Liberty, Anarchy and the Pragmatist’s Dilemma

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Erik Kain

Erik writes about video games at Forbes and politics at Mother Jones. He's the contributor of The League though he hasn't written much here lately. He can be found occasionally composing 140 character cultural analysis on Twitter.

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292 Responses

  1. Avatar Kimmi says:

    I’d settle for 1990’s health care, no Big Gov’t needed. And I’m the liberal here. We had a system that mostly worked, people that had insurance didn’t go bankrupt often…

    I don’t think there’s any way we can convince the hedge funds to give us it back though.

    Liberal: reluctant Big Government Enthusiast.

    I find it most interesting that the people who donate the most to charitable causes (the Catholic Church does NOT count, even if it spends some money on charity. it mostly spends it on operating a religion), are also the people who tend to be most liberal.

    Nah… I’m glad that Republican Assholes tend to be Freeloaders, who extract more from government while paying less. Makes it easier to avoid them. (ya can tell the assholery parts of the country, to a good degree, by how republican they vote).Report

  2. Look, if people want to pull the lever for a Democrat every two to four years, whatever. My more disdainful criticisms are reserved for those who treat the electoral charade as the be-all and end-all of social change, which I think one could fairly characterize much of the professional liberal blogosphere as believing in practice. But I would say that if you want to stand up to the Tea Party agenda, organizing protests, strikes and other forms of direct action seems to me a lot more effective than electing more and better Democrats, particularly given those Democrats don’t seem all too keen on standing up to Wall Street or defending the social safety net.Report

    • I agree, and share much of your disdain for Democrats. But then again, electoral politics can also help change the parties in question. Certainly the Tea Party has helped shift the Republican Party in a new direction.Report

    • Avatar Kimmi in reply to Charles Davis says:

      … acorn seems to have flopped. got more hope for EFF.
      The professional liberal blogosphere seems awfully keen on publishing recruitment info for Anonymous, and happy to keep feeding Mike Stark attention (that’s another nutball lawyer for you, once he takes the bar).
      Wikileaks is something that the “professional” blogosphere is rolling on, as well.Report

  3. > Times have changed and the costs associated
    > with major health catastrophe’s are simply
    > too high to provide vis-a-vis private charity
    > any longer.

    This sentence has a very large world of meaning attached to it. It says many things.

    To me, anyway.Report

    • Avatar E.D. Kain in reply to Pat Cahalan says:

      Of course it does. But no matter how much the costs have been driven up by our shitty healthcare system, they were going to go up on their own anyways.Report

      • Avatar Pat Cahalan in reply to E.D. Kain says:

        That says something else, too.

        What does it say?

        I’m not deliberately trying to sound inscrutable here. I think this is a path you need to walk down yourself for a few more thoughts.Report

        • Avatar E.D. Kain in reply to Pat Cahalan says:

          Pat, believe me when I say this: I have thought healthcare to death, and blogged it to death also, and my thoughts on this issue are as clear as they can be. Just come out and say whatever it is you want to say.Report

          • Avatar Pat Cahalan in reply to E.D. Kain says:

            If costs are going up, regardless of the current craptacular design of our healthcare system… and they’re going up to the point that no small-scale systemic approach can reasonably provide coverage for emergency care, moving the entire kit and kaboodle to the largest-possible systemic approach means several somethings.

            It means that we will likely never be able to move it back, first of all. So we need to be very careful about what parts of “it” we move.

            It means that we’re moving some set of medical coverage into the commons. If we’re going to do this (and rest assured, I don’t think this is necessarily a bad idea, for some definition of “some set”), I don’t want this to happen.

            It will, though. I see this as a big problem.

            I also see a major impediment that already screwed the first attempt at HCR and made it actually worse than it ought to have been. That whole group of people that Hate This Idea. So I’m not sure that we can get this in our political climate.

            What really got me on that sentence to which I originally replied wasn’t all that, though.

            If the justification to move medical coverage into the commons is because it’s simply too expensive for the individual in the general case, it seems like we should first spend a lot more time talking about much more easily implemented temporary solutions that might help this problem. Like, opening 40 government-subsidized medical schools that will train GPs for free, provided they work as GPs for 5 years at an incredibly cheap-ass wage. Or something. Or some set of somethings.

            That we can cancel or cut back, if it works (or doesn’t).

            Because if costs are (naturally) spiraling out of control anyway to the point where it’s not fixable except by bumping things up one or two layers of abstraction, I’d argue that major efforts towards cost control are immediately indicated much more than moving the bucket. If we’re in a race condition, we need to fix that first.Report

            • Avatar Kimmi in reply to Pat Cahalan says:

              EHR. that’ll drop you 10% of waste, at least, I guarantee it. (numbers pulled out of my ass — i’ll google later).Report

            • Avatar DarrenG in reply to Pat Cahalan says:

              We’ve already moved a lot of medical coverage into the commons via the Hippocratic Oath, EMTALA, and the rest of our combination of formal and informal decisions that we generally don’t want people dying from treatable medical conditions due to inability to pay.

              What we’re largely talking about now is *how* to pay, not *whether* to pay.

              While I don’t really agree that health care cost inflation is in a race condition, it is a very important concern that should be paramount in any discussion of reform, and for the actual policy wonks it seems to be.

              Tying back to Erik’s concerns about pragmatism and real-world examples, every state-run health care system in the world is currently experiencing less cost inflation than the U.S., so while it may be an article of faith in some quarters that increased government presence automatically drives costs upward, we have a large body of data that seems to indicate otherwise in the case of health care.Report

              • Avatar Pat Cahalan in reply to DarrenG says:

                > What we’re largely talking about
                > now is *how* to pay, not
                > *whether* to pay.

                Oh, you always pay. Well, somebody does. Cost-shifting if nothing else.

                Somebody has to pay the janitor.Report

              • Avatar MFarmer in reply to DarrenG says:

                “Tying back to Erik’s concerns about pragmatism and real-world examples, every state-run health care system in the world is currently experiencing less cost inflation than the U.S., so while it may be an article of faith in some quarters that increased government presence automatically drives costs upward, we have a large body of data that seems to indicate otherwise in the case of health care.”

                Are you saying we haven’t had a large government presence in healthcare? Have you worked in healthcare?Report

              • Avatar DarrenG in reply to MFarmer says:

                Are you saying we haven’t had a large government presence in healthcare? Have you worked in healthcare?

                Yes, I’ve worked in health care (technology end, not practitioner end, if that makes a difference), and no, I’m not saying that we haven’t had a large government presence in health care.

                Instead, I’m saying the available data strongly suggests that increasing the government presence in health care does not necessarily increase costs, and may have the opposite effect at times.Report

              • Avatar MFarmer in reply to DarrenG says:

                So, it’s your position that government-control of healthcare in the US can possibly lower healthcare costs and maintain decent quality of care?Report

              • Avatar MFarmer in reply to MFarmer says:

                “I’m saying the available data strongly suggests that increasing the government presence in health care does not necessarily increase costs, and may have the opposite effect at times.”

                Of course, no data exists in the US since we haven’t yet increased government presence to the full extent of what’s been passed in congress. One also has to wonder why so many businesses are seeking exemptions if their healthcare costs will be reduced.Report

              • Avatar DarrenG in reply to MFarmer says:

                Depending (heavily) on what you mean by “government control of healthcare,” yes.

                I think the PPACA, if/when fully implemented will both decrease costs and increase quality of care.

                I think we could also see further improvements in both quality and cost if we were to evolve more toward a Dutch-style system, or a Singaporean-style system as Erik mentions above.

                For the record, I don’t think a British or Canadian style system would work very well at all here, though.Report

              • Avatar DarrenG in reply to MFarmer says:

                Of course, no data exists in the US since we haven’t yet increased government presence to the full extent of what’s been passed in congress.

                Except that we have, over time, gathered a lot of data on the effect of other changes to health care policy in the U.S. has done to costs over time.

                Plus, of course, we have the world of data from different systems outside the U.S., and no, I don’t buy the “but the U.S. is so fundamentally different we can’t possibly learn anything from any other country” argument, either.Report

              • Avatar MFarmer in reply to MFarmer says:

                Another aspect of this relates to the claim that free market healthcare hasn’t been tried. If we take America as a country which can’t legitimately be compared to Britain, France, Canada, etc, we can also say that government-run healthcare hasn’t been tried comprehensively in America, so either way, it would be an experiment. I’m not even sure the evidence gathered from other countries speaks favorably to government-run healthcare when you look at the problems and the fact it hasn’t been in effect for a long time, historically speaking. A few countries cherry-picked doesn’t mean that evidence is viable when applied to the US. We just don’t know what more government involvement will create.Report

              • Avatar MFarmer in reply to MFarmer says:

                “gathered a lot of data on the effect of other changes to health care policy in the U.S. has done to costs over time.”

                Like what?Report

              • Avatar DarrenG in reply to MFarmer says:

                Another aspect of this relates to the claim that free market healthcare hasn’t been tried.

                At the risk of triggering a No True Scotsman argument, what do you consider the U.S. health care system pre-Medicare to have been?

                If we take America as a country which can’t legitimately be compared to Britain, France, Canada, etc, we can also say that government-run healthcare hasn’t been tried comprehensively in America,

                Except I explicitly reject the idea that we can’t legitimately be compared to other countries, nor do I believe I was cherry-picking countries in my previous post. I do think some countries’ systems would function better in the U.S. than others’, though (I honestly expected this to be a uncontroversial claim).

                And while any change would indeed be somewhat of an experiment, I think it’s much wiser to experiment along lines that have proven successful previously than ones that haven’t.

                Like what?

                Medicare Advantage, for example.Report

            • Avatar Jaybird in reply to Pat Cahalan says:

              If costs keep going up, we should look at the dynamic of price being a function of supply and demand and why supply is not growing at the same rate of demand and address that fundamental imbalance.Report

              • Avatar E.D. Kain in reply to Jaybird says:

                I am of the mind that tackling healthcare means tackling both the supply-side price distortions (which I’ve written about many times) and lack of access to insurance coverage which afflicts older, poorer, and sicker Americans. This will take a mixed approach of market mechanisms and government aid.Report

              • Avatar Jaybird in reply to E.D. Kain says:

                There are also issues with demand insofar as Medical Care is a positive good… and the question of “what is a person entitled to?” is very, very unpleasant to answer.Report

              • Avatar Tod Kelly in reply to Jaybird says:

                True. But not asking it for 50 years is exactly why we’re in the mess we are now.Report

              • Avatar DarrenG in reply to Tod Kelly says:

                I wouldn’t say “exactly” for the reasons I list below.

                We could be delivering the same quantity and quality of medical care we currently do at a much lower cost without getting into the whole “death panels” debate.

                We absolutely should address the issue, particularly regarding end-of-life care, but it’s not the only factor in our current cost predicament.Report

              • Avatar Tod Kelly in reply to Tod Kelly says:

                I’m not actually talking about death panels. I’m talking about the fact that HC, unlike any other system I am aware of, is the only one where demand and price increase as supply does. The system can only absorb 7-10% increases every year so long.Report

              • Avatar DarrenG in reply to Tod Kelly says:

                Any time you open the “what is a person entitled to” debate, you get the death panels debate, though.

                Demand and price increase with supply in the case of some kinds of luxury goods and entertainment or communications products, but these obviously don’t have the emotional or political impact of health care.Report

              • Avatar RTod in reply to Tod Kelly says:

                Darren – Regarding first paragraph: frickin’ tell me about it.

                Regarding livery goods, ent. & comm, that sounds right. I don’t work with those so had never considered.Report

              • Avatar RTod in reply to Tod Kelly says:

                Obviously I meant luxury goods, not livery goods.Report

              • Avatar Jaybird in reply to Tod Kelly says:

                Play your cards right and there’s overlap.Report

              • Avatar DarrenG in reply to Jaybird says:

                Health care costs largely aren’t being driven by a supply crisis, at least not of the nature you seem to suggest.

                Some of the increase is because health care is just a much, much bigger thing than it used to be. We have many more tools to diagnose and treat injuries and disease, and these naturally cost more than “take 2 aspirin and call me in the morning.”

                Increased demand is also a factor because of an aging population that also is afflicted with more and more chronic diseases. You can control some of this sort of inflation from the supply side, but the aggregate demand is still going to drive up aggregate costs, and at large chunk of the chronic disease issue really needs to be addressed from the demand side (i.e. preventing the disease in the first place rather than treating it for years/decades).

                Some of it is caused by gross inefficiencies in our current administrative and delivery systems. When small providers have to hire 2-3 people to shuffle paper and peck at keyboards for every person treating patients there’s something broken. This extends up the chain to the number of entities involved in the billing and payments process, all of whom want their cut.

                There’s also the major problem of treating the uninsured and medical bankruptcies, which shift a huge cost burden on to those of us with good insurance.Report

              • Avatar Jaybird in reply to DarrenG says:

                Having your health care needs met will automatically result in more health care needs (if not today, tomorrow).

                This is why the question “what is a person entitled to?” so very important unless we hammer out the scarcity problem (because price is signalling a problem with scarcity).Report

              • Avatar E.D. Kain in reply to Jaybird says:

                Not necessarily. If you devised a single-payer system along the lines of Singapore’s healthcare system you’d have an effective use of HSA’s to prevent too much needless spending, coupled with some good public options to keep costs down, and everyone entitled to catastrophic coverage above say 10% of income. There’s one answer to this line of questioning: people are entitled to anything over ten percent that is not elective.Report

              • Avatar DarrenG in reply to E.D. Kain says:

                Even there the friction comes in defining “not elective,’ which is a serious problem world-wide.

                The U.S. has other, bigger problems layered on top of that, though.Report

              • Avatar Brandon Berg in reply to E.D. Kain says:

                That’s very obviously the wrong answer. There has to be an upper bound. There’s a reason that countries that don’t ration medical care by price ration it in other ways.Report

              • Avatar DarrenG in reply to Jaybird says:

                True, but incomplete, I think.

                The “more, more, more” dynamic you describe only accounts for a portion of our health care cost inflation, and certainly doesn’t explain why U.S. health care costs are increasing so much faster than every other OECD country.Report

              • Avatar Jesse Ewiak in reply to DarrenG says:

                Medicare costs are increasing slower than private insurance despite the fact Medicare is full of old people.Report

              • Avatar Jaybird in reply to DarrenG says:

                Will wikipedia do or do you want all sorts of numbers and stuff?Report

              • Avatar DarrenG in reply to DarrenG says:

                Numbers are always nice, but I’m interested in anything that provides evidence beyond naked assertion that Medicare accounts for all, or even most, of the difference in cost inflation between us and countries whose whole system resembles…Medicare.Report

              • Avatar Jaybird in reply to DarrenG says:

                Well, here’s from Wikipedia:

                The costs of Medicare doubled every four years between 1966 and 1980.[47] Medicare spending increases mostly in response to increases in overall health care costs, and it grew at a slower rate than spending by private insurance plans from 1998-2008.[48]

                I’m going to focus on the “overall healthcare costs” portion of the paragraph that inspires the increased costs. That has to do with how we have been pouring money into medical care for the last century as if we’d never run out… which has resulted in some *AMAZING* medical advances (and, quite honestly, I keep hoping for more).

                The problem is that the expectation is that if there is something that would work then the patient is entitled to it despite the cost.

                I mean, imagine if you were given the option between getting 1995 technology for free (along with free access to doctors who stopped going to conferences in 1995!) or paying for 2011 medical technology (and very, very young doctors).

                Which would you pick?

                Now imagine if both were offered at no cost.

                Well, in our little thought experiment, it seems to me that we’d see the cost skyrocket because everybody would want the latest and greatest.

                This seems to me to map to what has actually happened.

                Good enough or do you want more?Report

              • Avatar DarrenG in reply to DarrenG says:

                That’s just a restatement of what I termed the “more, more, more” problem above.

                The quote even concedes that Medicare cost inflation is *less* than costs covered by private insurance, so no, I don’t think you’ve established that Medicare is responsible for any of the difference between us and other OECD countries, who also largely have the “more, more, more” problem.

                As Erik correctly states in the OP, medical costs have reached the point where some sort of insurance is necessary, so the direct sort of price signalling you seem to envision is largely not possible in the areas where costs are growing the fastest (end-of-life and emergent care).Report

              • Avatar Jaybird in reply to DarrenG says:

                The quote covers only 1998 to 2008. I’d say that the biggest problem is how it grew for the 30 years prior and that to which we became accustomed… which is to say that the cost and the price is more or less divorced from the consumer.

                People aren’t worried about health care as much as they’re worried about health care *COVERAGE*.

                We even had a question about whether a young person who chose not to purchase insurance who made bad decisions and then got into an awful situation should be saved anyway… thus leading to a discussion of how cruel the people are who would let this young man die.

                There is no relationship between what health care coverage consists of and what health care consists of.
                There is no acknowledgment of scarcity.

                Much of that was kicked off by Medicare.

                (Better?)Report

              • Avatar DarrenG in reply to DarrenG says:

                Better, but still not convincing 🙂

                The disconnect between health care and health care coverage you describe came into being largely as a result of the combination of group insurance and the natural evolution of technology.

                Medicare didn’t lead to the invention of synthetic antibiotics, MRI machines, or chemotherapies for cancer, and the debate over how much care to give terminal or indigent patients long predates Medicare, too.

                And once again, we don’t have to discuss this in a vacuum of pure theory. We know that other countries insulate their people from direct health care costs to an even larger degree than we do, yet their health care cost inflation is a fraction of ours.Report

              • Avatar Jaybird in reply to DarrenG says:

                I can live with that.

                My suspicion is that the US has done the lion’s share of medical research and is doing the heavy lifting when it comes to new and innovative stuff. (I once sat down and did a breakdown of Nobel Prizes by where the work was done… I remember thinking that the US was definitely punching above its weight.) I tried to do something similar for pharmaceuticals as well but that hit a brick wall for reasons I can’t remember (I think that there were a lot of offshored companies or something like that and I didn’t know how to count them.)Report

              • Avatar Chris in reply to DarrenG says:

                Jay, of course much if not most of that medical research is funded by the federal government, and even when it’s not, the basic research that underlies it almost certainly was.Report

              • Avatar Jaybird in reply to DarrenG says:

                So that’s more cost that is invisible to the consumer? Yes?Report

              • Avatar DarrenG in reply to DarrenG says:

                So that’s more cost that is invisible to the consumer? Yes?

                Yes, no, and “it’s complicated.”

                In pharmaceuticals and DME it’s easy to amortize R&D on a per-unit basis, and there’s little direct government funding except for really, really basic research in molecular biology and such.

                I think your instinct that the U.S. pays more than our fair share for innovation was true in the past, but the trends are toward evening this out with a lot more research being funded and performed outside the U.S. and by corporations and NGOs rather than government agencies or grants.

                It’ll be very interesting to watch what happens to medical research in China as they increasingly experience the health effects of their environmental issues over the coming couple decades, too.Report

              • Avatar Jaybird in reply to DarrenG says:

                I understand that their FDA is much more… utilitarian… as well.Report

              • Avatar Chris in reply to DarrenG says:

                Well, there’s certainly funding for much more than “basic” research outside of pharmaceuticals. The NIH is huge.Report

              • Avatar Pat Cahalan in reply to DarrenG says:

                Just to chime in an aside here:

                I don’t think any sufficiently credible link can be made either to Medicare or private insurance being the primary driver of health care costs.

                On the other hand, I think you can very easily make the case that the two of them, hand-in-hand, are driving both health care costs and treatment defaults, with a slight edge given to Medicare in both cases.

                What Medicare covers becomes what private insurance covers, usually. So once you add “electric scooters for the elderly diabetic who can’t walk” to the “available treatments via Medicare”, private insurers are hard pressed to make that a default care option as well.

                There is some collusion here as the scooter company has a big incentive to wine and dine their senator and get their scooters covered by Medicare.

                Now, their scooters certainly do increase mobility and independence for those seniors, and they’re certainly good in those regards, but they may not be the best treatment option for the underlying cause and they certainly therefore may not be the treatment option that we cover with Medicare, effectively both subsidizing it directly with government funds and putting huge market pressure on the open market to add it, too.

                I’m sure there are also plenty of examples of people wining and dining their senator to get a perfectly excellent treatment option covered via Medicare.

                I’m not so certain this is the best way to get treatment options to the general public.

                On the other hand, I’m not so sure having drug companies wine and dine private physicians is a good alternative either.

                I’m full off constructive observations this evening. “All available options suck!”Report

              • Avatar Kimmi in reply to DarrenG says:

                Jaybird,
                Patent Office is what you’re looking for. America isn’t doing jack-all anything except medical research these days (or should I say greenbacking?)Report

            • Avatar Tom Van Dyke in reply to Pat Cahalan says:

              Well, that’s out of the box, Mr. Cahalan and not a massive Big Govt intervention. As it stands now, the med school cabal limits the number of doctors it produces; if and when we open the gates to more demand for medical service, we’re understaffed to serve it.

              As for the linked Jim Henley post, we move to a broke guy whose truck broke down to socializing the medical industry. [Why was he bankrupted by his wife’s bills? Did she have insurance? If not, why not? Not saying it’s the case here, but a lot of these heartbreaking anecdotes don’t hang together under greater scrutiny.]

              Along the lines of PatC’s suggestion, we could look at expanding catastrophic coverage as a function of the safety net rather than tearing down and rebuilding the whole thing.Report

              • > As it stands now, the med school cabal
                > limits the number of doctors it
                > produces; if and when we open the
                > gates to more demand for medical
                > service, we’re understaffed to serve it.

                Foreign medical schools are already taking up some of this slack, which would seem to indicate that you’re onto something there, Tommy me lad.

                The medical school environment is also somewhat encouraged to produce specialists, which isn’t the animal that is going to reduce base load costs.

                The GP is the base load power plant of the medical industry. The specialists are the peak load plants. We have too many of the second and not enough of the first.

                These guys and gals are also paid significantly less than their specialist brethren, so I’m certain that this has at least as much to do (if not more) with the shortage of GPs as any cabalistic behavior of the med schools.

                But yeah, we need more of these folk. Unfortunately, the more of ’em we produce, the lower their value is in the open labor market. Bitch. Again with the no constructive options! I’m just useless this evening.Report

              • Avatar Tom Van Dyke in reply to Pat Cahalan says:

                Brother Cahalan, you’re entirely useful this evening. For the record, “GP” is a pejorative in the medical industry. “General Practice.” It means no specialty atall, a leftover from the olden days.

                “FP” [Family Practice] is the term for the generalist, but a certified specialist, too. Internist is “IM,” [internal medicine], meaning adults. Then you got yr pediatricians, etc., not to mention the other specialties.

                Working from memory here from my 3 months as a headhunter for doctors, but I think I’m on the beam. Even FPs are “specialists.”

                By contrast, much NHS primary care is gatekeeped by nurse practitioners, if not treated. [NPs.] American get pissed off at not seeing a real doctor, unless they go to Walmart.

                I’ve done a bunch of reading and research on all this, Pat, but the wonkage and epistemology just wears me out. These dudes disagree with each other—what can I add? If I’m not gonna get paid, I’d rather do Plato and Aquinas and shit, y’know?

                And play the blues, dude. Even that takes some serious wonkage if you know what I mean. It ain’t karaoke, which anybody and everybody can do, more or less. The worst thing in the world is karaoke blues.Report

              • You are correct that people have moved away from the term GP. The wording has gotten sloppy, but his point about (non-surgical) primary care physicians is pretty much on the mark.

                FPs are technically specialists, but when people talk about specialists, they’re not talking about FP’s. This is true even when FP’s are talking.Report

              • Avatar Tom Van Dyke in reply to Will Truman says:

                Just cleaning up the terms, WillT, & thx. PatC is right on here, just wanted to clarify. GPs are leftovers from the Age Before Specialization, although I’ve heard that Dr. Force and Dr. Mears [MD, GP, RIP] seem to have saved my life several times each without further certifications.

                [This is not to dis FPs or IMs. Pls. I got my case against academization, but this ain’t one of ’em. WTruman is quite right about residencies. You can slob yr way through medical school and call yrself a GP, but where you did yr residency is actually where it’s at in the med profession. It’s complicated.]Report

              • Avatar Trumwill in reply to Will Truman says:

                It used to be the case that once you got through medical school, you could hang up your shingle as a GP. That’s my understanding, anyway. But probably around the time GPs became FPs, residency became required just to get licensure.

                The kind of residency (and/or subsequent fellowships) matters for what you can do when you get out*. The quality of the residency matters for what jobs you can get (if you did your residency at the Boise State University, you’re not likely to get that job at Johns Hopkins). But mostly, to practice medicine at all, you just need residency.

                Not to talk everybody’s ear off. This is obviously a subject of great interest to me.

                * – Partially due to board certification, but also to get privileges at a hospital, if you need to do work at once. My wife has performed more deliveries and C-Sections than your average obstetrics residency graduate, but since it wasn’t an obstetrics residency, she can’t get privileges at a lot of hospitals. When people talk about doctors having turf wars against non-doctors, it’s easy to forget they have them against one another, too.Report

              • Also, you’re quite right about people wanting to see a genuine doctor.

                I’ve long wondered if the preference for American caregivers will solve this problem. As fewer American docs want to go into primary care, these residency slots will be filled by foreigners. Given the choice between a foreign doctor or an American Mid-Level Provider, I think that people might happily choose the latter.Report

              • Avatar Tom Van Dyke in reply to Will Truman says:

                As fewer American docs want to go into primary care, these residency slots will be filled by foreigners. Given the choice between a foreign doctor or an American Mid-Level Provider, I think that people might happily choose the latter.

                WTruman continues to speak truth on the medical thing, word up. It’s not xenophobia as much as wanting to be understood as you prattle on about yr symptoms. It’s a human thing.

                If you’re going to send my X-rays or MRIs electronically to some other lab for analysis, at this point I’ll take my chances on the one in India. [They’re doing that now, if ya didn’t know.]

                Oh, and BTW, the UK is skimming off the cream of foreign docs for the NHS, leaving their home countries understaffed. Welcome to life in the macrocosm.Report

              • Avatar Rufus F. in reply to Will Truman says:

                It’s a bit like musical chairs here in Canada. Our best and brightest medical student go to the US to practice where they can make big money. Not all of them, but a chunk. Canada makes this up by appealing to foreign med students to come to Canada and make more money than they would at home. Then the government makes them do all of their schooling again because it won’t accept their foreign medical degrees. It’s pretty dumb.Report

              • Rufus, this is tangential but interesting: An article on practicing medicine in Canada vs the United States.Report

              • Avatar Kimmi in reply to Tom Van Dyke says:

                I like it when a GP mentions what they specialize in. (roughly speaking, what journals they’re reading and keeping up to date on). Lets me figure out who’s probably best for me.Report

              • Med schools are not the bottleneck, residencies are. If you were to start up 50 new medical schools tomorrow, the only result would be (a) squeezing out foreign docs and (b) creating a waiting list for residencies. If you opened up more residencies, you could get more (foreign) docs overnight without opening any new med schools.

                Also, I should note that there is no single controlling authority over medical schools. MDs are handed out by the LCME, the single accrediting administration for MDs. But there are also DO’s, which are handed out by the American Osteopathy Association. The AOA wants more medical schools. They want more of a presence in the medical community.

                The problem? Medical schools are expensive. Law schools (of which we have a surplus) are profit centers, but not med schools.

                I wrote more about all of this here.Report

              • Avatar Kimmi in reply to Will Truman says:

                UPMC seems to make tons of profit. Maybe that’s because it’s a huge research engine.Report

              • > Med schools are not the bottleneck,
                > residencies are. If you were to start
                > up 50 new medical schools
                > tomorrow, the only result would
                > be (a) squeezing out foreign docs
                > and (b) creating a waiting list for
                > residencies. If you opened up more
                > residencies, you could get more
                > (foreign) docs overnight without
                > opening any new med schools.

                I admittedly know bufkus about this part of the process, Will. Thanks for the link, I’ll check it out.Report

              • Whelp, we can certainly subsidize the creation of new medical schools, and shorten residency for foreign-trained doctors to expedite the process, yes?

                Perhaps international accreditation for an actual “general practitioner”; bring back the old label for someone better than a med student but not necessarily a full FP?

                How can we increase the number of residency programs – is this doable?Report

              • You get a lot of resistance to tinkering with residency in the medical establishment and *not* (just) for the oft-stated reason of wanting to limit the number of doctors. Most FPs want more doctors, but you’ll still run into resistance. It’s a matter of professional pride and hazing mentality (“They should have to go through what we went through”), but it’s not entirely wrong. They had to put in the 80-hour weekly cap at legal gunpoint. Letting anyone, foreign or domestic, forgo the process entirely would be difficult.

                The “at gunpoint” would be difficult in this case, too, because the decisions of licensure are primarily made by 51 medical boards across the country. These medical boards are generally run by physicians. That makes it hard to set national policy on the matter. Even states with huge shortages don’t want to seem to budge.

                International agreements are tough. Most countries don’t want to make it easier for their doctors to emigrate to the United States.

                Increasing the residency slots is doable and simple. The PPACA actually makes movement on this (it’s one of the untouted features). The problem is that it’s also expensive and bankrolled almost entirely by the federal government. The only logistical difficulty (other than looking under sofa cushions for the money) is that these residencies have to be staffed by doctors.Report

              • Avatar Jaybird in reply to Will Truman says:

                I know that if I’m not well, I want a doctor who hasn’t eaten anything in two days and survives on cigarettes and diet coke.

                “If you want to run cool, you’ve got to run on heavy, heavy fuel”Report

            • “Like, opening 40 government-subsidized medical schools that will train GPs for free, provided they work as GPs for 5 years at an incredibly cheap-ass wage.”

              I’d do that. Right now my only other options are to go 200,000 into debt while simultaneously trying to feed and provide shelter for a wife and three kids -or- and this is what I’m 99.99% leaning towards, exchanging my future skills as a future position for tuition and salary from the military. I’ll either be playing with chemical weapons in D.C. or on a ship somewhere unkilling a relatively small percentage of the people the politicians got killed. Either way, I’ll be contributing nothing to health care in the U.S. until I’m about 45.Report

            • Avatar Jaybird in reply to Pat Cahalan says:

              Like, opening 40 government-subsidized medical schools that will train GPs for free, provided they work as GPs for 5 years at an incredibly cheap-ass wage. Or something. Or some set of somethings.

              Have them work as a GP in Cicely, Alaska for five seasons.Report

            • Avatar DensityDuck in reply to Pat Cahalan says:

              “Like, opening 40 government-subsidized medical schools that will train GPs for free, provided they work as GPs for 5 years at an incredibly cheap-ass wage.”

              Is the government offering free malpractice insurance and a free office and free supplies, then? Because it’s really not like med school is the only cost that a GP sees.Report

              • Avatar Patrick Cahalan in reply to DensityDuck says:

                I’d hazard a guess that people on welfare and medicare (and those that will wind up in the health care exchange) to some extent already bill the government. There’s also the Reservation clinics Kim mentioned elsewhere.

                Setting up a few government-subsidized clinics wherein the “already subsidized” folk get access to lower-cost health care doesn’t seem beyond the pale. Malpractice insurance would have to come with the gig, absolutely.Report

  4. Avatar greginak says:

    I’d slightly reword Zworlinski’s quote to say people have found government needed to solve collective action problems in general.

    Henley’s post was excellent. I’d actually have some vague positive emotional attraction to the ideal left-libertarian vision also. But then again there are many ideal visions that all sound good. It’s almost like any thing sounds great and works perfectly in the ideal. Reality, well that is bit different. Pragmatism and empiricism seem absolutely vital to making anything work but more importantly are only ignored by ideologues. The people who scare me most are ideologues of any shape, they are ones who start swinging swords or walking over dead bodies when the world doesn’t agree with their ideas.Report

  5. Avatar Tom Van Dyke says:

    The Democrats and Republicans may both be rotten, but the latter is the rottener of the two

    I think we’ve found the official LoOG drinking game.Report

  6. Avatar Sam MacDonald says:

    Don’t most or all of these arguments apply to the War on Drugs, too?Report

  7. Avatar Sam MacDonald says:

    PS, when you say the libertarian approach to healthcare, do you mean Libertarian? I think there are lots of libertarian leaning members in congress, but very few are actually proposing some John Galtian vision of a pure market. here’s the lead about Medicare from Cato’s book for policy makers. It mentions… taxes!

    Congress should

    ? establish, in all parts of Medicare, premiums proportionate to
    lifetime earnings;
    ? allow seniors to opt out of Medicare completely, without losing
    Social Security benefits;
    ? give Medicare enrollees a means-tested, risk-adjusted voucher
    with which they may purchase the health plan of their choice;
    ? limit the growth of Medicare vouchers to the level of inflation;
    ? allow workers to save their Medicare taxes in a personal,
    inheritable account dedicated to retirement health expenses;
    and
    ? fund any ‘‘transition costs’’ by reducing other government
    spending, not by raising taxes.

    I dont see much about throwing Aunt mabel out on the street to be eaten by dogs. I know. The hardcore libertarians will axcuse Cato of being softies. But I think “If Cato says it” amounts to a pretty good gauge of how libertarian something is.Report

  8. Avatar DarrenG says:

    I dont see much about throwing Aunt mabel out on the street to be eaten by dogs.

    Those would be the parts about turning Medicare into a voucher system whose spending growth is capped at less than 1/4 the average growth of health insurance costs and the “private accounts” bit which eliminates the entire concept of risk pools.

    I also think Cato is describing what they consider politically feasible given the status quo, not their ideal health care system.Report

    • Avatar Sam MacDonald in reply to DarrenG says:

      Cato is considering what’s politically feasible? Wow. Libertarians can’t win, can they? First they get accused of idealism so rabid that they’d rather let Aunt Mabel die that tolerate any kind of taxation for any purpose. When they agree to compromise, they get accused of hiding their true agenda. So which is it?Report

      • Avatar DarrenG in reply to Sam MacDonald says:

        Of course Cato considers what’s politically feasible, at least on materials specifically designed for policy makers like the one you quote. It’s hardly a secret that a number of politicians outside the Libertarian party read and use materials from Cato when crafting or debating policy. Personally I wish more would use Cato’s criminal justice stuff and fewer use their economic stuff, but c’est la guerre.

        And of course “making politically practical recommendations” is not the same as “hiding their true agenda.”Report

  9. Avatar Sam MacDonald says:

    “Times have changed and the costs associated with major health catastrophe’s are simply too high to provide vis-a-vis private charity any longer.”

    Actually, would insurance truly designed to respond to major health catastrophe’s really be all that expensive?

    I should add that Yglesias had a really good post up the other day about HMOs. They actually did do a really nice job of controlling costs. So why didn’t America see more of them? Because in addition to catastrophic coverage, Americans want their health insurance to cover basic health maintenance. They also want direct, immediate access to world-class specialists for any and all conditions. They are not willing to wait for anything.

    Fair enough. I want these things, too. They just happen to make medical care really, really, really expensive. It’s not coverage for catastrophic events people can’t afford. It’s same-day service for normal care.Report

    • Avatar DarrenG in reply to Sam MacDonald says:

      So why didn’t America see more of them? Because in addition to catastrophic coverage, Americans want their health insurance to cover basic health maintenance. They also want direct, immediate access to world-class specialists for any and all conditions. They are not willing to wait for anything.

      Or, perhaps, many of us didn’t like being told the nearest in-network GP or hospital was 60 miles away, and that any access to a specialist at all was out of the question regardless of what the GP recommended, or any number of other cases where your insurance company decided they knew better what course of treatment you needed than your doctor. (They may have, in fact, been right on this much of the time, but I don’t think we should feign surprise that patients were displeased by this, especially when the insurer always recommended less care, not more.)

      But remember, we’ve never had have wait lists or rationing in this country, so everything’s just fine…

      It’s not coverage for catastrophic events people can’t afford. It’s same-day service for normal care.

      A big chunk of the developed world has managed to pay for same-day access to normal care at a fraction of what we pay here without it, so there’s that, too.Report

    • Avatar Brandon Berg in reply to Sam MacDonald says:

      Actually, would insurance truly designed to respond to major health catastrophe’s really be all that expensive?

      For a single 30-year-old man in Washington state, about $100/month.Report

  10. Avatar Brandon Berg says:

    5. As for the supposed counterproductive nature of some or all social-welfare programs, I came to doubt that this was an iron law of social welfare. It might just be that our existing programs were too chintzy to do any good.

    Well, I’m convinced. Can’t argue with that logic.Report

  11. Avatar Michael Drew says:

    I think that this piece by Henley is worth a read in full by everyone concerned with libertarianism in any significant way. I think it could be an excellent framing device for a really good first-principles type introductory symposium here between libertarians and non-libertarians. Sometimes I think that in our discussions here, libertarians come to the table with a body of assumptions and shared conclusions that then don’t all get fully aired in discussion with non-libertarians, while non-libertarians definitely come to the table with prejudices and assumptions about what they think libertarians are coming to the table with: and this all short-circuits discussion to some extent. Libertarians could respond point by point to Henley’s critique, after which non-libertarians could ask questions about what they still aren’t convinced by in libertarian thought, or points of Henley’s that they think weren’t responded to convincingly. Perhaps some greater mutual understanding could be achieved.

    Perhaps we could have this in a sidebar post in which we’d (with the author’s permission) reproduce Henley’s piece in full. We could perhaps repeat the exercise with a similar piece chosen by libertarians here.

    This is just an idea that popped into my head; do with it as you please, League officials. In any case I’d be interested in getting the libertarians’ around here responses (if they have them) more directly to Henley’s piece in some way, since this thread drifted off in a different, (IMO) somewhat unfortunate direction for some reason.Report

    • Avatar Tom Van Dyke in reply to Michael Drew says:

      Mr. Drew, EDK’s limn of Jim Henley intrigued me enough to follow the links; a further balkinization of the LoOG, where it’s of interest only to the smallest of slivers of the American polity, may be in the cards in due time.

      Although I’m neither left nor libertarian, I took the initiative. I think I got it. And may I say for the record—in view of today’s discussions—that diverse POVs are not balkinization; they are the antidote to it. I found the original Henley essay a cornucopia of false choices.Report

      • Avatar Michael Drew in reply to Tom Van Dyke says:

        There is a point at which your cutesy way of dancing around the simple matter of directly conveying as idea or two gets tiresome, Tom. I don’t really know what you just said, except that you don’t like Henley’s piece. So we could discuss it in a thread dedicated to the activity; or we could not. You could participate or not. What else can I say.Report

  12. “There is no political dynamic that gets us from a rickety welfare state to a viable left-libertarian “voluntaryist” minarchism. A left-libertarian, post-state society where neighbor cares for neighbor and we crowd-source help for the needy by leveraging internet technology still appeals to me on a deep emotional level. But no American political movement with the energy and power to eliminate the existing social-welfare system will be animated by the impulses needed to make Voluntaryland work as desired.”

    Perhaps Jim Henley should subtract ten years from his age, take up some strenuous exercise, start listening to whatever the kids are listening to, and jump out of an airplane with a parachute or something, because this sounds like an old fart selling out.Report

  13. Avatar James K says:

    I think Henley makes a good point, his arguments are why I don’t oppose welfare programmes, even if I’m not all that enthusiastic about them.

    As for your Pragmatist’s Dilemma, I see the conundrum. The problem I have with using “is anyone else doing it?” is that everything was unprecedented once. After all, I’m sure the Founding Fathers were criticised for some of their bold experiments. An elected executive serving a limited term, no established church, judicial restraint of the legislature. These things were new to the world. For that matter, abolitionism was dismissed as a radical notion with no historical backing, in fact Thomas Carlyle found the idea so ludicrous he branded economics as “The Dismal Science” because of the abolitionism of the early economists.

    Sure, international precedent matters, and should be taken seriously. But sometimes you need to reach beyond what exists, and unfortunately the only way to experiment with policy is to actually try things and see what happens.Report

  14. Avatar b-psycho says:

    It’s a matter of which you find more Hell Will Freeze Over First between meaningful reform of the state and a useful undermining of it.

    For all the difficulty in the groundwork for a transition to a post-state society, it still strikes me as more likely in the long run, if only because the concept of a concentration of power that is somehow not inherently corrupt and self-serving — the defense of government made by well-meaning people — sounds like “we can make a square circle if we try hard enough, honest!” to my ears.Report

  15. Avatar Jason Kuznicki says:

    At this point we reach what I will call the Pragmatist’s Dilemma. I’ve reached it with many aspects of libertarianism. Universal healthcare, for instance, has many working examples across the developed world. Free market healthcare, on the other hand, does not.

    The Pragmatist’s Dilemma would never have given us the First Amendment, either.

    I am not saying it’s necessarily the right approach to decontrol everything about medicine. But I am saying that if you’ve found the right approach, it’s for the wrong reason.Report

    • Avatar E.D. Kain in reply to Jason Kuznicki says:

      Oh I’m not sure about that. The First Amendment was a long time coming, I think. Nor would I compare the absence of government healthcare to something like freedom of speech. In any case, as I’ve said before I’d happily deregulate healthcare and just have government pay the bills (my favorite cost-control mechanism is still some combination of HSA’s and government insurance on top of a fairly deregulated healthcare industry).Report

      • Avatar Jason Kuznicki in reply to E.D. Kain says:

        Significant aspects of the First Amendment were entirely untried, including banning post-publication censorship (and not just banning prior restraint), as well as disestablishment of religion over a large geographic area.

        The First Amendment may have been a long time coming, but only a few could see it at the time.

        But again, I’m not comparing the absence of government healthcare to the First Amendment. I’m saying that “no one’s ever tried it before” is not a very convincing reason.Report

        • Avatar E.D. Kain in reply to Jason Kuznicki says:

          True, but that’s not the entirety of the argument. Re: anarchy, the argument Matt provides above is that an anarchist society will be unstable because of outside hostilities, not merely because we’ve never tried it before. We’ve certainly had a society that did not provide healthcare to all its citizens, though it may not be a mirror image of the free-market version of health provision that libertarians provide. More to the point, I think healthcare is one area where libertarians do not get bang for their buck, and where influencing the sort of universal healthcare we eventually adopt makes more sense than opposing it outright.Report

          • Avatar Pat Cahalan in reply to E.D. Kain says:

            > The argument Matt provides above is
            > that an anarchist society will be unstable
            > because of outside hostilities, not merely
            > because we’ve never tried it before.

            I’m sympathetic to this argument (it’s my argument against cap-L libertarianism), but it’s admittedly weak.

            There are great number of non-libertarian, non-anarchical societies in the historical record that ain’t around any more, and a non-insignificant proportion of them failed because of outside hostilities.

            This includes empires, polities, city-states, monarchies, republics, clans, dictatorships, democracies, and a partridge in a pear tree.

            Given a big enough “outside hostility”, you can make anything fail. The question is, which ones are resilient to what sorts of outside hostilities.

            One can certainly make the case that the Afghan clan structure has survived outside hostilities for a lot longer than anything else, even as it has been submerged under another layer of regime time and again.Report

            • Avatar E.D. Kain in reply to Pat Cahalan says:

              Sure, and I think we’ve stumbled on a pretty good mixture of resilient non-state institutions coupled with a democratic government. We should obviously work to improve the status quo, and there are many areas of government that should be more severely limited, but in my opinion those areas are almost all either related to the war on drugs/terror/actual wars.Report

              • Avatar Koz in reply to E.D. Kain says:

                I don’t. The consolidation and centralization of the public sphere at the expense of the private sphere has taken away the ability of private actors to set the cultural agenda.

                And considering how much you tend to oppose the Drug War, I wonder why you want to make an exception for it. Control over public policy is about more than numbers. There might be a majority of Americans who would like to dial back the Drug War. But the institutions running the Drug War have some unopposed cultural power to continue the Drug War according to the laws of inertia, cultural power which you seem to endorse.Report

              • Avatar Pat Cahalan in reply to Koz says:

                > The consolidation and centralization
                > of the public sphere at the expense
                > of the private sphere has taken away
                > the ability of private actors to set
                > the cultural agenda.

                Here’s one of those cases where you take the football and run off the end of the earth with it, Koz.

                One can easily make the case that the consolidation of the public sphere has had a negative impact on the greater culture. I gots no beefs with you there, sir. On board. Ticket ready for the conductor.

                But “cultural agenda” is a pretty fuzzy concept to begin with, and “taken away” is somewhat overreaching, given that “cultural agenda” itself is a pretty fuzzy concept.Report

              • Avatar Koz in reply to Pat Cahalan says:

                I disagree. I think it’s pretty clear what cultural agenda means here, ie the policies and related crap from the Drug War. The people who implement the Drug War are in fundamental ways not accountable to us and pretty clearly organized against us.

                And this situation goes beyond the Drug War as well.Report

            • Avatar Stillwater in reply to Pat Cahalan says:

              I would add that an anarchist society would be vulnerable to ‘inside’ hostilities as well.Report

          • Avatar Chris in reply to E.D. Kain says:

            anarchist society will be unstable because of outside hostilities

            This is something I’ve heard a lot, but it doesn’t seem to have any evidence behind it, at least if the “threats” are of violence. The first days of the Spanish Civil War, and the Makhnovshchina against Denikin, imply differently, to take a couple examples. Anarchist groups seem, to me at least, to be able to organize and react, and to move organically, in a way that is quite effective against outside threats.

            Even if the threats are not military, I think the sentiment comes from a failure of imagination, rather than a real consideration of the weaknesses of anarchism.Report

          • Erik, you sound like a Hobbesian.Report

        • Avatar Tom Van Dyke in reply to Jason Kuznicki says:

          For the record, the First Amendment didn’t disestablish. Religion was left to the states. Massachusetts had an official state church until 1833. I know you knew that, but some may have got a false impression.Report

      • Avatar Koz in reply to E.D. Kain says:

        “..(my favorite cost-control mechanism is still some combination of HSA’s and government insurance on top of a fairly deregulated healthcare industry)..”

        Let’s stipulate that this is our desired end state (HSA’s = MSA’s right?).

        The operational mode of political activism of Team Blue, ie the centralization and consolidation of cultural power to public actors at the expense of private actors, is the barrier that keeps us from getting from here to there.

        As we’ve seen with PPACA and Medicare, government consolidation of healthcare is an existential threat to the private economy, therefore generates substantial political resistance. In order to overcome this resistance, the actual government health care programs/policies must be generous and comprehensive (especially comprehensive). That’s the difference between PPACA and Medicare on one hand, and Medicaid on the other. Because Medicaid is less generous and its beneficiaries less powerful, it’s less of a threat because when push comes to shove you can always cut Medicaid.

        If you flip it around, to a path where the collectivization doesn’t happen first, you don’t have this problem. People get into the habit of paying medical and quasi-medical expenses themselves (and get the benefits of cost-shopping, like you’re supposing) and then will look for public or private insurance to cover the risk they don’t want to take.Report

        • Avatar Kimmi in reply to Koz says:

          say whut? rofl.
          Big Auto ran Obama’s health care pitch (and not because he bailed them out — they started it well before).

          Not having universal health care puts all non-health-care industries at a competitive disadvantage to overseas companies.

          “Existential threat to the free market” bhahaha.Report

          • Avatar Koz in reply to Kimmi says:

            Hmm, it’s hard to see offhand why this should be so difficult for you.

            The world economy is being roiled by a series of sovereign debt crises. The biggest contributing element to sovereign debt crises is health care expenses, for just about every country that’s having one, of which there are many. Increasing HC converage increases HC expenses.

            This basic dynamic is crippling the US, and a bunch of other countries as well.Report

    • At some point in the past every new creation had no prior working examples.Report

  16. Avatar Stillwater says:

    Excellent post, EDK. It gets me athinkin’…

    Ideology can be criticized from the ‘outside’ on two counts: that it may (or may not) be internally inconsistent or based on false premises, and that substantive policy prescriptions derived from (a priori) first principles still require empirical justification. Most critics of a particular ideology like to focus on the first, but it’s the second that really carries the weight, at the end of the day, since any enacted policy by definition exists in the empirical world and has real world effects. So empirical evidence ought to, and in fact does, come into play here, and in a big way.

    Now, I’d like to characterize ideology as a set of beliefs based on self-justifying a priori truths that can be rationally maintained independently of empirical evidence. And maybe that’s the right way to characterize it. But if a theory purports to explain/prescribe real world, empirical phenomena, which is certainly the case with ideological theories of political-economy, then it must include an algorithm which incorporates relevant evidence back into it’s own basic principles to be complete. If reality doesn’t act as a check on the theory, or otherwise inform the theory, then I’m not sure what utility the theory has beyond mere emotionalism, tribal identification and/or opposition.

    And each of those can be useful roles for an ideology to play, especially given the complexity of policy and diversity of culture. But if these are the identified roles justifying ideology, then it is transparently limited and incomplete, since by assumption, it eliminates or discounts the intrusion of the empirical into what ought to be, and in fact is an (almost entirely) empirical issue.

    And given the limits of ideological thought, one could construct an Ideologue’s Dilemma: can someone embrace an ideology while accepting that empirical evidence ought to play a role in justifying it? Can someone rationally choose to limit the range and types of evidence that ought to inform their beliefs?Report

  17. As far as health care goes, there’s no doubt I support a national single-payer system, but worse than that would be hastily crafting a national single-payer system. It might be more prudent for the time being to let federalism work like it’s supposed to and have the states serve as laboratories.Report

    • Avatar Jesse Ewiak in reply to Christopher Carr says:

      I don’t support throwing people away for the crime of living in the wrong state. On a lot of the little things, I’m perfectly OK with the states having leeway. But on certain things, if we’re not going to do things as a nation, what’s the point of _being_ a nation? If as some libertarians want, we let Social Security, Medicare, and everything else run by the states and have the federal government only around to fund the military and give tax cuts to rich people, why don’t we just split into a few different nations?Report

      • “Why don’t we just split into a few different nations.”

        Provided none of these had *our* immigration policy, I’d support formal dissolution over greater centralization.Report

        • Avatar Jesse Ewiak in reply to Christopher Carr says:

          I guess that’s where we differ. I may be a social democratic agnostic-atheist, but I’m still an American and I believe that we’re better off as one nation figuring things out that letting the South crater into a second-tier Banana Republic. Or if you’re of a conservative persuasion, let California go into default within three weeks.Report

          • That’s not really what I’m talking about, but since you brought it up, I’ll repeat what I said in different words: that as long as there is freedom of movement, our citizens would be better off as a whole and the south will not devolve into a banana republic. The other alternative is people who think they know more about what I should do than I do telling me what to do. That can’t do.Report

  18. Avatar Tom Van Dyke says:

    Trum, it comes down to whether we obviate “society” and simply make it synonymous with government. This is how they do it in the Eurostate, where the giving patterns are roughly the same as Blue America’s.

    To hit the Reason article per Arthur Brooks,

    The people who give the least are the young, especially young liberals. Brooks writes that “young liberals—perhaps the most vocally dissatisfied political constituency in America today—are one of the least generous demographic groups out there. In 2004, self-described liberals younger than thirty belonged to one-third fewer organizations in their communities than young conservatives. In 2002, they were 12 percent less likely to give money to charities, and one-third less likely to give blood.”

    Now, the 12 percent part falls almost within the margin of error; I don’t make much of it.

    But giving blood? This is something we all can do regardless of circumstances, state, or financial situation. This I find of some significance. Unless the gov’t starts a plasma draft [not unthinkable], the organic notion of “society” still has a vital claim to the polity.Report

    • In my experience, young liberals are not the most vocally dissatisfied group in America. That distinction belongs square on the shoulders of the Tea Party.Report

      • Avatar Tom Van Dyke in reply to Christopher Carr says:

        Dude, the Tea Party is new, and libertarian at that. It took a lot to get them out of their homes, where they prefer to be.

        Young liberals, they been at this like forever. Let’s get real here. We’re talking about giving blood, or at least the stats are. This doesn’t make “young liberals” bad persons, but c’mon, CC, there’s a quantifiable phenomenon here that can’t be fogged over.Report

        • Avatar Jaybird in reply to Tom Van Dyke says:

          They don’t strike me as particularly libertarian but I imagine that my vantage point is significantly different from that of others.

          If they remind me of anybody, they remind me of the ANSWER crowd.

          Republicans like drum circles too.

          Who knew?Report

          • Avatar Tom Van Dyke in reply to Jaybird says:

            The Tea Party is libertarian. Deal w/it. There’s a residue of social conservatism, but sodomy laws are not going to be reinstituted, if Roe is overturned, abortion law simply reverts to the states, and current drug law is not going to be intensified.

            Neither is theocracy on the agenda. In Jesus Christ We Trust is not going to make its way into the Constitution or onto our currency. So let’s dispense with the demagogic hysteria, and call a spade a spade. The Tea Party is the first real expression of libertarianism since like ever.Report

            • Avatar Jaybird in reply to Tom Van Dyke says:

              Don’t get me wrong. I’m not *OPPOSED* to the tea party. I think that people getting together and petitioning their government (or just standing on the corner and holding signs that say some variant of “HONK”) is a sign of an engaged population and, for many years, the only folks who would go out and yell things were the “Free Mumia” people.

              That doesn’t mean that I don’t seriously get a vibe of “it’s only a Constitutional Republic unless we’re a majority in which case it’s a Democracy” from them, though.Report

              • Avatar Robert Cheeks in reply to Jaybird says:

                I think the TPers are guns, Bibles, the American flag. They’re primarily baby boomers, and real conservatives whose agenda is federalism, state’s rights, instituting the 9th and 10th Amendments, and getting rid of Obama I and commie-dems. While they don’t intend to stomp on anyone’s liberties,, they’re tired of subsizing everyone from the voluntarily poor to corporations.Report

              • Avatar Kimmi in reply to Jaybird says:

                J,
                I am. Reactionary Romantic Astroturfing? Ain’t my cuppa.Report

            • Avatar Kimmi in reply to Tom Van Dyke says:

              In Koch We Trust.
              (seriously, who chose him to rep your movement? I think that’s just nucking futz.)Report

            • Avatar Jason Kuznicki in reply to Tom Van Dyke says:

              The Tea Party is libertarian. Deal w/it.

              I will believe that the Tea Party is libertarian when they start complaining about the War on Drugs. Not until.Report

        • I’m not trying to fog over anything. I’m just qualifying your point.Report

        • Avatar Kimmi in reply to Tom Van Dyke says:

          say whut now? Reactionary romantics are now libertarian? If I was a libertarian, I wouldn’t want to be associated with such ilk.Report

    • Avatar NoPublic in reply to Tom Van Dyke says:

      As long as tithing to your local mega-church so they can build a bigger school for your kids to go to or a bigger ampitheatre for rallies counts as charity this metric is going to be irreparably skewed.Report

      • Avatar Will Truman in reply to NoPublic says:

        And the donated blood? They’re using it as paste for the amphitheaters? Is the money they give to non-religious charities really some sort of complex laundering scheme?

        More seriously, if you want to dismiss inconvenient data. First, determine what data you are dismissing. Christopher Carr comes up with a good reason why conservatives might donate blood, for instance.

        But you dismissed the data without knowing what it is by assuming that it was data (total annual giving to any charitable organization) easy to not only dismiss, but present as selfish.Report

        • Avatar Tod Kelly in reply to Will Truman says:

          If I may, I think this is an instance where both sides are arguing slightly related truths from different points of view.

          As I said up a bit, Tom is correct individuals in conservative and poorer states give more per capita than other states. I think Tom & Will are right that this deserves some consideration, and at the very least should be enough for liberals to reconsider whatever “conservatives just want people to suffer” caricature they have bouncing around in their head. (I have never seen stats regarding Tom’s claim that young libs give less, but I can’t say it would surprise me.)

          But the other side has a macro point, too. Issues like feeding the poor, education for the non-rich, medical care, caring for the developmentally disabled, etc… These are things that private charities did in fact do before the government stepped in – but they only did it for a small part of those in need. The idea that these people were all given a hand up until the government stepped in is as much a myth as the ‘conservatives wanted people to suffer’ line. Hell, there is a reason that government stepped in to feed the poor, and school those not wealthy enough for private schools, or make sure the developmentally disabled weren’t just left to die from neglect. It is because private enterprise and charity didn’t do a very good job of it.Report

          • Avatar E.D. Kain in reply to Tod Kelly says:

            Good point, Tod.

            I’d like to add that this is all sort of a smoke and mirrors discussion anyways. Red states give more to charity. They also take more in government dollars than they pay out. They also have higher percentages of people who attend church and pay into church charities. Blue states pay higher taxes so there’s less money to go to charities, but a lot of those taxes are used for the same purpose and in conjunction with a lot charity work.Report

            • Avatar MFarmer in reply to E.D. Kain says:

              This doesn’t say anything about the tax rates of individuals in “red” states who give to charity. Talk about smoke and mirrors. Just because the state as a whole gets more from government than it pays in, says nothing about individuals. The individuals who give to charity could be paying just as much in taxes as those in the same brackets in “blue” states, and they may not receive directly anymore in services paid from federal dollars than the average person in a “blue” state. The whole blue state, red state thing is silly to start with.Report

            • Avatar Will Truman in reply to E.D. Kain says:

              They also take more in government dollars than they pay out.

              Because Yellowstone National Park is nothing but a welfare program for Wyomingans. And the PILTs the government pays on the half of Idaho it owns is charity to Idahoans. The military bases in Montana and the personnel there are not payments for services rendered, but are really giveaways. The same applies to the nuclear silos in the Dakotas.

              I mean hey, look at the map. The red states OWE US (or the blue staters, anyway). They only HAVE the money to donate to charity because the federal government spends more in those states than it takes in. Look at the map, man!Report

              • Avatar Tom Van Dyke in reply to Will Truman says:

                Red state/blue state is an unnecessary blurring of the basic claim: only true if liberals have different giving patterns in Wyoming than they do in New York, or conservatives in West Virginia and Massachusetts. This is not in evidence so far.

                As for the tithe thing, Arthur Brooks claims elsewhere that “Believers give more to secular charities than non-believers do.”

                http://www.hoover.org/publications/policy-review/article/6577

                Basically, I was contemplating giving patterns in the Eurostates being similar to those of the leftish persuasion in America. Brooks wrote in 2003:

                If this prediction seems hyperbolic, one should only look at the nations of Western Europe, often considered the ideological models for the American left, and in which religious practice and charity levels are generally far lower than those in America. Take Spain as an example: As this traditionally Catholic country ran full tilt toward socialism starting in 1982, the concomitant attitude of the Spanish governments toward organized religion and private philanthropy became unsympathetic. Charities and churches were viewed as usurping centralized power in social welfare and, even worse, as devolving funding decisions to individual (often wealthy, conservative) donors. The result was a tax system and other public policies that did not encourage private charity or a healthy nonprofit and voluntary sector.

                Today, the average Spaniard is 20 percentage points less likely than the average American to classify himself as “religious,” gives less than half as much to charity, and volunteers about one-fifth as often.7 And Spain has the highest level of charitable giving per capita in Western Europe (and has church attendance rates that are among the highest as well).

                Basically, I’m not making a big deal of this; it was only as counterfactual to the facile claim liberals give more [presumably because they’re nicer people]. However, I do think there’s strong indication that the more we leave social services to the state, the less we do on our own.Report

              • Avatar Kimmi in reply to Tom Van Dyke says:

                you’re distorting my argument. my argument was that the biggest givers are also quite liberal.Report

              • Avatar Jaybird in reply to Kimmi says:

                You may need to start naming the names of your spokespeople.Report

              • Avatar Will Truman in reply to Kimmi says:

                Kimmi, his comment is in reply to me, which is in reply to EDK.Report

              • Avatar Patrick Cahalan in reply to Tom Van Dyke says:

                > Red state/blue state is an unnecessary
                > blurring of the basic claim: only true
                > if liberals have different giving patterns
                > in Wyoming than they do in New York,
                > or conservatives in West Virginia
                > and Massachusetts. This is not in
                > evidence so far.

                Thank you, Tom. Yes, this is the actual question to be asked and answered at this point (and oddly enough, this is the first time in all the Red/Blue GOP/Dem blathering about charity that anyone’s mentioned this). Are you sure you’re not a closet sociologist?

                Somebody somewhere has to be working on this.Report

              • Avatar Tom Van Dyke in reply to Patrick Cahalan says:

                Pat, my guess is that the academy has zero interest in proving Brooks right.Report

              • In fact, the article you cite doesn’t really look at red state and blue state, but is specifically looking at liberals and conservatives wherever. There are reasons to be suspicious of it or dismiss it, but not that damnable, distorting map.Report

          • Avatar Will Truman in reply to Tod Kelly says:

            Tod, I don’t disagree with a thing you say here. I agree that private enterprise and charity have their limitations.Report

        • Avatar NoPublic in reply to Will Truman says:

          I know at least an anecdote’s worth of young liberals who don’t donate blood because the blood bank sells it.

          I know many folks who don’t claim charitable donations on their tax returns because they believe it’s a bad idea to make charity deductible.

          On the other hand I know bugger all folks who donate to shiny mega churches who don’t take out full page ads trumpeting how wonderful they are.

          Given these data (anecdotes) I draw my own conclusions on all collections of data on these subjects.

          YMMV.

          (Happy now?)Report

          • Avatar NoPublic in reply to NoPublic says:

            Non-snark answers

            1) Charitable giving metrics are
            a) unreliable
            b) skewed to Conservative directions by church tithing
            c) not an accurate measure of actual charity (see HfH etc.)

            2) When being gay, traveling to certain countries or getting a piercing or a tattoo in the last 12 months disqualifies you from donating blood I don’t know how any even remotely liberal 20-something ever manages to donate these days (ok, that was still a little snarky)Report

  19. Avatar Rufus F. says:

    Will an anarchist utopia come to pass? Probably not, but that’s fine. A society defined completely by any one political ideology would most likely be miserable to live in.

    Anarchist ideas are still helpful in understanding why large, hierarchical organizations seem to manifest all of the same problems: administrative bloat, little to no information flow between layers (everyone lying to their boss or subordinates), needless replication of functions, fraud, waste, and intellectual sclerosis: it’s the power/authority at their base. The anarchist ideal is to form social groupings under intentionally anti-hierarchical, non-coercive, and cooperative lines. Stephen Pearl Andrews offered the image of an ideal anarchist society as a dinner party in which authority dissolves into mutually inclusive conviviality. An implication, I think, of that image is that the model works best in smaller groups: bookstores, seminars, small shops and businesses, co-ops, bars and restaurants, and the like. I’ve taken part in “anarchist” versions of all of the above, as well as seen plenty of others that unwittingly and unintentionally formed along “anarchist” lines. It’s just another model for doing things that tends to work a lot better than most people expect. The assumption is always that someone has to be in charge and holding the sticks and carrots or nothing will get done. It’s not always the case.Report

    • Avatar Kimmi in reply to Rufus F. says:

      Anonymous serves as another anarchist model.Report

      • Avatar Rufus F. in reply to Kimmi says:

        If online groups count, we could say any number of websites and groups “serve as an anarchist model”. Even this one, from time to time. It’s debatable whether the norms governing the internet itself aren’t more anarchist than hierarchical.

        But we’re talking, or we should be, about how people organize themselves in real world social groups to get things done. Having to live and work with other people in the world should count for something. It’s harder than hiding behind a fake identity in the make-believe world online. It’s too easy to use the internet as a substitute for real world interactions. And all too common.Report

        • Avatar Rufus F. in reply to Rufus F. says:

          Also, we’re all clear on the Internet being profoundly counterrevolutionary, right? Or will it take another generation for that to sink in?Report

            • Avatar Rufus F. in reply to Tod Kelly says:

              You know those elderly Tea Partiers that my younger friends all joke about (in their Facebook updates natch) because they can’t use the Internet very proficiently? Because of that, they’re forced to get out and march around and use the older social media, like signs and bullhorns, to get their points across. Meanwhile, people in my age group, if they get really fired up, will forward an angry post from Twitter or Facebook to their friends. Maybe if they’re really mad, they’ll write a blog post and, hey, maybe thousands of people around the globe will see it and nod their heads.

              Next year, whose opinions do you think will be better reflected by the existing social and political structures?Report

              • Avatar Kimmi in reply to Rufus F. says:

                #egypt/#libya disagree with you.Report

              • Avatar Rufus F. in reply to Kimmi says:

                It’s not possible that the conditions under Middle Eastern tyrannies are different from those in North America?Report

              • Avatar Rufus F. in reply to Rufus F. says:

                Also, since it’s entirely possible to imagine the street protesters without any Twitter still toppling the government and totally impossible to imagine a Twitter feed without anyone in the streets actually toppling a government, I’m not sure why those #people would actually disagree, if they really would.Report

              • Avatar Kimmi in reply to Rufus F. says:

                … are you familiar with flashmobs?Report

              • Avatar Rufus F. in reply to Rufus F. says:

                Are you familiar with revolutions before Twitter?Report

              • Avatar Kimmi in reply to Rufus F. says:

                ya mean that revolution they based off The Postman, or the one before that?
                I can make a convincing argument that democratizing the fourth estate tends to coincide with revolution/revolt (I think. not a history major)Report

              • Avatar Rufus F. in reply to Rufus F. says:

                Ah, now it’s ‘coincides’, where below it was ‘produces’. Look, my argument is very simple. If I call my friend Tom on the phone and we agree to rob a bank together, and then do so, the phone did not produce the bank robbery any more than Twitter produced a revolution. The unsatisfying flip side of that, I suspect, for many Westerners is that people who tweeted about the revolution from the comfort of their living rooms in North America were not actually taking part in a revolution themselves.Report

              • Avatar Kimmi in reply to Rufus F. says:

                … so does the google exec count as a revolutionary or not?
                How about Julian Assange?

                The internet is a tool, and a fascinating one at that. It reduces the need for men as leaders — agents like Facebook are able to produce consensus in a fashion more conducive to women leading.

                (yes, I changed from “produces” to coincides. I might be able to defend “facilitates”, particularly if I throw in global strikes — produces is far too strong a claim to be able to substantiate over the long term).Report

              • Avatar Kolohe in reply to Rufus F. says:

                “It reduces the need for men as leaders — agents like Facebook are able to produce consensus in a fashion more conducive to women leading.”

                Super serious – would you do a guest post on this. I don’t agree, but would really like to hear a contrary argument.

                (It would, at the very least, be super-ironic given Facebook’s origin as a method of rating the attractiveness of coeds)Report

              • Avatar Kimmi in reply to Rufus F. says:

                oh, it’s definitely Possible. But Anonymous is a First World organization, primarily.
                You can make the argument that
                1) the amount of revolution the internet has produced is relatively minimal compared to its size/capacity
                2) the amount of attention-draining (chris-chan/Encyclopedia Dramatica) is making the internet ineffectual.
                3) That changing multiple states in another part of the world isn’t really significant (visavis the contemporary power structures. I would counter with stockmarket realignments during that period).Report

              • Avatar Kolohe in reply to Kimmi says:

                Plus, we don’t know how that will all play out.Report

              • Avatar RTod in reply to Rufus F. says:

                I guess whether it is counter revolutionary depends greatly upon who you are rising up against.

                This is a really good point.Report

              • Avatar Rufus F. in reply to RTod says:

                Okay, I sort of jumped past a point I was trying to make and it’s important to get my language clear because some of my words are fuzzy. What I said was that anarchist theory is one way of understanding how people can organize social groups in order to accomplish things together. All of that is maybe vague, but specifically, by “social groups” what I meant was maybe the ‘old’ meaning in which a social group is a collection of individuals bound by fellowship or companionship in the company of one another on a semi-regular basis. It is how people associate with one another in each other’s company in the physical world. Therefore, by ‘social group’, I don’t mean something like the Youtube message board or 4Chan or the League of Ordinary Gentlemen. We are not in each other’s company and, more importantly, we don’t have to live with each other in any capacity, work together, or interact in any sort of face to face relationship. It’s nothing personal to you folks, but I consider this to be a communications network, even if it is generally a friendly one, and not a social group.

                This is separate from the question about the revolutionary potential of the Internet.Report

              • Avatar RTod in reply to Rufus F. says:

                I get that, and I think your observation is dead on. I hadn’t tied it back to the anarchy part.

                Whenever I hear about computers being revolutionary, I always assume it means in an anti-corporatist business sense.Report

          • Avatar Jaybird in reply to Rufus F. says:

            we’re all clear on the Internet being profoundly counterrevolutionary, right?

            Utopia has always been counterrevolutionary.Report

  20. Avatar Tom Van Dyke says:

    Hey Johnny, what are you rebelling against?

    –Whadda you got?Report

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