What I think I am nearly certain about

by on January 4, 2008 at 6:07 am in Data Source | Permalink

My apologies if this list sounds dogmatic or polemic.  I’m not trying to persuade you (now), I’m simply listing the inner contents of my mind, so you may compare this with my post on what I am uncertain about.  Here is an incomplete and desultory list of what I (think I) am nearly certain about:

1. Polarizing America won’t make interest group politics go away, no matter how hard either the right-wingers or progressives wish it so.  It may even make interest group politics worse, and in the meantime the polarizer is simply demonstrating a lack of meta-rationality on the part of the polarizer.

2. We cannot do economic policy as we might arrange pieces on a chessboard.  What you ask for is rarely what you get, and your recommendations had better be prepared for this discrepancy.

3. Government-dominated health systems, insofar as they work well (a number of them do), succeed simply by lowering costs.  Health care has a murky relationship to human health, pharmaceuticals and broken limbs aside.  A version of the single-payer system, as might be adopted in the United States, would not lower costs.  We would be raising taxes and lowering medical innovation to give poor people a good deal more financial security and a slight bit more health; that is the relevant trade-off.

4. Overall, despite its many flaws, America is a force for liberty in the greater global community.

5. We are programmed to respond to the "us vs. them" mentality and highly intelligent people are no less captive to this framing.  We should try very hard to get away from this framing.

6. America is a beacon of innovation for the world, and it is critically important that we allow the preconditions for American innovation to continue.

7. It would be a disaster if American taxation ever reached 55 percent of gdp.

8. Which institutions work well is often country-specific. 

9. The West European way of life is a marvel, unprecedented in human history.  That said, I am not sure that the degree of economic security to date can persist in a more mobile and more diverse future (this second sentence retreats to what I am uncertain about).

10. No one has a good idea what the equilibrium looks like for nuclear proliferation.  This is very worrying.

11. The possibility of pandemics receives insufficient attention.  The world sleepwalked through AIDS for a long time, mostly because "it doesn’t affect people like you and me."  The next time around could be much worse.

12. It is a big mistake — even in rhetoric — to conflate concern for the poor with comparative egalitarian intuitions.  The left ought to turn its back on this mistake, although it would mean losing one of their most effective rhetorical tools.

13. Most people are sincere in their views (even if wrong), and polemic attacks on them signal a weakness of the attacker, not the attackee.

14. The chance that a protectionism will be an economically rational form of protectionism is very low.

GreatZamfir January 4, 2008 at 6:53 am

Could you explain what you are referring to in 1.? It is formulated in general terms, but you probably have specific cases in mind. What interest groups might or might not go away? Who are the people that promote polarization as a an antidote to those interest groups?

odograph January 4, 2008 at 7:47 am

The benefit of socialized medicine should be certainty that you (and your child) are covered. I’d pay a little more for “coverage denied” horror stories to go away.

jon January 4, 2008 at 8:22 am
odograph January 4, 2008 at 8:31 am

BTW, my short story is that in simply extending my COBRA coverage my insurance company told me X. I was lucky that I called California’s health insurance hotline. They told me to call them back and say that I knew X was illegal.

This is a system?

No, but most people don’t want to believe it is our system.

Mcwop January 4, 2008 at 8:51 am

The benefit of socialized medicine should be certainty that you (and your child) are covered. I’d pay a little more for “coverage denied” horror stories to go away.

But I do not want to trade that benefit for treatment denied or delayed, or the outlawing of the freedom to purchase private insurance or seek private care.

http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/1118315110253_28/?hub=TopStories

A Tykhyy January 4, 2008 at 9:07 am

There was “employee”, then “payee” and now finally “attackee”! Aaaah! *keels over and dies*
Jokes aside, I didn’t get the 12. point at all. How can one conflate concern with institutions?

PS: Orwell was right when he predicted the evolution of English in the direction of isolating languages.

Theodore Scroatsky January 4, 2008 at 9:28 am

Wow, this is the kind of inane doctrinaire bullshit that has made me unsubscribe to carpe diem, and now your incessant barking. Vietnam, Cambodia, Laos, Guatemala, El Salvador, Nicaragua, Iraq, etc. all thank you for your unflinching support of liberty.

odograph January 4, 2008 at 9:48 am

Mcwop, I suppose it is unavoidable that any health care system have an adversarial barrier to care. We want, and they pay, with private or national health.

I think though, that I’m more comfortable with the barrier being with a nurse or doctor across the table from me, rather than a traditional insurer at the end of a phone.

Maybe that’s why I’m in an HMO now. My card always gets me in the door, and a doctor or nurse tells me if I need anything.

That can be abused, HMO horror stories are similar to Canadian horror stories … but I honestly think there is less pure BS in that kind of barrier.

No “you said your shoulder was sore last year, so we are denying you for pre-existing condition, even though you never sought treatment of any kind.”

Peter January 4, 2008 at 10:30 am

We cannot do economic policy as we might arrange pieces on a chessboard. What you ask for is rarely what you get, and your recommendations had better be prepared for this discrepancy

Probably true for all types of policy, not just economic policy.

Gerard D. January 4, 2008 at 10:48 am

Would someone be kind enough to explain what “12. It is a big mistake — even in rhetoric — to conflate concern for the poor with comparative egalitarian intuitions” means?

In particular, it is not obvious to me what the meaning of “comparative egalitarian intuitions” is. Thanks.

Floccina January 4, 2008 at 10:50 am

11. The possibility of pandemics receives insufficient attention. The world sleepwalked through AIDS for a long time, mostly because “it doesn’t affect people like you and me.” The next time around could be much worse.

What about the slow drip of car deaths over a long period of time is a pandemic worse?

GreatZamfir January 4, 2008 at 11:06 am

@Jon: Given that basically every developed country in the world has both redistribution and capitalism, seeing them in another light then us vs them can’t be that hard.

Ron Hardin January 4, 2008 at 11:27 am

What you ask for is rarely what you get, and your recommendations had better be prepared for this discrepancy.

The reason is seldom given, namely that all the problems that can be fixed by direct action have already been fixed. What remains are problems that respond to fixes with perverse results.

Which is why conservatives are mostly always right today.

The fallacy of composition (“If everybody stands on their toes, everybody can see better”) eventually stands alone.

Mario Rizzo January 4, 2008 at 11:36 am

I have an EPISTEMIC problem. What does it mean to THINK that you are (nearly) certain about something? You ARE nearly certain or you are NOT. When someone says “I am nearly certain…” it is a statement about his degree of belief. He still could be totally wrong about whatever he says he is nearly certain. Now it is possible that sometimes Tyler is nearly certain about these things and sometimes he is not. That is okay. He should have said so. But presumably at the time he wrote the post he was of one mind.

Yes, this is a pedantic comment!

Mark January 4, 2008 at 12:38 pm

“Polarizing America won’t make interest group politics go away, no matter how hard either the right-wingers or progressives wish it so. It may even make interest group politics worse, and in the meantime the polarizer is simply demonstrating a lack of meta-rationality on the part of the polarizer.”

I couldn’t agree more. I just wish you were more unequivocal than saying that polarization “may” make interest group politics worse. I don’t think there should be a “may” about it.

The trouble with polarization is that it leads myriad interest groups to hitch all their hopes to one political party or the other, resulting in the interest groups conforming their secondary and tertiary interests with the polarizer’s. When this takes place within the context of a political party, it creates the equivalent of one mega-interest group; people are defined as either a hundred percent part of the team or as actively working to undermine it. The result is that the party simply represents the top priority issues of each of its constituent interest groups. Since the constituent interest groups each have their own top priorities, the end result is a kind of “pu-pu platter” partisanship that is more concerned with keeping constituent interests happy on their top-line issues than it is with anything resembling principle.

Effectively, this means that polarization undermines the constitutional safeguards meant to mitigate faction by reducing all or most of politics to two mega-factions. The corrupting influence of subsidiary factions becomes tremendous because those subsidiary factions effectively have a monopoly on the party’s political positions within their interest area.

Raul January 4, 2008 at 12:55 pm

6. America is a beacon of innovation for the world, and it is critically important that we allow the preconditions for American innovation to continue

What’s the spirit behind this one? As a “citizen of the world”, a paternalistic “we-need-the-beacon-for-the-good-of-the-rest-of-the-world”?

TGGP January 4, 2008 at 2:38 pm

What is it that makes America a force for liberty around the world?

Steve January 4, 2008 at 3:32 pm

Stephen Downes – nice set of rebuttals!

Cliff – how exactly does Stephen’s mention of specific examples of human rights abuses by the US or the discussion of higher life expectancy in Canada constitute “zero evidence or support of any kind”? The stats are everywhere on the health system – outcomes higher, costs lower in a universal health care system (not to mention the hidden costs that Stephen alludes to).

Stephen, I am 100% convinced that elements in the US would rather sabotage a universal health care system rather than admit it works just to prove their ideology is right.

Two final points: “which policies work best is country-specific” is another way of saying that “just because it works in Europe and everywhere else in the world doesn’t mean it will work here”. (see sabotage point above).

“lack of attention to AIDS” – I would say that the gay lobby ensured that massive attention was paid to AIDS in the 1980s. Watch the excellent documentary by British actor Stephen Fry (himself gay) on how the gay community has forgotten or ignored the AIDS message (or in some cases deliberately seek infection).

TheRadicalModerate January 4, 2008 at 4:29 pm

I think I can boil this list down to three items:

1) Something fundamental has changed and caused groups to self-select for orthodoxy of opinion much more than they did in the past. (1, 5, 12, and 13.)

2) Complex, self-organizing systems work pretty well if you leave them alone. (4, 6, 8, and 9).

3) Complex, self-organizing systems are largely resistant to all known forms of engineering. (2, 3, 7, 9, 10, 11, and 14.)

Better than Ezra January 5, 2008 at 1:07 am

3) Government-dominated health systems, insofar as they work well (a number of them do), succeed simply by lowering ‘wages’, ‘outcomes’, and ‘expectations’.

Fixing your “typo”…

Daniel Merritt January 5, 2008 at 3:15 am

Whoops, I just bothered to read the last few comments, and Tyler already addressed that.

Let me also note that this comment: “(i.e. state-run systems tend to let older citizens die off without a bunch of expensive treatments… perhaps it is more “ethical” to deny old people care instead of people who have less money).” gets to the heart of why America has the worst of both worlds right now. We do have a strong, state-managed health care system – it’s called Medicare. Instead of the state stepping in to help the poor or those who’s health problems render them unemployable (a huge, huge gap in the current system), we essentially give massive government subsidies to highly questionable treatments for the elderly and massive outlays of money on the last weeks of life. Sometimes the ‘patient’ is too far gone to even care, but we milk all the procedures we can out of it, because darn it, that’s what the government subsidies and biases the ‘rationing’ (ultimately, up until the magical day everybody can have any procedure they want, there WILL be rationing of some form or another) towards. It’s much, much harder for young people to get inexpensive treatments that could give them dozens of productive years of life.

If we want government involvement in health care, let’s go whole hog and reap the benefits associated with comprehensive plans and weather the downsides. If we want to let the market deal with it, we need to scale back Medicare. Since the second is politically infeasible, I think the only real option has to be the first, which will likely indirectly up reforming Medicare in a way nothing else can.

Greg Gentschev January 5, 2008 at 11:31 am

This is a complete tangent, but Better Than Ezra, your typo fix on healthcare doesn’t make any sense to me. Lots of health outcomes are better in other countries, like life expectancy, infant mortality, etc. Granted, there are tricky measurement and demographic differences. But those measurement differences also make some of the US’s supposedly superior health outcomes, like Giuliani’s prostate example, highly questionable. To my limited knowledge, outcomes are basically comparable across systems except perhaps at the technological margin, yet other countries pay about half as much for health care. In the US, you also find a very high incidence of unnecessary procedures, partially due to torts and partially due to the fee for service system. Private insurance also leads to very high billing costs. And the uninsured end up sometimes creating higher costs in the end by foregoing basic care.

I’m still unsure of how exactly I would improve the US healthcare system, but here are some ideas:

1) Go to single payer to minimize billing overhead, provide economic security for people, and encourage greater consumption of basic care

2) Systematically ration some procedures with questionable utility and high cost – not sure exactly what this list would entail, but caesareans, hysterectomies, and spinal fusion come to mind.

3) Pay doctors salaries with bonuses for good outcomes, rather than fee for service.

4) Moderately reform the tort system to shift away from jury verdicts and high damages on the whole, while allowing some recourse for particularly egregious cases. This would also help reduce overutilization of things like MRI’s, I believe.

I’m curious to hear counter-proposals, but just saying that the current system works well enough seems oddly complacent.

Greg Gentschev January 5, 2008 at 6:20 pm

James,

Excellent points, although I’m not sure I agree with all of them.

1) I agree government workers and processes tend to be inefficient, but I still think that eliminating most of the billing and reimbursement complexity in the current US system would yield significant efficiency gains even while giving up some individual worker efficiency. For example, I’ve heard anecdotes of comparably sized US and Canadian hospitals having billing staff of 300 and 3, respectively.

2) Paying for your own care would minimize overtreatment assuming you have a transparent market. Even with the Internet and whatnot, I would argue that most people rely on doctors rather than really knowing what they’re getting, and medicine is an even easier area to get screwed in than car repair or housing contracting. And that’s saying something.

3) So are you saying this is impossible? I would start with simple things like giving hospitals a bonus if people don’t get IV infections, bed sores, sponges in internal cavities, etc. Rewarding outstanding performance is probably harder, but it seems doable. Even now, hospitals are starting to realize how widely their infection rates, life expectancies for chronic conditions (e.g., cystic fibrosis), and recoveries vary. I’d say the biggest obstacle has been medical providers’ unwillingness to publish data.

4) Not up on my constitutional law, but judges do criminal sentencing in the US. I imagine the same would be doable for civil penalties without an amendment.

I like 5-7 a lot. I’m heading to dinner, so I’ll have to think about 8-9 later.

michael chalk January 6, 2008 at 4:49 am

“The USA” sees itself as a force for liberty in this world, but sadly this is far from the truth.

i would agree that the People of America have been a wonderfully significant force for human change and cultural evolution all over the planet; inventive and courageous, inspiring in their creativity.

However i am very concerned about the tendency of the US Government to weaken and destroy the liberty it claims to champion. This government has consistently over the last fifty years undermined liberal democracy around the world in favour of military control, and recently begun to systematically destroy the civil / liberal underpinnings of democracy at home as well.

Ask anyone in Latin America who has seen their regime toppled by clandestine CIA activities; (and now in the Middle East, outright illegal invasion for cynical purposes concealed by media spin.)

11 September 1973..? Democratically elected government of Chile overthrown thanks to US govt determination. Many years of brutal dictatorship follow.

The military imperialism of the US is now dedicated to entrenching its supreme hegemony, especially under the recent neo-conservative regime. Can it be true that the US population is largely unaware of the situation, due to the secrecy of the president’s private army (the cia)?

i would love to agree with you, because i too believe in some of the ideals behind the US-American adventure. But something has gone terribly wrong.

Anonymous January 6, 2008 at 3:48 pm

Overall, despite its many flaws, America is a force for liberty in the greater global community.

This is true, but not for the reason that some may think. The US has a decidedly mixed track record in its global actions and interventions; rather, its main influence has been as a kind of economic role model. Other countries take note that America has for some time been the richest large country in the world, and wishing to emulate that, they are receptive to emulating the democratic institutions and personal liberties and popular culture that are perceived to be part of the recipe for prosperity.

Today however, we are witnessing China’s rise. So far they are defying the conventional wisdom that prosperity and authoritarian government cannot go hand in hand. If China continues to boom but America and the West falter badly in the current credit crunch, it will be interesting to see what conclusions are drawn by ruling elites worldwide. African governments, for one, are already eagerly accepting Chinese trade and aid with no pesky human-rights strings attached.

It is not entirely out of the question that large parts of the world will conclude in the coming decades that democratization was a failed experiment. Russia is already there. We are far from the “end of history”. Pundits shouldn’t sneer at the ideals that America represents and sometimes falteringly fails to live up to. You’ll miss them when they’re gone.

Greg January 7, 2008 at 6:44 pm

James,

Aren’t you essentially advocating a system similar to the current US one with some fiddling at the margins? US healthcare costs are roughly double those of many other countries, I don’t see that as a great solution.

1) Just tax cigarettes more! Haha, just kidding. I’m not nearly familiar enough with taxation to comment.

2) Not sure I understand what you’re saying. Overtreatment is a result of patients not being willing to pay?

3) In general I’m a proponent of the market processing information better than government and so on, but US insurers and healthcare providers have not been able to provide good quality measures, control costs, and so on over a matter of decades. Based on that evidence, I’m inclined to conclude that there are one or more market failures at work. Otherwise, I wouldn’t even propose such extensive government intervention.

Ltrain January 10, 2008 at 1:38 pm

I am uncertain whether this means the left should turn ts back on the poor, or whether it should turn its back on egalitarianism. Either way, it’ not going to happen.

I am certain it didn’t mean either one. The point very clearly was about the conflation of the ideals, not the abandonment of either one. Strawmen very rarely bring evidence and rationality to any debate, but I applaud your skill with the matches …

And on a different note, I think am nearly certain that Tyler’s irony wasn’t comletely lost on almost all of the readers of this post….

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