  In 1835 he published Democracy in America (what turned out to be Volume I) which was a comprehensive survey of the new republic’s origins and its political, and social institutions.

De Tocqueville first considers the substrate out of which the United States grew.  He considers the geography, the Anglican predispositions and temperament, and the social conditions that gave rise to the democratic intuitions that spread through the colonies.  He makes the case that it was the unique contribution of all three of these factors that allowed democracy to take root here.

He then goes on to describe how government at the local then state then federal level works not merely as a sterile civic lesson but in the real world as American responded to and shaped these institutions.  What was striking to me about this was how we interface with these same institutions as our forefathers did 180 years ago.  For the most part de Tocqueville is quite impressed with what he sees and I for one come away with a sense of pride in this nation of which I am a part.

However, he ends Volume I with a chapter, The Present And Probable Future Condition Of The Three Races That Inhabit The Territory Of The United States, which could be subtitled America’s Dirty Little Secret. In this chapter, the longest in either volume, he delineates our deplorable relations with blacks and Indians, the enormity of the problem, and its intractability. With copious notes and statistics and poignant anecdotes the lays bare the problem at the time and presciently predicts the future that awaited our country. 

Volume II was written five years later in 1840 with an entirely different purpose and an entirely different format.  De Tocqueville firmly believed that democracy was coming to a country you will be living in.

“ . . . the democratic revolution which we are witnessing is an irresistible fact against which it would be neither desirable nor wise to struggle . . .”[1]

That said there are downsides as well as upsides to this inexorable march of democracy and the purpose of Volume II is, using America as an example, to outline how democracy will both positively and negatively effect the thoughts, feelings, and manners of people who adopt democracy.

Volume II is laid out in four Books, each with as many as 26 chapters.  However, each of these chapters is no longer than 12 pages (most 5 pages or less) and each is really a self-contained essay that gives a rather accurate snapshot of some aspect of the how life will change when democratic institutions are adopted.  He predicts “fake news”. He describes the “Rat Race”.  He worries that we will reach a place where people end up “talking without speaking; hearing without listening”. Nearly all of the changes good and bad are the result of moving from societies that are static and hierarchical to ones that are ever changing and egalitarian (or at least perceived to be so by those who live in it.)

He is not trying to denigrate democracy he is trying to paint an honest picture of it. As he says, “ . . . it is because I am not an adversary of democracy, that I have sought to speak of democracy in all sincerity.

I was persuaded that many would take upon themselves to announce the new blessings which the principle of equality promises to mankind, but that few would dare to point out from afar the dangers with which it threatens them. To those perils therefore I have turned my chief attention, and believing that I had discovered them clearly, I have not had the cowardice to leave them untold.”[2]

De Tocqueville is a brilliant writer and thinker and particularly in Volume II he is so accessible because you can pick nearly any chapter and in a few pages treat yourself to the writing of a great thinker and get new insights into how the world we are living in works and how we got here.

Below is a link to to the entire text as well as a partial list of chapters, all in Volume II, I found most illuminating.

http://xroads.virginia.edu/~hyper/detoc/toc_indx.html

Book 1 Chapter XL

Book 1 Chapter XVII

Book 2 Chapter XIII

Book 3 Chapter I

Book 4 Chapter VI

---

[1] Democracy in America Alexis de Tocqueville Author’s Preface To The Second Part

[2] Ibid