The People's Alliance of New Brunswick (PANB) has said that it will not support the government's controversial health care cuts. The NB government is planning to end over night ER services as six rural hospitals as well as a slew of other changes that include ending surgeries, ambulatory care, and acute care admissions. While I do not have this confirmed, Facebook groups that have popped up to oppose the cuts are suggesting that some medical staff have already been laid off or transferred or soon will be.
I stated that the PANB would likely go down with the ship on this and support the Higgs PC government to the end. I was wrong. They will not. I thought they would continue to support the PCs because of political calculations. As a third party, they had unusual influence over a government that needed their votes in the legislature to keep going.
In addition, one PC MLA (the former Deputy Premier) has resigned and left the PCs. He will sit as an independent. Word is that the current Legislative speaker (right now a Liberal), will step down from his position in the near future and force the Tories to elect one of their own to that position. If all this happens, this is what it will mean. The Tories will be down to 20 votes in the House (and possibly 19 if another MLA breaks away as the Sussex MLA is hinting) (22 seats - 1 resigned MLA - 21 - 1 for speaker = 20. If the Sussex MLA voted against the government, too, this would mean that they'd be down to 19 votes in the Legislative Assembly, a position that is clearly untenable).
The combined opposition would now have 28 and possibly more votes: 21 Liberals + 1 independent former Tory + 3 Green + 3 PANB. If the Sussex MLA voted with them they would be up to 29. This would be a significant defeat, much greater than Gallant's after the last provincial election.
Why was I wrong in my assessment of the PANB? The simple answer is that my reasoning gambled that the PANB would trade influence and longevity for other folks health care. They didn't. Perhaps the issue resonated with their largely rural supporters. Perhaps they read the writing on the wall. As I explained in my last post, the Higgs government was likely going down anyway. I thought the math was close. I did not spell it out but I was guessing that they could scrape together 23-4 votes depending ... on a range of factors. The Liberals and Greens would have 23-4 (depending on who was speaker) so a future non-confidence motion was not guaranteed.
The PANB might have done the same math and figured they did not want to end up carrying the Tories water. They might honestly and sincerely support rural health care and I am sure that a goodly part of their supporters do. But, they might also have recognized that the Tory ship was sinking and he little desire to go down with it.
What can the Tories do now? I don't know. They might get lucky and something else will distract attention or boost their fortunes, but I'd have to say that it does not look good for them. The Liberals have an election issue, they have a clear point of differentiation between them and the Tories, and so if one were PC, it does not look good.
I guess Higgs could try back tracking enough to keep the recalcitrant MLA in the fold. This strategy might allow him to split the opposition enough that he could stay in power. If he gave on the health care issue, this would allow the two Tories outside the fold to come back in and vote against a non-confidence motion on the grounds that they opposed health care cuts but other than that had no problems with the government. Such a strategy might, likewise, work to re-secure PANB support. This would push Tory votes back up to 24 tying them with the Liberal/Green opposition and letting the now Tory speaker cast a vote in favour of the government.
I am not going to say that is the strategy Higgs will follow but it might be the only one open to him.
Showing posts with label Health Care. Show all posts
Showing posts with label Health Care. Show all posts
Sunday, February 16, 2020
Friday, February 14, 2020
The Politics of Stupidity: ER Cuts and Public Life in NB
Elections are never decided on a single issue ... but someone remind me: wasn't it health care cuts to small communities that helped do in Bernard Lord's government? In New Brunswick we have a minority Progressive Conservative (PC) government that is propped up by a small anti-bilingualism third party called the People's Alliance of New Brunswick (PANB). The result of the 2018 provincial general election was improbable. The Tories secured a slim plurality of seats (which allowed them to claim that they "won" the election) on the basis of less than 32% of the popular vote. The Liberals garnered 37.8% of the vote but the character and nature of its distribution as well as the success of the Green Party relegated them to second place in seats. The Liberals tried to hang on to government, but the legislature was against them, their government fell, and current Premier Higgs and his 32% Tories were asked to try to form a government. Since that date, Higgs has governed with the support of the PANB.
Around the time Higgs assumed government, I attended a panel discussion of the provincial election results. The general conclusion was that New Brunswickers would almost certainly be back at the polls inside of six months. That did not happen. Higgs managed to govern by trying to give the PANB what it could -- rejecting the report of the NB Commissioner of Official Languages, making more room for uni-lingual anglophone health care workers in francophone regions of the problem, promising the end of the immersion education for anglophone kids. While there was a large community of interest between the Tories largely rural anglophone vote and the PANB, the PANB was holding the reigns of power. The Higgs government gave them no reason to stop supporting the government and I actually don't think they will now.
PANB support was not the only reason Higgs has stayed in government. A series of other factors came together to help him out. First, the concerns of the PANB were actually easy to address because the party is, more or less, single-issue. Despite having a platform there is no evidence that its supporters were particularly interested in issues other than languages politics. But, the PANB's position on, say, fracking was almost the same as the PCs so no modifications needed there and it had no significant views on lands and forests, fishing, school curricula, social welfare, policing, immigration and migration, other forms of energy. In retrospect this has made it remarkably easy for the PCs to find common cause with the PANB.
Second, for its own reasons, the PANB has come to have a vested interest in the Higgs government, which is why I think they will continue to support it despite the mess in which it currently finds itself over health care cuts. The PANB has every reason to want a continued minority PC government that depends on them for support. They are unlikely to increase their seat count in any future provincial election and, even if they could, they were never close to winning enough seats to even be the leading party in a minority government. Moreover, the polls show them going in the wrong direct. They are losing support. The most recent poll numbers (admittedly before the current ER room closing fiasco) suggest that potentially none or only one of their three seats are safe if there was another election. So ... why would the PANB do anything but try to keep the Tories in power which guarantees their influence on the issue that matters that most to them. From their perspective, not only would an election almost certainly carry negative consequences for their party, but if things went the other way and, say, the Liberals returned to power, they would have no influence and a party committed to reversing what Higgs has done would be in the driver's seat.
Third, the Liberals had no leader. Former Premier Gallant resigned in the wake of his government's collapse. Without a leader -- and with just about no one seemingly wanting the job -- the Liberals themselves did not want to force any issue. Their francophone and middle class base was concerned with what Higgs was doing but the Liberals seemed to have little desire to fight an election. For its part, outside of language, the Higgs government was doing as little as it could to upset anyone. I will confess, I was surprised by its moderation compared to, say, the Ford and Kenney governments. The Higgs government may or may not have wanted to go after civil servants and teachers, but it must have recognized that it needed to keep its powder dry. It might have wanted to dramatically cut government spending, but took very few steps in that direction.
This moderation seemed to be working: the polls (see previous link), showed the PCs running around 40%, perhaps dropping a bit in late 2019 and the Liberals in the 30% ballpark. It does not look like the Tories were taking Liberal votes and I don't think they were. I think the Liberal bleed was going to the Green Party (more on this below), but they were taking a bit and likely siphoning off PANB voters. This did not necessarily do the Tories any good because taking PANB seats was not going to actually increase their overall legislative support. It was just going to re-arrange the chairs on the deck, as it were. But, it did show that Tory moderation deprived the Liberals of an issue that could animate an election campaign.
For their part -- and despite their opposition to just about everything the Higgs government was doing -- the Green Party did not want an election either. I don't think Green activists see themselves as a viable alternative government in NB, at least as of yet. They did well in the 2018 election, but were exhausted by it. The Greens in NB are incredibly grass roots. Their supporters are devoted and enthusiastic and committed but they are by and large not a professional organization. That is an incredible strength and one of the reasons for their victories in 2018. But, it also carries with it a downside and that downside is that fund-raising is more difficult and organization tough and it can tire. I also think that the Greens were not 100% certain of how solid their vote was. They garnered 11.8% of the vote (less than the PANB), but was that support or the product of circumstances and popular local candidates and the collapse of the NDP?
Finally, the one issue that really might have been divisive was fracking but the energy glut took that off the agenda. Where fracking had been a wedge issue that drove votes away from the Tories in 2014, it is now absent because there is no reason to frack in 2019 and 2020. Even if the Tories wanted to frack -- and I think they do -- it has become a non-starter for industry.
So, you put all this together and the PCs were riding high. They had no particular reason to force an election themselves because they were already in power and needed time to increase their support. They had easy PANB support; the other opposition parties didn't want an election. There was, in fact, no threat to them. They were in power, they were guiding the ship of state and there were no storms on the horizon .... until ...
Until the engaged in an act of unmitigated political stupidity. They returned to the issue that contributed to their demise in the past (was it Lord? Am I mis-remembering that?) as if they did not know their own party history. Whatever the particular merits of health policy in general, here is what the Tories did wrong with their recent announcement that they will scale back emergency services at six rural NB hospitals.
Around the time Higgs assumed government, I attended a panel discussion of the provincial election results. The general conclusion was that New Brunswickers would almost certainly be back at the polls inside of six months. That did not happen. Higgs managed to govern by trying to give the PANB what it could -- rejecting the report of the NB Commissioner of Official Languages, making more room for uni-lingual anglophone health care workers in francophone regions of the problem, promising the end of the immersion education for anglophone kids. While there was a large community of interest between the Tories largely rural anglophone vote and the PANB, the PANB was holding the reigns of power. The Higgs government gave them no reason to stop supporting the government and I actually don't think they will now.
PANB support was not the only reason Higgs has stayed in government. A series of other factors came together to help him out. First, the concerns of the PANB were actually easy to address because the party is, more or less, single-issue. Despite having a platform there is no evidence that its supporters were particularly interested in issues other than languages politics. But, the PANB's position on, say, fracking was almost the same as the PCs so no modifications needed there and it had no significant views on lands and forests, fishing, school curricula, social welfare, policing, immigration and migration, other forms of energy. In retrospect this has made it remarkably easy for the PCs to find common cause with the PANB.
Second, for its own reasons, the PANB has come to have a vested interest in the Higgs government, which is why I think they will continue to support it despite the mess in which it currently finds itself over health care cuts. The PANB has every reason to want a continued minority PC government that depends on them for support. They are unlikely to increase their seat count in any future provincial election and, even if they could, they were never close to winning enough seats to even be the leading party in a minority government. Moreover, the polls show them going in the wrong direct. They are losing support. The most recent poll numbers (admittedly before the current ER room closing fiasco) suggest that potentially none or only one of their three seats are safe if there was another election. So ... why would the PANB do anything but try to keep the Tories in power which guarantees their influence on the issue that matters that most to them. From their perspective, not only would an election almost certainly carry negative consequences for their party, but if things went the other way and, say, the Liberals returned to power, they would have no influence and a party committed to reversing what Higgs has done would be in the driver's seat.
Third, the Liberals had no leader. Former Premier Gallant resigned in the wake of his government's collapse. Without a leader -- and with just about no one seemingly wanting the job -- the Liberals themselves did not want to force any issue. Their francophone and middle class base was concerned with what Higgs was doing but the Liberals seemed to have little desire to fight an election. For its part, outside of language, the Higgs government was doing as little as it could to upset anyone. I will confess, I was surprised by its moderation compared to, say, the Ford and Kenney governments. The Higgs government may or may not have wanted to go after civil servants and teachers, but it must have recognized that it needed to keep its powder dry. It might have wanted to dramatically cut government spending, but took very few steps in that direction.
This moderation seemed to be working: the polls (see previous link), showed the PCs running around 40%, perhaps dropping a bit in late 2019 and the Liberals in the 30% ballpark. It does not look like the Tories were taking Liberal votes and I don't think they were. I think the Liberal bleed was going to the Green Party (more on this below), but they were taking a bit and likely siphoning off PANB voters. This did not necessarily do the Tories any good because taking PANB seats was not going to actually increase their overall legislative support. It was just going to re-arrange the chairs on the deck, as it were. But, it did show that Tory moderation deprived the Liberals of an issue that could animate an election campaign.
For their part -- and despite their opposition to just about everything the Higgs government was doing -- the Green Party did not want an election either. I don't think Green activists see themselves as a viable alternative government in NB, at least as of yet. They did well in the 2018 election, but were exhausted by it. The Greens in NB are incredibly grass roots. Their supporters are devoted and enthusiastic and committed but they are by and large not a professional organization. That is an incredible strength and one of the reasons for their victories in 2018. But, it also carries with it a downside and that downside is that fund-raising is more difficult and organization tough and it can tire. I also think that the Greens were not 100% certain of how solid their vote was. They garnered 11.8% of the vote (less than the PANB), but was that support or the product of circumstances and popular local candidates and the collapse of the NDP?
Finally, the one issue that really might have been divisive was fracking but the energy glut took that off the agenda. Where fracking had been a wedge issue that drove votes away from the Tories in 2014, it is now absent because there is no reason to frack in 2019 and 2020. Even if the Tories wanted to frack -- and I think they do -- it has become a non-starter for industry.
So, you put all this together and the PCs were riding high. They had no particular reason to force an election themselves because they were already in power and needed time to increase their support. They had easy PANB support; the other opposition parties didn't want an election. There was, in fact, no threat to them. They were in power, they were guiding the ship of state and there were no storms on the horizon .... until ...
Until the engaged in an act of unmitigated political stupidity. They returned to the issue that contributed to their demise in the past (was it Lord? Am I mis-remembering that?) as if they did not know their own party history. Whatever the particular merits of health policy in general, here is what the Tories did wrong with their recent announcement that they will scale back emergency services at six rural NB hospitals.
- They picked an issue that will drive some of their core voters away. I drove by the protest in Sackville yesterday against the ER cuts and the protesters were an incredibly diverse lot. This has upset people who I've known as lifetime conservative voters. There were a lot of +50 people at the protest and those people vote. IOW, they did not upset, say, just young people (whose voting record is more checkered), but people who will vote and for whom this issue is important. IOW, they upset people who will *vote* on this issue.
- The issue resonates. The problem is not just the six communities that will lose emergency services, but that other communities and other voters will start to wonder about their health care services. It turns out that in Sackville, for instance, scaling back emergency services is just part of the changes being introduced, which include ending acute care hospitalization and the already modest ambulatory care that was available. The Sackville Memorial Hospital, it appears, is to be turned into a weigh station for seniors on their way to care facilities.
- The Higgs government does not seem to have briefed their own caucus on ER closures. Two Tory MLAs seem poised to vote against this measure and seemed, in fact, broad-sided by it. If one were going to do something controversial, a government should make sure its own members are in the loop.
- They handed the Liberals a key and easy to understand election issue. It took less than one day for Liberal social media to state clearly and unequivocally: if you elect a Liberal government, these hospitals will stay open. It is clear, quick, and sets up a dichotomy that everyone can understand: vote Tory and lose your health care. Vote Liberal; keep it.
- The announcement was mistimed. It is rushed: implementation is to begin in early March, which looks really really bad. It looks like a government, whose claim to democratic legitimacy was already shaky, is trying to rush a policy through because it knows that it will be unpopular. It looks like they are saying "screw you" to rural communities and that is not a good optic. It is made worse, however, because the Liberals now have a leader, an anglophone with some name recognition. Will he be a good premier? Who knows? But, from a political perspective, that might be at least a bit beside the point.
- The Tories seem not to have recognized that times have changed in other ways. While the declining popular support of the PANB likely means they are not interested in an election and so will continue to support the PCs come what may, the Liberals are now not afraid of an election, Nor is the Green Party. The polls show its vote increasing and its strong showing in NB in the recent federal election also bodes well for it. Green Party leaders can read these numbers as easily as I can.
Put all this together and the Tories are in trouble. Even if they withdraw the policy, they have created a wedge issue that will drive votes away from them. Even if they survive an impending non-confidence motion (and they could; the math is tight but they could survive), the issue will not go away. The protesters, in Sackville at least, are well organized, make effective use of social media, know the community supports of them. In Sussex, the news reports suggest real anger.
This all makes me ask: why did Higgs do it? Is this really a response to health care problems in NB? I suspect that there was a political calculation. Four of the six hospitals affected are in Liberal or Green ridings. And, I do think there is another level of calculation here that relates to the unwinding of the Tories plans for economic rejuvenation in NB. I just think that they made the wrong calculation.
Thursday, August 03, 2017
The Economics of Health Care or, the Return of the Repressed
The upshot of my last -- none Jays -- post is general and specific. General: democracy as now practiced works in a way that creates a disjuncture between reality and image. Specific: in the case of health care in the US, this leads people to (a) see problems where their might not be, (b) draw the wrong conclusions about the character and nature of needed reforms, and (c) believe that they can "get something for nothing." What I'd like to pick up on in this post is to look at the idea of getting something for nothing and how it is presented in contemporary public discourse. How is this idea -- that you can get something for nothing -- presented to people during election campaigns? How is it organized in public discourse? And, what is the effect?
"There is no free lunch." We've all heard the expression but, as my last post suggests, we don't actually understand what it means. If we use the concept of "opportunity cost" (see my last post), then we understand that it does not mean that you did (or, did not) pay cash for the lunch you just ate. It means that you paid something. The person buying you lunch may have wanted your time. They were willing to shell out for a lunch for you and you were willing to accept it because, heck, it was just an hour but that was the cost. You had to listen to them for an hour or could not take a nap or paint the shed or whatever else you were going to do. In other words, everything has a cost, whether in cash or time or annoyance or incurred obligation or whathaveyou. Costs are not bad. They are part of life and, as adults, we recognize this. As kids, we might not. I remember my daughter saying "just go get more money out of that machine" when I explained to her I could not buy something because I did not have enough money. To her, at that age, money was magical. It came out of a machine and it was free for the asking. As adults, we know this is not true ....
And, yet, we let a bunch of people tell us it is true, at times on the basis of shockingly little evidence. Think about health care and premiums or taxes as an example. Politicians running for election fall all over themselves to try to say "I have found a free lunch for you." They don't use precisely those words but that is the import of what they are saying. Every time someone says "waste is the problem" or "unneeded tests" or ... lazy doctors or nurses ... what they are saying is this: I have found a way for you to get something for nothing. They say "we have to eliminate the waste" or "this is a case of government mismanagement" or "it is those sick people's fault that they are sick and so we should not really pay for them." Or, whatever stock line you prefer.
The key thing to note about this line of argument is that it is not new. I've been listening to "waste is the problem" my entire life. Governments have been "cutting the fat" (aka eliminating waste) as long as I can remember. In Canada, I remember Mulroney campaigning on it, Chretien, Harper. They don't always use precisely this language but this is the substance: the other guys have allowed too much waste, too many people feeding from the trough, and the like. Just about every provincial election carries the same discourse. Sometimes people say "this is typical state mismanagement" or something like that: "the private sector is more efficient." But, the substance is the same and the message sent to the electorate is the same: you can get something for nothing or, you are not getting something for nothing because someone else is ripping you off. (This discourse often takes on nasty xenophobic dimensions when immigrants or Mexicans or Blacks are blamed for economic malaise as if, if there were not so many Mexicans going to school, school would cost less.) And, again, it is not new. In fact, it is old.
I make the point about its age because ... well ... history is against this argument. Those governments that were most effective at controlling the debt (Chretien in Canada and Clinton in the US) tended to make less use of this discourse than their political opponents and tended to focus on other means to address the provision of state services (Chretien's government, for instances, downloaded a lot of them). History is against this argument because people keep saying it despite the fact that repeatedly the great plan to address waste and make us all rich comes to naught. Real wages are not rising and have not been for some time, for example. Thus, for those interested in an empirical test, the idea that "waste is the problem" runs into an empirical problem. It does not seem to be true,
And, yet, people believe it. Or, perhaps, they want to believe it because the answer "you can get something for nothing" sounds preferable to "you have to pay for what you want." There is, I think, a reason why no one campaigns on the "vote for me and your taxes might actually increase" line. If given a choice, people will vote for the person promising the free lunch, even after they recognize that that lunch is not free ... because they keep hoping that it will be ... one of these days.
If waste is not faulted for the problem, mismanagement, immigrants, women, ethnic minorities, etc. are often faulted. Here in NB, about once a year someone will say "if we did not have bilingualism, we could save money." AKA, what they mean is that if French-speaking citizens were not treated equally, well, that would be cheaper than equality (because, I guarantee, none of the opponents of bilingualism are thinking about getting rid of English as an official language). Said differently, the argument is always that there is a free lunch if we just reign in women, immigrants, Muslims, whoever ... trans-gendered soldiers. In my last post, I noted that this discourse periodically resorts to unabashed metaphysics when they start talking about things like "entrepreneurial spirit." The private sector will save us money ... how? Asking this question, btw, is not irrational, socialistic, lefty or whatever. It is democratic. If I am going to vote for you or your party, I have the right to know how your policies are going to work, particularly if you are asking me to stake my health and that of my family on something as vague as "spirit". If someone cannot explain their policies to you ... I'd argue that you should reconsider voting for them because their policies might not be explainable.
Where does this leave the health care debate in the US? There are may reasons why health care costs money and saving on waste, limiting super-profits and the like are likely ethically sound and good policies to follow. I'd recommend them. But, they will not by themselves limit health care costs enough to make a difference. It is like getting rid of welfare bums, something else all political parties promise to do and something else I've been listening to my entire adult life. Yet, getting rid of welfare bums does not really help the bottom line of the state's budget does it? We've been getting of them for 30 years and governments are still running in the red.
And, I would argue, Republicans in the US know this. They know that the problem is not waste, state involvement, or Obama. They know that the reason there there are health care costs is sick people. That sounds simplistic, I know, but think about it. What causes medical costs? By and large: illness. I go to the doctor (incur a cost) because I am sick. I don't go to chat about our kids badminton team. Better preventative medicine will help, too, but that is an immediate cost designed to save money long-term. It is not white and black, this will save money. There are costs involved.
Republicans know that they cannot save money through "entrepreneurial spirit," or better management or free markets, etc., in their hearts of hearts and this is why they are trying to de-insure people -- about 35 million at last count. They are trying to de-insure people because they know that this is the only way to limit health care costs: limit the number of sick people. And, in the US, the only way to do this is to deprive these sick people of health insurance.
Let me illustrate what I mean with an example. Imagine you serve sandwiches for lunch. There are 100 people and each sandwich costs $1.00. The total you need, then, is $100.00. Now, imagine you raise this $100.00 via taxes. It is election time and the opposition says "$100.00 is too much. We will do it for $90.00 and you good taxpayers will get $10.00 back. You will get something for nothing. No service will be lost." And ... the opposition wins. They get into office and discover that there are reasons -- other than the previous government's mismanagement -- that sandwiches cost $1.00. They cost $1.00 each because that is what they cost. The bread costs so much, as does the cheese or jam and the people who make the sandwiches need to be paid. So, try as they might, they can't find a 10% saving on labour or resources. So, how do they solve the problem? Well, there is only one way: lower the number of people eating sandwiches. If they can get the number of people eating sandwiches to drop from 100 to 90 ... well, they save the 10%. This means 10 people go without sandwiches ... that is: are de-insured.
This is what is going on with Republican health care policy. The only way to get costs down is to cut people's access to health. This is why every Republican proposal for "reform" is also a proposal for cuts, or de-insuring.
Having a section of the population, in effect, without health care is the price of lowered costs. There are further implications to this. For instance, Republicans, I am sure, expect more people to use "free clinics." That is, they plan to off load costs because sick people will seek out medical care even if they are de-insured. They might rely on the charity of doctors: that is, to see how many people there are out there who will work for free or below market costs. But, make no mistake about it, sick people are the repressed and the repressed will return. Any proposal to reform Obamacare in the US will involve some cut, some section of the population that will go uninsured and, hence, without health care. It is not just Republicanism but simple economics.
Don't believe me? ... watch.
"There is no free lunch." We've all heard the expression but, as my last post suggests, we don't actually understand what it means. If we use the concept of "opportunity cost" (see my last post), then we understand that it does not mean that you did (or, did not) pay cash for the lunch you just ate. It means that you paid something. The person buying you lunch may have wanted your time. They were willing to shell out for a lunch for you and you were willing to accept it because, heck, it was just an hour but that was the cost. You had to listen to them for an hour or could not take a nap or paint the shed or whatever else you were going to do. In other words, everything has a cost, whether in cash or time or annoyance or incurred obligation or whathaveyou. Costs are not bad. They are part of life and, as adults, we recognize this. As kids, we might not. I remember my daughter saying "just go get more money out of that machine" when I explained to her I could not buy something because I did not have enough money. To her, at that age, money was magical. It came out of a machine and it was free for the asking. As adults, we know this is not true ....
And, yet, we let a bunch of people tell us it is true, at times on the basis of shockingly little evidence. Think about health care and premiums or taxes as an example. Politicians running for election fall all over themselves to try to say "I have found a free lunch for you." They don't use precisely those words but that is the import of what they are saying. Every time someone says "waste is the problem" or "unneeded tests" or ... lazy doctors or nurses ... what they are saying is this: I have found a way for you to get something for nothing. They say "we have to eliminate the waste" or "this is a case of government mismanagement" or "it is those sick people's fault that they are sick and so we should not really pay for them." Or, whatever stock line you prefer.
The key thing to note about this line of argument is that it is not new. I've been listening to "waste is the problem" my entire life. Governments have been "cutting the fat" (aka eliminating waste) as long as I can remember. In Canada, I remember Mulroney campaigning on it, Chretien, Harper. They don't always use precisely this language but this is the substance: the other guys have allowed too much waste, too many people feeding from the trough, and the like. Just about every provincial election carries the same discourse. Sometimes people say "this is typical state mismanagement" or something like that: "the private sector is more efficient." But, the substance is the same and the message sent to the electorate is the same: you can get something for nothing or, you are not getting something for nothing because someone else is ripping you off. (This discourse often takes on nasty xenophobic dimensions when immigrants or Mexicans or Blacks are blamed for economic malaise as if, if there were not so many Mexicans going to school, school would cost less.) And, again, it is not new. In fact, it is old.
I make the point about its age because ... well ... history is against this argument. Those governments that were most effective at controlling the debt (Chretien in Canada and Clinton in the US) tended to make less use of this discourse than their political opponents and tended to focus on other means to address the provision of state services (Chretien's government, for instances, downloaded a lot of them). History is against this argument because people keep saying it despite the fact that repeatedly the great plan to address waste and make us all rich comes to naught. Real wages are not rising and have not been for some time, for example. Thus, for those interested in an empirical test, the idea that "waste is the problem" runs into an empirical problem. It does not seem to be true,
And, yet, people believe it. Or, perhaps, they want to believe it because the answer "you can get something for nothing" sounds preferable to "you have to pay for what you want." There is, I think, a reason why no one campaigns on the "vote for me and your taxes might actually increase" line. If given a choice, people will vote for the person promising the free lunch, even after they recognize that that lunch is not free ... because they keep hoping that it will be ... one of these days.
If waste is not faulted for the problem, mismanagement, immigrants, women, ethnic minorities, etc. are often faulted. Here in NB, about once a year someone will say "if we did not have bilingualism, we could save money." AKA, what they mean is that if French-speaking citizens were not treated equally, well, that would be cheaper than equality (because, I guarantee, none of the opponents of bilingualism are thinking about getting rid of English as an official language). Said differently, the argument is always that there is a free lunch if we just reign in women, immigrants, Muslims, whoever ... trans-gendered soldiers. In my last post, I noted that this discourse periodically resorts to unabashed metaphysics when they start talking about things like "entrepreneurial spirit." The private sector will save us money ... how? Asking this question, btw, is not irrational, socialistic, lefty or whatever. It is democratic. If I am going to vote for you or your party, I have the right to know how your policies are going to work, particularly if you are asking me to stake my health and that of my family on something as vague as "spirit". If someone cannot explain their policies to you ... I'd argue that you should reconsider voting for them because their policies might not be explainable.
Where does this leave the health care debate in the US? There are may reasons why health care costs money and saving on waste, limiting super-profits and the like are likely ethically sound and good policies to follow. I'd recommend them. But, they will not by themselves limit health care costs enough to make a difference. It is like getting rid of welfare bums, something else all political parties promise to do and something else I've been listening to my entire adult life. Yet, getting rid of welfare bums does not really help the bottom line of the state's budget does it? We've been getting of them for 30 years and governments are still running in the red.
And, I would argue, Republicans in the US know this. They know that the problem is not waste, state involvement, or Obama. They know that the reason there there are health care costs is sick people. That sounds simplistic, I know, but think about it. What causes medical costs? By and large: illness. I go to the doctor (incur a cost) because I am sick. I don't go to chat about our kids badminton team. Better preventative medicine will help, too, but that is an immediate cost designed to save money long-term. It is not white and black, this will save money. There are costs involved.
Republicans know that they cannot save money through "entrepreneurial spirit," or better management or free markets, etc., in their hearts of hearts and this is why they are trying to de-insure people -- about 35 million at last count. They are trying to de-insure people because they know that this is the only way to limit health care costs: limit the number of sick people. And, in the US, the only way to do this is to deprive these sick people of health insurance.
Let me illustrate what I mean with an example. Imagine you serve sandwiches for lunch. There are 100 people and each sandwich costs $1.00. The total you need, then, is $100.00. Now, imagine you raise this $100.00 via taxes. It is election time and the opposition says "$100.00 is too much. We will do it for $90.00 and you good taxpayers will get $10.00 back. You will get something for nothing. No service will be lost." And ... the opposition wins. They get into office and discover that there are reasons -- other than the previous government's mismanagement -- that sandwiches cost $1.00. They cost $1.00 each because that is what they cost. The bread costs so much, as does the cheese or jam and the people who make the sandwiches need to be paid. So, try as they might, they can't find a 10% saving on labour or resources. So, how do they solve the problem? Well, there is only one way: lower the number of people eating sandwiches. If they can get the number of people eating sandwiches to drop from 100 to 90 ... well, they save the 10%. This means 10 people go without sandwiches ... that is: are de-insured.
This is what is going on with Republican health care policy. The only way to get costs down is to cut people's access to health. This is why every Republican proposal for "reform" is also a proposal for cuts, or de-insuring.
Having a section of the population, in effect, without health care is the price of lowered costs. There are further implications to this. For instance, Republicans, I am sure, expect more people to use "free clinics." That is, they plan to off load costs because sick people will seek out medical care even if they are de-insured. They might rely on the charity of doctors: that is, to see how many people there are out there who will work for free or below market costs. But, make no mistake about it, sick people are the repressed and the repressed will return. Any proposal to reform Obamacare in the US will involve some cut, some section of the population that will go uninsured and, hence, without health care. It is not just Republicanism but simple economics.
Don't believe me? ... watch.
Monday, July 31, 2017
Democracy's Disjuncture: Money, Economics, Health Care and Politics
In my last post, I tried to pick up a thread from over a year ago where I looked at Trumpism for what it tells us about the shifting dynamics of American public life. This is not a discussion of whether Trump is right or wrong; good or bad. We have to engage empirical issues in any analysis. That is life and if you don't believe that ... well ... you and I have different conceptions of what constitutes analysis. But, if we put the question of Trump's merits or demerits on hold and look at what the discourses associated with his government tell us about American public life (or, the changing character of American public life), we can, I think, produce both interesting, nuanced and accurate treatments of this subject. This analysis may have some implications for Canada as well.
Last post I tried to argue that there were important implications to the disjuncture between image and reality in American public life with regard to health care. The right-wing discourse of the problems of Obamacare, for instance, focused on a failure that was, in important ways, difficult to specify. The American health care system has its problems. No one debates that but, overall, the issue of the cost of health care -- associated by Republicans in the US with Obamacare -- is intensely problematic because it fails to understand why health care costs have increased. There are a number of reasons for this, but one reason is that health care is expensive. I've made this point with regard to Canada. Canadians periodically complain about taxes being too high (which is both an empirical and philosophic issue) but those doing the complaining fail to tell us what those taxes dollars have done. And, one thing they have done is improve the health of the country. We now, for instance, live longer than we used and not by a little bit. By a lot. Moreover, the recovery from serious health problems -- say, heart attacks or strokes -- is astronomically better than it was when I was a kid. Said differently, we are getting things for our dollars.
Does this mean that one cannot have health care "reform." Of course not, but it does mean that if you start from the wrong premise, you get the wrong answer. If you begin, for example, from the assumption that the cost of health care is *not* related to its increasingly high tech nature and increased costs but must, instead, be related to something the government is doing, one begins to toy around with policy when, in fact, that might *not* be the thing to do.
In this blog, let me take a long diversion to make a point about taxes, honesty, and democracy. Trump and his crew may have problems with honesty. Frankly, I think they believe their own propaganda. But, ultimately, I want to suggest that on economic issues there is a disjuncture built into democracy between reality and ... well ... image, for lack of a better term. We can use the health care debate in the US to illustrate this point.
This is an important consideration for the US because we key proponents in the health care debate tell people something that is not true. I've complained about this before. The anti-tax perspective in Canada, for example, tends to ignore the costs of not paying taxes? There is a cost to not paying taxes?! Does not lower taxes, in fact, save us money? As anyone who has taken economics 101 will tell you -- and this is the reason that there were so few economists on board with ant-tax think tanks -- there is a cost to everything. This is called, in economics, "opportunity cost" and it is a basic principle of economics. It is not, in other words, some fancied up confusing newfangled idea. It is a basic foundation upon which the discipline is built.
What is it? In effect, the principle of opportunity cost states that there is a price for everything. Money is a valuation of that price but it is a valuation only. Saving money saves you money but it also comes at a price. What is that price? You give up what you otherwise would have done with that money. Let me give you an example or two. Imagine that I have a dollar and I can buy a hamburger for that dollar. I decide to not buy the hamburger and keep the dollar. What is that price of that dollar? The hamburger I could have had. So, I have a dollar in my pocket -- money I have "saved" -- but I am hungry. Likewise, I go to work to make money. The price of going to work (even if I like my job) is what I could have done outside that job (say, go for a hike, weed my garden, sit in my hot tub, etc.).
This relates to taxes in this sense: the issue is not "how much money would you have if you had not paid taxes" but what is the cost of not paying those taxes? What does our society -- and the people in it -- not have that they otherwise would have had? In Canada, these costs are big. Taxes are used to pave roads (which are often, btw, needed for business development), make sure the medicines we buy are safe to use, pay the coast guard, repair the water supply, maintain schools, keep electricity flowing, make sure I don't get mugged walking down the street, etc. Said differently, we can give up on taxes but we also have to give up on all the things that we get from those taxes. That is the cost of *not* paying taxes.
What this means is that for most people, there are good reasons to pay taxes. Some people -- say, just about everyone who lives in New Brunswick -- is a net beneficiary of the tax system. That is, what is being purchased through taxes is fairly valuable and are things that we don't want to give up. Moreover, because we do them collectively, we realize something called "an economy of scale". This is another important concept that is also *not* fancied up. An economy of scale is something you all know. That is: it is less expensive per item to do things on a big scale. For instance, if I am making shirts, one shirt costs a lot to make. If I am making 1000 shirts, however, the cost per shirt falls because I can get a deal of raw materials, set up an assembly line, etc. Thus, while making one shirt might cost per shirt $25.00. The per unit cost of a 1000 shifts might fall to $15.00. Making things on a big scale, in other words, for a lot of people, allows those lot of people to benefit.
Taxes can be like this. If we all pay into a central fund and organize, say, our health care or education or road paving or electrical supply collectively, we can all save money. Yes, we have to pay taxes but those taxes are buying us something at a lower rate than if we tried to go out an buy it individually.
I don't want to get more deeply into this at this point in time. What I am trying to indicate, however, is, I hope, by now clear. Taxes are not just a loss. There is a price to lowering taxes and that price might be significant. Moreover, there are good reasons to have central purchasing of some product because they allow us to realize an economy of scale, thus lowering the per unit costs for everyone. Said differently, taxes can actually save you money if you get a product that you would otherwise have bought for less. Health care is an obvious example. In Canada we buy it collectively and it costs us less than it does for Americans who buy it individually (through insurance premiums). Why? Economies of scale.
I've taken too long to get to my point but bear with me just a nick longer. What does all this have to do with the health care debate in the US? If you use these simple tools of economics, you start to realize that the debate is on the wrong track. The anti-Obamacare people do not explain in their discussion that if you get rid of Obamacare, there is a cost and that cost is health care. Yes, you will pay less. But, you also will not get the same product. And, why would you? We live in a capitalist society and you have to pay for what you get, right? That is the nature of capitalism.* (*I will provide a refresher on markets and lower costs in a future blog.)
What this means, for the federal governments and an increasingly section of the population (as they come to understand the issues) is this: you can't get something for nothing. I recognize that that is not an ethical position that, if you are a politician, wins elections. If I come out and say to people -- in the US or Canada -- look, I am running for election and what I have to tell you is that you have to pay taxes *if* you want certain things -- roads, health care, a military, disease control, schools, police officers, fire departments, electricity, etc. -- and, because of that, if you elect me, I will not lower taxes, I doubt I will win. The person who says "I have found a way to save you money" and this will mean that you will get to keep all you are getting now and still have more money in your pockets, will have a better chance of winning. If they say, I will lower taxes and you will still have good roads (in fact, I'll make them better), you will still have health care (in fact, I will make sure its cheaper), you will still have a military (in fact, I will rearm), etc. ... which position will sound better to the average Joe? This person is the person more likely to get elected even if they are not telling the whole truth?
What this means is that here is a bit of a disjuncture built into democracy. When it comes to economic issues, like taxes, there is a strong incentive to not tell the whole truth. Now, I recognize some people don't tell the whole truth because they believe something other than this. They believe, for instance, that "entrepreneurial spirit" will lower taxes. Exactly what this is, is never explained and I, myself, am deeply concerned about things that are not -- or, cannot -- be explained. I recognize that someone who believes in this might say "gee, Andrew, if you were a business person you would understand" but I have a brain. Explain it to me. I've never been to the moon and I can understand what the moon is like when a scientist explains it to me. Don't tell me "you can't understand because you are not X" because that basically says only people X can understand and, that being the case, why would anyone believe you? The only thing we can do -- if we cannot understand -- is accept it on faith and that is the definition of metaphysics. And, I, personally, think metaphysics is not a good ground on which to build a polity.
What this means, though, is that democracy suffers from a problem. It suffers from a disjuncture between reality and image and that is connected to electoral politics.
Last post I tried to argue that there were important implications to the disjuncture between image and reality in American public life with regard to health care. The right-wing discourse of the problems of Obamacare, for instance, focused on a failure that was, in important ways, difficult to specify. The American health care system has its problems. No one debates that but, overall, the issue of the cost of health care -- associated by Republicans in the US with Obamacare -- is intensely problematic because it fails to understand why health care costs have increased. There are a number of reasons for this, but one reason is that health care is expensive. I've made this point with regard to Canada. Canadians periodically complain about taxes being too high (which is both an empirical and philosophic issue) but those doing the complaining fail to tell us what those taxes dollars have done. And, one thing they have done is improve the health of the country. We now, for instance, live longer than we used and not by a little bit. By a lot. Moreover, the recovery from serious health problems -- say, heart attacks or strokes -- is astronomically better than it was when I was a kid. Said differently, we are getting things for our dollars.
Does this mean that one cannot have health care "reform." Of course not, but it does mean that if you start from the wrong premise, you get the wrong answer. If you begin, for example, from the assumption that the cost of health care is *not* related to its increasingly high tech nature and increased costs but must, instead, be related to something the government is doing, one begins to toy around with policy when, in fact, that might *not* be the thing to do.
In this blog, let me take a long diversion to make a point about taxes, honesty, and democracy. Trump and his crew may have problems with honesty. Frankly, I think they believe their own propaganda. But, ultimately, I want to suggest that on economic issues there is a disjuncture built into democracy between reality and ... well ... image, for lack of a better term. We can use the health care debate in the US to illustrate this point.
This is an important consideration for the US because we key proponents in the health care debate tell people something that is not true. I've complained about this before. The anti-tax perspective in Canada, for example, tends to ignore the costs of not paying taxes? There is a cost to not paying taxes?! Does not lower taxes, in fact, save us money? As anyone who has taken economics 101 will tell you -- and this is the reason that there were so few economists on board with ant-tax think tanks -- there is a cost to everything. This is called, in economics, "opportunity cost" and it is a basic principle of economics. It is not, in other words, some fancied up confusing newfangled idea. It is a basic foundation upon which the discipline is built.
What is it? In effect, the principle of opportunity cost states that there is a price for everything. Money is a valuation of that price but it is a valuation only. Saving money saves you money but it also comes at a price. What is that price? You give up what you otherwise would have done with that money. Let me give you an example or two. Imagine that I have a dollar and I can buy a hamburger for that dollar. I decide to not buy the hamburger and keep the dollar. What is that price of that dollar? The hamburger I could have had. So, I have a dollar in my pocket -- money I have "saved" -- but I am hungry. Likewise, I go to work to make money. The price of going to work (even if I like my job) is what I could have done outside that job (say, go for a hike, weed my garden, sit in my hot tub, etc.).
This relates to taxes in this sense: the issue is not "how much money would you have if you had not paid taxes" but what is the cost of not paying those taxes? What does our society -- and the people in it -- not have that they otherwise would have had? In Canada, these costs are big. Taxes are used to pave roads (which are often, btw, needed for business development), make sure the medicines we buy are safe to use, pay the coast guard, repair the water supply, maintain schools, keep electricity flowing, make sure I don't get mugged walking down the street, etc. Said differently, we can give up on taxes but we also have to give up on all the things that we get from those taxes. That is the cost of *not* paying taxes.
What this means is that for most people, there are good reasons to pay taxes. Some people -- say, just about everyone who lives in New Brunswick -- is a net beneficiary of the tax system. That is, what is being purchased through taxes is fairly valuable and are things that we don't want to give up. Moreover, because we do them collectively, we realize something called "an economy of scale". This is another important concept that is also *not* fancied up. An economy of scale is something you all know. That is: it is less expensive per item to do things on a big scale. For instance, if I am making shirts, one shirt costs a lot to make. If I am making 1000 shirts, however, the cost per shirt falls because I can get a deal of raw materials, set up an assembly line, etc. Thus, while making one shirt might cost per shirt $25.00. The per unit cost of a 1000 shifts might fall to $15.00. Making things on a big scale, in other words, for a lot of people, allows those lot of people to benefit.
Taxes can be like this. If we all pay into a central fund and organize, say, our health care or education or road paving or electrical supply collectively, we can all save money. Yes, we have to pay taxes but those taxes are buying us something at a lower rate than if we tried to go out an buy it individually.
I don't want to get more deeply into this at this point in time. What I am trying to indicate, however, is, I hope, by now clear. Taxes are not just a loss. There is a price to lowering taxes and that price might be significant. Moreover, there are good reasons to have central purchasing of some product because they allow us to realize an economy of scale, thus lowering the per unit costs for everyone. Said differently, taxes can actually save you money if you get a product that you would otherwise have bought for less. Health care is an obvious example. In Canada we buy it collectively and it costs us less than it does for Americans who buy it individually (through insurance premiums). Why? Economies of scale.
I've taken too long to get to my point but bear with me just a nick longer. What does all this have to do with the health care debate in the US? If you use these simple tools of economics, you start to realize that the debate is on the wrong track. The anti-Obamacare people do not explain in their discussion that if you get rid of Obamacare, there is a cost and that cost is health care. Yes, you will pay less. But, you also will not get the same product. And, why would you? We live in a capitalist society and you have to pay for what you get, right? That is the nature of capitalism.* (*I will provide a refresher on markets and lower costs in a future blog.)
What this means, for the federal governments and an increasingly section of the population (as they come to understand the issues) is this: you can't get something for nothing. I recognize that that is not an ethical position that, if you are a politician, wins elections. If I come out and say to people -- in the US or Canada -- look, I am running for election and what I have to tell you is that you have to pay taxes *if* you want certain things -- roads, health care, a military, disease control, schools, police officers, fire departments, electricity, etc. -- and, because of that, if you elect me, I will not lower taxes, I doubt I will win. The person who says "I have found a way to save you money" and this will mean that you will get to keep all you are getting now and still have more money in your pockets, will have a better chance of winning. If they say, I will lower taxes and you will still have good roads (in fact, I'll make them better), you will still have health care (in fact, I will make sure its cheaper), you will still have a military (in fact, I will rearm), etc. ... which position will sound better to the average Joe? This person is the person more likely to get elected even if they are not telling the whole truth?
What this means is that here is a bit of a disjuncture built into democracy. When it comes to economic issues, like taxes, there is a strong incentive to not tell the whole truth. Now, I recognize some people don't tell the whole truth because they believe something other than this. They believe, for instance, that "entrepreneurial spirit" will lower taxes. Exactly what this is, is never explained and I, myself, am deeply concerned about things that are not -- or, cannot -- be explained. I recognize that someone who believes in this might say "gee, Andrew, if you were a business person you would understand" but I have a brain. Explain it to me. I've never been to the moon and I can understand what the moon is like when a scientist explains it to me. Don't tell me "you can't understand because you are not X" because that basically says only people X can understand and, that being the case, why would anyone believe you? The only thing we can do -- if we cannot understand -- is accept it on faith and that is the definition of metaphysics. And, I, personally, think metaphysics is not a good ground on which to build a polity.
What this means, though, is that democracy suffers from a problem. It suffers from a disjuncture between reality and image and that is connected to electoral politics.
Friday, July 28, 2017
Twitter Politics: Health Care and Being Voted Off the Island
I was going to begin this post by saying that at least American politics is interesting but it really might not be. I suspect it is interesting both to the partisans of American politics and to those interested in the changing character and nature of US public life. In a previous series of blogs, I tried to suggest that one should avoid the pro/con dialogue on Trump in favour of an analysis that looked at what his rise (and I would have said this whether or not he "won" the presidential election) told us about the changing nature of US politics. I suggested that it said something about: the nature of American Christianity, the public culture of economics in the US, and disturbing trends in the increased legitimacy of racialized politics. Trumpism, in other words, benefited from a series of cultural changes that overtook a section of the US population.
A year later I see no reason to change my mind. The recent debate over health care and the tweet regarding trans-gendered people in the military epitomizes these changes and the culture that upholds them. What do I mean?
Before getting into that I should say that I am no expert on the United States or American politics and I think this is an important consideration. Canadians can find it all too easy to look across the border and make quick comments about the bizarre and retrogressive character of American politics. The fact that this retrogressive character actually seems to be ringing true lends some force to these comments. But, we also need to understand why Canadians make these comments on a regular basis when, in fact, they are often preaching to converted. This can be the subject of another blog. For now, it is a warning.
Instead of criticizing Trumpism, it is important to understand it, at least from an academic point of view, because that is what we do. Our analysis should strive for the same level of nuance, care, and precision that we bring to other analyses. That is: instead of simply dismissing Trump and his politics, we need to grapple with what motivates them. (I fully concede, too, that sometimes what motivates these politics can be disturbing.) In this light, what is going on? Let's take a quick look at healthcare first to illustrate what I am arguing is a broader trend.
The debate over health care illustrates a disjuncture between reality and discourse that pervades part of American public life. Make no mistakes about it. The Republicans will eventually get rid of Obamacare. It has not been saved. By this time next year millions of Americans will be without healthcare insurance and those that have it will be paying higher premiums. The Affordable Healthcare Act has a reprieve but that is all. The key to the disjuncture here is that millions of Americans have now discovered that (a) while they don't like Obamacare, they (b) don't actually know why and, (c) no one can really tell them, and (d) the alternatives aren't very good (and hence the interest in single payer).
Republicans, for their part, have discovered that the United States is divided on this issue. For political reasons, they will try to blame Democrats (and politically, Democrats might be wise to let them but that is a discussion for another day), but they have also discovered that the Democrats are not going down without a fight, that they -- the Republicans -- don't really have an alternative policy that withstands close scrutiny (why? because their plan to lower premiums involved un-insuring people: the poor, the ill, the elderly). Hence, the idea that Obama had somehow personally screwed Americans and taken money from their pockets for no good reason ... well ... that idea has run aground on the reality of the contemporary economics of health care.
In this sense the question is not "is there a disjuncture between reality and discourse" but which prevails? Republicans sold their plan on health care to their constituents -- not all Americans -- by promising lower premiums and by working with a bit of nostalgia for a world that no longer exist. They never explained why those premiums would be lower and hearkened back to an ideal of a small town doctor charging reasonable prices to middle class people just so long as the government did not get involved and "force" him to charge more. A kindly man in a white coat fixed you and your kids. The fact that that world no longer existed does not really matter in the politics of image. They said over and over again that Obamacare had destroyed America ... but how had it? What was actually wrong with it? Like most matters of public policy, the issue is not white and black and there are pros and cons. But what are those? Could the average Republican voter actually tell you?
What is wrong with this disjuncture is not just that it is politicized but that it is dishonest and prevents a real engagement with the issue of health care and its meaning and importance. How is it dishonest? Without being shocked that a politician stretched the truth, it is dishonest not just because it claims that Obamacare had destroyed America without explaining why but because it never explained why healthcare costs money. After all, recall that nice nostalgic image of the kindly town doctor. He didn't charge too much, did he?
Maybe he didn't, but that is not the healthcare world in which we live today. In the US, some healthcare costs are high because some people are making mega profits off of it. There is an expectation of remarkable wealth, at least on the part of some people, and there are a chain of people who actually benefit from the mega healthcare profits (again, something we can get to later). But, another reason healthcare has increased in cost is because ... well ... it got more expensive. I know that sounds simple but consider how high tech medicine has gotten.
For good or ill, I've had some health problems of late and have had to go through some tests over the last few years. The tests I get are remarkably more sophisticated than they were when I was a kid. People are, by and large, living longer. The machines we have in our hospitals tell us more than the machines we used to have and the medicines we have do more for us than the ones we used to have.
All of these things cost money. I cited Canadian data above re life expectancy, but US data will show us the same thing. This is a good news story that is not just happening by itself. It has happening because society -- through their governments -- are investing a lot of money into keeping people alive. There is much more that we could do and I am not talking about heroic and unusual intervention here. I am talking about progress on improving survival rates for people who have serious diseases that would have killed in a short time when I was a kid.
These are good costs. I am glad we have paid for them and I hope we -- and the folks in the US -- continue to pay for them. I think investing in people's lives is a good thing to do viz investing in, say, more consumer goods that we don't really need. But, and this is the point I want to make, these things cost money. The machines we use for tests are expensive. Training the highly qualified people who look after these tests and who provide care to us is expensive. My complaint is not that they are expensive. In fact, I'm not even complaining. I am analyzing. And, what this analysis points to is this: many Americans don't understand why healthcare is so expensive. They work with an idealized and antedated (even if nostalgically pleasing) image of what healthcare actually is. They don't understand that the money we have paid for healthcare on a social level has worked. It has improved quality of life and it has improved life expectancy. It is not perfect, but if one understood reality, one might start to think again about those promising to "fix" a problem that, in reality, might not exist in the fist place. Or, more exactly, not in the same way it has been presented.
What does all this have to do with American public life. It highlights the problem of the disjuncture between reality and discourse. Because Americans are not grappling with the real reasons why healthcare has increased in cost, they cannot have a real -- as in potentially effective -- debate about good healthcare policy. Hence, rather than celebrating the improved quality of life and longer life and socially broader health care, they see only problems that are not the problems that they really need to address. Instead, they approach a healthcare debate not in a manner that looks forward and asks "how do we keep the ball rolling?" but instead in a manner of trying to figure out who will be voted off the island.
A year later I see no reason to change my mind. The recent debate over health care and the tweet regarding trans-gendered people in the military epitomizes these changes and the culture that upholds them. What do I mean?
Before getting into that I should say that I am no expert on the United States or American politics and I think this is an important consideration. Canadians can find it all too easy to look across the border and make quick comments about the bizarre and retrogressive character of American politics. The fact that this retrogressive character actually seems to be ringing true lends some force to these comments. But, we also need to understand why Canadians make these comments on a regular basis when, in fact, they are often preaching to converted. This can be the subject of another blog. For now, it is a warning.
Instead of criticizing Trumpism, it is important to understand it, at least from an academic point of view, because that is what we do. Our analysis should strive for the same level of nuance, care, and precision that we bring to other analyses. That is: instead of simply dismissing Trump and his politics, we need to grapple with what motivates them. (I fully concede, too, that sometimes what motivates these politics can be disturbing.) In this light, what is going on? Let's take a quick look at healthcare first to illustrate what I am arguing is a broader trend.
The debate over health care illustrates a disjuncture between reality and discourse that pervades part of American public life. Make no mistakes about it. The Republicans will eventually get rid of Obamacare. It has not been saved. By this time next year millions of Americans will be without healthcare insurance and those that have it will be paying higher premiums. The Affordable Healthcare Act has a reprieve but that is all. The key to the disjuncture here is that millions of Americans have now discovered that (a) while they don't like Obamacare, they (b) don't actually know why and, (c) no one can really tell them, and (d) the alternatives aren't very good (and hence the interest in single payer).
Republicans, for their part, have discovered that the United States is divided on this issue. For political reasons, they will try to blame Democrats (and politically, Democrats might be wise to let them but that is a discussion for another day), but they have also discovered that the Democrats are not going down without a fight, that they -- the Republicans -- don't really have an alternative policy that withstands close scrutiny (why? because their plan to lower premiums involved un-insuring people: the poor, the ill, the elderly). Hence, the idea that Obama had somehow personally screwed Americans and taken money from their pockets for no good reason ... well ... that idea has run aground on the reality of the contemporary economics of health care.
In this sense the question is not "is there a disjuncture between reality and discourse" but which prevails? Republicans sold their plan on health care to their constituents -- not all Americans -- by promising lower premiums and by working with a bit of nostalgia for a world that no longer exist. They never explained why those premiums would be lower and hearkened back to an ideal of a small town doctor charging reasonable prices to middle class people just so long as the government did not get involved and "force" him to charge more. A kindly man in a white coat fixed you and your kids. The fact that that world no longer existed does not really matter in the politics of image. They said over and over again that Obamacare had destroyed America ... but how had it? What was actually wrong with it? Like most matters of public policy, the issue is not white and black and there are pros and cons. But what are those? Could the average Republican voter actually tell you?
What is wrong with this disjuncture is not just that it is politicized but that it is dishonest and prevents a real engagement with the issue of health care and its meaning and importance. How is it dishonest? Without being shocked that a politician stretched the truth, it is dishonest not just because it claims that Obamacare had destroyed America without explaining why but because it never explained why healthcare costs money. After all, recall that nice nostalgic image of the kindly town doctor. He didn't charge too much, did he?
Maybe he didn't, but that is not the healthcare world in which we live today. In the US, some healthcare costs are high because some people are making mega profits off of it. There is an expectation of remarkable wealth, at least on the part of some people, and there are a chain of people who actually benefit from the mega healthcare profits (again, something we can get to later). But, another reason healthcare has increased in cost is because ... well ... it got more expensive. I know that sounds simple but consider how high tech medicine has gotten.
For good or ill, I've had some health problems of late and have had to go through some tests over the last few years. The tests I get are remarkably more sophisticated than they were when I was a kid. People are, by and large, living longer. The machines we have in our hospitals tell us more than the machines we used to have and the medicines we have do more for us than the ones we used to have.
All of these things cost money. I cited Canadian data above re life expectancy, but US data will show us the same thing. This is a good news story that is not just happening by itself. It has happening because society -- through their governments -- are investing a lot of money into keeping people alive. There is much more that we could do and I am not talking about heroic and unusual intervention here. I am talking about progress on improving survival rates for people who have serious diseases that would have killed in a short time when I was a kid.
These are good costs. I am glad we have paid for them and I hope we -- and the folks in the US -- continue to pay for them. I think investing in people's lives is a good thing to do viz investing in, say, more consumer goods that we don't really need. But, and this is the point I want to make, these things cost money. The machines we use for tests are expensive. Training the highly qualified people who look after these tests and who provide care to us is expensive. My complaint is not that they are expensive. In fact, I'm not even complaining. I am analyzing. And, what this analysis points to is this: many Americans don't understand why healthcare is so expensive. They work with an idealized and antedated (even if nostalgically pleasing) image of what healthcare actually is. They don't understand that the money we have paid for healthcare on a social level has worked. It has improved quality of life and it has improved life expectancy. It is not perfect, but if one understood reality, one might start to think again about those promising to "fix" a problem that, in reality, might not exist in the fist place. Or, more exactly, not in the same way it has been presented.
What does all this have to do with American public life. It highlights the problem of the disjuncture between reality and discourse. Because Americans are not grappling with the real reasons why healthcare has increased in cost, they cannot have a real -- as in potentially effective -- debate about good healthcare policy. Hence, rather than celebrating the improved quality of life and longer life and socially broader health care, they see only problems that are not the problems that they really need to address. Instead, they approach a healthcare debate not in a manner that looks forward and asks "how do we keep the ball rolling?" but instead in a manner of trying to figure out who will be voted off the island.
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