A dozen states have yet to expand Medicaid, a decision that has led to untold suffering for millions without healthcare.

This has also led to:

• more healthcare “deserts” in poor and rural areas
• economic damage in non-expansion states
• higher costs for uncompensated care in non-expansion states
• more hospital closures due to lack of coverage/reimbursement

(I’ve written about this a lot.)

it looks like things might be evolving; Georgia is making progress, Expansion is on the ballot in South Dakota and there have been referenda in several Republican-led states.

Reality is states that expanded Medicaid saw significant positives; healthier people, improved economies, greater Federal financial support, and major job growth.

What does this mean for you?

Poorer folks need Medicaid, and there’s a ton of data showing why every state should do this.

Work comp folks – here’s how this affects you.

Time to check in on how our Ukrainian friends are doing…

Last time we focused on strategy vs tactics…today we’ll cover why the Russians continue to do stupid stuff while the Ukrainians take full advantage of technology.

How who follow this closely know that the Russians are relying almost entirely on massive artillery barrages to level towns, cities, and villages before trying to push troops in. That was working, and Ukrainian forces were hard-pressed to withstand the bombardment.

From the Kyiv Independent: “artillery dominance compensates for the weak performance of Russia’s infantry.” 

That was then.

It’s quite different now, mostly because A) NATO countries have sent hundreds of artillery tubes (think cannons) and dozens of rocket systems to Ukraine and B) Russian logistics are awful.

A – These NATO weapons are much more accurate and have greater range than most of the stuff the Russians are using.

This allows the Ukrainians to shoot from further away, reducing the risk from Russian “counter-battery fire” (radar can identify where the outgoing shells and rockets are coming from so the enemy can shoot back). The new weapons systems are also much more mobile; our HIMARS rocket systems can shoot and be gone in 2 minutes. (thank you American taxpayers!)

Since mid-June, Ukrainian artillery has become increasingly lethal and extremely effective. This from the Kyiv Independent.

On June 15, a massive explosion occurred near the city of Khrustalniy (formerly Krasniy Luch) in occupied Luhansk Oblast. Explosions continued for days. According to satellite images, the blasts created a destruction zone spanning some 500 meters around the epicenter. The site was one of Russia’s largest ammunition depots

July 2, Ukraine’s military published a video showing an enormous explosion at another large depot in the city of Popasna…Two days later, another devastating blast destroyed a large depot in the city of Snizhne. Three more depots were also hit in Donetsk.

Which leads us to B – Russian logistics.

Faithful readers will know Russian logistics – in English the process of supplying troops with fuel, munitions, water, spare parts, and equipment – is awful. They don’t use forklifts to move heavy stuff, but rely on manpower. They don’t have pallets, but rely on manpower. They don’t have enough trucks, so they rely on trains.

That’s why the Ukrainians have been able to destroy thousands of tons of Russian artillery shells and other munitions; the Russians move those munitions to giant storage depots, where people offload the shells and trucks transport the shells to the artillery locations.

It’s pretty easy to identify where trains are off-loading, and even easier to use a few artillery rounds to set off giant, days-long fireworks shows.

reportedly a large Russian ammo depot; actual video is here.

So, the Russians move the depots further from the front lines  – out of range of most artillery.

Enter HIMARS – which has a range of almost 50 miles with current rockets – can hit pretty much any target inside Ukraine.

From Igal Levin, a Ukraine-born Israeli defense expert.

“…if all those forwarded bases, depots, repair facilities, all of the logistics chains are destroyed — [Russians] will have to deal with the need to bring supplies from beyond the Ural Mountains, then be thinking how to store and distribute them, how to bring munitions to artillery.”

The takeaway.

Russia has a far larger army, exponentially more artillery weapons, and enough artillery rounds in storage to fight for decades.

They also have a wildly corrupt economy, where kleptocrats stole billions of rubles intended to feed, clothe, and equip soldiers.

Ukraine has a much smaller military – and had a history of corruption, albeit one that pales in comparison to Russia’s. Their troops – men and women – are way more motivated, fighting for their families and  land, and increasingly well-supplied.

They are also very well led by commanders who have years of experience fighting the Russians in Crimea and the Donbas and are taking full advantage of Russia’s limitations and NATO largesse.

What do we need to do.

Keep the faith, people.  Russia’s invasion of Ukraine is a major contributor to inflation, driving up fuel and food costs around the world. Yes this sucks, but our sacrifices are nothing compared to what Ukrainians are doing every minute of every day.

This too shall pass. When it does Putin and Russia will be far less dangerous, food and fuel prices will be much lower, and the world will be a way better place.

If you can, please help Ukrainians suffering from hunger, homelessness, injury and disease by donating to Care.

How could anyone think a riot would overturn an election and keep an unelected person in office?

That more than two centuries of carefully nurtured democracy could be trashed in a few hours?

18 months ago we watched in stunned disbelief as our Capitol was attacked, police officers were brutalized and beaten, and bizarre characters wandered the halls, stole mementos and put their feet up on desks, ascended to the podium and eerily called for the heads of the Speaker of the House and Vice President.

For me, yesterday’s January 6 hearing made the insanity of it all stunningly clear. The testimony of a very young staffer crystallized how far we’d gone off track, and why.

Cassidy Hutchinson’s placid, calm recounting stood in stark contrast to the events she was describing, none more jarring than her description of then-President Trump’s furious and frantic effort to get his Secret Service detail to open up the Capitol, remove magnetic detectors and thereby allow his “wonderful people” to bring guns, knives, automatic weapons, pistols, bear spray, and spears to wreak mayhem on Congress’ certification of the 2020 election.

Trump’s megalomania, narcissism and bloody-minded pursuit of power at any price was on full display yesterday. Hutchinson’s recounting of agents describing Trump as irate because the agent wouldn’t drive him to the Capitol so he could “let his people in” says it all.

Five police officers died as a result of the insurrection.

Dozens more may well have been killed if the Secret Service had bowed to Trump’s  insane demands.

For what?

What made Trump think that he could stay in office, prevent Biden from assuming the Presidency, reject the will of the American people?

How could Trump possibly think he could stay in office?  That a bunch of weirdos, military fetishists, tinfoil-hat-wearing simpletons and assorted other nutjobs could turn the United States into a banana republic, one where a strongman could keep power because a few thousand criminally-stupid idiots wanted him to?

Did Trump actually think our entire government, our military, our law enforcement and security and intelligence operations, all of us would stand by and let him stay in the White House? Because a moron wearing a buffalo headdress says so?

Hutchinson’s testimony made it clear Trump is completely detached from reality.

Trump wants power at any price – up to and including killing police officers, destroying our Capitol, and ending the United States of America as we know it.

What does this mean for us?

We are each individually responsible. Ensuring our kids and grandkids live in a free country is up to each of us.

After what was a really awful/crappy/despair-inducing week, we divert into the most important story of the year – Russia’s invasion of Ukraine.

Because the news there is actually kinda good. The dominant story line in the popular press is Ukraine is getting hammered, Russia is taking territory, and Ukraine’s allies aren’t doing enough.

Well…yes and no.

Briefly…

Ukraine is getting hammered – but Russia is expending huge quantities of munitions and soldiers which it cannot replace.

Russia is taking tiny bits of territory – at huge ^ cost.

Ukraine’s allies are doing waaaaay more than the popular press would have you think. Examples…

• monitoring Russian naval activity in the Black Sea (south of Ukraine) (the picture below shows an airborne surveillance plane circling just south of Ukraine)
  
• those fancy artillery and rocket systems we are sending are having an impact – which will only increase.  Russian generals 40 mile behind the front lines are waking up dead, surrounded by destroyed equipment, fuel, and supplies.
  
• Thanks to the Dutch and (FINALLY!) the Germans for their support
• The super-capable and highly advanced rocket systems the US has provided are taking out critical Russian ammo dumps.
  
• And other prime targets…
  

As a result, the Russians are facing a huge logistical problem – they’ve used up millions of artillery rounds/missiles/bombs, some of their remaining supplies are being destroyed, they can’t get what’s left from storage depots to the front lines, and they can’t set up storage depots far enough away from those front lines to avoid the missiles and advanced artillery rounds we are supplying (HIMARS).

More important – yet rarely reported – is the strategy behind combatants’ tactics. Think of strategy as the long game – what the combatants want to achieve at the end of the war; tactics are supposed to be (but often aren’t) the moves you make to achieve your strategic goals.

Example – Russia is using its vaunted artillery (cannons and rockets and missiles plus bombs) to pulverize Ukrainian positions, forcing Ukrainian troops to retreat or be destroyed. That’s “working”; Ukraine recently evacuated its troops from Severodonetsk allowing Putin to claim a “victory”…

“The loss of Severodonetsk is a loss for Ukraine in the sense that any terrain captured by Russian forces is a loss — but the battle of Severodonetsk will not be a decisive Russian victory,” said the Institute for War.

In fact, the Ukrainians forced the Russians to expend huge quantities of shells, missiles, rockets and bombs – and likely incur thousands of casualties – to capture what is now a bunch of rubble.

Reports indicate Russian morale is awful, drunkenness among troops is widespread, medical care is non-existent and food scarce,

History is replete with tactical decisions that cost a strategic victory; Napoleon’s invasion of Russia is a prime example.  In 1812, Napoleon marched his half a million-strong Grand Armee’ to Moscow, trying to force Russia to stand and fight. Russia refused battle and Napoleon had to march back through the Russian winter, in the process losing 9 out of every 10 soldiers.

Russia’s strategic goal was to increase Russian power and weaken the West (that’s us and Europe). Putin figured his invasion would:

• divide the West,
• disrupt and weaken NATO,
• capture territory including really valuable energy and agricultural assets; and
• make Ukraine a Russian territory.

What does this mean?

Despite murdering tens of thousands of kids, grandparents, moms and dads, Putin’s idiotic war has been an abject strategic failure. And that isn’t going to change.

Russia is:

• much weaker than it was before the invasion,
• its economy is in a shambles,
• the territory it has “captured” is a hellscape of rubble from which Ukrainian guerrillas pop up to shoot Russian generals, destroy supplies and vehicles, and
• the West is united as never before.

While Putin’s tactics are just stupid, his strategy was even dumber.

I posted on the slaughter of kids and Black Americans a couple weeks ago; David Vittoria, Carisk’s Chief Behavioral Health Officer sent this in as a comment  – it is well worth your time. (lightly edited; highlights are mine. Carisk is an HSA consulting client

It’s time for action.

There are always “calls to action” after these kinds of horrific events, but they’ve fallen short. It’s time to rethink the role of behavioral healthcare in helping our young people when they are suffering. Our industry should be hyper-focused on caringly confronting this head on, bringing together really smart, insightful, compassionate, and committed people, so that we can do better for our kids and communities.

I think there are many factors that contribute to gun violence in America. I definitely don’t pretend to have solutions for them all. Yet as a behavioral healthcare leader, psychotherapist, dad, and someone who’s spent many years working with children and adolescents, I know our industry can show up more and better for at-risk kids before they commit acts of violence like we saw this week in Uvalde.

By the time I would encounter these teens in residential or inpatient psychiatric facilities, they were often so aggressive and disengaged, we couldn’t really help them, no matter how hard we tried.

They typically disrupt the treatment setting more than they commit to treatment. They are at a point where they won’t take medications and are non-compliant with outpatient programs. Then it’s too late. The system of care will continue to fail teens unless we intervene earlier where they are in a better position to be helped. We need to be able to intervene early on to build the empathy they have for themselves, so that we can, in turn, help them have to have more empathy for others. But it must be thought about and acted on so much sooner than our current system supports.

As a behavioral health industry, we need to go on the offense.

We need a lot more mental health resources and support to reach all teens. Flexible, outpatient and other interventions, with evidence-based, engaging content. Interventions that are focused on skills and tools that equip teens to tolerate stress better, meaningfully connect with people and their purpose more, and see the power of their real potential. I can tell you…this is largely missing in the current approach.

We need preventative approaches and early detection. We need all the things that exist in medical care. Just as endocrinologists and cardiologists focus on diet and exercise with patients at risk for diabetes and cardiovascular disease, behavioral health should focus on giving teens the skills to develop empathy, tools to better understand their emotions, and practically-applicable ways to manage stressors in their relationships, especially at home and in school. We need to understand how critical, early, preventative attention and intervention can play a central role in saving lives. There are many more things that can be done so that a child/teen does not escalate to having the capacity to take another human life.

Will this work 100% of the time? No. 30% of the time? Maybe not. Is the problem a mental health problem more than a gun violence problem? That’s a convenient distraction. But if we go on the offense and focus our efforts as a mental health industry on lifting children up more, addressing their mental health needs earlier and better, and place the focus on information, education, support, and proper care, focused on empathy…we will have a come a long way.

Thank you David.

What does this mean for you?

Support behavioral health for all kids – especially yours and your kids’ friends. 

Personal note – we have three wonderful kids who are all employed (Yay!), have stable, loving relationships, and are contributing members of society. Without getting into details, this “outcome” was undoubtedly helped by early and often use of counseling and therapy, and intervention.

I’ve been on meds for panic attacks for 25 years and have been very open about that. The vast majority of behavioral health issues are absolutely solvable – but only if you own them.

Putin is losing.

The West is winning.

Ukraine and Ukrainians are what we should aspire to be.

There is no way Russia will “win” in Ukraine; Putin is running out of troops, ships, armor, money and time.

Meanwhile his objectives for the war on Ukraine, namely:

• easily capture Kyiv and install a puppet government in Ukraine;
• split the West using his oil and gas as leverage,
• damage NATO; and
• scare smaller countries into abandoning the US-led alliance

are further away than ever.

Putin has strengthened NATO and the European Union, unified the West, pushed once-nominally neutral countries including Finland, Sweden, and Moldova into embracing the West, and shown the world that his armed forces are weak, poorly led, poorly equipped, and no match for a country a quarter the size of Russia.

A couple of things worth noting.

It is highly likely US intelligence assets (satellites, NSA, communications intercepts, aerial surveillance) have and are playing a major role in the war (as are the UK’s and almost certainly other western countries’). Reports indicate:

• the sinking of Russia’s largest warship in the Black Sea was aided by US intel
• US intel likely helped lead to the shockingly high number of Russian generals killed (a dozen so far)
• Ukrainian forces are getting early warnings of Russian missile attacks from US  assets
• in the early hours of the war US intel led to Ukraine shooting down a giant transport plane carrying hundreds of Russian soldiers on its way to take over a critical airfield.

a downed Russian plane (likely a fighter)

Ukraine is showing the world how an incredibly motivated, really smart, and very creative people can defeat what used to be thought of as the world’s second strongest armed forces.

A few examples

Ukrainians have made drones – big ones, small ones, tiny ones; armed ones; ones with cameras and ones adapted to carry explosives; commercially-available ones and military-only ones – a major part of their arsenal.

Much of this is appears to be the work of regular Ukrainians…many of whom were are not in the military before Russia’s attack.

A drone drops what appears to be a mortar shell through the sunroof of a car stolen by Russian soldiers…

A Ukraine-developed anti-ship missile is likely the weapon used to sink two of Russia’s biggest warships and destroy a troop transport.

Now that Ukraine has the latest artillery (thanks to France, Canada, the UK, the US, the Netherlands and other countries) it is using it to deadly effect.

Meanwhile Russia is calling up retired service members to fill “administrative” roles in its army. This shows just how deep into the morass Putin is, and how willing he is to keep digging himself even deeper.

What does this mean for you?

There are so many lessons we can learn from this…

• preparation and constant attention to detail are critically important and way under-valued,
• never under-estimate the power of very motivated people,
• leaders that employ only those that agree with them will fail miserably.