I've been struggling with this as well (as one of the liberal Democrats who has moved towards social democracy), mostly with my friends who fit to a tee the strategic description Freddie offers ("Earn a razor-thin majority, pass laws favoring your party, and hope nothing bad happens"). I think this is a ridiculous strategy, Freddie's optimism above aside: the bad blood from 2016 represents a real urban-rural divide that is as polarized as it's been since the Civil War, and in a couple years (when the Democrats likely lose the House in 2022) we are going to see individual states literally defy duly enacted executive decisions. Future shock and what I guess people call "late-stage capitalism" are driving us into incredibly intense partisanship that's not going away.
So I agree (to an extent) with the Democrats' diagnosis, but not their solution. WTF should MY plan be?
This is where working in the labor field helps. To me, even though I'm not a Marxist, the answer remains organizing: not the stupid progressive self-devouring organizing, but deep community-building organizing that brings people who disagree together. (In other words, I firmly disagree with the third "plank" Freddie describes. I don't have any broad policy goals--politics can go ahead and do its thing, and I'll vote for people who are likeliest to push my preferred policies, but it's not going to help much until we do the work of rebuilding communities. So I believe in community organizing and also in rebuilding the fabric of communities: reworking the infrastructure of cities and towns and rebuilding institutions at the local level to foster interaction instead of isolation.
It's probably also a doomed approach, but hell, at least it gives me something to do.
that was roller coaster ride thru logic and argument. totally agree on the multi-racial aspect, and in fact write about it in one of my first posts here
so that makes sense that they would consider themselves white and vote accordingly. However, most of my friends are in mixed-raced marriages, and have bi-racial kids. It is more rare for me to see couples of the same race then mixed now. And it makes logical sense that they vote across the board. I know several couples of white husband and Hispanic wife that both voted for trump.
disagree strongly on the tax thing. we make less than $100K a year, and trumps tax cuts saved us $4k a year in taxes.
tbh I think if you look at what actual people say they want, the picture is nowhere near as bleak--for the country, at least. The parties are a different story. But in policy polling, for many things, you see a convergence in interests for both self-identified conservatives and self-identified liberals: they want healthcare to be cheaper; they are leery of the monopolistic power of Amazon, Apple, Google, etc, and think they ought to be curbed; they dislike the power that the NSA has; they dislike the increase in crime and want workable solutions to crime and drug addiction; they want police reform to better align police interests with public interests; they want kids to receive a good, well-balanced education; they want housing to be reined in. They don't always agree on the exact ways these things should be accomplished, but they are willing to compromise and hear what others have to say. There seems--at least to me--to be a huge space in which compromise and cooperation is perfectly possible.
Some politicians are moving into this space (which seem to me to very typical moderate Democrat spaces, or at least would have been twenty years ago) to great success. Once you get away from twitter and avowed partisans, people are sick of both parties. They're sick of the grandstanding. They're sick of the hypocrisy. They're sick of the corruption. Any politician who can pick up on that and align themself to the forming majority consensus could be very successful. Hell, this is arguably what propelled Trump into office (against, it should be remembered, the explicit wishes of the Republican party) and led him to gain more votes in 2020 than he did in 2016 (even after he proved a poor politician and presided over a devastating plague). Trump was wildly successful despite truly sucking; anyone who can actually play the game and get stuff done should be nigh untouchable.
I don't think this is borne out by the evidence. Negative polarization is currently a huge problem, according to polling: people don't like their party, but they HATE the other party. And it doesn't really have to do with policy, much: it's much more affective than issue-based. In other words, this convergence of issues doesn't matter... Democrats will hate Republicans and vice versa even where they agree.
Here's a nice link on the issue. Remember that two-thirds of America, more or less, declare a party affiliation, and that most independents end up being fairly consistently partisan:
Trump, I would say, did not win by entering the moderate space: he won by leaning on the partisanship and seeing the other party as the enemy, and he earned 75 million votes or whatever by doing the same thing throughout his presidency.
"People don't like their party, but they HATE the other party."
That's kind of what I was getting at: people are unhappy with their choices, and if someone can finally get a viable third-party going that touts these easy consensus topics, that might be very successful. Now, there's a lot of monied interests and corporate media and such aligned against this happening, and third parties are difficult to build to begin with, but if it could happen...it might do well. A radical realignment of one or both parties (which is kinda already underway) might have similar effects.
And it's just anecdotes, but for the all the polarization talk, I've been amazed at how easy it is to sit down with people and get them to agree with things. I've talked with life-long Republicans, both Trump supporters and not. I've talked with life-long Dems who voted for Trump and life-long Dems who would beat him to death with a golf club given the opportunity. I've talked with people who hate politics in general. And it is really easy, on a decent selection of topics, to have a conversation where people quickly come to a comprised consensus about what would be a good hypothetical path forward.
"That's kind of what I was getting at: people are unhappy with their choices, and if someone can finally get a viable third-party going that touts these easy consensus topics, that might be very successful."
But this has been the dream for, what, forty years? The structural disadvantages don't help--understatement there--but I don't think it's what people actually want. Everyone says, for example, they don't like negative campaigning, but guess what does the best job of turning out your base? Negative campaigning. People want and need an enemy--especially now.
Don't get me wrong, I truly believe that we need depolarization. I'm literally a member of an organization that's working on just that. (check out Braver Angels!) But I don't think the answer to doing that is a party offering a thin gruel of non-controversial fixes, because that's not where the conflict is. The conflict is that most people on one side think that the other side opposes their fundamental values. The situation right now is a values conflict, not an issues conflict, and the route to resolving it is not offering an alternative group to belong to, but getting the two sides to stop despising each other quite so much.
I absolutely agree that the conflict now is primarily a cultural one. That said, why is politics so heated in that case? The cultural conflict is expressing itself in the political sphere and both parties are eager to exploit it in order to turn out votes.
I do think there are structural reasons for this. Our Constitutional structure leaves us with so many veto points that playing zero-sum politics is a lot easier here than in, say, a parliamentary democracy. Thus, there are political incentives for polarization that don’t exist elsewhere. It’s the nature of being a beta test for republican democracy.
maybe it's too early in the morning for me, but I found a lot of this confusing. I'm a new reader of your stuff, so I guess there are some underlying assumptions and such that I'm not aware of. For example, is Chris Hayes (and pundits in general) supposed to be a political actor in this? Like do you take what he says as having an effect on politics, or is it a more downstream expression of other people's effect on politics? It seems there is a notion that this rhetorical sphere is the main venue for politics (Matt Yglesias says this, people on twitter say that, etc). Discourse in the form of TV, posts, and books seems more like corporate entertainment to me and about as interesting politically as the local news, but maybe you have a deep read on that? This whole post kinda feels like a TV re-cap from my perspective
Also, gay marriage as a left issue? Is the basic rhetorical assumption that if people call it a left issue it becomes one? Or is it that correlation (people who are politically left generally are pro gay marriage) indicates a deeper relation?
maybe I need some coffee cuz I didn't really get what a lot of the references to 'left' 'liberal' and 'democrat' were functioning as here
"is Chris Hayes (and pundits in general) supposed to be a political actor in this"
"It seems there is a notion that this rhetorical sphere is the main venue for politics (Matt Yglesias says this, people on twitter say that, etc). Discourse in the form of TV, posts, and books seems more like corporate entertainment to me and about as interesting politically as the local news, but maybe you have a deep read on that?"
People should say things that are true and good rather than things that are untrue and bad, especially if they have large audiences, as these people do
"Also, gay marriage as a left issue?"
Gay marriage has been a left issue as long as it has been an issue, so I think this is a you thing.
Have you read 'against equality'? That's kinda more the perspective that I'm coming from, so I would agree that gay marriage is a left issue only in a surface extensional way (ie, people who think X also often think Y), but if we're trying to really figure things out, it's not (or at least it's not obvious and the case needs to be made).
I mean, look, I am aware of left arguments that gay marriage is conservatizing, and right arguments that gay marriage is really a way to expand traditionalist norms, and I think they're interesting. But I don't see the utility of denying that by every conventional standard gay marriage has been associated with the left-of-center since it became a mass political issue in the last 25ish years. People who are more left are dramatically more likely to support gay marriage than people who are more right, even after all of the general leftward direction in this issue.
that's fair, it's also what I noted above, it's a "correlational" view of this stuff which I think is a kinda notable approach to defining things like 'left' and the source of I think some of my confusion in reading your post today. I kept asking myself "does he mean by this word just the common surface unreflected upon meaning of this word or is he staking real claims here". I guess it was the first one
"People should say things that are true and good rather than things that are untrue and bad, especially if they have large audiences, as these people do"
I think I disagree with a load of stances that I suspect are behind this sort of response and I would love to see them spelled out (not in the comments necessarily, just wishing for a future post). I think your apparent opinion that this stuff is real adult discourse with real consequences and not silly/pernicious corporate distractions is interesting, cuz I disagree with it and it seems like it paints and shapes so much of what you write
For perhaps a majority of normal people, who work full time and raise kids, these pundits are where they are getting their political news and their political opinions made. That is why it matters, whether their discourse is "adult" or not.
I think this type of reasoning is not all that different from saying: we should really pay close attention and treat as important what is trending on twitter, because that's what shapes the discourse that pundits are swimming in
I'm personally tired of caring what in particular minutia the chattering class says. I don't doubt that people can convince themselves to fret about it and parse it closely, but I think it's kinda deluded or a trap
I think all manner of propaganda influences people's political opinions and what I take issue with is treating the effect of, say, Chris Hayes as somehow essentially different from the effect the ads that play on during his show.
As long as mass media exists, they are culture makers. And what they accept as paid ads on their show is part of their culture-making. Which is how we've ended up with conservatives who place faith in essential oils and supplements, and liberals who don't believe in vaccination, or LeBron James speaking up for China.
I'm not arguing that these people are serious thinkers, or serious at all. I'm arguing that what they broadcast is widely influential, and that is a serious issue itself.
I don't think I disagree all that much on what you're saying here. I draw my own personal line on this notion that I have to pay attention to what TV pundits say, spectator like
Gay marriage was also championed by conservative figures like Andrew Sullivan, who was making an argument for it decades before it happened. Hayes is a self-described "red diaper baby" so I guess the argument is that Hayes is a sellout because he isn't preaching socialism every night. His last big anti-establishment rant was in defense of the lady who lied about Biden harassing her. Her claims, when scrutinized, fell apart in a humiliating manner (I'm glad they were fully aired and investigated). But yeah, that was his big tearful on air moment and it was totally embarrassing.
That was great and very informative. There are also bipartisan taboo themes though.
Much reported, including Ed Snowden "Topic of this year - Pegasus", is disclosure of continuous over time surveillance ability of all smart-phones of all conversations and pin-point location-accuracy even when phone is turned off.
Therefore, certainly many governments (certainly of Israel and the US) know EXACTLY and for ALL Epstein's associates and "guests" -- who, when, where, how long, and why they were with pedophile Epstein !!
Yet we still don't know, after all this time, for example, even what Epstein's multiple passports show. As courageous Eric Weinstein stated -- Epstein was "a construct" - by one or more intelligence services.
No, not all smartphones are being tracked all the time. It is possible to do so and maybe even likely that all of Epstein's associates were being tracked, but peons like you and me don't have that much to worry about.
Are you talking ONLY about "Pegasus" spyware? Pegasus is spyware developed by the Israeli cyberarms firm NSO Group that can be covertly installed on mobile phones (and other devices) running most[1] versions of iOS and Android.
"The socialist alternative is that money no longer determines the provisioning of medical care"
I'm not sure what you mean. We'd still need to determine what percentage of GDP we're going to allocate to healthcare. So "money" would still play a huge role. Or do you just mean money at the point of service?
I mean that a truly socialized economy has no GDP to measure. This is kind of the point: even people who are conversant in socialist vocabulary or are actively associated with socialism as a goal have transformed socialism in their minds to "the government pays for stuff." Under a socialist system in the traditionalist sense, the ruling body says to a doctor "give this person medicine," and medicine is given, and no currency changes hands between anyone in the process - indeed, there is no currency to exchange.
"I mean that a truly socialized economy has no GDP to measure."
There is the current capacity to provide goods and services so GDP.
"Under a socialist system in the traditionalist sense, the ruling body says to a doctor "give this person medicine," and medicine is given, and no currency changes hands between anyone in the process - indeed, there is no currency to exchange."
But you couldn't command GE to give everyone a home MRI machine because the economy wouldn't have the ability to produce that volume of large manufactured items. GDP would be your limiting factor. That would hold true for anything.
But you see the point - you're making the argument against a certain old-school definition of socialism. I'm saying that the kids these days don't know that that was what was once frequently meant by socialism, a command economy. The most far out thing they can envision is a mild market socialism. And my point is that this is a victory for the liberals.
What would a victory for true socialists look like? Is there even a theoretical framework by which those arguments come back into vogue? Aren't we just arguing about which gradation of welfare-state neoliberalism is best?
Except there are always tradeoffs. There will always be the question of how much resources should be spent on a one in ten million disease or whether a colonoscopy should is needed for a 30 year old. And there are always gonna be people hurt by these tradeoff. No economy has unlimited resources and there's always going to be decisions like this made, even in education and health, and the only way we know of to represent "labor+resources" is by using money. I don't know how else you'd even represent that.
Meh – even in the most utopian depictions of "luxury space communism" there are still _clear_ limits on all kinds of resources. (Tho maybe they're just 'clear' to me because I'm looking for them!)
One of my favorite examples is from one of The Culture series books where a character is described as being upset because they aren't allowed to experiment with adding (active) volcanoes to a part of a 'space world' on which they live. Another example that's indirectly observable is where people live – not everyone can live where they _most_ want.
Obviously we're at the very early stages. But take that technology and run with it... And then people can all live where they want and add volcanoes to their worlds, etc.
That's a possibility, but even simulations would require some kind of 'real' physical infrastructure to run them (as long as we're assuming technology short of 'magic').
I'm also pretty skeptical of the feasibility of simulations – especially as a permanent replacement of physical reality. There's a number of macroscopically visible phenomena that are quantum-mechanical in nature. I certainly don't see how even tech way beyond ours could ever support something like a realistic microscope – and if they don't, that seems like a very sadly limited simulation in which to live.
But _maybe_, in a simulated world, it'd be possible to avoid or workaround some limitations, but I suspect that 'people limitations', e.g. wanting to be around other specific people (like friends or family), or around groups of strangers (like at a concert or other public event), would still hold, to at least some degree.
But I'm all for fully automating even current 'luxuries' – to the degree that's possible! I just suspect that 'money' will survive even that.
Right and what would be the signaling mechanism for goods and services? How would this repository of administrative and bureaucratic omniscience be created?
The issue with all command economies is that they presuppose an intelligence that is nearly as efficient as markets and that has never come to fruition.
The five year plans for potatoes and eggs always failed. So now that society is exponentially more complex, what would the plan be exactly?
Furthermore, a command economy political apparatus would be necessary centralized and authoritarian. How many people really want a technocracy administering these decisions? Are we sure this technocratic elite will be fair and wise? What advantage would such a centralized system have compared to a libertarian left system where you get an insurance card, UBI, EBT for food, a housing voucher, etc. and then you decide what healthcare healthcare, food, housing YOU want rather than having it administered to you?
In 2021, entertaining command economics just seems silly. Tell me why I'm wrong.
"The five year plans for potatoes and eggs always failed."
That's not true. The Soviet Union did rapidly industrialize and living standards did increase significantly. It all sort of petered out during the Brezhnev era. And of course China's 5 year plans have been going gangbusters.
Same, I am very interested in seeing Freddie exposit/defend his version of socialism, as he keeps bringing it up obliquely in comments and posts -- for over a decade now! -- but I have yet to actually see him explain it in any context. He obviously isn't an idiot so I'm very, very, very curious how he thinks that a command economy could/should be implemented in America, because it really seems questionable at every level. Is it a symbolic belief? I remember he said a few years ago that he sees his socialism as somehow 'inherited' from his parents/grandparents (as I recall? not sure), so maybe that explains it?
I don't think Freddie expects there to ever be a command economy in the US. Detailing how it would be implemented would be like me describing how I would make love to Kate Upton. Both of our time is probably better spent on what we have influence over.
Again, this is a debate about the wisdom of that vision of socialism. I am here discussing the fact that the younger generation of socialists/"socialists" have abandoned support for that vision, without even seeming to know that they're doing it, in a way that demonstrates liberal victory.
Beyond even the 'planning fallacy', it occurred to me the other day that there's a kind of 'economic goods nebulosity fallacy' that might, arguably, be even more important – beyond the problem of (successfully) running a command economy for some existing set of goods and services, there's the 'problem' of discovering all of the _potential_ goods and services that might be (more) valuable than what's already being commanded to be produced or provided. It's not _impossible_ that a command economy could do this tho; just much more less likely IMO.
Do modern command economy proponents talk about this stuff? It's sort of my field so I'd be pretty interested.
Some basic but very important concepts in CS and Machine Learning were developed by mathematicians like Kantorovich to help solve these types of problems. Of course it quickly turned an ideological battle so never got a fair shot. Also, their computers sucked.
Some most. I don't have any citations because 1) there are just very few real command economy proponents left anymore - even a lot of older school ML types avoid the subject more than defend the principle and 2) I very rarely read explicitly communist/radical socialist stuff anymore because I spent too much of my life in sectarian fights and I find the whole enterprise depressing these days.
How would a AI command economy differ from a market economy? Do we want cars to have heated steering wheels or do we want to fund a very marginally superior chemotherapy drug?
It doesn't help that a lot of these problems are basically as hard as possible for any problem to be (as in either mathematically impossible, to at least solve _perfectly_, or arbitrarily difficult to solve even for fairly 'toy' sized instances).
And when it got that good, it would likely decide that humans were superfluous and get rid of them ... haven't you read slatestarcodex/astralcodexten on AI safety???
This is so true -- "even people who are conversant in socialist vocabulary or are actively associated with socialism as a goal have transformed socialism in their minds to "the government pays for stuff."
I'm not sure if this is what you meant, but I don't think 'getting rid of money' actually does anything – there still has to be some way (let alone a 'system' with 'rules') by which economic decisions are made, and people's need to weigh possibilities would result in something economically equivalent to 'money' inevitably.
It would be great if, at some point, there was a broader explanation for why the brightest minds of the Left think that M4A is such a 'good idea.'
Single payer is not common. Most European countries have decentralized systems using private insurance more akin to Obamacare with a few exceptions. Canada has single payer, Norway has single payer. Anyone else? The UK's system is more like VA-care for all than M4A.
The primary criticism of M4A is not that it's politically inconvenient. It's that Medicare is not scaleable. That is, if you forced hospitals and providers to just take Medicare payments a lot of hospitals would close and a lot of services wouldn't be provided that are provided now.
You might be able to pay doctors 60 cents on the dollar and cut wages for nurses and respiratory therapists and some other health professionals. But office staff, electricians, engineers, etc. could choose to simply not work for a hospital or hospital system rather than take a pay cut. There are also issues related to development of therapeutics. Those making the billion $ bets on drug development will put their money somewhere else (other than healthcare innovation) if there isn't a market. If you get a disease in 20 years, and there is a $50 billion annual treatment pool, the probability that care will be better is much higher than if there is a $5 billion annual pool. Another major issue is the implicit assumption that insurance companies are bad at negotiating prices for medical goods and services but technocrats in Washington DC would be wise and fair. Big assumption.
If we can be adults, we should also concede that a major way that Canada and countries in Western Europe keep prices down is by health care rationing. There are long waits for specialized care in Canada and in the UK there are 5 million people on waitlists in a population of 70 million. Healthy people want cheap insurance. Sick people want care.
Anyways, despite M4A being both the idée fixe and core ideological mantra of a generation it has been relatively unexamined. At some point its enthusiasts will have to defend it in more detail. The discussion of this issue eventually has to go beyond Bernie Sanders stomping his feet and pointing at Canada.
I think that M4A is really just a stand-in for "Something where the government provides enough funding to make sure everyone has good-enough health care." The specifics don't matter (and I don't have too many quibbles with yours, except perhaps your arguments about innovation).
I'm more or less down with that approach--that is, make a moral argument that we need something better and then hammer out the details. But by most metrics our health care here is TERRIBLE. We need something a lot better than what we have.
The problem--well, _a_ problem--is that we've painted ourselves into such a corner on health care that any new change is going to make things much much worse before it makes things better. We've hit a local maximum and we're going to have to go down before we go up again. That's the truth that no one seems willing to look in the eye.
I think if we just expanded Medicaid again modestly it would provide a pretty good safety net, could get us close to universal coverage, wouldn't break the bank, wouldn't throw the baby out with bathwater in terms of benefits of a market system, and would be minimally disruptive.
Yeah, I think the financing has to get figured out. The red states, particularly in the South, have reason to be anxious: they are generally poorer so there will have to be more redistribution to make it viable.
Gallup has done polling on medical care for years. A sizable majority of US'ians are happy with their health care coverage. The big dip? When Obamacare was enacted.
Same polls also say that a majority are very worried about costs! Many, many people know that they are at risk, at any moment, for the kind of medical lightning bolt that could lead them to medical bankruptcy.
Most people get pretty decent coverage. But the cost is just insane.
Yeah, but for the insured most of the cost is borne by the insurer. Plus
1) The danger with "medical" bankruptcies is overstating the correlation between medical debts and bankruptcy. Yes, people who declare bankruptcy often have medical bills but they also often have other sizable debts as well. The key distinction is between medical debt as the sole driver of bankruptcy versus one more straw on the proverbial camel's back.
2) Any concerns about potential costs still don't bring those Gallup numbers down to 50%.
I think this is it. True medical bankruptcies are rare. Although there are exceptions, if you are going into bankruptcy in the setting of $5k or even $10k of medical debt it is almost certainly because you are not working and there are general benefits from bankruptcy well beyond medical debt.
2) My point was that if you ask if someone is "happy" about something in general that to my mind that means adding up all the pluses and minuses and then evaluating on the sum.
Yeah, Megan McArdle did a great piece on Elizabeth Warren's medical bankruptcy research. I'm not inured to the disruption that medical bills can impose the uninsured but the data suggesting that true medical bankruptcies are common seems very weak.
Psychiatric care is a big exception to this. Most psychiatrists are not in a health care network and even when they are, reimbursement is a fraction of bills and patients are expected to cover the difference.
I spend a small fortune each year on my psychiatric care and am glad that I can afford to do so.
I live in Switzerland. It is actually quite easy to explain how the Swiss provide universal coverage:
1. There is no public insurance or insurance through employment. Everyone must purchase basic insurance, which covers everything—not just doctor visits and hospitalization, but also prescription drugs, physical therapy, drug treatment, psychiatric care, etc.
2. By law insurance companies are nonprofits and are only permitted to ask your age and sex when quoting prospective customers the price of a policy.
3. There is a free and easy-to-use site to compare plans.
4. Any healthcare costs above 9 percent of net income are paid for by the government.
That’s it. It’s simple, and Switzerland is able to provide significantly better care to its entire population (including foreigners like me) at half what it costs in the US.
It's also worth noting that Europeans are able to purchase drugs, devices, technology, etc. at a lower price because most medical innovation is developed and priced for the US market.
So, the per capita cost differentials are in part due to the US paying full freight for innovation while Europe gets a major discount rather than European models being 'more efficient.'
What's the difference between a bullet and a VA nurse? A bullet can draw blood. A bullet can only kill one soldier at a time. And you can fire a bullet. Nyuk nyuk nyuk.
With M4A the hospitals are mostly independent non-profits like they are now. With VA care the hospitals are owned and run by the government.
" There are long waits for specialized care in Canada and in the UK there are 5 million people on waitlists in a population of 70 million."
At least in the UK you can buy inexpensive supplemental insurance (50/month) that lets you go to the front of the line, get the latest drugs, etc.. The vast majority of people don't bother. If it was as big of a problem as some in the US think it is more people would opt for the supplemental insurance.
I don't think it's fair to say that single-payer health care has been "unexamined." There have been scholars and advocates looking at it for some time. Plenty of studies have studied its effects. The reason it's so appealing in the U.S. context is the absolute bloat and waste that's *currently a feature* of the U.S. system as a direct consequence of the private insurance industry.
From Reuters in 2020: More than a third of U.S. healthcare costs go to bureaucracy
From Health Affairs in 2020: How Administrative Spending Contributes To Excess US Health Spending
"In the research literature, “administrative spending” is defined in many ways, but it almost always includes billing and insurance-related costs, as well as other program and practice overhead... In 2018 testimony before the US Senate Health, Education, Labor, and Pensions Committee, council member David Cutler of Harvard University cited a range of estimates that place administrative spending at 15 percent to 30 percent of total health spending—three times what the United States spends on cancer care every year." https://www.healthaffairs.org/do/10.1377/hblog20200218.375060/full/
From the Center for American Progress: Excess Administrative Costs Burden the U.S. Health Care System
You get the idea. The insurance industry is vast, complex, almost unbelievably expensive, and ultimately benefits almost no one except for its shareholders. It's a Gordian knot, and abolishing it in favor of a single-payer system is the clearest way to slice through it. Maybe there's some kind of tinkering around the edges that could get us universal coverage, but the ACA tried that, and its core component, the individual mandate, got struck down by the courts. The ACA's greatest successes came from Medicaid expansion, not making the private insurance market better.
A few other scattered points:
1)Current Medicare reimbursement rates don't necessarily reflect what reimbursement would be under Medicare For All. And, by getting rid of the need for huge billing departments, it may actually improve hospital finances. Again, Health Affairs: https://www.healthaffairs.org/do/10.1377/hblog20191205.239679/full/
2) While it's true that most European countries rely on mixed public/private insurers, the "private" companies are often smaller non-profits. Using Germany as an example, as its often cited as a model for the U.S., the private "sickness funds" are nonprofits; only about 11% of the population uses private insurance.
3) We also currently have "health care rationing" in the United States — care is rationed based on who is insured, how they're insured, and who is not insured. Yale recently issued a study that found people with high deductibles are less likely to go to the ER even for something as severe as chest pain: https://twitter.com/YaleSPH/status/1412497371255160832 (This is to say nothing of the UNinsured.)
4) I don't think it's unfair to say that a single-payer "Medicare for All" system would have problems and issues. But could it really be worse than the current system, which costs more than any other, with worse outcomes? Tens of thousands of deaths a year are caused by lack of insurance. Even among those who have insurance, high deductibles can cause stress and financial strain.
Dependent on what model? Excess mortality attributed to lack of insurance coverage and access to care is pretty well documented in the United States.
"Researchers at Harvard Medical School and the City University of New York’s Hunter College analysed federal surveys on health insurance coverage. They found that the number of uninsured Americans increased by roughly 2.3 million between 2016 and 2019 – resulting in as many as 25,180 deaths before the COVID-19 pandemic hit the country."
"Based on the ACS coverage data, we estimate that between 3,399 and 10,147 excess deaths among non-elderly US adults may have occurred over the 2017-2019 time period due to coverage losses during these years."
"The findings suggest that lack of health insurance is correlated with hospital mortality in patients hospitalized with disease and disorders of nervous system, with an increased disparity in vulnerable populations."
I was going to dig up some citations but you yourself posted up a study with a low range of 3,399. In a country of 320 million people that number is effectively zero.
That's a low range of deaths of non-elderly adults attributable to *loss of coverage* in a narrow window. It's not an estimate of total deaths due to general lack of coverage. It also notes: "These figures do not completely capture the population effects of coverage loss, as they exclude the excess deaths that would likely result from coverage losses among children. In 2020 and beyond, we can project even more loss of life if, as expected, millions more lose health coverage due to the economic downturn associated with the pandemic."
Anyway, I still believe that ANY number of excess deaths caused by lack of insurance coverage is unacceptable when an alternative system is possible. And anyway, focusing narrowly on deaths from lack of insurance coverage misses the forest of *all the other bullshit that's wrong with the U.S. system.*
1. We're not seriously going to debate the existence of studies that show almost no impact from health insurance on outcomes versus the validity of those studies, right?
2. The problem with an argument about any number of excess deaths has been rehashed ad nauseum. When you say "any number" do you mean that literally? Would one truly be unacceptable? 12? 25? And what if the cost to prevent each death was on the order of say $1 trillion?
Are NHS waitlists acceptable? Not reading cancer scans for weeks. Poor cancer outcomes even when diagnosed in a timely manner. Blindness because patients aren't being seen in a timely way for glaucoma. 5.3 million on wait lists.
I have a family member who has been the public health director of a county for a couple decades. All of the care they provide at clinics is free, although the volume is down 50% since Obamacare.
A sizable proportion of the Medicaid expansion represents insurance for people who were receiving healthcare without having insurance. I not saying the Medicaid expansion isn't an improvement, but it also replaced some things that were already there.
Also, let's say you a heart attack and are taken to a hospital without insurance. You will receive care and, statistically, better care on average than in the UK or Canada.
Yeah, I understand the rhetorical framework which boils down to: health care administration in the US is expensive and the government could do it much more cheaply and efficiently.
Basically this is an argument that you don't need the market to negotiate prices and that optimal amounts of health care can be created via centralized price setting. This argument, not incidentally, is made primarily by those who seek to have administrative control over the endeavor.
There are a number of aspects of the modeling that I find suspect and overstated. For example, 'administrative costs' conflate a lot of different things including provider insurance, provider documentation, and the actual management structure of hospitals. Much of this wouldn't go away with universal Medicare. The actual medical billers providing documentation for insurance companies are not that expensive, make $40k-$50k a year, and are a very small part of hospital staff. Academic medical centers (much less hospital systems) are large and complex and require a lot of management. We're going to just do away with the majority of the administrative framework of hospital systems, presuming that the bureaucracy is just there to process payments and doesn't do much else? Remember that Canada doesn't have research or clinical hospitals that are on par with a Cleveland Clinic or Hopkins or the Harvard system.
Another major fault with this argumentation has to do with eliding health care and health insurance.
Health insurance is a financial product. Health care is a commodity. You can have health insurance but not be able to access health care (because it is rationed) and vice versa. In the UK you can have health insurance but be on a waiting list for years for necessary treatment. In Canada, patients with chronic conditions who aren't getting specialized health care (they are in the interminable queue) flood the emergency departments on the weekend - talk to an ED doctor in Canada. I have family in Canada who sang the praises of the system when they were younger and only accessed primary care. Now that they are older and need specialized care, the health system is a nightmare. The US system has significant problems, but it also has advantages. Just because someone doesn't have insurance doesn't mean that they can't get healthcare. The network of charity and state and local health care for the uninsured has been subsumed to a significant degree by the Medicaid expansion but it is still present. All that said, let's get to the bottom line: what percent of Americans don't have health insurance? 8%? That is the about same percent of the UK population that is on waitlists for care (5/70 million). So 8% of Americans don't have health insurance; reduce that percentage to those who actually need care for a specific problem, then further subtract charity care. You can make a good argument that a larger proportion of the population in the US has access to needed health care than than in the UK or Canada.
A couple other quick points. First, Canadian health care spending is artificially low because of the US market. The US pays for drugs, devices, and technology at a market rate. That market allows Canada to access similar resources at a much lower price. If we divested healthcare innovation and started paying 'Canadian rates' there is no larger market that would in turn subsidize us. There is no way of getting around the fact that entry costs for new therapeutics is high.
Another issue is outcomes: The US has higher murder rates, car accident rates, obesity rates, and a large number of other factors that contribute to outcomes that aren't directly connected to the healthcare system. The question is how much variance do expect a good versus bad healthcare system to account for? In a multivariable model, probably only a modest amount. When you start comparing the US to Europe and Canada in terms of staged cancer diagnoses or acute myocardial infarction, standardized scenarios where health systems do account for a lot of variance, the US does very well.
To loop back around again, I don't think the government in the US is as bad as many Americans think it is. I also don't think the Canadian government is as good as many Canadians think it is. But even in societies where governance is much better than the US (Germany, Switzerland, most of Scandinavia, etc.) there isn't centralized healthcare price setting and single payer. Most countries used a decentralized framework with some degree of market influence. The theoretical benefits of using a Canadian model which isn't used much elsewhere and which is possible only because Canada is an appendage to the US market are oversold.
Finally, regarding Obamacare, it's obvious why the individual mandate didn't work (it didn't have teeth). But Medicaid expansion did work and shrunk the number of uninsured dramatically. Medicaid could be modestly expanded to provide near-universal insurance with minimal disruption. The technocrats enthusiastic to put our health care system under federal discipline need to make a much stronger case than they have.
We live in a time of miracles. Hep C can be cured. New generations of HIV treatment provide better control with fewer side effects. Biologics have led to dramatically improved outcomes for autoimmune diseases like IBD and MS. Operational improvement has led to dramatically reduced morbidity and mortality from acute coronary disease. A range of new treatment modalities have improved cancer outcomes. Biotech solved COVID within a year. Yet... what exactly?
I am middle aged and am astounded by the pace of therapeutic innovations I have seen in my lifetime. OK, how to socialize the cost of these innovations in care has not been optimized. Fine. That can be worked on.
But that is not the main issue; the main issue is an elision of personal disappointments and the cultural and spiritual shortcomings of our culture with a critique of medicine and technology. You are free to confuse the issues, but I don't think it will do you any good. Healthcare and therapeutics are progressing as they should
I'm impressed by how Freddie was able to get close to the implications of radical liberal thought. The implications are contradictory, pessimistic, and confusing. I hadn't thought about it until reading this piece, but, as Freddie says, a whole lot of liberal thought is premised on "we need to get lucky in one really specific way, and anything that reduces the likelihood of getting lucky in that exact way is very bad."
Hit "post" too quickly, but was going to add that Freddie is also correct in that putting all your eggs in that "get lucky in one hyperspecific and unlikely way" basket is a bad strategy... if you imagine that strategy as applied to anything else, from Nasim Taleb-style capitalist disaster preparedness, to sports, to republican or even centrist political strategy... it raises the question, what is it about left-liberal politics that makes it such a good idea to gamble on a highly unlikely and hyper-specific scenario?
Because organizing is a) too much work, and b) gets in the way of effectively hating the people who need to be organized and thinking of them as racist bumpkins. Also, the left in politics is dominated by the professional-managerial class who think that the main solutions should be technocratic instead of getting one's hands dirty.
Sure, but when are these awesome DSA types going to get their hands dirty and convince some Republican voters in the Midwest? It always rankles me as a Midwesterner when Brooklyn leftists tell us we're being unnecessarily mean to our neighbors. Again, I invite the Brooklyn leftist to move down here - Midwest is a great place to live, you could even afford to buy a house or not choke on rent. But please, come down here and try your hands at progressive organizing. I'd love to see it. Prove your point.
I’ll forgive you for not knowing my backstory. But I’m a union organizer in northern Minnesota. So I may get a little touchy.
We’ve got a bunch of DSA people on staff (I am not one, to be fair) and are trying—fitfully, to be sure—to figure out how to do exactly what you’re saying while staying true to progressive values. It’s hard, because people are still clinging to the performative parts of the progressive agenda and can’t figure out how to do that while reaching out to the rapidly reddening folk of rural Minnesota.
At any rate, it’s happening here too. You just have to know where to look.
(Starts reading) I wonder if I should post that the Emerging Democratic Majority stuff is bullshit.
(Continues reading) Never mind.
Two observations though: I don't really think that the conflict between the two parties is genuinely predicated on racial issues given that it's really a conflict between two rival factions of the white middle/upper class. That said I am hopeful that a migration of working class blacks and Hispanics into the GOP shreds the illusion even further compared to 2020.
As for Trump kicking the bucket, he's 3 years younger than Biden.
He just embarked on another series of campaign rallies in places like Florida and Ohio and as far as I can tell he hasn't deteriorated appreciably. Plus Biden to me looks frail: a cheat sheet with photos of the friendly reporters he was supposed to call on for his press conference?
I lean towards Trump making it to 2024 and campaigning again. I am far less bullish about Biden either a) making it that long or b) deciding that he is going to run again.
Let me clarify: if somebody is a conservative black or Hispanic, and they are voting Democrat right now, then the country as a whole would actually benefit if they switched to the GOP. How could that not be the case? For one thing it would probably reduce racial polarization between the two parties.
I watch a lot of MSNBC in the evenings (don't ask me why). It's incredible how often the entire A-block on these shows is 1) January 6th, and 2) Corruption in the Trump administration.
I'm not saying those things should never be covered, but at this point shouldn't it be like a D-block update? You can watch an hour of MSNBC and not learn anything about what is happening in the present day, night after night.
It's SO WEIRD. I can understand covering Trump if they think Trump=ratings. But they don't even cover recent news about Trump very often. It's all about his administration and the riot. I've never seen an entire news network focus so heavily on the past, night after night, 6+ months after any of those events occurred.
And they don't even explain why. It's just, "Good evening, thanks for joining us. How close did America come to the worst case scenario on January 6th...."
I hope Chris Hayes writes a memoir one day about what this time was like. He started as a lefty, activist, internet nerd type guy, and I still enjoy his podcast. But the incentives confronting his cable show seem really perverse. Or maybe he believes this is what we need every night, I don't know.
"I hope Chris Hayes writes a memoir one day about what this time was like. He started as a lefty, activist, internet nerd type guy, and I still enjoy his podcast. But the incentives confronting his cable show seem really perverse. Or maybe he believes this is what we need every night, I don't know."
I constantly debate writing a piece about him specifically because it's such an obvious and tragic case, but no one would read it in good faith because I'm me and it would be ignored. But somebody should write it. He was at least smart and perceptive and self-critical and he has become the saddest self-parody of an MSNBC man I can imagine. And he clearly has no idea.
Agreed. I would enjoy the piece. About MSNBC generally, a lot of what plagues the network seems to be caused by Rachel Maddow's ratings success compared to all the other primetime shows. I understand why they try to emulate her, but even her fans will not watch three hours of January 6th coverage every night for seven months. Rachel already repeats herself A LOT, within the hour and from day to day.
I think plenty of other concepts could work in primetime, but they'd need to be willing to start from zero and grow an audience rather than trying to cling to the viewers who have been dropping off since Biden got elected. Those viewers aren't appealing to advertisers anyway because they're very old.
I think there is a question of 'what MSNBC is trying to be'. If it's supposed to be the left-wing equivalent of Fox News, operating essentially as the media wing of the Democratic party, I'm not sure covering 1/6 and Trump is a bad decision. Those are things where the average American sides with the Democratic party and subjects that rile up the base. They should cover Trump for the same reason Fox News covers Clinton.
The problem is that I don't think there's a huge market for this kind of thing. But I'm not sure there'd be a huge market for 'a left wing cable network, but good' either though. 'MSNBC sucks' is not a pressing problem for most politically active people I know because they watch little to no cable television.
I suppose "big government" might work in Heaven. But everyone there's an angel and God is benevolent. The danger is in thinking we can replicate this on earth when neither are the case.
Both sides peddle their myths. The "right" is at least offers the individual a vision which is aspirational, something the DSA, etc can not.
I mean, I don't have a plan as well-developed as yours, which is to yell at me for being insufficiently devoted to Democrats in the comments of every post. But in my defense I did write a whole book, a third of which is my plan, Mark.
I did not read the book, but as I understand it the plan is a policy proposal, whereas "plan" as you use it in the title of this piece seems to mean how to get policies implemented, not just proposed.
I think the American left should build more and better institutions that can work within local communities and build our constituency, which allows us both to do small-scale activism and achieve positive change that way, while also building up a base in electoral politics such as through city council, school board, and local representative elections, which I've acknowledged will probably run through the Democratic party. I've expressed some version of that many times.
Sure, that's all fine. It's just really really slow. Meanwhile, if you want something like the child tax credit to become law in the next few months (rather than say a few decades), sniping at liberals (who worked hard to elect Democrats who would actually vote for the child tax credit) has no value that I can see.
But I don't understand how far this goes. I think liberal Democrats could do a better job at being liberal Democrats so I write posts like this one. Should I hold my nose and not write this stuff because they're kind of on my side? Doesn't seem like a very democratic attitude to me.
This is a bit unfair. Look at the paragraph about the child tax credit. Freddie notes that this pretty ambitious plan of redistribution pleased - didn't delight, but pleased - both the liberals and the DSs. And it will also be very popular with the country. Therefore someone like Freddie will say that it's still commodifying lives and livelihoods so it's not perfect, and Ezra Klein will say something boring and stupid about deficits, but both of them will ultimately prefer it to nothing because it improves the lives of regular families and shows them that redistribution can be fair and can work. Recognition of this is, itself, a plan - that a lot of the mutual sniping and fighting online can be rendered moot by actual redistributive policy.
And per his remark about his book - blank slate cognitive equality being a complete bust, Freddie posits an economic model that vastly reduces the connection between smarts and wealth, which would itself be radically redistributive.
It doesn't matter if both liberals and DSs like the child tax credit if it doesn't become law. And it will only become law if enough people in Congress vote for it.
I think Freddie might be oversimplifying the center-left consensus a little. It's not really "working-class whites are racist and the Senate is biased, therefore let's moderate our stances across the board". What they're proposing is to analyze public opinion on more than one dimension.
Working-class white voters tend to lean right on some issue categories, like race and immigration, while leaning left on others, like public spending. The approach Chait, Yglesias et al. have been pushing for the Dems is to talk more about public spending and less about anti-racism, and in particular not to try and *sell* public spending by calling it anti-racism. I think that fits pretty well with Freddie's own view of the relationship between race and class.
Trump dead in 18 months (or within 5 years as one of your other posts suggests)? Really? Dude seems almost invincible to me. He shrugged off COVID fairly easily. His level of energy for someone his age is astounding.
Yeah, I think it is something very close to denialism to automatically discount the possibility of a Trump/Biden or Trump/Harris or Trump/whoever rematch in 2024.
Part of it is I think an unconscious recognition that if not for Covid Trump would have probably cruised to victory, along with some other unpleasant realities.
I've been struggling with this as well (as one of the liberal Democrats who has moved towards social democracy), mostly with my friends who fit to a tee the strategic description Freddie offers ("Earn a razor-thin majority, pass laws favoring your party, and hope nothing bad happens"). I think this is a ridiculous strategy, Freddie's optimism above aside: the bad blood from 2016 represents a real urban-rural divide that is as polarized as it's been since the Civil War, and in a couple years (when the Democrats likely lose the House in 2022) we are going to see individual states literally defy duly enacted executive decisions. Future shock and what I guess people call "late-stage capitalism" are driving us into incredibly intense partisanship that's not going away.
So I agree (to an extent) with the Democrats' diagnosis, but not their solution. WTF should MY plan be?
This is where working in the labor field helps. To me, even though I'm not a Marxist, the answer remains organizing: not the stupid progressive self-devouring organizing, but deep community-building organizing that brings people who disagree together. (In other words, I firmly disagree with the third "plank" Freddie describes. I don't have any broad policy goals--politics can go ahead and do its thing, and I'll vote for people who are likeliest to push my preferred policies, but it's not going to help much until we do the work of rebuilding communities. So I believe in community organizing and also in rebuilding the fabric of communities: reworking the infrastructure of cities and towns and rebuilding institutions at the local level to foster interaction instead of isolation.
It's probably also a doomed approach, but hell, at least it gives me something to do.
Almost-communist socialists: public spending should be 50% of GDP.
Far-right conservatives: public spending should be 40% of GDP.
Beyond this difference everything else is culture war performance art.
that was roller coaster ride thru logic and argument. totally agree on the multi-racial aspect, and in fact write about it in one of my first posts here
https://riclexel.substack.com/p/multi-racial-in-america
I was surprised to learn that most adults with a background that includes more than one race do not consider themselves “multiracial.”
(https://www.pewresearch.org/social-trends/2015/06/11/multiracial-in-america/)
so that makes sense that they would consider themselves white and vote accordingly. However, most of my friends are in mixed-raced marriages, and have bi-racial kids. It is more rare for me to see couples of the same race then mixed now. And it makes logical sense that they vote across the board. I know several couples of white husband and Hispanic wife that both voted for trump.
disagree strongly on the tax thing. we make less than $100K a year, and trumps tax cuts saved us $4k a year in taxes.
great post again!
Ric
Lol TFW ‘socialism’ is literally neoliberalism. Denmark is literally neoliberal.
tbh I think if you look at what actual people say they want, the picture is nowhere near as bleak--for the country, at least. The parties are a different story. But in policy polling, for many things, you see a convergence in interests for both self-identified conservatives and self-identified liberals: they want healthcare to be cheaper; they are leery of the monopolistic power of Amazon, Apple, Google, etc, and think they ought to be curbed; they dislike the power that the NSA has; they dislike the increase in crime and want workable solutions to crime and drug addiction; they want police reform to better align police interests with public interests; they want kids to receive a good, well-balanced education; they want housing to be reined in. They don't always agree on the exact ways these things should be accomplished, but they are willing to compromise and hear what others have to say. There seems--at least to me--to be a huge space in which compromise and cooperation is perfectly possible.
Some politicians are moving into this space (which seem to me to very typical moderate Democrat spaces, or at least would have been twenty years ago) to great success. Once you get away from twitter and avowed partisans, people are sick of both parties. They're sick of the grandstanding. They're sick of the hypocrisy. They're sick of the corruption. Any politician who can pick up on that and align themself to the forming majority consensus could be very successful. Hell, this is arguably what propelled Trump into office (against, it should be remembered, the explicit wishes of the Republican party) and led him to gain more votes in 2020 than he did in 2016 (even after he proved a poor politician and presided over a devastating plague). Trump was wildly successful despite truly sucking; anyone who can actually play the game and get stuff done should be nigh untouchable.
I don't think this is borne out by the evidence. Negative polarization is currently a huge problem, according to polling: people don't like their party, but they HATE the other party. And it doesn't really have to do with policy, much: it's much more affective than issue-based. In other words, this convergence of issues doesn't matter... Democrats will hate Republicans and vice versa even where they agree.
Here's a nice link on the issue. Remember that two-thirds of America, more or less, declare a party affiliation, and that most independents end up being fairly consistently partisan:
https://www.annualreviews.org/doi/full/10.1146/annurev-polisci-051117-073034
Trump, I would say, did not win by entering the moderate space: he won by leaning on the partisanship and seeing the other party as the enemy, and he earned 75 million votes or whatever by doing the same thing throughout his presidency.
"People don't like their party, but they HATE the other party."
That's kind of what I was getting at: people are unhappy with their choices, and if someone can finally get a viable third-party going that touts these easy consensus topics, that might be very successful. Now, there's a lot of monied interests and corporate media and such aligned against this happening, and third parties are difficult to build to begin with, but if it could happen...it might do well. A radical realignment of one or both parties (which is kinda already underway) might have similar effects.
And it's just anecdotes, but for the all the polarization talk, I've been amazed at how easy it is to sit down with people and get them to agree with things. I've talked with life-long Republicans, both Trump supporters and not. I've talked with life-long Dems who voted for Trump and life-long Dems who would beat him to death with a golf club given the opportunity. I've talked with people who hate politics in general. And it is really easy, on a decent selection of topics, to have a conversation where people quickly come to a comprised consensus about what would be a good hypothetical path forward.
"That's kind of what I was getting at: people are unhappy with their choices, and if someone can finally get a viable third-party going that touts these easy consensus topics, that might be very successful."
But this has been the dream for, what, forty years? The structural disadvantages don't help--understatement there--but I don't think it's what people actually want. Everyone says, for example, they don't like negative campaigning, but guess what does the best job of turning out your base? Negative campaigning. People want and need an enemy--especially now.
Don't get me wrong, I truly believe that we need depolarization. I'm literally a member of an organization that's working on just that. (check out Braver Angels!) But I don't think the answer to doing that is a party offering a thin gruel of non-controversial fixes, because that's not where the conflict is. The conflict is that most people on one side think that the other side opposes their fundamental values. The situation right now is a values conflict, not an issues conflict, and the route to resolving it is not offering an alternative group to belong to, but getting the two sides to stop despising each other quite so much.
I absolutely agree that the conflict now is primarily a cultural one. That said, why is politics so heated in that case? The cultural conflict is expressing itself in the political sphere and both parties are eager to exploit it in order to turn out votes.
I do think there are structural reasons for this. Our Constitutional structure leaves us with so many veto points that playing zero-sum politics is a lot easier here than in, say, a parliamentary democracy. Thus, there are political incentives for polarization that don’t exist elsewhere. It’s the nature of being a beta test for republican democracy.
I would argue that it has gotten a lot worse over the last 30 years though.
Could not agree more.
maybe it's too early in the morning for me, but I found a lot of this confusing. I'm a new reader of your stuff, so I guess there are some underlying assumptions and such that I'm not aware of. For example, is Chris Hayes (and pundits in general) supposed to be a political actor in this? Like do you take what he says as having an effect on politics, or is it a more downstream expression of other people's effect on politics? It seems there is a notion that this rhetorical sphere is the main venue for politics (Matt Yglesias says this, people on twitter say that, etc). Discourse in the form of TV, posts, and books seems more like corporate entertainment to me and about as interesting politically as the local news, but maybe you have a deep read on that? This whole post kinda feels like a TV re-cap from my perspective
Also, gay marriage as a left issue? Is the basic rhetorical assumption that if people call it a left issue it becomes one? Or is it that correlation (people who are politically left generally are pro gay marriage) indicates a deeper relation?
maybe I need some coffee cuz I didn't really get what a lot of the references to 'left' 'liberal' and 'democrat' were functioning as here
"is Chris Hayes (and pundits in general) supposed to be a political actor in this"
"It seems there is a notion that this rhetorical sphere is the main venue for politics (Matt Yglesias says this, people on twitter say that, etc). Discourse in the form of TV, posts, and books seems more like corporate entertainment to me and about as interesting politically as the local news, but maybe you have a deep read on that?"
People should say things that are true and good rather than things that are untrue and bad, especially if they have large audiences, as these people do
"Also, gay marriage as a left issue?"
Gay marriage has been a left issue as long as it has been an issue, so I think this is a you thing.
Have you read 'against equality'? That's kinda more the perspective that I'm coming from, so I would agree that gay marriage is a left issue only in a surface extensional way (ie, people who think X also often think Y), but if we're trying to really figure things out, it's not (or at least it's not obvious and the case needs to be made).
I mean, look, I am aware of left arguments that gay marriage is conservatizing, and right arguments that gay marriage is really a way to expand traditionalist norms, and I think they're interesting. But I don't see the utility of denying that by every conventional standard gay marriage has been associated with the left-of-center since it became a mass political issue in the last 25ish years. People who are more left are dramatically more likely to support gay marriage than people who are more right, even after all of the general leftward direction in this issue.
that's fair, it's also what I noted above, it's a "correlational" view of this stuff which I think is a kinda notable approach to defining things like 'left' and the source of I think some of my confusion in reading your post today. I kept asking myself "does he mean by this word just the common surface unreflected upon meaning of this word or is he staking real claims here". I guess it was the first one
"People should say things that are true and good rather than things that are untrue and bad, especially if they have large audiences, as these people do"
I think I disagree with a load of stances that I suspect are behind this sort of response and I would love to see them spelled out (not in the comments necessarily, just wishing for a future post). I think your apparent opinion that this stuff is real adult discourse with real consequences and not silly/pernicious corporate distractions is interesting, cuz I disagree with it and it seems like it paints and shapes so much of what you write
For perhaps a majority of normal people, who work full time and raise kids, these pundits are where they are getting their political news and their political opinions made. That is why it matters, whether their discourse is "adult" or not.
I think this type of reasoning is not all that different from saying: we should really pay close attention and treat as important what is trending on twitter, because that's what shapes the discourse that pundits are swimming in
I'm personally tired of caring what in particular minutia the chattering class says. I don't doubt that people can convince themselves to fret about it and parse it closely, but I think it's kinda deluded or a trap
I think all manner of propaganda influences people's political opinions and what I take issue with is treating the effect of, say, Chris Hayes as somehow essentially different from the effect the ads that play on during his show.
As long as mass media exists, they are culture makers. And what they accept as paid ads on their show is part of their culture-making. Which is how we've ended up with conservatives who place faith in essential oils and supplements, and liberals who don't believe in vaccination, or LeBron James speaking up for China.
I'm not arguing that these people are serious thinkers, or serious at all. I'm arguing that what they broadcast is widely influential, and that is a serious issue itself.
I don't think I disagree all that much on what you're saying here. I draw my own personal line on this notion that I have to pay attention to what TV pundits say, spectator like
Gay marriage was also championed by conservative figures like Andrew Sullivan, who was making an argument for it decades before it happened. Hayes is a self-described "red diaper baby" so I guess the argument is that Hayes is a sellout because he isn't preaching socialism every night. His last big anti-establishment rant was in defense of the lady who lied about Biden harassing her. Her claims, when scrutinized, fell apart in a humiliating manner (I'm glad they were fully aired and investigated). But yeah, that was his big tearful on air moment and it was totally embarrassing.
That was great and very informative. There are also bipartisan taboo themes though.
Much reported, including Ed Snowden "Topic of this year - Pegasus", is disclosure of continuous over time surveillance ability of all smart-phones of all conversations and pin-point location-accuracy even when phone is turned off.
Therefore, certainly many governments (certainly of Israel and the US) know EXACTLY and for ALL Epstein's associates and "guests" -- who, when, where, how long, and why they were with pedophile Epstein !!
Yet we still don't know, after all this time, for example, even what Epstein's multiple passports show. As courageous Eric Weinstein stated -- Epstein was "a construct" - by one or more intelligence services.
No, not all smartphones are being tracked all the time. It is possible to do so and maybe even likely that all of Epstein's associates were being tracked, but peons like you and me don't have that much to worry about.
hmm - you are very decisive on meta-data collection.
Ed Snowden is much less so.
Certainly, the Israeli government has a huge responsibility here -- the buck stops there but -- all the blame and protection is --- on Huawei.
Are you talking ONLY about "Pegasus" spyware? Pegasus is spyware developed by the Israeli cyberarms firm NSO Group that can be covertly installed on mobile phones (and other devices) running most[1] versions of iOS and Android.
Yes I mean Pegasus spyware, or a similar level of information gathering.
I am aware of Snowden's metadata claims and believe him. I read Dark Mirror by Barton Gellman, a thoroughly terrifying experience.
"The socialist alternative is that money no longer determines the provisioning of medical care"
I'm not sure what you mean. We'd still need to determine what percentage of GDP we're going to allocate to healthcare. So "money" would still play a huge role. Or do you just mean money at the point of service?
I mean that a truly socialized economy has no GDP to measure. This is kind of the point: even people who are conversant in socialist vocabulary or are actively associated with socialism as a goal have transformed socialism in their minds to "the government pays for stuff." Under a socialist system in the traditionalist sense, the ruling body says to a doctor "give this person medicine," and medicine is given, and no currency changes hands between anyone in the process - indeed, there is no currency to exchange.
"I mean that a truly socialized economy has no GDP to measure."
There is the current capacity to provide goods and services so GDP.
"Under a socialist system in the traditionalist sense, the ruling body says to a doctor "give this person medicine," and medicine is given, and no currency changes hands between anyone in the process - indeed, there is no currency to exchange."
But you couldn't command GE to give everyone a home MRI machine because the economy wouldn't have the ability to produce that volume of large manufactured items. GDP would be your limiting factor. That would hold true for anything.
But you see the point - you're making the argument against a certain old-school definition of socialism. I'm saying that the kids these days don't know that that was what was once frequently meant by socialism, a command economy. The most far out thing they can envision is a mild market socialism. And my point is that this is a victory for the liberals.
What would a victory for true socialists look like? Is there even a theoretical framework by which those arguments come back into vogue? Aren't we just arguing about which gradation of welfare-state neoliberalism is best?
Luxury space communism aka a post scarcity society.
"Luxury space communism": what a great term. I'm going to use it in conversation all the time from now on.
Except there are always tradeoffs. There will always be the question of how much resources should be spent on a one in ten million disease or whether a colonoscopy should is needed for a 30 year old. And there are always gonna be people hurt by these tradeoff. No economy has unlimited resources and there's always going to be decisions like this made, even in education and health, and the only way we know of to represent "labor+resources" is by using money. I don't know how else you'd even represent that.
"No economy has unlimited resources"
So far. For all we know luxury space communism is right around the corner.
Meh – even in the most utopian depictions of "luxury space communism" there are still _clear_ limits on all kinds of resources. (Tho maybe they're just 'clear' to me because I'm looking for them!)
One of my favorite examples is from one of The Culture series books where a character is described as being upset because they aren't allowed to experiment with adding (active) volcanoes to a part of a 'space world' on which they live. Another example that's indirectly observable is where people live – not everyone can live where they _most_ want.
One of the explanations for the Fermi is that technology doesn't have to advance that much further for it to be possible to live in a simulation.
https://www.cnn.com/2021/07/15/health/man-speech-implant/index.html
Obviously we're at the very early stages. But take that technology and run with it... And then people can all live where they want and add volcanoes to their worlds, etc.
That's a possibility, but even simulations would require some kind of 'real' physical infrastructure to run them (as long as we're assuming technology short of 'magic').
I'm also pretty skeptical of the feasibility of simulations – especially as a permanent replacement of physical reality. There's a number of macroscopically visible phenomena that are quantum-mechanical in nature. I certainly don't see how even tech way beyond ours could ever support something like a realistic microscope – and if they don't, that seems like a very sadly limited simulation in which to live.
But _maybe_, in a simulated world, it'd be possible to avoid or workaround some limitations, but I suspect that 'people limitations', e.g. wanting to be around other specific people (like friends or family), or around groups of strangers (like at a concert or other public event), would still hold, to at least some degree.
But I'm all for fully automating even current 'luxuries' – to the degree that's possible! I just suspect that 'money' will survive even that.
Right and what would be the signaling mechanism for goods and services? How would this repository of administrative and bureaucratic omniscience be created?
The issue with all command economies is that they presuppose an intelligence that is nearly as efficient as markets and that has never come to fruition.
The five year plans for potatoes and eggs always failed. So now that society is exponentially more complex, what would the plan be exactly?
Furthermore, a command economy political apparatus would be necessary centralized and authoritarian. How many people really want a technocracy administering these decisions? Are we sure this technocratic elite will be fair and wise? What advantage would such a centralized system have compared to a libertarian left system where you get an insurance card, UBI, EBT for food, a housing voucher, etc. and then you decide what healthcare healthcare, food, housing YOU want rather than having it administered to you?
In 2021, entertaining command economics just seems silly. Tell me why I'm wrong.
"The five year plans for potatoes and eggs always failed."
That's not true. The Soviet Union did rapidly industrialize and living standards did increase significantly. It all sort of petered out during the Brezhnev era. And of course China's 5 year plans have been going gangbusters.
Same, I am very interested in seeing Freddie exposit/defend his version of socialism, as he keeps bringing it up obliquely in comments and posts -- for over a decade now! -- but I have yet to actually see him explain it in any context. He obviously isn't an idiot so I'm very, very, very curious how he thinks that a command economy could/should be implemented in America, because it really seems questionable at every level. Is it a symbolic belief? I remember he said a few years ago that he sees his socialism as somehow 'inherited' from his parents/grandparents (as I recall? not sure), so maybe that explains it?
I don't think Freddie expects there to ever be a command economy in the US. Detailing how it would be implemented would be like me describing how I would make love to Kate Upton. Both of our time is probably better spent on what we have influence over.
I think Freddie is a communist who has explained that he does not foresee a communist revolution in the U.S.
Again, this is a debate about the wisdom of that vision of socialism. I am here discussing the fact that the younger generation of socialists/"socialists" have abandoned support for that vision, without even seeming to know that they're doing it, in a way that demonstrates liberal victory.
Beyond even the 'planning fallacy', it occurred to me the other day that there's a kind of 'economic goods nebulosity fallacy' that might, arguably, be even more important – beyond the problem of (successfully) running a command economy for some existing set of goods and services, there's the 'problem' of discovering all of the _potential_ goods and services that might be (more) valuable than what's already being commanded to be produced or provided. It's not _impossible_ that a command economy could do this tho; just much more less likely IMO.
Sounds like the sort of thing a self-improving artificial intelligence could plausibly do well enough....
Maybe!
Do modern command economy proponents talk about this stuff? It's sort of my field so I'd be pretty interested.
Some basic but very important concepts in CS and Machine Learning were developed by mathematicians like Kantorovich to help solve these types of problems. Of course it quickly turned an ideological battle so never got a fair shot. Also, their computers sucked.
Some most. I don't have any citations because 1) there are just very few real command economy proponents left anymore - even a lot of older school ML types avoid the subject more than defend the principle and 2) I very rarely read explicitly communist/radical socialist stuff anymore because I spent too much of my life in sectarian fights and I find the whole enterprise depressing these days.
How would a AI command economy differ from a market economy? Do we want cars to have heated steering wheels or do we want to fund a very marginally superior chemotherapy drug?
> Also, their computers sucked.
It doesn't help that a lot of these problems are basically as hard as possible for any problem to be (as in either mathematically impossible, to at least solve _perfectly_, or arbitrarily difficult to solve even for fairly 'toy' sized instances).
And when it got that good, it would likely decide that humans were superfluous and get rid of them ... haven't you read slatestarcodex/astralcodexten on AI safety???
I'm pretty sure he was assuming the super-intelligence is friendly!
This is so true -- "even people who are conversant in socialist vocabulary or are actively associated with socialism as a goal have transformed socialism in their minds to "the government pays for stuff."
I'm not sure if this is what you meant, but I don't think 'getting rid of money' actually does anything – there still has to be some way (let alone a 'system' with 'rules') by which economic decisions are made, and people's need to weigh possibilities would result in something economically equivalent to 'money' inevitably.
It would be great if, at some point, there was a broader explanation for why the brightest minds of the Left think that M4A is such a 'good idea.'
Single payer is not common. Most European countries have decentralized systems using private insurance more akin to Obamacare with a few exceptions. Canada has single payer, Norway has single payer. Anyone else? The UK's system is more like VA-care for all than M4A.
The primary criticism of M4A is not that it's politically inconvenient. It's that Medicare is not scaleable. That is, if you forced hospitals and providers to just take Medicare payments a lot of hospitals would close and a lot of services wouldn't be provided that are provided now.
You might be able to pay doctors 60 cents on the dollar and cut wages for nurses and respiratory therapists and some other health professionals. But office staff, electricians, engineers, etc. could choose to simply not work for a hospital or hospital system rather than take a pay cut. There are also issues related to development of therapeutics. Those making the billion $ bets on drug development will put their money somewhere else (other than healthcare innovation) if there isn't a market. If you get a disease in 20 years, and there is a $50 billion annual treatment pool, the probability that care will be better is much higher than if there is a $5 billion annual pool. Another major issue is the implicit assumption that insurance companies are bad at negotiating prices for medical goods and services but technocrats in Washington DC would be wise and fair. Big assumption.
If we can be adults, we should also concede that a major way that Canada and countries in Western Europe keep prices down is by health care rationing. There are long waits for specialized care in Canada and in the UK there are 5 million people on waitlists in a population of 70 million. Healthy people want cheap insurance. Sick people want care.
Anyways, despite M4A being both the idée fixe and core ideological mantra of a generation it has been relatively unexamined. At some point its enthusiasts will have to defend it in more detail. The discussion of this issue eventually has to go beyond Bernie Sanders stomping his feet and pointing at Canada.
I think that M4A is really just a stand-in for "Something where the government provides enough funding to make sure everyone has good-enough health care." The specifics don't matter (and I don't have too many quibbles with yours, except perhaps your arguments about innovation).
I'm more or less down with that approach--that is, make a moral argument that we need something better and then hammer out the details. But by most metrics our health care here is TERRIBLE. We need something a lot better than what we have.
The problem--well, _a_ problem--is that we've painted ourselves into such a corner on health care that any new change is going to make things much much worse before it makes things better. We've hit a local maximum and we're going to have to go down before we go up again. That's the truth that no one seems willing to look in the eye.
I think if we just expanded Medicaid again modestly it would provide a pretty good safety net, could get us close to universal coverage, wouldn't break the bank, wouldn't throw the baby out with bathwater in terms of benefits of a market system, and would be minimally disruptive.
Unless you live in a red state, of course. ;)
My preference is probably for a well-subsidized public option overall.
Yeah, I think the financing has to get figured out. The red states, particularly in the South, have reason to be anxious: they are generally poorer so there will have to be more redistribution to make it viable.
Gallup has done polling on medical care for years. A sizable majority of US'ians are happy with their health care coverage. The big dip? When Obamacare was enacted.
Same polls also say that a majority are very worried about costs! Many, many people know that they are at risk, at any moment, for the kind of medical lightning bolt that could lead them to medical bankruptcy.
Most people get pretty decent coverage. But the cost is just insane.
Yeah, but for the insured most of the cost is borne by the insurer. Plus
1) The danger with "medical" bankruptcies is overstating the correlation between medical debts and bankruptcy. Yes, people who declare bankruptcy often have medical bills but they also often have other sizable debts as well. The key distinction is between medical debt as the sole driver of bankruptcy versus one more straw on the proverbial camel's back.
2) Any concerns about potential costs still don't bring those Gallup numbers down to 50%.
I think this is it. True medical bankruptcies are rare. Although there are exceptions, if you are going into bankruptcy in the setting of $5k or even $10k of medical debt it is almost certainly because you are not working and there are general benefits from bankruptcy well beyond medical debt.
1) I mean this in the least assholish way possible; I'd love to see any data you have on medical bankruptcies that foster your point.
2) But I wonder if they are happy with the _coverage,_ as opposed to the cost. The danger of polling.
I also wonder how people feel about their health coverage elsewhere, comparatively.
1) There is obviously a ton of research on this stuff, both pro and con.
https://plusfourinc.com/blog/medical-bankruptcies-may-not-common-thought/
2) My point was that if you ask if someone is "happy" about something in general that to my mind that means adding up all the pluses and minuses and then evaluating on the sum.
Yeah, Megan McArdle did a great piece on Elizabeth Warren's medical bankruptcy research. I'm not inured to the disruption that medical bills can impose the uninsured but the data suggesting that true medical bankruptcies are common seems very weak.
You can read McArdle piece here:
https://www.theatlantic.com/business/archive/2009/06/elizabeth-warren-and-the-terrible-horrible-no-good-very-bad-utterly-misleading-bankruptcy-study/18826/
Psychiatric care is a big exception to this. Most psychiatrists are not in a health care network and even when they are, reimbursement is a fraction of bills and patients are expected to cover the difference.
I spend a small fortune each year on my psychiatric care and am glad that I can afford to do so.
Yes. Poor reimbursements for psychiatric care are a major shortcoming.
Mental health care in this country should be grounds for common agreement between both parties: it's a disaster.
"It would be great if, at some point, there was a broader explanation for why the brightest minds of the Left think that M4A is such a 'good idea.'"
It's a good easy to understand slogan. Walking people through the Dutch or German or Swiss healthcare system just makes people's eyes glaze over.
I live in Switzerland. It is actually quite easy to explain how the Swiss provide universal coverage:
1. There is no public insurance or insurance through employment. Everyone must purchase basic insurance, which covers everything—not just doctor visits and hospitalization, but also prescription drugs, physical therapy, drug treatment, psychiatric care, etc.
2. By law insurance companies are nonprofits and are only permitted to ask your age and sex when quoting prospective customers the price of a policy.
3. There is a free and easy-to-use site to compare plans.
4. Any healthcare costs above 9 percent of net income are paid for by the government.
That’s it. It’s simple, and Switzerland is able to provide significantly better care to its entire population (including foreigners like me) at half what it costs in the US.
Half? No. Switzerland spends 12.2% of GDP while the US spends 17.7%. Otherwise thanks for details!
It's also worth noting that Europeans are able to purchase drugs, devices, technology, etc. at a lower price because most medical innovation is developed and priced for the US market.
So, the per capita cost differentials are in part due to the US paying full freight for innovation while Europe gets a major discount rather than European models being 'more efficient.'
Can you explain the difference between M4A and VA care for all?
What's the difference between a bullet and a VA nurse? A bullet can draw blood. A bullet can only kill one soldier at a time. And you can fire a bullet. Nyuk nyuk nyuk.
With M4A the hospitals are mostly independent non-profits like they are now. With VA care the hospitals are owned and run by the government.
" There are long waits for specialized care in Canada and in the UK there are 5 million people on waitlists in a population of 70 million."
At least in the UK you can buy inexpensive supplemental insurance (50/month) that lets you go to the front of the line, get the latest drugs, etc.. The vast majority of people don't bother. If it was as big of a problem as some in the US think it is more people would opt for the supplemental insurance.
No way around UK has a supply problem with healthcare, tho.
The UK has a for profit healthcare system for those who can afford it.
It certainly does.
I don't think it's fair to say that single-payer health care has been "unexamined." There have been scholars and advocates looking at it for some time. Plenty of studies have studied its effects. The reason it's so appealing in the U.S. context is the absolute bloat and waste that's *currently a feature* of the U.S. system as a direct consequence of the private insurance industry.
From Reuters in 2020: More than a third of U.S. healthcare costs go to bureaucracy
"Over one third of all healthcare costs in the U.S. were due to insurance company overhead and provider time spent on billing, versus about 17% spent on administration in Canada, researchers reported in Annals of Internal Medicine." https://www.reuters.com/article/us-health-costs-administration/more-than-a-third-of-u-s-healthcare-costs-go-to-bureaucracy-idUSKBN1Z5261
From Health Affairs in 2020: How Administrative Spending Contributes To Excess US Health Spending
"In the research literature, “administrative spending” is defined in many ways, but it almost always includes billing and insurance-related costs, as well as other program and practice overhead... In 2018 testimony before the US Senate Health, Education, Labor, and Pensions Committee, council member David Cutler of Harvard University cited a range of estimates that place administrative spending at 15 percent to 30 percent of total health spending—three times what the United States spends on cancer care every year." https://www.healthaffairs.org/do/10.1377/hblog20200218.375060/full/
From the Center for American Progress: Excess Administrative Costs Burden the U.S. Health Care System
"The largest share of [billing and insurance-related] costs is attributable to insurance companies’ profits and overhead and to providers8 where BIR costs include tasks such as record-keeping for claims submission and billing. https://www.americanprogress.org/issues/healthcare/reports/2019/04/08/468302/excess-administrative-costs-burden-u-s-health-care-system/
You get the idea. The insurance industry is vast, complex, almost unbelievably expensive, and ultimately benefits almost no one except for its shareholders. It's a Gordian knot, and abolishing it in favor of a single-payer system is the clearest way to slice through it. Maybe there's some kind of tinkering around the edges that could get us universal coverage, but the ACA tried that, and its core component, the individual mandate, got struck down by the courts. The ACA's greatest successes came from Medicaid expansion, not making the private insurance market better.
A few other scattered points:
1)Current Medicare reimbursement rates don't necessarily reflect what reimbursement would be under Medicare For All. And, by getting rid of the need for huge billing departments, it may actually improve hospital finances. Again, Health Affairs: https://www.healthaffairs.org/do/10.1377/hblog20191205.239679/full/
2) While it's true that most European countries rely on mixed public/private insurers, the "private" companies are often smaller non-profits. Using Germany as an example, as its often cited as a model for the U.S., the private "sickness funds" are nonprofits; only about 11% of the population uses private insurance.
3) We also currently have "health care rationing" in the United States — care is rationed based on who is insured, how they're insured, and who is not insured. Yale recently issued a study that found people with high deductibles are less likely to go to the ER even for something as severe as chest pain: https://twitter.com/YaleSPH/status/1412497371255160832 (This is to say nothing of the UNinsured.)
4) I don't think it's unfair to say that a single-payer "Medicare for All" system would have problems and issues. But could it really be worse than the current system, which costs more than any other, with worse outcomes? Tens of thousands of deaths a year are caused by lack of insurance. Even among those who have insurance, high deductibles can cause stress and financial strain.
How many deaths a year are due to lack of insurance is dependent on the model, and the range of estimates is from essentially zero to thousands.
Dependent on what model? Excess mortality attributed to lack of insurance coverage and access to care is pretty well documented in the United States.
"Researchers at Harvard Medical School and the City University of New York’s Hunter College analysed federal surveys on health insurance coverage. They found that the number of uninsured Americans increased by roughly 2.3 million between 2016 and 2019 – resulting in as many as 25,180 deaths before the COVID-19 pandemic hit the country."
https://www.openaccessgovernment.org/us-health-insurance-coverage/96659/
"Based on the ACS coverage data, we estimate that between 3,399 and 10,147 excess deaths among non-elderly US adults may have occurred over the 2017-2019 time period due to coverage losses during these years."
https://www.healthaffairs.org/do/10.1377/hblog20201027.770793/full/
"The findings suggest that lack of health insurance is correlated with hospital mortality in patients hospitalized with disease and disorders of nervous system, with an increased disparity in vulnerable populations."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935226/
Do we know the exact number? No, but it's a LOT more than "zero," and should therefore be unacceptable.
I was going to dig up some citations but you yourself posted up a study with a low range of 3,399. In a country of 320 million people that number is effectively zero.
That's a low range of deaths of non-elderly adults attributable to *loss of coverage* in a narrow window. It's not an estimate of total deaths due to general lack of coverage. It also notes: "These figures do not completely capture the population effects of coverage loss, as they exclude the excess deaths that would likely result from coverage losses among children. In 2020 and beyond, we can project even more loss of life if, as expected, millions more lose health coverage due to the economic downturn associated with the pandemic."
Anyway, I still believe that ANY number of excess deaths caused by lack of insurance coverage is unacceptable when an alternative system is possible. And anyway, focusing narrowly on deaths from lack of insurance coverage misses the forest of *all the other bullshit that's wrong with the U.S. system.*
1. We're not seriously going to debate the existence of studies that show almost no impact from health insurance on outcomes versus the validity of those studies, right?
2. The problem with an argument about any number of excess deaths has been rehashed ad nauseum. When you say "any number" do you mean that literally? Would one truly be unacceptable? 12? 25? And what if the cost to prevent each death was on the order of say $1 trillion?
Are NHS waitlists acceptable? Not reading cancer scans for weeks. Poor cancer outcomes even when diagnosed in a timely manner. Blindness because patients aren't being seen in a timely way for glaucoma. 5.3 million on wait lists.
https://www.theguardian.com/uk-news/2020/jan/09/more-glaucoma-patients-going-blind-due-to-delays-report-finds
https://www.theguardian.com/society/2019/jul/19/nhs-cancer-scans-unread-pension-row
https://www.bbc.com/news/health-57820336
https://www.raconteur.net/healthcare/cancer/the-covid-effect-clearing-the-cancer-backlog/
https://www.pulsetoday.co.uk/news/referrals/more-than-one-in-10-patients-on-nhs-wait-lists-in-22-areas/
For people without health insurance in the United States, "waitlists" are infinity long.
What if they receive charity or public care?
I have a family member who has been the public health director of a county for a couple decades. All of the care they provide at clinics is free, although the volume is down 50% since Obamacare.
A sizable proportion of the Medicaid expansion represents insurance for people who were receiving healthcare without having insurance. I not saying the Medicaid expansion isn't an improvement, but it also replaced some things that were already there.
Also, let's say you a heart attack and are taken to a hospital without insurance. You will receive care and, statistically, better care on average than in the UK or Canada.
(Again - conflating health insurance with health care)
Whenever you let 'markets' determine something, it is rationed, just rationed against the poor.
Yeah, I understand the rhetorical framework which boils down to: health care administration in the US is expensive and the government could do it much more cheaply and efficiently.
Basically this is an argument that you don't need the market to negotiate prices and that optimal amounts of health care can be created via centralized price setting. This argument, not incidentally, is made primarily by those who seek to have administrative control over the endeavor.
There are a number of aspects of the modeling that I find suspect and overstated. For example, 'administrative costs' conflate a lot of different things including provider insurance, provider documentation, and the actual management structure of hospitals. Much of this wouldn't go away with universal Medicare. The actual medical billers providing documentation for insurance companies are not that expensive, make $40k-$50k a year, and are a very small part of hospital staff. Academic medical centers (much less hospital systems) are large and complex and require a lot of management. We're going to just do away with the majority of the administrative framework of hospital systems, presuming that the bureaucracy is just there to process payments and doesn't do much else? Remember that Canada doesn't have research or clinical hospitals that are on par with a Cleveland Clinic or Hopkins or the Harvard system.
Another major fault with this argumentation has to do with eliding health care and health insurance.
Health insurance is a financial product. Health care is a commodity. You can have health insurance but not be able to access health care (because it is rationed) and vice versa. In the UK you can have health insurance but be on a waiting list for years for necessary treatment. In Canada, patients with chronic conditions who aren't getting specialized health care (they are in the interminable queue) flood the emergency departments on the weekend - talk to an ED doctor in Canada. I have family in Canada who sang the praises of the system when they were younger and only accessed primary care. Now that they are older and need specialized care, the health system is a nightmare. The US system has significant problems, but it also has advantages. Just because someone doesn't have insurance doesn't mean that they can't get healthcare. The network of charity and state and local health care for the uninsured has been subsumed to a significant degree by the Medicaid expansion but it is still present. All that said, let's get to the bottom line: what percent of Americans don't have health insurance? 8%? That is the about same percent of the UK population that is on waitlists for care (5/70 million). So 8% of Americans don't have health insurance; reduce that percentage to those who actually need care for a specific problem, then further subtract charity care. You can make a good argument that a larger proportion of the population in the US has access to needed health care than than in the UK or Canada.
A couple other quick points. First, Canadian health care spending is artificially low because of the US market. The US pays for drugs, devices, and technology at a market rate. That market allows Canada to access similar resources at a much lower price. If we divested healthcare innovation and started paying 'Canadian rates' there is no larger market that would in turn subsidize us. There is no way of getting around the fact that entry costs for new therapeutics is high.
Another issue is outcomes: The US has higher murder rates, car accident rates, obesity rates, and a large number of other factors that contribute to outcomes that aren't directly connected to the healthcare system. The question is how much variance do expect a good versus bad healthcare system to account for? In a multivariable model, probably only a modest amount. When you start comparing the US to Europe and Canada in terms of staged cancer diagnoses or acute myocardial infarction, standardized scenarios where health systems do account for a lot of variance, the US does very well.
To loop back around again, I don't think the government in the US is as bad as many Americans think it is. I also don't think the Canadian government is as good as many Canadians think it is. But even in societies where governance is much better than the US (Germany, Switzerland, most of Scandinavia, etc.) there isn't centralized healthcare price setting and single payer. Most countries used a decentralized framework with some degree of market influence. The theoretical benefits of using a Canadian model which isn't used much elsewhere and which is possible only because Canada is an appendage to the US market are oversold.
Finally, regarding Obamacare, it's obvious why the individual mandate didn't work (it didn't have teeth). But Medicaid expansion did work and shrunk the number of uninsured dramatically. Medicaid could be modestly expanded to provide near-universal insurance with minimal disruption. The technocrats enthusiastic to put our health care system under federal discipline need to make a much stronger case than they have.
This is something I think you (and others in this thread) should read, though it is not a response to any specific point you make, it seems like it is relevant to this discussion. https://hotelconcierge.tumblr.com/post/111846326184/pyrrhic-medicine
This strikes me as rank speculation, no more.
It is speculation. But the idea that the US is trading miracles for general health is a compelling one to me.
We live in a time of miracles. Hep C can be cured. New generations of HIV treatment provide better control with fewer side effects. Biologics have led to dramatically improved outcomes for autoimmune diseases like IBD and MS. Operational improvement has led to dramatically reduced morbidity and mortality from acute coronary disease. A range of new treatment modalities have improved cancer outcomes. Biotech solved COVID within a year. Yet... what exactly?
I am middle aged and am astounded by the pace of therapeutic innovations I have seen in my lifetime. OK, how to socialize the cost of these innovations in care has not been optimized. Fine. That can be worked on.
But that is not the main issue; the main issue is an elision of personal disappointments and the cultural and spiritual shortcomings of our culture with a critique of medicine and technology. You are free to confuse the issues, but I don't think it will do you any good. Healthcare and therapeutics are progressing as they should
I'm impressed by how Freddie was able to get close to the implications of radical liberal thought. The implications are contradictory, pessimistic, and confusing. I hadn't thought about it until reading this piece, but, as Freddie says, a whole lot of liberal thought is premised on "we need to get lucky in one really specific way, and anything that reduces the likelihood of getting lucky in that exact way is very bad."
Hit "post" too quickly, but was going to add that Freddie is also correct in that putting all your eggs in that "get lucky in one hyperspecific and unlikely way" basket is a bad strategy... if you imagine that strategy as applied to anything else, from Nasim Taleb-style capitalist disaster preparedness, to sports, to republican or even centrist political strategy... it raises the question, what is it about left-liberal politics that makes it such a good idea to gamble on a highly unlikely and hyper-specific scenario?
Because organizing is a) too much work, and b) gets in the way of effectively hating the people who need to be organized and thinking of them as racist bumpkins. Also, the left in politics is dominated by the professional-managerial class who think that the main solutions should be technocratic instead of getting one's hands dirty.
Sure, but when are these awesome DSA types going to get their hands dirty and convince some Republican voters in the Midwest? It always rankles me as a Midwesterner when Brooklyn leftists tell us we're being unnecessarily mean to our neighbors. Again, I invite the Brooklyn leftist to move down here - Midwest is a great place to live, you could even afford to buy a house or not choke on rent. But please, come down here and try your hands at progressive organizing. I'd love to see it. Prove your point.
I’ll forgive you for not knowing my backstory. But I’m a union organizer in northern Minnesota. So I may get a little touchy.
We’ve got a bunch of DSA people on staff (I am not one, to be fair) and are trying—fitfully, to be sure—to figure out how to do exactly what you’re saying while staying true to progressive values. It’s hard, because people are still clinging to the performative parts of the progressive agenda and can’t figure out how to do that while reaching out to the rapidly reddening folk of rural Minnesota.
At any rate, it’s happening here too. You just have to know where to look.
(Starts reading) I wonder if I should post that the Emerging Democratic Majority stuff is bullshit.
(Continues reading) Never mind.
Two observations though: I don't really think that the conflict between the two parties is genuinely predicated on racial issues given that it's really a conflict between two rival factions of the white middle/upper class. That said I am hopeful that a migration of working class blacks and Hispanics into the GOP shreds the illusion even further compared to 2020.
As for Trump kicking the bucket, he's 3 years younger than Biden.
Trump is younger, but he’s fat, stupid & unhealthy. I think 18 months is optimistic but he won’t make it past 80. I could be wrong.
He just embarked on another series of campaign rallies in places like Florida and Ohio and as far as I can tell he hasn't deteriorated appreciably. Plus Biden to me looks frail: a cheat sheet with photos of the friendly reporters he was supposed to call on for his press conference?
I lean towards Trump making it to 2024 and campaigning again. I am far less bullish about Biden either a) making it that long or b) deciding that he is going to run again.
Also Trump is only 75 now. He would still be under your cap for the 2024 campaign.
You're hoping more people join the GOP?
Let me clarify: if somebody is a conservative black or Hispanic, and they are voting Democrat right now, then the country as a whole would actually benefit if they switched to the GOP. How could that not be the case? For one thing it would probably reduce racial polarization between the two parties.
I watch a lot of MSNBC in the evenings (don't ask me why). It's incredible how often the entire A-block on these shows is 1) January 6th, and 2) Corruption in the Trump administration.
I'm not saying those things should never be covered, but at this point shouldn't it be like a D-block update? You can watch an hour of MSNBC and not learn anything about what is happening in the present day, night after night.
It's SO WEIRD. I can understand covering Trump if they think Trump=ratings. But they don't even cover recent news about Trump very often. It's all about his administration and the riot. I've never seen an entire news network focus so heavily on the past, night after night, 6+ months after any of those events occurred.
And they don't even explain why. It's just, "Good evening, thanks for joining us. How close did America come to the worst case scenario on January 6th...."
I hope Chris Hayes writes a memoir one day about what this time was like. He started as a lefty, activist, internet nerd type guy, and I still enjoy his podcast. But the incentives confronting his cable show seem really perverse. Or maybe he believes this is what we need every night, I don't know.
"I hope Chris Hayes writes a memoir one day about what this time was like. He started as a lefty, activist, internet nerd type guy, and I still enjoy his podcast. But the incentives confronting his cable show seem really perverse. Or maybe he believes this is what we need every night, I don't know."
I constantly debate writing a piece about him specifically because it's such an obvious and tragic case, but no one would read it in good faith because I'm me and it would be ignored. But somebody should write it. He was at least smart and perceptive and self-critical and he has become the saddest self-parody of an MSNBC man I can imagine. And he clearly has no idea.
You should write it. We won't ignore it.
Agreed. I would enjoy the piece. About MSNBC generally, a lot of what plagues the network seems to be caused by Rachel Maddow's ratings success compared to all the other primetime shows. I understand why they try to emulate her, but even her fans will not watch three hours of January 6th coverage every night for seven months. Rachel already repeats herself A LOT, within the hour and from day to day.
I think plenty of other concepts could work in primetime, but they'd need to be willing to start from zero and grow an audience rather than trying to cling to the viewers who have been dropping off since Biden got elected. Those viewers aren't appealing to advertisers anyway because they're very old.
I think there is a question of 'what MSNBC is trying to be'. If it's supposed to be the left-wing equivalent of Fox News, operating essentially as the media wing of the Democratic party, I'm not sure covering 1/6 and Trump is a bad decision. Those are things where the average American sides with the Democratic party and subjects that rile up the base. They should cover Trump for the same reason Fox News covers Clinton.
The problem is that I don't think there's a huge market for this kind of thing. But I'm not sure there'd be a huge market for 'a left wing cable network, but good' either though. 'MSNBC sucks' is not a pressing problem for most politically active people I know because they watch little to no cable television.
Would be a good piece. He certainly has an idea of what he is. A $5 million a year salary directs behavior.
I suppose "big government" might work in Heaven. But everyone there's an angel and God is benevolent. The danger is in thinking we can replicate this on earth when neither are the case.
Both sides peddle their myths. The "right" is at least offers the individual a vision which is aspirational, something the DSA, etc can not.
Freddie deBoer asks "Do Liberals Have a Plan Other Than Whining", presents no plan of his own.
Film at 11.
I mean, I don't have a plan as well-developed as yours, which is to yell at me for being insufficiently devoted to Democrats in the comments of every post. But in my defense I did write a whole book, a third of which is my plan, Mark.
I did not read the book, but as I understand it the plan is a policy proposal, whereas "plan" as you use it in the title of this piece seems to mean how to get policies implemented, not just proposed.
I think the American left should build more and better institutions that can work within local communities and build our constituency, which allows us both to do small-scale activism and achieve positive change that way, while also building up a base in electoral politics such as through city council, school board, and local representative elections, which I've acknowledged will probably run through the Democratic party. I've expressed some version of that many times.
Sure, that's all fine. It's just really really slow. Meanwhile, if you want something like the child tax credit to become law in the next few months (rather than say a few decades), sniping at liberals (who worked hard to elect Democrats who would actually vote for the child tax credit) has no value that I can see.
But I don't understand how far this goes. I think liberal Democrats could do a better job at being liberal Democrats so I write posts like this one. Should I hold my nose and not write this stuff because they're kind of on my side? Doesn't seem like a very democratic attitude to me.
Insulting people is rarely effective at getting them to do a better job.
This is a bit unfair. Look at the paragraph about the child tax credit. Freddie notes that this pretty ambitious plan of redistribution pleased - didn't delight, but pleased - both the liberals and the DSs. And it will also be very popular with the country. Therefore someone like Freddie will say that it's still commodifying lives and livelihoods so it's not perfect, and Ezra Klein will say something boring and stupid about deficits, but both of them will ultimately prefer it to nothing because it improves the lives of regular families and shows them that redistribution can be fair and can work. Recognition of this is, itself, a plan - that a lot of the mutual sniping and fighting online can be rendered moot by actual redistributive policy.
And per his remark about his book - blank slate cognitive equality being a complete bust, Freddie posits an economic model that vastly reduces the connection between smarts and wealth, which would itself be radically redistributive.
It doesn't matter if both liberals and DSs like the child tax credit if it doesn't become law. And it will only become law if enough people in Congress vote for it.
I think Freddie might be oversimplifying the center-left consensus a little. It's not really "working-class whites are racist and the Senate is biased, therefore let's moderate our stances across the board". What they're proposing is to analyze public opinion on more than one dimension.
Working-class white voters tend to lean right on some issue categories, like race and immigration, while leaning left on others, like public spending. The approach Chait, Yglesias et al. have been pushing for the Dems is to talk more about public spending and less about anti-racism, and in particular not to try and *sell* public spending by calling it anti-racism. I think that fits pretty well with Freddie's own view of the relationship between race and class.
Trump dead in 18 months (or within 5 years as one of your other posts suggests)? Really? Dude seems almost invincible to me. He shrugged off COVID fairly easily. His level of energy for someone his age is astounding.
Yeah, I think it is something very close to denialism to automatically discount the possibility of a Trump/Biden or Trump/Harris or Trump/whoever rematch in 2024.
Part of it is I think an unconscious recognition that if not for Covid Trump would have probably cruised to victory, along with some other unpleasant realities.