After the Future

The Healthcare Technocracy & the Pandemic

So, without realizing what has happened, the physician in the last two centuries has gradually relinquished his unsatisfactory attachment to subjective evidence—what the patient says—only to substitute a devotion to technological evidence—what the machine says. He has thus exchanged one partial view of disease for another. As the physician makes greater use of the technology of diagnosis, he perceives his patient more and more indirectly through a screen of machines and specialists; he also relinquishes control over more and more of the diagnostic process. These circumstances tend to estrange him from his patient and from his own judgment.

...

There are, one may be sure, very few doctors who are satisfied with technology’s stranglehold on medical practice. And there are far too many patients who have been its serious victims. What conclusions may we draw? First, technology is not a neutral element in the practice of medicine: doctors do not merely use technologies but are used by them. Second, technology creates its own imperatives and, at the same time, creates a wide-ranging social system to reinforce its imperatives. And third, technology changes the practice of medicine by redefining what doctors are, redirecting where they focus their attention, and reconceptualizing how they view their patients and illness.

Neil Postman, Technopoly, 1992 (pp. 77-79).

I think it was Pascal who made the distinction between the spirit of geometry and the spirit of finesse. We need both; what is lacking, particularly in the technocratic Liberal Order these days, is the latter. Finesse is another name for what Aristotle called phronesis, which is usually translated as 'practical wisdom'. It combines intuition with what we've learned from experience. The spirit of geometry is what we mostly encounter in the healthcare system and all the ways that healthcare judgments have been subordinated to statistical probabilities and the data generated by machines. One would think that the spirit of finesse is something that one would value in a competent health care provider, but that's rarely what one finds. 

The problem, of course, is that in the technocratic ethos that defines the delivery of health care in American society, finesse and subjectivity are not privileged in the same way that data-driven decisions are. And while the spirit of finesse, like most talents, is something some people have more innate capacity for than others, it's a talent that needs to be developed through use and experience. But its chances for development are attenuated in a society that does not value it. 

It doesn't require finesse to determine that 2 + 2 = 4. You just need a mind that operates in a mechanically logical way. And in our day-to-day life a lot of what passes for wisdom is really process knowledge that follows algorithms--it's automatic and mechanical. And too often this is the kind of solution you're going to get when you go to your doctor complaining about this or that ailment. His remedy is very algorithmic--x problem requires y procedure or z med. You're up the creek if you have a pattern of symptoms the algorithms don't recognize. Horror stories abound, and I have my own to share. It's no wonder to me why people would look outside the system for solutions to problems it seems unable to adequately to deal with. 

Anybody who has dealt with healthcare system has probably had to deal with people who are nice and well meaning, but rigidly conventional in their thinking. In a technocracy that means that their thinking is circumscribed by the spirit of geometry. They will only tell you about solutions that research or the data support. They will reject personal testimony as unscientific and anecdotal. And that's fine so far as it goes, but much better is to find a provider who both knows the research and also has a well developed spirit of finesse. In other words, a mensch. But it's unlikely that you will ever find one. 

While anybody who has read this blog over the years knows that my biases are with the Left, I have always found that I share common ground with the Right's distrust of technocracy. And I think that many on the Left might be more sympathetic to the underlying distrust that attracts so many Americans to MAGAism and its fear of big government and bureaucratic control if they spent some time reading Left-ish critiques of the technocracy, such as the critiques of Neil Postman and Christopher Lasch. And understanding their critiques might be helpful in understanding why all this distrust has come to a head during the pandemic.

And it's important for Democrat elites to use the pandemic as an opportunity to look at themselves in the mirror and face the fact that in the popular imagination the Democratic Party has become identified with the promotion of a soulless technocracy. I don't know that very many Democrats in this country fully understand the implications. That's because most educated Democrats are very well adapted to living in a technocracy and tend to be blind to its inadequacies until the have a personal crisis that requires that they deal with it, particularly in its health and legal systems. 

The common ground shared by both Left and Right critiques is a distrust for a class of trained "experts" who know the data but who lack any common sense or any of what I'm describing here as the spirit of finesse. We want to deal with people who know what the rules are, but also know when to break them. That requires a well-developed spirit of finesse. But the healthcare system is mainly designed to protect itself and to enrich its principals. There can be no rule breaking because that makes the system vulnerable to lawsuits. So regardless of the competency or good will of individuals working within it, the system has given ordinary Americans little reason to trust or admire it. 

Most Americans have encountered the healthcare system only when they have a personal or familial healthcare crisis, and that's when they learn what a soulless system it is. In that system, you are only your data, and while you might find a provider that has a cheery bedside manner, it's only a thin veneer that hides the training and protocols that require this person to make strictly algorithmic decisions about your care.

So the problem lies in that most people's experience of the healthcare system they often find that they are dealing with providers whose jobs are about serving them in moments of when they are coping with the profoundest issues of life and death, but who are forced by the system to work with them as if they were just data points on a spread sheet. It's understandable why so many Americans have come to see healthcare professionals as cheerful robots at best or arrogant Gregory Houses and imperious Nurse Ratcheds or at worst.  

I'm not saying that healthcare providers don't care about their patients. I'm not saying that they are themselves soulless robots. But the system forces them to behave as if they were. Even if they would bring a certain menschiness to their treatment decisions, the threat of a lawsuit hangs over every decision they make that does not follow strict protocols. There are no incentives within the system for anyone to exercise the spirit of finesse.  

I think that the pandemic has brought the contradictions inherent in the healthcare system to a head. This has been a time when we needed to trust the expertise of our healthcare professionals, but our experience with it has given us little reason to. Many Americans for good reasons are predisposed not to trust it. 

But during a pandemic the tragedy lies in that what we need is what we most dislike about the healthcare system, which is the rigor of the spirit of geometry.  A pandemic is the one place in medicine where the individual doesn't matter; he or she really is just a data point on a spread sheet because public health is all about statistical outcomes. The individual's well being is deeply implicated in the well being of billions of others. And whether freedom-loving Americans like it or not, they are all part of a global system where their individual well being and behavior is deeply linked to the well being and behaviors of people across the globe. A global pandemic is one situation where one's individual freedom must be subordinated to the common good, and it's one place where data and algorithmic calculation should shape national policy.

The tragedy lies in that people who understandably distrust the technocratic ethos of the healthcare system from their own personal experience of it, are likely to distrust it regarding public health. When they hear the pronouncements of the epidemiological bureaucrats, It feels like the same old soulless bureaucratic thing that they've come to hate about the healthcare system. If you dislike or distrust the healthcare system in one context, why should you trust it in this other? I think Anthony Fauci is a mensch, but I understand why he's so vulnerable to be vilified in the way he has been. 

Over the last several weeks the talking-head docs on TV have been saying that the vaccine hesitant should trust their local health care providers and their exhortations to get vaccinated. But how many people have a personal relationship with their local healthcare provider? And so why would they be more likely to trust him or her? Why would they trust anybody whom they see as merely a functionary of the healthcare technocracy?

In my own case, my provider is a nice enough guy, but I don't know him and he doesn't know me except for what's on my chart. When I visit for my once-a-year check up, I listen and ask questions, but I take every thing he says with a grain of salt. He provides some information that I recognize as important, but I evaluate it within a broader spectrum of information I take into consideration when making decisions about my health. 

For better or worse, I trust my own spirit of finesse over the recommendations of someone whose advice is legitimated only by the spirit of geometry. I have come to believe that I must supply what he lacks. Better if I could find a doc who had both, but good luck finding one. 

Stephanie Kelton, Big Gummint, Central Banks, and the American Future

An MMT view of the monetary system changes the way we think about what it means for currency-issuing nations to “live within their means.” It asks us to think in terms of real resource constraints—inflation—rather than perceived financial constraints. It teaches us to ask not “How will you pay for it?” but “How will you resource it?” It shows us that if we have the technological know-how and the available resources—the people, the factories, the equipment, and the raw materials—to put a man on the moon or embark on a Green New Deal to tackle climate change, then funding to carry out those missions can always be made available. Coming up with the money is the easy part. Managing the inflation risk is the critical challenge. More than any other economic approach, MMT places inflation at the center of the debate over spending limits. It also offers a more sophisticated array of techniques for managing inflationary pressures than what we have today.

Kelton The Deficit Myth (pp. 234-35). 

I've been reading Stephanie Kelton's The Deficit Myth, and it's one of the best things out there to clarify why Bernie was right and why the Clinton/Obama/Biden/Pelosi wing of the party was wrong--not to mention all Republicans of the Paul Ryan ilk. The federal deficit isn't really a deficit, and anybody who uses the term "deficit spending" pejoratively to justify cutting entitlements or to resist spending on programs like Medicare for All is either ignorant or cynical.

Every time some smart-ass journalist asks a Sanders or a Warren how they are going to "pay for it", they are asking a political, not an economic question. It's political because most Americans think that the federal budget is essentially the same as a business or family budget where expenses have to be covered by revenues. It's just not how it really works. But politicians need  to justify their programs in terms that economically unsophisticated Americans can feel comfortable with. So they feel compelled to come up with some pretext to justify their program by analogy to the household budget. 

The Republicans might come up with some ridiculous pretext to justify their tax cuts by saying that they will stimulate the economy, which in turn will increase tax revenues that will pay for them. But it's been proven time and again with Reagan, Bush, and now Trump that these cuts only increase the so-called deficit. But each time the Republicans want their tax cut, they bring out their demonstrably false trickle down argument. But even so, the problem with the Republican tax cuts is not that they increase the deficit, but that they aggravate egregious concentrations of wealth and power in the hands of so relatively few.

But even Democrats buy into the 'deficit myth'. Bill Clinton did when he worked so diligently to balance the budget by cutting entitlements, and even now we see the influence of this myth when Nancy Pelosi insists on  "PAYGO". The U.S. is not in debt to the Bank of China, as Obama once said. The U.S. is not Greece or Venezuela or Bangladesh. As long as the U.S. has a vibrant productive economy and it has what Kelton calls monetary sovereignty, the government cannot run out of money or default--unless it chooses to, by for instance not raising the debt limit. Everybody--Democrats included-- who thinks that we have a defecit problem or that we are burdening future generations with debt is buying into an ideology that makes no sense after the collapse of the Bretton-Woods system in 1971.

Since then, the U.S. and other countries with fiat currencies can print as much money as they want, and the only limiting factor is inflation. That's a real limiting factor, but running "deficits" is not inflationary if managed competently. China isn't going to call in its chits, and the government isn't going to default so long as the U.S economy remains vibrant and productive. There are no economic reasons for Social Security to run out of money or for not funding universal healthcare or a robust program to renew the national infrastructure. The obstacles for achieving all these things and more are political not economic. The challenge is not lack of money, but lack of imagination and political will. 

For many Fiscal Puritans, the phrase "fiat currency" connotes an immoral profligacy. You can't just create money out of thin air, right? Money has to be grounded in something, like gold. Just letting it be whatever a government wants it to be is just wrong. This kind of Fiscal Puritanism runs strong in the American collective psyche, but it is the primary cause of the aforementioned lack of imagination that insists on focusing on delusional moralistic problems rather than real ones. Running the federal government like a business is a false analogy; it simply does not reflect how the economy works in countries with strong economies like the U.S., Canada, Japan, Australia, the U.K. and others that have monetary sovereignty. 

I am not going to rehearse all Kelton's arguments here, but there is no more withering, easily understood critique than hers to be found of the Neoliberalism that has dominated the elite thinking of the Washington Consensus whose destructive ideology has played a major role in creating the conditions that allowed for the rise of Donald Trump.

I have some hope that in the post-Trump reconstruction of American political institutions that we will find a way to reset to pre-Reagan when there was actually a consensus built around the legitimacy of the New Deal. We actually had a social democracy there for a while, but after 1980 the Neoliberals came to dominate elite thinking, and everything went badly wrong. It is astonishing how many smart people who should have known better--and who I think wanted to act in good faith--could be taken in by the Neoliberal con. Hopefully books like Kelton's and the emergence of the Sanders/Warren/AOC wing of the party will change that permanently. 

The challenge for them is rhetorical rather than technical: how to persuade most Americans that deficit spending is ok. That's a heavy lift because it just seems wrong. It's counter-intuitive, and it goes against everybody's common sense and experience about how money works in their personal lives. If we as individual households, businesses, and even state and local governments have to balance our expenditures with revenues, why shouldn't the federal government? If it doesn't, it should. . .  right? That's one point of resistance. The other is Americans' mistrust of big government and their discomfort with giving it too much power. This is a legitimate concern, but big gummint--bigness in general--is here to stay. The question is whether in the future ordinary Americans can make bigness work in their interests rather than in the interests of the oligarchs. 

***

Anybody who has read this blog over the years knows that I like to frame issues in loosely dialectical terms, as presenting polarities and then seeking to reconcile them. The fundamental polarity at work in the American political psyche pertaining here is Jefferson vs. Hamilton. The Jeffersonian impulse was carried mainly by Democrats through the 19th century, and the Hamiltonian impulse was carried by the Federalists, then the Whigs, and finally by the Republicans. None of us is completely Jeffersonian or Hamiltonian, but we lean one way or the other with recessive traits of the other manifesting from time to time. Yankees lean toward Hamilton; Southerners toward Jefferson.

Jeffersonians define freedom primarily in terms of freedom from big government and big concentrations of wealth and power in institutions like central banks. Hamilton wanted the U.S. to be a world economic and military power, and he saw a strong central government and a central bank as playing a critical role in effecting this rise to power. Hamilton won early on, but the Jeffersonians dominated the decades in the early 19th Century running up to the Civil War--although among Southerners Hamiltonian recessive traits emerged with their support for the war with Mexico and their fantasies of imperial expansion into the rest of Latin America. The Hamiltonian legacy was developed by his Whig heirs Henry Clay and Daniel Webster.

I think of Lincoln, a Whig-turned-Republican, as a Hamilton-dominant politico with recessive Jeffersonian traits. His greatness lies in his efforts to reconcile both, as so beautifully articulated at Gettysburg, but after him, the Republican Party became the vehicle for Hamilton-dominant thinking between the Civil War and WWI. Equality ideals were forgotten as Social Darwinism took hold in the North and Jim Crowe in the South.

By the second decade of the 20th Century, the heretofore Jeffersonian southern Democrats like Woodrow Wilson morphed into Hamiltonians in supporting the WWI and in bringing back the one thing truly anathema to Jeffersonians--the central bank. The Federal Reserve was created on his watch in 1913. By the time FDR took office, the only members of the Democratic party interested in invoking Jefferson were southern segregationists who looked for any pretext to stymie the federal government from interfering with their post-reconstruction apartheid system. In the late 19th Century Republican phase, the U.S. became a world economic power; in the post-Wilson Democratic phase, it became both a world economic and military power. The Party of Jefferson had become assimilated into the Party of Hamilton. 

There were, of course, the cranks like those in the John Birch society who were ok with the big business part of the Hamiltonian legacy, but were appalled that big gummint accompanied it. They were Jeffersonians of convenience like the Southern oligarchs. They hated a big government that would restrict them with regulations and anti-trust laws from doing as they please. They were the country-club Hamiltonians who saw FDR as a traitor to his class. But nobody in the power establishment took those cranks seriously until Ronald Reagan made it ok to be a Neoliberal. And we came to see that crankiness normalized through the efforts of the Koch Brothers and others who fund right-wing think tanks whose sole goal is to give a kind of intellectual legitimacy to ideas that are crudely designed to justify the dominance of the 1%.

Jefferson's vision for America was obsoletized by the Industrial Revolution and by the emergence of the U.S. as a world military power after WWI, and yet his influence lingers in positive and negative ways. We are Jeffersonians when we feel inspired by the ideals articulated in the Declaration of Independence. We are Jeffersonians when we feel uncomfortable not just with how the central U.S. government has grown into this massive surveillance state with hundreds of military bases throughout the world, but also with the way Wall Street and huge concentrations of corporate power and wealth have come to dominate the economic sphere. And we are Jeffersonians when we are appalled at how huge concentrations of corporate power meld with political power.

But we are Jeffersonians in the negative sense when we think naively that our freedoms only thrive to the degree that big government stays out of our lives. Bigness in the private and public sectors is a real problem, but you deal with it by making it accountable, and big government is the only means to keep huge, amoral corporate powers in check. And that requires a vigilant citizenry, not the morally complacent citizenry that lets a quasi-authoritarian crackpot like Trump get elected. 

We need to keep those positive aspects of the Jeffersonian imagination of America alive, but we need to realize that we live in a world that is shaped primarily by forces that Hamilton celebrated and are now out of balance. The question before us now is how to effect a political coincidentia oppositorum, i.e., to achieve Jeffersonian ideals using Hamiltonian means. In other words bigness is here to stay, and to wish it away is delusional, and to the degree that bigness leads to greater levels of inequality and unfreedom, it must be resisted by harnessing it. For me the question is whether a new leadership can emerge from the Trump chaos that has an imagination of an American future that embodies what is best about both the Hamiltonian and Jeffersonian legacies. 

The challenge is to manage bigness in such a way that the huge concentrations of wealth and political power don't accrue to the 1%--or the 20% for that matter. The challenge before us is to harness American economic power to enact policies that solve the problems of inequality and concentrations of wealth and power--not just in this country, but throughout the world. Going forward, the only real solutions are global solutions.

That might seem kind of unrealistic because it seems to require a mentality and an imagination of future possibility that is so not  who we are now. But if we live in this Hamilton-dominant imagination of America at the moment, I believe that our recessive Jeffersonianism--the most positive aspects of it articulated in the Declaration--can emerge as a balancing, integrating factor. Right now we are in chaos; we are anything but integrated and balanced. The thing to be feared is that we will embrace any kind illiberal order as an alternative to the chaos, but that just creates other imbalances that kick the basic problem down the road.  

If there is not an aggressive assertion of political will from progressives, the illiberal Right will win by default. Obama was a decent president, but he was a timid technocrat, and his timidity and his acquiescence to the Washington Consensus aggravated the conditions that promoted Trump's emergence. If Biden is another Obama, expect someone to emerge on the Right who will have learned from Trump. He willl have learned how easy it is to do egregiously illegal, unconstitutional things that can be tied up in the courts for years while he bends government institutions to his authoritarian will. If the courts finally decide against him, he will ignore them as Andrew Jackson did. It doesn't matter what the courts decide if the executive branch won't enforce it. But there's a good chance courts will support a post-Trump authoritarianism because Mitch McConnell has been stacking the federal courts with right-wing ideologues. 

For now at least I'm going to allow myself to embrace the more optimistic possibilities for an American future, and hope that Trump's absurd, chaotic presidency has created a sense of urgency that make something new possible, and that out of his chaos something new and better can be born. I believe something better is possible even if such a possibly poses an enormous challenge to our collective political imagination.

As Kelton's book points out, we have the resources, the Hamiltonian means, to do very good things. The only question is whether we will be hamstrung by, on the one hand, a tight-assed Fiscal Puritanism, the kind we see on display with Mitch McConnell and the Republicans who just hate the idea of extending unemployment benefits during a pandemic; and on the other hand, by a widespread moral lassitude and ignorance among ordinary Americans that allowed a ridiculous figure like Trump to take the White House in the first place. 

Mike Konczal on the History of the Welfare State

My argument in my overly long piece posted over the weekend is similar to the one Konczal is making here in this important, informative essay in The Atlantic. His point is that the development of the welfare state during the Progressive and New Deal eras was organic--that it was not the work of social engineers, but of pragmatists responding to the scale and complexity of life in a rapidly industrializing capitalist society.

If you have conservative friends who insist that progressives are social engineers who are destroying the fabric of traditional communities in a misguided utopian mission to create the good society, have them read this article. The Progressive left in this country did not destroy traditional society; for better and worse, capitalism and the industrial revolution did. Progressives are simply people who have sought practical ways to mitigate the suffering caused by its disruptions.

The Progressive tradition in this country is one that is pragmatic and realistically adapted to the economic and social realities people live. The conservative tradition in this country is populated largely by people living in a nostalgic fantasy about a time that, if it existed at all in America, existed before the Civil War. (Perhaps this mentality persists in the south, the rural midwest, and the mountain west because industrial capitalism was slower to come to those parts of the country. It's more complicated than that, but it's probably a factor.) 

Nevertheless, insofar as these arguments are broadly accepted as justification for the dismantlement or privatization of the social safety net programs developed over the last hundred years by Progressives, we are indeed regressing to the situation the Progressives confronted starting around the 1880s. My argument in the Burke v. Paine piece is that  Progressives are the more Burkean in their political approach, and that conservatives and Neoliberals are Tory reactionaries insofar as they are seeking to return the country to some impossible status quo ante of their imaginations. In doing so, they are forcing American society into unnecessary suffering that will simply require the development of solutions along the lines that we have already done. 

There are basically two arguments offered by Libertarians and Neoliberals that justify the dismantlement of entitlements. The first is the one that Konczal destroys in this article--it's better to let private charities handle it than faceless government bureaucracies. The second is that we can't afford it, and all the freaking out about the national debt, Social Security, and Medicare.

Is there some merit to the freak out? Yes and no.

Yes, because the Bush administration irresponsibly ran the country into the ground by lowering taxes at the same time that he began an enormously expensive and unnecessary war, and introduced Medicare Part D without cost constraints (e.g., allowing importation of prescription drugs from Canada) and raising taxes. That's Republican fiscal conservatism for you. 

Yes, because in the recent attempt to reform healthcare in the U.S., an attempt that was absurdly circumscribed by Neoliberal market ideology, we did little to nothing to address absurdly escalating costs in the healthcare system that people like Steven Brill have been exposing for their absurdity. 

No, because there's a difference between saying we can't afford it and we don't want to pay for it. The money is there, but it's in the pockets of people  who would rather spend it in buying politicians to make sure the poor and middle class get poorer than to support existing programs that mitigate their suffering or provide ways to deliver them from it.

The money is there, it's just a question of who gets to decide where it gets spent. That's a practical problem with a pragmantic solution, and that solution is impeded by, not driven by, ideologies divorced from reality. 

Crashing the Frame

I've thought a lot over the years about persuasion and why it's so difficult, especially when it comes to political values and opinions, and the best conceptual tool that helps me to understand the difficulty is 'frames'. There are individual and group mindframes, and more often than not you can predict the individual's thinking if you know his group allegiances. Independent thinking is rare. Arguments are about mindframes butting against one another, and mostly the mindframes of the individuals engaged in argument are determined by their conflicting group mindframes.

It's refreshing when you find an independent thinker. You have a chance, then, to engage in an honest conversation, but most people are not. Most people's thinking is derivative, they are mouthing what other, smarter people on their team have said. And even when they seem to have lost an argument, they console themselves in thinking that if Rush or Rachel were here, he or she would have set that guy straight. It's not the ideas that matter; it's the team you're playing for that matters. 

So to even have a conversation with such people you have to make arguments that accept as normative that person's frame, and in doing so you are usually doomed to failure when the interior logical architecture of the frame more often than not excludes the logic or facts you muster. You can argue about how much practical sense a single payer health care system makes, but the only response you're going to get from a Neoliberal is "That's socialistic; let's find a market solution."

So then your only option is to crash the other's frame and to introduce yours as a more adequate or desirable replacement. But that is extraordinarily hard to do--too much is personally invested in a frame, especially "ethos frames" (see below) because so much of one's sense of self and identity is invested in it, and with it one's sense of what is right and just. Let me explain.

The rhetorical tradition leans heavily on three foundational concepts: logos, pathos, and ethos, and I think it's helpful to think about logos frames, pathos frames, and ethos frames. A logos frame is defined by facts, analytical prowess, competency, practicality, getting things done--it's the frame that wonks work in and take most seriously. An ethos frame is defined by a group's beliefs, its sense of virtue and rightness, its values. It's the frame that most politicians operate in, whether they are influenced by the Tea Party Right's ethos, or the politically correct ethos of the cultural left.  A pathos frame is defined by a person's or group's desires and fears: What do we really want? What do we want to avoid? The Frank Underwoods are primarily driven by the pathos of power or greed, and logos and ethos arguments are irrelevant for them except as they can use them to further their own interests. 

Remember rock, scissors,paper? Well, logos, pathos, ethos works similarly. Pathos/emotion beats ethos/beliefs, ethos beats logos, but here's the difference--logos doesn't beat anything. Logos wonkery works only within established  ethos or pathos frames. All logos arguments work within frames that have prerational (ethos or pathos) foundations. You don't want to deal with facts and details until you've been sold, and you get sold because an idea, a product purchase, an opportunity 'fits' with your existing sense of what's right. (Tea Party) Or because it serves your self interest. (Frank Underwood)

Or if it conflicts with your values, you can get sold because you really, really want it or really, really fear it. We might feel guilty, but advertizers understand that pathos beats ethos for most people most of the time. Facts, reason, competency come into play only once you've established your pathos or ethos frame, and the argument moves to a more deliberative discussion of strategy and tactics about how to accomplish the goals that we want or align with our beliefs. The most powerful arguments are those that work with a confluence of ethos and pathos, when your hopes and fears align with what you most deeply believe. And when you get that going on a collective level, then you have a very powerful social movement. Once again, the Tea Party is a good example. The political left? I don't know? What does it believe? What is it willing to put its neck on the line for? Where is its pathos?

So when you are in an argument, you have either to work within the frame of your opponent, or you have to crash it. Eisenhower and Nixon were considered conservatives in their day, but since they felt constrained to operate within the New Deal ethos frame, they are perceived as way to the left of conservatives today. Barry Goldwater tried to crash the New Deal frame and failed miserably. Ronald Reagan tried again 16 years later and succeeded. We have lived since then within a Neoliberal  frame, and now so-called Liberals like Bill Clinton and Barack Obama seem conservative when contrasted with Nixon and Eisenhower. A single payer healthcare system never had a chance in the 2010 healthcare debate because it makes no sense--it just doesn't feel right to anyone who inhabits a Neoliberal frame, and that's the frame that dominates the thinking of Washington policymakers. If you are unable to crash the Neoliberal frame, the ACA was the best possibility.

I supported Obama over Hillary Clinton in 2008 because with Hillary I knew I was getting a Neoliberal and because Obama talked as if he wanted to crash the Neoliberal frame. I wasn't certain that he would do it, but there was a chance he would. And I believed, and still do, that Obama at his worst would be no worse than Clinton at her best. As it turns out we got Obama at his worst, not because he's weak or bad but because he never attempted to crash the Neoliberal frame. It would be ironic if Hillary runs for the Democratic nomination again and loses to Elizabeth Warren. If she does, it's because Warren is someone who represents herself as a frame crasher, and that's deep down what all of us want. Whether she would do any better than Obama I have no idea. 

Obama's hands, as a result, were tied from the beginning. He adapted to the Neoliberal ethos frame as Eisenhower and Nixon adapted to the New Deal frame. The results were  predictable as soon as he hired his economic team, and considering the over-the-top vehemence of his GOP antagonists, his results aren't terrible--he avoided complete collapse so we could return to the status quo ante of the Bush years. The problem isn't primarily his competency or lack of it; the problem is the frame. The ACA as perceived from within any ethos-neutral Logos frame was an unnecessarily complex patchwork, and as such a disaster waiting to happen. But Logos only works within an existing Ethos frame in politics--and the disaster was always very likely. If this whole fiasco says anything about Obama's competency, it's because he seems not to have anticipated it.

Did Obama miss an opportunity in 2009-10? Well, going back to my rock, scissors, paper analogy, the only thing that beats an ethos frame is a pathos frame, and there was a lot of fear to work with after the financial crisis of 2008. He chose not to work with that fear, but rather to suppress it and get things back to the status quo ante, and in doing so he aligned himself with the Neoliberals on Wall Street, and if there was ever a chance of his breaking the Neoliberal frame, it was unlikely after making those alliances so central to his presidency. 

But the fear that was released by the 2008 crisis didn't just evaporate after the bailouts and the calming of the markets; it was absorbed into the the Tea Party, and the tragedy is that the rank and file in the Tea Party fear the right things, but don't have a constructive ethos frame to channel their pathos productively. 

Whatever else you may think about the Tea Party, the people in it are right to fear the Beltway cronyist mindframe. They want to crash that frame, and so should the rest of us want to. The problem, of course, is that the Tea Party doesn't seem to care if crashing it also crashes the world economy, as the sans culottes didn't care about anything except expressing their resentment, rage, and fear. 

And the irony, or course, lies in that the populist rage that drives the rank and file in the Tea Party has been coopted precisely by the cronyists who are using them to reinforce their own bunkers of entrenched privilege. They coopted Obama by constraining him in a Neoliberal straitjacket, and then they coopted the Tea Party by channeling its anger at the spendthrift, big government with Obama at its head. They are deftly playing the one off the other. They shore up their entrenched positions by setting up a very powerful pathos frame for the Tea Party and a constraining ethos frame for Obama, who, like many Liberals, prides himself as operating within a Logos frame, which doesn't beat anything. So anybody who understands this watches in frustration (or glee) as the he tries to reason and talk sense with people whose ethos frame makes it impossible for them to trust him, and whose pathos has been aroused to destroy him.

Obama might have seized the opportunity presented to him to channel all the anger that was directed toward Wall Street when he first assumed the presidency, but he felt he had to rely on precisely the people he should have been fighting. Maybe nothing else was possible even for a shrewder, stronger man, but that was the moment when something could have changed because there was all this pathos up for grabs, and it just needed an effective ethos frame to channel it constructively. Maybe next time.

What's the solution? I don't think there is one. Pathos--fear/anger, and desire/hope--are the only things that have the power to crash an ethos frame and inspire the erection of a new one. We had our opportunity in 2009, and we missed it. We just have to ride it out now and contain the damage as best we can until a new opportunity presents itself.

 

The ACA and the Technocratic Mentality (Updated)

 I know that there are millions of Americans who are content with their health care coverage – they like their plan and they value their relationship with their doctor. And that means that no matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what. My view is that health care reform should be guided by a simple principle: fix what's broken and build on what works. Obama, June 2009

So, all these insurance cancellation notices are going out to people who already have insurance because their existing insurance doesn't meet ACA standards. This is such a symbolic gift to the Republicans, even if it is a statistically insignificant problem. It also shows the top-down technocratic mindset of policy types who have close to zero political acumen. 

I know; it will blow over, but still--this was an unforced error.

Here's the thing: If, as ACA apologists are arguing, there is such a small number of cancelled insureds whose rates will be going up, why was it necessary to insist that they give up their existing health care, even if it is inferior to what they can find on the exchanges? Why not let them keep what they have and let them shop for something better on their own? Why force them to give up what they have if they are happy with it? What's the down side of that compared to the down side of freaking people out by forcing them off their current insurance and onto exchanges that they cannot access? 

This is a problem because some policy technocrats think they know better what people need than the people do, and this is exactly what infuriates people about big-government programs. This policy is the product of the same patronizing mentality that  banned super-sized soft drinks in New York. Whatever public good might come of it, it feeds a big-brother/big mother stereotype that negates the benefits because it helps to delegitimize government in the mind of ordinary folks who rightly resent government making their choices for them. 

UPDATE: Maybe I'm wrong.  There's this (in comments):

Neither Obama or Sebelius lied, folks. The insurance companies did! They are the ones who cancelled the policies, not the Administration. They are the ones who between March 2010 and now altered their policies for high risk clients, so they could cancel them, under the terms of the ACA which they helped to draft. Do not think for one minute that the ACA was ever anything other than a gift to the insurance industry - one that they drew up the specifics of and made sure were included. Most of the policies that the insurance industry are canceling, because they changed them in the grace period by raising rates or co-pays or changing coverage, are being canceled to force the holders onto the exchanges where the insurance companies can get away with newer higher rates because they have to cover what the old policies did not, like pre-existing conditions, continuous care, and preventative care at no cost. So could someone please stop blaming the idiots in the Administration, and look at who is actually canceling policies because they gave themselves an escape clause with help from the Democrats in Congress.

If that's true, then I retract my the points made about the technocratic mentality above. Even if the plans in effect since 2010 have been grandfathered in, that doesn't mean that the insurance companies can't decide to cancel them. The fault lies with the market, not with the governent, except that the government has created a program that all along has given too much freedom to the insurance companies. 

Quote of the Day: Michael Lind

Commenting on the Konczal post I referred to yesterday:

Unlike conservatives, who are right-wingers first and Republicans second, all too many progressives put loyalty to the Democratic Party — most of whose politicians, including Obama, are not economic progressives — above fidelity to a consistent progressive economic philosophy.  These partisan Democratic spinmeisters are now treating Obamacare, not as an essentially conservative program that is better than nothing, but as something it is not — namely, a great victory of progressive public policy on the scale of Social Security and Medicare.

In doing so, progressive defenders of Obamacare may inadvertently be digging the graves of Social Security and Medicare.

If Obamacare — built on means-testing, privatizing and decentralization to the states — is treated by progressives as the greatest liberal public policy success in the last half-century, then how will progressives be able to argue against proposals by conservative Republicans and center-right neoliberal Democrats to means-test, privatize and decentralize Social Security and Medicare in the years ahead?

I predict that it is only a matter of time before conservatives and Wall Street-backed  “New Democrats” begin to argue that, with Obamacare in place, it makes no sense to have two separate healthcare systems for the middle class — Obamacare for working-age Americans, Medicare for retired Americans.  They will suggest, in a great bipartisan chorus:  Let’s get rid of Medicare, in favor of Lifelong Obamacare!  Let’s require the elderly to keep purchasing private insurance until they die!

I’m sure a number of token “centrist” Democrats will be found, in due time, to support the replacement of Medicare by Lifelong Obamacare.  And with neoliberal Democratic supporters of the proposal as cover, the overclass centrists of the corporate media will begin pushing for Lifelong Obamacare as the sober, responsible, “adult” policy in one unsigned editorial after another.

A very plausible scenario. I wonder, though, if Neoliberalism's days are numbered. Elite bipartisan opinion is still enamored of it, so it still has legs. But Neoliberal education reform, at least, seems to be buckling because parents and teachers are finally "getting it" and are fighting back locally. In the long run it's winning the local fights that will change things in D.C. The Right understands this in a way the Left doesn't yet.

I think economic progressives like me are forced to support Democrats and their awful Neoliberal programs like Obamacare, because the Right has been very successful in keeping progressives in a defensive posture. The Right is far more energized than the Left, and until that changes, the Democrats must be supported as the dike wall that holds back the flood. 

Quote of the Day: Mike Konczal

Talking about the ACA rollout:

Some of the more cartoony conservatives argue that this is a failure of liberalism because it is a failure of government planning, evidently confusing the concept of economic “central planning” with “the government makes a plan to do something.”

However, the smarter conservatives who are thinking several moves ahead (e.g. Ross Douthat) understand that this failed rollout is a significant problem for conservatives. Because if all the problems are driven by means-testing, state-level decisions and privatization of social insurance, the fact that the core conservative plan for social insurance is focused like a laser beam on means-testing, block-granting and privatization is a rather large problem. As Ezra Klein notes, “Paul Ryan's health-care plan -- and his Medicare plan -- would also require the government to run online insurance marketplaces.” Additionally, the Medicaid expansion is working well where it is being implemented, and the ACA is perhaps even bending the cost curve of Medicare, the two paths forward that conservatives don’t want to take.

The Rube Goldberg complexity of the ACA is driven by neoliberal ideology, not by what makes any practcial sense. Read Konczal's whole post to see why this mess was inevitable and didn't have to be. 

 

Krauthammer on The Daily Show

I don't know what happened to Charles Krauthammer. I read him in The New Republic back in the 80s, and he was a run of the mill foreign policy realist. And then The New Republic went all neoconservative and crazy pro-Israel, and I stopped reading The New Republic, and the next thing I know Krauthammer is a right-wing bastion and a regular on Fox News. 

Well it was interesting to see him on The Daily Show earlier this week. He was charming and reasonable. I don't know if he is sincere, or whether he just saw this as an opportunity to get people like me to read his book, because I haven't read him in over a decade precisely because I thought he had become a right-wing loon. Nevertheless, the discussion between Stewart and him was refreshing because they were using real ideas rather than talking points, or so it seemed. 

Krauthammer says he respects Ted Cruz's passions and views, but dissociatates himslef from his tactics. He argued that Social Security and Medicare are among the great accomplishments of the liberal state, but that the welfare state is at a crossroads, and the question is whether we can continue to afford them. And then that Obamacare is a disaster because with a 17 trillion dollar national debt we cannot afford another expensive entitlement. He said that while he shares Stewart's passion to find ways to insure the uninsured, it was absurd for the government to create a program like Obamacare that would be so disruptive to a sector of the economy that contributes 16% to GDP. Unless I misunderstood him, he said that he and Stewart agree that extending Medicare would have been preferrable. (See part 3.) 

So that's kind of how it went--not a disagreement about goals but about how to achieve them, and when Stewart pointed out that no conservative in office agrees with Krauthammer, Krauthammer allied himself with Paul Ryan. And this is where it started getting incoherent--at least to me. And it just struck me as interesting but irrelevant. 

As I said, I haven't read him in years, and I have no idea whether Krauthammer is an honest man, or whether he's just a shill trying to make a reasonable case for ideas he knows don't matter.  Part of the conservative playbook is to deploy conservative intellectuals to keep liberals distracted debating ideas that seem to have some validity while their rich friends rob everything in sight. 

I don't know, and it doesn't matter. The power game is not about who has the best ideas; it's about which interests have the most clout. Obamcare debate was never about ideas or about what was best for the country; it was always first and foremost about what was politically possible. And the possible was determined by the power of the insurance and healthcare industries to shape the healthcare reform agenda to meet their needs first. They are the pigs feeding at the trough; the uninsured get the slop that splashes on the ground. 

I question Krauthammer's sincerity because surely he knows that the richest economy in the world can afford this 'entitlement' if it had the political will to change the tax structure to do it. He knows that it was the Republicans during the Bush administration that ran up the debt by cutting taxes while starting an expensive war. By passing Medicare D without any plan to pay for it. By supporting financial deregulation trends that led to the financial crisis and the bailout in 2008. He must know that the Republicans are playing a cynical game that is all about running up huge debts so that they can prevent the Democrats from doing anything because the country can't afford it after GOP recklessness.

Political conservatism in America, whether naively or cynically, embraces doctrines that serve the interests of the already rich and powerful. Those interests will seize on any ideas that give them cover, and Krauthammer's ideas serve those interests' purposes whether he intends them to or not. 

 

 

The Obamacare Mess

So why is it that the technology available to Mr. Obama as president doesn’t compare to the technology he used to win an election? Much of the problem has to do with the way the government buys things. The government has to follow a code called the Federal Acquisition Regulation, which is more than 1,800 pages of legalese that all but ensure that the companies that win government contracts, like the ones put out to build HealthCare.gov, are those that can navigate the regulations best, but not necessarily do the best job. That’s evidenced by yesterday’s Congressional testimony by the largest of the vendors, CGI Federal, which blamed everyone but itself when asked to explain the botched rollout of the new Web site. (Source)

I think this kind of problem is inherent to government, including state and local governments. It's very difficult to find the best vendors because because of interest politics and graft, and the regulations developed to prevent graft, which when worked around spawn more regulations, and so on. It's an ecosystem of red-tape complexity that breeds more complexity and with it turgid inefficiency. The expectation that this would be anything other than a mess was always silly. So what? Sooner or later they'll work it out. A year from now, no one will care.  

The political process almost always makes the optimal solution an impossibility. There would have been no problem, of course, had Obamacare simply used the Medicare infrastructure in a single-payer system that the uninsured could opt into. But that would never happen because conservatives fear it would be too successful. And so the silly politics led us to adopt this unnecessarily complex system that becomes a parody of government inefficiency that would be a challenge for the meanest, cleanest tech company to coordinate effectively. 

This mess is business as usual, and so one of the things I find rather annoying is the way Liberal media types are so upset about this. It's as if they feel they must show their moral superiority to conservatives by criticizing someone on their team. Conservatives who would never criticize their own. But of course in doing so Liberals reinforce the distorting conservative narrative that government can do nothing right: Even Liberals think that Obamacare is a mess."

Government can do a lot right, but it can only do it rather messily. The price paid is worth it for the benefits received. I'm with Joan Walsh here. Liberals should get off their high horse and recognize that they are belaboring the obvious and that their outrage is misplaced. 

 

Rawls v. Nozick

I am by no means a Rawlsian, but I can find some common ground with those who claim to be. I cannot fathom the mind of the Nozickian when it claims as it does to be "moral", and this piece in the NYT Stone lays out why. Closing graf:

Rejecting the Nozickian worldview requires us to reflect on what justice really demands, rather than accepting the conventional wisdom that the market can take care of morality for us. If you remain a steadfast Nozickian, you have the option of biting the bullet (as philosophers like to say) and embracing the counterintuitive implications of your view. This would be at least more consistent than what we have today: an ideology that parades as moral common sense.

I think the problem in this debate is that it seems always to be posed in either/or terms--that it's either the market or the state. And it's not; it's both. The political challenge is to find the right balance between them. That's what the principle of subsidiarity is all about. 

If there is anybody out there reading here who leans libertarian, please tell me why a single-payer system in health care, like Medicare, is immoral or an abrogation of your liberty rather than the most effective way to provide for a basic human need. Do you really believe that the only motivation for talented people to go into healthcare is to get rich? Do you think most people are only extrinsically motivated by financial rewards? Or is it possible that most people who are attracted to the healthcare professions are motivated intrinsically, by the desire to help and to make a difference in people's lives, by the intellectual and creative challenges posed by sickness and disease? If you think it's the first, what does that say about the culture's moral imagination. 

I'm not interested in arguments against single payer that we can't afford it--we can if we want to. I'm interested in moral arguments. If we can come to some agreement on a moral values level, we can work out the practicalities relatively easily. 

Data Mining

David Simon, the creator of HBO's "The Wire" says this about the Snowden leaks:

The question is not should the resulting data exist. It does. And it forever will, to a greater and greater extent. And therefore, the present-day question can’t seriously be this: Should law enforcement in the legitimate pursuit of criminal activity pretend that such data does not exist. The question is more fundamental: Is government accessing the data for the legitimate public safety needs of the society, or are they accessing it in ways that abuse individual liberties and violate personal privacy — and in a manner that is unsupervised.

And to that, the Guardian and those who are wailing jeremiads about this pretend-discovery of U.S. big data collection are noticeably silent. We don’t know of any actual abuse. No known illegal wiretaps, no indications of FISA-court approved intercepts of innocent Americans that occurred because weak probable cause was acceptable. Mark you, that stuff may be happening. As happens the case with all law enforcement capability, it will certainly happen at some point, if it hasn’t already. Any data asset that can be properly and legally invoked, can also be misused — particularly without careful oversight. But that of course has always been the case with electronic surveillance of any kind.

Simon's point is that the problem isn't with the program itself, but with its potential for abuse, and that's my problem with it, too. And it's because I think the potential and likelihood for those abuses is more damaging than whatever benefit we receive from this program, the program needs to be severely curtailed. I know it won't be, but that's my position for what it's worth. 

For all the time, money, and manpower that is going into the development of this massive data mining operation, does it pay off? Did it prevent the Boston Marathon Bombing? Could it have? Did it stop Adam Lanza? Could it have? 

For me there's an analogy here to the way we Americans deal with healthcare issues. We have this enormously expensive, highly technologized system that produces mediocre outcomes. The WHO ranks the U.S. #38 despite our spending more than any other country. We do all this expensive, sophisticated stuff, but we still don't get the job done as well as others do. Because getting the job done--whether it's producing better healthcare outcomes or catching criminals--requires another approach, a more human approach, a more realistic approach than the one American technocrats instinctively are inclined to take.

Any government has legitimate police powers. Bad guys, whether crazies like Adam Lanza, predators like Bernie Madoff, or criminal warlords like those shown in "The Wire" will always be with us, and they have to be checked. But the idea that we have to do everything in our power and use any means necessary to exterminate them is as absurd as thinking that we can exterminate death and disease. We need to contain and mitigate, not eliminate. And the same goes for terrorism. We need a containment policy, not an extermination policy.

The whole NSA apparatus is born of and justified to the public from an obsession to eliminate the possibility of another 9/11. But we never ask why 9/11 happened in the first place. We never seek to understand the causes that create that kind of blowback, and we never accept that our own stupidity and bullying abroad abets the cycle of violence that comes back to bite us. The challenge is to break the cycle of violence, but it's easier to create this massive, expensive, technologically sophisticated but rather clumsy and easy to abuse surveillance infrastructure and then to vilify those who point to its folly.  

Individual Mandate in Trouble? [Updated]

I think it probably is. I wrote this last spring:

The individual mandate is a fundamental element in the flawed architecture of this HCR bill, and the best thing about it is its not going into effect for another four years. I think there's a good chance that by the time 2014 rolls around it won't be part of the new HCR system.  Already people are talking about court challenges to it, and I'd be surprised if it survives.

I don't care what the wonks say about it, the idea of the government forcing Americans to buy health insurance from hated, profit-driven companies is bad politics, and it's tossing a lazy softball to the political right to hit out of the park, and I, for one, will not come to the administration's defense.

It will go to the supremes now, and what do you think its chances will be in the Robert's court? This was ill-conceived from the beginning. It's typical of obtuse, wonkish, top-down thinking. It's anathema to what I've described as the structural Progressive approach. The Medicare buy in would have been so much simpler and easier to sell, but it was never about what's best for the country or the American people; it was about what was best for the insurance industry.

UPDATE: Klein talks about the impacts on HCR if the individual mandate is ultimately ruled unconstitutional:

-Repeal of the requirement to buy insurance would mean more people would wait until they get sick to buy insurance in the new nongroup exchanges, which would increase the average premium by 27 percent in 2019.

-Retaining the law’s insurance reforms, but repealing the subsidies as well as the requirement to purchase insurance, would further discourage people from buying insurance when they’re healthy. Premiums in 2019 would cost twice as much as projected under the law as a result.

-Retaining the law but repealing the mandate would newly cover fewer than 7 million people in 2019 rather than the 32 million projected to be newly covered by the law. Federal spending, however, would decline by only about a quarter under this scenario since the sickest and most costly uninsured are the ones most likely to gain coverage.

I have not doubt all this is true, but that's why it was so ill-conceived. Is there any hope that this might force reconsideration of a public option?  Probably not likely with the new congress, but if the supremes kill the individual mandate, it would appear that whole thing will fail to deliver what were its promised ameliorative effects, namely reducing premiums and reducing the numbers of uninsured.

I have to say that I'm ambivalent. I have from the beginning rejected the fundamental architecture of this deal, but accepted that it was better for the people to have some crumbs rather than nothing. So preserving the individual mandate is the only way to preserve the delivery of those crumbs, it would appear.  So maybe it would be better to scrap the whole thing rather than let it become the entrenched HC system.

The Individual Mandate

The individual mandate is a fundamental element in the flawed architecture of this HCR bill, and the best thing about it is its not going into effect for another four years. I think there's a good chance that by the time 2014 rolls around it won't be part of the new HCR system.  Already people are talking about court challenges to it, and I'd be surprised if it survives.

I don't care what the wonks say about it, the idea of the government forcing Americans to buy health insurance from hated, profit-driven companies is bad politics, and it's tossing a lazy softball to the political right to hit out of the park, and I, for one, will not come to the administration's defense.

This comment at Ezra Klein's blog this morning reflects my thinking about it all along:

Random Thoughts on HCR (Updates I & II)

It's remarkable how HCR has brought out the feverish dark side of the American psyche.  First a couple of anecdotal bits.  From TPM:

And then from Ezra Klein:

Jon Cohn spent part of Saturday wandering through the patches of protesters on Capitol Hill. What surprised him, however, was that the protests seemed less about health-care reform than about redistribution itself. To the protesters, Jon says, health-care reform is "about having their money taken for the sake of somebody else's security. When they hear stories of people left bankrupt or sick because of uninsurance, they are more likely to see a lack of personal responsibility and virtue than a lack of good fortune." . . .

From me: I saw a bumper sticker in Seattle the other day that said "I'll Keep My Religion, My Guns, My Liberty, and My Money. KEEP YOUR CHANGE." This sums up the bunker mentality that afflicts the cultural right in this country, doesn't it? The guns are always a part of the formula because they're needed to defend the bunker, especially when you otherwise feel so impotent. You send the troops, and we'll fight you off.

I know that this doesn't come close to representing majority thinking, but it's considered legitimate thinking in this country. The sanctimony of the left is annoying, but the sanctimony of the right, especially toward those whose lives have been destroyed by this HC system, is just ill-informed, myopic, and plain mean. If you're not in the bunker with us, we just don't care about you.

Upside of HCR Failure (Updated)

Marcia Angell on Moyers made the case why it shouldn't pass.  She thinks overall it's going to make things worse despite its positives.  And if it's going to get worse, better it should do so without government-run healthcare to blame.  Maybe she's right.  I'd like to hear her in a debate with Ezra Klein.  But if nothing else, her argument makes me feel a little better if this bill goes down. You should watch the whole interview, but this except is the heart of her point:

BILL MOYERS: But the President is pushing ahead; he wants Congress to act in the next month. What would you have us do?

MARCIA ANGELL: I think the problem is this, Bill. If this plan is passed, and I think there's real doubt as to whether it will be, and there's even more doubt as to whether it would ever be fully implemented, but let's say that it's passed. It will begin to unravel almost immediately. And then what will people do? Well, they'll say, "We tried health reform, and it didn't work. Better not try that anymore."