Socialised health care as feasible utopia

by John Quiggin on September 7, 2011

As I’ve mentioned a few times, I got a lot out of Erik Olin Wright’s Envisioning Real Utopias, and am still hoping our long-promised book event comes to fruition. The general idea of the book was in line with my thinking that technocratic rationality, of the kind offered by, say Obama or Blair, is not a sufficient answer to the irrationalist tribalism of the right – the left needs a transformative vision to offer hope of a better life, both for the increasing proportion of the population in rich countries who are losing ground as a result of growing inequality and for the great majority of the world’s population who are still poor by OECD standards[2]. So, Utopia matters.

But it’s just as important that utopia be feasible. Utopia as a dream may be comforting, but is unlikely to inspire effective political action. And attempts to implement a utopia that isn’t feasible are bound to end in failure, quite possibly disastrous failure, as the experience of communism showed us.

So, my idea was to think about what kind of transformative vision might be both feasible, and capable of inspiring effective action. I had a first go at this here and here, in relation to education.

Turning to health care, we could start with a utopian ideal where everyone got all the health care that could benefit them. But that would be utopian in the pejorative sense – the scope for expanding health services is effectively infinite, and the resources available to society are not.

Thinking about feasible utopia, on the other hand, it seems to me that the system of socialised health care in modern social democracies is not a bad model. That is, if all of society worked like the health care system at its best, we could regard the political project of social democracy as a success.

Perhaps no country gets it perfectly right. In Australia for example, the basics (general practitioner services, pharmaceuticals, critical hospital services) are covered pretty well, but we don’t do so well on mental and dental health, and there are lots of complaints about waiting lists for elective (=desirable, but not lifesaving) surgery. Still, outside the US, the big worry about going to doctors or hospitals is whether the treatment will be successful, not whether you will go bankrupt trying to pay for it.

The big question is whether this model can be replicated more broadly. Health care has the special characteristics that, on the one hand, there isn’t a big issue of consumer preferences (mostly, people want the treatment that has the best chance of a cure, though there is sometimes a risk-return trade-off) and, on the other hand, markets perform very badly.

The public provision model wouldn’t work for, say, motor cars. Still, it seems that it ought to be possible to limit the domain of inequality in such a way that no one was left without the basic requirements for a decent life and social participation while, at the same time, those who chose to work harder, or worked more productively, could still enjoy higher consumption of discretionary items like expensive cars and granite benchtops.

fn2. A billion or more of whom are poor by the absolute standard of not having enough food to eat, or access to basic housing and medical care

{ 92 comments }

1

straightwood 09.07.11 at 2:43 am

A large fraction of the American population believes in the “deserving poor.” Racism and Xenophobia coupled with a narcissistic success culture lead to demonization of the poor. This is why a socialist health care system will not emerge in America for at least a decade. Only when we literally cannot afford to continue paying for health through the current absurd system will a national single-payer system prevail, and this system will still be reviled by the Ayn Rand cultists and Tea Party crazies.

The utopia that cruel and selfish people wish to see is one in which the poor live in squalor and die in misery because these are fit punishments for laziness, stupidity, and parasitism. Until large numbers of Americans abandon the ideology of punishing the poor, there is no hope for more enlightened health care policy.

2

Bruce Wilder 09.07.11 at 2:46 am

A reasonable question to ask might be, what’s the relationship of utopia to diagnosis?

Both make use of theory and evidence, in counterfactuals. The utopia is an assembly of such counterfactuals; diagnosis is a chain of counterfactuals leading to prognosis and treatment.

The great obstacle to the social democratic vision of cooperation and consensus, it seems to me, is the inevitability of competition, conflict and domination. What use are we to make of competition, conflict and domination? What limits are feasible? What channels serve?

Given that hierarchically organized society will have an elite, should we propose a utopian vision of anarchy, in order to inspire the overthrow of an sclerotic elite? Or a neo-liberal, or libertarian, utopia of “free market” competition, where concentrations of private predatory power are to be regretted ever so sincerely, or celebrated, as taste may allow?

3

Simon 09.07.11 at 2:46 am

Another great post from John. As an aspiring physician I actually have considered moving to Australia, as reciprocity is easier there and one is more able to make a difference.

4

engels 09.07.11 at 3:43 am

Erik Olin Wright’s Envisioning Feasible Utopias

‘Envisioning Real Utopias’, I think it’s called.

D’oh! Fixed now – JQ

5

derrida derider 09.07.11 at 6:31 am

On the narrow point about health care, there is definitely no ideal – or even good – system extant. Market failure is pervasive, but then so is government failure. Simon I think the Australian solution is better than the US one, but not by all that much. I reckon some of the continental Europeans provide a less dispiriting environment for an idealistic young doctor than either of us.

6

Harald Korneliussen 09.07.11 at 7:13 am

One “real utopia” that I can’t help being excited about is zero-fare public transport.

7

Henri Vieuxtemps 09.07.11 at 9:00 am

I found this Ricardo quote (here: http://www.marxists.org/archive/marx/works/1861/economic/ch14.htm):

The natural price of labour is that price which is necessary to enable the labourers, one with another, to subsist and to perpetuate their race, without either increase or diminution. The power of the labourer to support himself and his family does not depend on the quantity of money which he may receive for wages, but on the quantity of food, necessaries, and conveniences which that money can purchase. The natural price of labour, therefore, depends on the price of the food, necessaries, and conveniences…. With a rise in the price of food and necessaries, the natural price of labour will rise; with a fall in their price, it will fall.

IOW, cost of labor is directly correlated with the cost of the necessities of life, of which health care (arguably, but pretty obvious) is one. Capitalists, as a class, benefit from the price of food, clothing, shelter, and health care being as low as possible. So, it seems that affordable health care (and, arguably, it can only be affordable when socialized) can be viewed not as utopia, or some glorious social-democratic victory, but an innate characteristic of capitalist systems.

Now, why it’s not happening in the US – that’s a good question. I dunno, maybe the US is a less civilized/more barbaric place, where health care is not yet considered a necessity of life?..

8

ajay 09.07.11 at 9:05 am

we could start with a utopian ideal where everyone got all the health care that could benefit them. But that would be utopian in the pejorative sense – the scope for expanding health services is effectively infinite, and the resources available to society are not.

Is this actually true, though? Surely there’s a limit to the amount of healthcare services people can consume, even with no price to pay.
I mean, I am served by the NHS, so I can already get certain sorts of health care completely free, but I don’t spend all my free time down at the GP’s surgery getting my blood pressure monitored and my hearing checked. I’ve got better things to do.

Similarly with Harald’s example (though he’s not saying that it’s not feasible); if you made all the public transport in London free, people are still not going to consume an infinite amount of it.

9

ajay 09.07.11 at 9:08 am

Capitalists, as a class, benefit from the price of food, clothing, shelter, and health care being as low as possible.

Ah, yes, but an individual capitalist who is in the business of selling food, clothing, shelter or health care is in quite the opposite position, isn’t she?

10

Henri Vieuxtemps 09.07.11 at 9:34 am

Yes, but in the realm of politics one would expect the business elite to strongly support a cheaper, socialized basic health care system, as well as wide affordability of basic food, clothing, and housing.

So, I’m disputing the idea that socialized health care (and particularly with that ‘but it has to be feasible’ caveat) is some sort of “political project of social democracy”. It seems perfectly consistent with any political project of cut-throat capitalism.

11

Chris Bertram 09.07.11 at 9:39 am

_the scope for expanding health services is effectively infinite_

I’m puzzled at the way economists tend to say this kind of thing John. After all, as I (along with everyone else) have things I want to do in my life other than receive health care, demand can’t be infinite even at zero price (even, in fact, if we were being paid to receive it!). Presumably the accent there is on the “effectively” then, and the thought is that there’s always some improvement possible …. but even so.

12

Chris Bertram 09.07.11 at 9:40 am

(Sorry, I see ajay said the same thing first)

13

maidhc 09.07.11 at 9:40 am

Maybe art museums are an interesting example? In London, many of these are free, and the museums are well attended, but I don’t think it is a major problem that people camp out in front of a Holbein to maximize their consumption of taxpayer-supported art.

In the US, you generally have to pay to visit the museum, but there are frequently provisions for supporting people like art students, who we think should be able to access the museum, but who can’t afford to pay. So instead you make people jump through some kind of hoop of inconvenience: you can get in free on the first Tuesday of the month, or entrance is half price after 6 PM and free for the last hour before we close (which is really 45 minutes since we chase everyone out). If you are willing to visit the museum in 45 minute chunks day after day, you can eventually see the whole thing for free.

So if you don’t have the money, you have to pay an equivalent amount in self-mortification to make sure you really appreciate the opportunity and are not just being a freeloader viewing art for frivolous purposes.

14

John Quiggin 09.07.11 at 10:13 am

@Chris and ajay – For healthy people looking for routine care that’s true, but at the other end of the spectrum, it’s possible to pour essentially unbounded resources into keeping terminally ill patients alive for a few more days. The US does a lot of this, which is one (of many) reasons for its high health costs and poor outcomes.

In between, in cases of acute or chronic conditions, there are always cost constraints on the services that can be provided. Perhaps over time it will be possible to provide unconstrained care for a wider range of conditions, but I doubt that the cost constraint is going away any time soon.

15

J. Otto Pohl 09.07.11 at 10:16 am

I do not think that universal health care is very utopian since it has existed in a lot of countries. I lived in the UK for a few years and found their health care provisions to be very good, but hardly utopian. People still get sick and die due to the limits of medical knowledge. The interesting thing is not that the UK has a much better health care system than the US. But, rather that some much poorer countries such as Ghana where I live now have much better health care provision than the US. That seems to refute the claim that the issue is one of costs and resource allocation. Socialized health care like socialized education works because it is basically part of the larger infrastructure rather than a retail good. Government built roads and bridges also work well.

16

ajay 09.07.11 at 10:20 am

in the realm of politics one would expect the business elite to strongly support a cheaper, socialized basic health care system, as well as wide affordability of basic food, clothing, and housing.

Well, would one? Why? I can see that Henry Ford would support cheap food; it means he can pay his workers less and still be confident that they’ll be well-fed enough not to faint at the assembly line. But JM Sainsbury won’t want anyone to be selling cheap food, because he won’t be able to make any money; either he’ll have to cut prices or he’ll lose customers.

ISTM that the best you can say is that “one would expect some parts of the business elite to strongly support a cheaper, socialized basic health care system, as well as wide affordability of basic food, clothing, and housing” – with the exception of those bits of the business elite who are currently making money from providing non-cheap food, clothing, housing and health care. And given the proportion of the economy those four represent, well, that might be getting on for a majority.

17

ajay 09.07.11 at 10:30 am

it’s possible to pour essentially unbounded resources into keeping terminally ill patients alive for a few more days. The US does a lot of this, which is one (of many) reasons for its high health costs and poor outcomes.

Very large, but I dunno about “essentially unbounded” – but I think this is just a debate about definitions now and would need some figures. I know that a quarter of lifetime medical spending is in the last year of life, but I don’t know how much that would increase in a case without financial constraints; I wonder what King Fahd’s medical bills looked like?
As important if not more important for US healthcare costs are overpaying of medical staff, especially doctors, and insurance bureaucracy.

18

John Quiggin 09.07.11 at 10:39 am

“overpaying of medical staff, especially doctors”

This is an important factor, but is just a reflection of US income inequality, not something specific to the health care system. Doctors aren’t overpaid relative to others in comparable jobs, and particularly relative to those in the financial system. And it’s worth pointing out that the costs of college education (ruinous for anyone who undertakes a medical degree and doesn’t go into a financially rewarding area of practice) feed into the costs of medical care.

19

Andrew F. 09.07.11 at 11:21 am

But ajay, most businesses aren’t producing food, or clothing, or health-care. The firms that produce food would certainly prefer lower clothing and health-care costs; the firms that produce health-care would prefer lower food and clothing costs; and so forth.

So for any proposal the only issue of which is whether cheap X is desired, the faction opposing cheap X will be outnumbered. It’s never the only issue, of course, but that’s irrelevant.

And just one note to John’s post: the big worry in the US for some is that they won’t be able to afford medical bills – but for most of the US, which has health insurance – and good health insurance at that – this is not normally the concern. Sometimes the left trips over itself by offering transformative visions when the majority simply want small but significant improvements.

20

Nick 09.07.11 at 12:04 pm

“So for any proposal the only issue of which is whether cheap X is desired, the faction opposing cheap X will be outnumbered. It’s never the only issue, of course, but that’s irrelevant.”

It sounds like the old case of concentrated benefits versus dispersed costs. A healthcare lobby, whose supporters benefit immediately and directly from increased costs, can be much more successful at keeping costs high than the larger set of organisations and people that all benefit marginally and less obviously from lower costs. In the political arena, you usually get more bang per buck by lobbying for a specific benefit to you, then a general benefit that you share a little bit in.

21

Del Cotter 09.07.11 at 12:12 pm

Andrew F., ajay is arguing that the Corn Laws can happen, you’re arguing that repeal of the Corn Laws ought to happen. You’re both right, since both those things happened. (cue the joke about the two economists and the dollar bill on the ground)

Economic sense seems to predict that capitalists will campaign for, and get, good cheap health care for all, the better to pay its workers less; and yet here we are.

22

Henri Vieuxtemps 09.07.11 at 12:16 pm

ISTM that the best you can say is that “one would expect some parts of the business elite to strongly support a cheaper, socialized basic health care system, as well as wide affordability of basic food, clothing, and housing” – with the exception of those bits of the business elite who are currently making money from providing non-cheap food, clothing, housing and health care

Subsidies, all businesses should be, logically, in favor of government subsidies and other government policies that make the necessities of life affordable for their workers. They can still make money, not to mention charge a lot for organic food and chinchilla coats.

Of course if you own a medical insurance company, the NHS puts you out of business, and that’s a different story; but still, this has to be a very small portion of the business elite acting against the interests of overwhelming majority of it.

23

Matt McIrvin 09.07.11 at 12:26 pm

In the US, you generally have to pay to visit the museum

The Smithsonian museums on the Mall in Washington, DC are a big, big exception. (One that they threaten to take away whenever there’s talk of budget cuts; it’s hard to gauge how serious this is.)

24

Matt McIrvin 09.07.11 at 12:27 pm

…And the National Gallery of Art, which is actually not part of the Smithsonian Institution, though it’s often lumped together with the Smithsonian.

25

John Quiggin 09.07.11 at 12:42 pm

“Subsidies, all businesses should be, logically, in favor of government subsidies and other government policies that make the necessities of life affordable for their workers.”

Businesses, qua businesses should favor this, but affordability for workers is only improved if the subsidies are paid for by non-workers, and the only non-workers with income are the owners of capital, including the owners of businesses.

26

Henri Vieuxtemps 09.07.11 at 12:52 pm

Subsidies can be (and typically are) paid for not by the owners of capital but by workers in higher income category (‘middle class’). Capital gains tax is typically very low (if I am not mistaken, zero in some countries); earned income tax is, typically, high.

27

Alex 09.07.11 at 12:59 pm

Some of this reminds me of the Laffer curve. It’s very unlikely that the consumption of healthcare will literally be infinite or even maximal at a zero price (prices can be negative after all). The entire population of the UK is not in fact permanently camped at the GP’s surgery. Diminishing marginal returns are one of the more defensible of the standard economic assumptions.

As with Laffer, though, it’s not really that useful in itself. Sure, tax revenue isn’t maximised at a 100% tax rate. So what? It doesn’t provide any information about what level is in fact maximal, and it provides even less about what level is socially optimal. Similarly, asserting that if healthcare is free people will consume more is only trivially true. It doesn’t say at what level consumption would be maximal, and it certainly doesn’t say anything about how much GDP spent on medicine is enough or too much.

In fact, a Laffer curve is a simple device to determine partisan affiliation. You stand over the Laffer and shake opinions out of a sack. The ones that slide down the right-hand side are Tories.

28

Steve LaBonne 09.07.11 at 1:01 pm

Hmm. The OP was about the need for the left to present people with a vision of how life should and could be; the discussion immediately became mired in technocratic details. A neat demonstration of the morass in which we currently are stuck.

29

Matt McIrvin 09.07.11 at 1:11 pm

Sure, tax revenue isn’t maximised at a 100% tax rate. So what? It doesn’t provide any information about what level is in fact maximal, and it provides even less about what level is socially optimal.

This is characteristic of current American economic discourse: there’s always this slip from a nightmare vision of what might happen in some extreme taxing-and-spending situation to a claim that that situation is what’s happening now and is the source of all our troubles. To be a conservative or libertarian in the US, you have to believe not just in the Laffer curve, but that we are currently on the negative-slope side of the peak, no matter how low taxes get.

30

Henri Vieuxtemps 09.07.11 at 1:32 pm

the discussion immediately became mired in technocratic details

Well, isn’t it kind of important whether your vision is a real thing (something that goes against the interests of the establishment, to the benefit of the ordinary people), or it’s a sort of pseudo-achievement, beneficial to the establishment, introduced and implemented with no (or minimal) resistance?

31

Steve LaBonne 09.07.11 at 1:38 pm

Well, isn’t it kind of important whether your vision is a real thing

But first there has to BE a vision (which was JQ’s point). Without vision, the people perish. You can’t skip that step!

32

Steve LaBonne 09.07.11 at 1:44 pm

To be more explicit, we know that more that one kind of universal health care system DOES work. The point in this discussion is not to get down in the weeds of exactly how they work and which system might be better. The point is to realize that 1) they DO work, and 2) they came to exist in those societies which had a robust vision of the common good which had as a corollary that health care for all is a basic right. So, how do we recapture that kind of vision- which is rapidly being lost even in much of Europe- and generalize it to other social and political institutions, in a way that the average voter can grasp and will desire? The technocratic details can wait, we KNOW those can be worked out.

33

Alex 09.07.11 at 1:59 pm

TBH, you even know that it’s possible to pass a single payer bill through the House and get 40-50 Ds for it in the slave states’ committee – the rest is a question of tactics, rather than vision or technical detail.

34

Barry 09.07.11 at 2:00 pm

derrida derider 09.07.11 at 6:31 am

” On the narrow point about health care, there is definitely no ideal – or even good – system extant. Market failure is pervasive, but then so is government failure. “

First, ‘no ideal system extant’ means absolutely nada. As for good, a number of other countries have a variety of systems which outperform the USA.

35

Omega Centauri 09.07.11 at 2:12 pm

To try to get a bit closer to the OP. I think at least in the USA the term “utopia” is radioactive. No amount of careful caveats about what you really mean can cover this. The soundbite “utopian = communism = tyranny” will prevail. We’ve got to find a different framing.

36

philofra 09.07.11 at 2:24 pm

Imagine, George W. Bush succumbed to the utopian vision of universal health care when he created the costly new entitlement of prescription drugs in Medicare. But America did not yet know that it couldn’t afford such an entitlement because of the huge tax cut Bush gave the rich. Cynic, though, might say that Bush expanded Medicare to enhance his friends in the pharmaceutical business and to get votes, only to be right.

One must be suspicious of utopian schemes. Generally they are schemed to advance some self-interest.

37

Pete 09.07.11 at 3:07 pm

“robust vision of the common good”

Look, the reason why this stuff doesn’t fly in the US but does in almost every democratic country in the world is that a large part of the US population wants nothing to do with a large other part. It’s that simple.

It’s deteriorating slowly in the UK along class lines as the common suffering of WW2 retreats into distant memory. As it does we get some of the more stupid US ideas imported.

(No the US did not experience signifigant common suffering during WW2, there wasn’t any bombing. Although I’m suprised to discover that there was rationing.)

38

Chris Williams 09.07.11 at 3:18 pm

Americans: if you ever want to make this work, may I suggest that you sell it thus: “Let’s make the health care system more like the VA!”. After all, quite a few of you already have a single-payer system, and it works just fine, despite the massive load thrown at it by demography over the last three decades. HTH.

39

ajay 09.07.11 at 3:45 pm

if you own a medical insurance company, the NHS puts you out of business, and that’s a different story; but still, this has to be a very small portion of the business elite

Well, not all that small. IIRC healthcare represents 16% of the entire US economy.

20 and 21 both make a lot of sense, thanks.

38: Medicare is a single-payer service; I think the VA is more like a single-provider service (it runs its own hospitals etc) along the lines of the NHS. I like the idea though. First say “VA care is for veterans and their spouses and children as long as they shall live”; then extend it to grandchildren (and really, a fairly massive percentage of the US population must have at least one parent or grandparent who’s a veteran, thanks to WW2 and the draft); and then you’re pretty much there, and extending it to cover recent immigrants and their children is just a matter of strategically losing a lawsuit or two.

40

MPAVictoria 09.07.11 at 3:53 pm

“Medicare is a single-payer service; I think the VA is more like a single-provider service (it runs its own hospitals etc) along the lines of the NHS. I like the idea though. First say “VA care is for veterans and their spouses and children as long as they shall live”; then extend it to grandchildren (and really, a fairly massive percentage of the US population must have at least one parent or grandparent who’s a veteran, thanks to WW2 and the draft); and then you’re pretty much there, and extending it to cover recent immigrants and their children is just a matter of strategically losing a lawsuit or two.”

Newsletter. Would like to subscribe. etc.

41

Alex 09.07.11 at 4:12 pm

Yeah, Ajay really needs a blog…

42

Barry Freed 09.07.11 at 4:30 pm

Yeah, Ajay really needs a blog…

I’ve thought that for years now and have told him so (and I know I’m not the only one) but if he did so I’d be afraid that his prolific commenting would diminish at all the blogs he comments at; he’s like a one-man wumao dang army, only with quality.

43

Salient 09.07.11 at 4:48 pm

It’s a brilliant idea, but the trouble is we’d get about 24 hours of mileage out of it before the Republican operatives got all the talking heads to chant some variation on the theme of “we should privatize the VA in order to make it better!” and no amount of pointing out how the efficiency of the VA vastly exceeds that of private medical services would have any impact on the discussion. I don’t ever want to give Sean Hannity the opportunity to snivelingly ask, “While we’re on the topic of the VA, why are we leaving the care of our soldiers to government bureaucrats?”

44

Henri Vieuxtemps 09.07.11 at 4:50 pm

Fine, so this may be one explanation for the US situation. Plus that the businesses probably sense that current system is advantageous in that by linking health care to employment it creates a sort of serfdom.

Still, I’m afraid I have to insist that this is not a very good example of a utipian dream come true, since it fits reasonably well (as I hope you agree we’ve established) with the dominant socioeconomic system. Wake me up when you manage to expropriate $10-15 trillion from the top 1%.

45

mds 09.07.11 at 4:59 pm

Economic sense seems to predict that capitalists will campaign for, and get, good cheap health care for all, the better to pay its workers less; and yet here we are.

… with a system that’s enabling them to pay their workers less without even one extra penny of that hateful taxation that good cheap health care for all would require. So I’m not sure the capitalists are working against their own interests here.

46

mpowell 09.07.11 at 5:35 pm

Regarding the point that health care expenditures can approach infinity quite easily… it is time the non-economists got on board with this, and quickly. Evaluating the costs of health care in the United States this has become overwhelmingly obvious that is not only theoretically possible but actually a real phenomenon in health care provided by well meaning human beings operating relatively open loop that costs in end-of-life care can get quite out of hand. You actually do need death panels to regulate the kinds of end-of-life care that are appropriate in different situations. The UK does this explicitly by evaluating the expected quality life years versus the cost of treatment. Medicare does not and will be an issue that has to be tackled explicitly or implicitly to prevent long term health care costs from growing to the point where the political will to support the cost will no longer exist.

Regarding the point about Ricardo and health care costs, this is both wrong and quite irrelevant to this discussion. He is talking about continuation of the species type of care. There is definitely a question as to whether good prenatal and early life care is cheaper than simply having women try multiple times to get their kids up to an age where they can survive pretty easily without professional assistance, but really that is a minor point. Most of the costs of health care apply to the elderly who are neither necessary for the propagation of the species or productive workers. And the minority who require care just to get through their working years intact are not required either. It is quite reasonable from the capitalists perspective that health care expenditures by the labor class be effectively zero because they receive no professional health care. It has been this way for most of human history. Socialized medicine may not be a bad thing for the capitalist, but it is not part of his agenda! Don’t get distracted by this red herring.

47

Henri Vieuxtemps 09.07.11 at 6:00 pm

Well, it’s been this way for most of human history, but not anymore, we’ve evolved. Taking care of old people was the responsibility of their children, so it had to be reflected in their wages.

Today, with Social Security and Medicare, the guy making $70K/year is helping to take care of the parents of someone making $30K/year, which is, from the point of view of the masters of the universe, a perfect arrangement; it allows to keep wages of the $30K/year guy low. But of course once the payroll taxes are not enough to cover the expenses, and the MOUs are expected to chip in, it immediately becomes a bad arrangement.

48

roy belmont 09.07.11 at 6:01 pm

One less visible bit of the health-care question is what else is happening in that area there. We see the accomplishments of medicine as a relatively pure defense against hostile attack from disease etc., but maybe something else is happening there at the same time.
Maybe by taking over almost all our own evolutionary pressures, dismantling them, but not replacing them with anything other than economic versions of predation and response, we’ve not managed to better the system in any but the most immediate, temporary, way.
Also, allowing individual humans to profit from other humans’ miseries, in whatever form, may be ubiquitous and obvious now, but overall it’s a pretty bizarre way to preserve a species.
But maybe preserving the species isn’t really what we’re on about anymore?

49

hartal 09.07.11 at 6:11 pm

check out footnote 7 on p. 100. Wright gets it exactly opposite: It’s the theory of capitalist dynamics–what he calls historical materialism–that is defensible, not sociological Marxism, anchored in data on inequality and a moral outcry against it and social irrationality. One gets the feeling that Wright staked out his positions before 2008. Unlike his better book Capital, Crisis and the State, this one sidesteps the question of the limits of stabilization policy. I also don’t get the point of a scatter-shot, haphazard list of what is wrong with capitalism. Put Capital, Crisis and the State back in print. It’s a really important book.

50

hartal 09.07.11 at 6:18 pm

” It is also possible that capitalism will enter into a long-term process of intensifying crisis and permanent decline, but in the absence of of a compelling theory of the mechanisms that generate such intensification, this is a purely speculative argument.”
Wright, Envisisioning Utopia, p. 320
Also see pp. 100-3 against the thesis of crisis intensification. Elsewhere in the book Wright claims that a disciplined labor movement could work with the state to ensure full employment. But offers little in the way of analysis of the grave difficulties in getting such an outcome.

51

OCS 09.07.11 at 6:21 pm

#37

(No the US did not experience signifigant common suffering during WW2, there wasn’t any bombing. Although I’m suprised to discover that there was rationing.)

I wonder if WWII wasn’t more important in the US than you give it credit for. You’re right, the US wasn’t getting bombed. But don’t underestimate the sense of common purpose that WWII instilled. Millions of men went to war, the economy retooled, the people at home experienced a certain amount of deprivation and many lost loved ones. (And then there was the massive propaganda effort — even Bugs Bunny was selling war bonds).

Probably more important was the sense that the country could pull together for a common purpose, with the government successfully coordinating the effort. Maybe after your government has helped win a global war, the idea that it can successfully regulate businesses and provide a social safety net doesn’t seem so crazy.

Those are my guesses, anyway. I’m curious if anyone has actually studied WWII’s affect on attitudes towards community and country in the US. Anyone know?

52

OCS 09.07.11 at 6:38 pm

#38

Americans: if you ever want to make this work, may I suggest that you sell it thus: “Let’s make the health care system more like the VA!”.

You would think so. But if “Just like Medicare, but for everyone!” wouldn’t fly, I’m not sure the VA (which I think even fewer people are familiar with) is going to sell single payer. Especially, as has been pointed out, since it’s more of a single provider program. It’s bizarre that it is politically impossible to extend the hugely popular single payer system for old people to everyone else.

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mds 09.07.11 at 6:54 pm

But if “Just like Medicare, but for everyone!” wouldn’t fly, I’m not sure the VA (which I think even fewer people are familiar with) is going to sell single payer.

Dishonest rhetorical attacks on Medicare’s constitutionality, affordability, etc, are one thing. Rhetorical attacks on veterans as a group might (might) be considered somewhat more unpalatable. Hence, replacing “Get on the same government insurance program as your grandparents” with “We honor veterans’ sacrifices for freedom by providing their families’ health care too.”

54

engels 09.07.11 at 8:01 pm

it’s possible to pour essentially unbounded resources into keeping terminally ill patients alive for a few more days

It’s possible to spend millions of dollars freezing your body after death in the hope that you will be resurrected a few centuries down the line. I understand this is quite popular with the American super-rich. The inference as to what rational people, on the other hand, would choose to do with such resources remains unclear to me.

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engels 09.07.11 at 8:09 pm

I think this post is a nice clear summary of the standard neo-classical wisdom re markets and health care. If I were a social democrat I think I might find it a bit worrying to learn that fairly humdrum and meagre entitlements that have been taken for granted in the civilised world for half a century are now considered a utopian vision, but I’m not so I don’t.

56

Josh R. 09.07.11 at 8:14 pm

This question brought to mind Rousseau in his Gov’t of Poland writings, where he considers a similar problem. If I recall, his ‘solution’ was to channel competitiveness to the national, or community’s, glory rather than to the individual’s. In other words, co-opt competition through various mechanisms. So, I wonder if, underlying your question is yet another: can competition be both made to serve the public good and to serve a public that is widely considered, rather than narrowly.

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engels 09.07.11 at 8:16 pm

‘a left version of the standard neo-classical wisdom’ — markets aren’t perfect, in exceptional cases other methods of distribution are preferable and their excesses need to be constrained…

58

engels 09.07.11 at 8:20 pm

(And naturally a world without motor cars, or even one where Californians don’t have two each when Africans have to walk, is the stuff of utopian dreams…)

59

StevenAttewell 09.07.11 at 8:36 pm

Regarding the question of elites – the argument that they’d be in favor of, basically socializing major risks and freeing up income for market goods, only really holds if we assume that businessmen are solely motivated by the desire for aggregate economic growth and aggregate profits (as opposed to their profit margins). However, businessmen also have their own ideologies – and theirs revolves around a desire for deference based on unfettered economic power. Enlightened businessmen are thin on the ground for a reason.

Also, agreed with SteveLaBonne at 32. The excellent point that OP makes – that as part of a social democratic utopia, we should think about what kinds of goods we want to “de-commodify” (to steal Daniel Rodgers’ term) – is being lost here. Some potential additions: housing and employment.

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Henri Vieuxtemps 09.07.11 at 9:17 pm

only really holds if we assume that businessmen are solely motivated by the desire for aggregate economic growth and aggregate profits

Look, if I’m the owner of GM, whatever I pay for my workers’ medical insurance, and whatever extra I’m paying to my $50K/yr workers, for them to be able to afford their portion of the premium – this either comes out of my pocket directly, or indirectly, by reducing my competitiveness. A half of it is a waste (insurance companies’ profits, inflated doctors/hospital fees, unnecessary procedures), and a bulk of the rest could’ve been paid, under a socialized scheme, by $100K/yr Microsoft employees. Do I really need to be all that enlightened to see it?

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StevenAttewell 09.07.11 at 9:40 pm

Well, given GM’s early opposition to universal health care, I’d say yes. My payments may be costly, but as people have already mentioned, they make my workers less likely to leave/revolt, and importantly, I prefer to have these benefits doled out under my noblesse oblige rather than by a state that could compete for the loyalty of my workers and potentially dictate plant policy to me. Sanford Jacoby’s Modern Manors is great on this.

62

John Quiggin 09.07.11 at 9:56 pm

@58 – Engels, you don’t seem to care much what kind of utopia it is, just so it’s utopian.

For the record, I’m for the second one, with solar electric cars (and of course, engine capacity measured in pony power). But that’s for another post.

63

mpowell 09.07.11 at 9:57 pm

Henri @ 47: You are just floundering around here. What do you think Ricardo was talking about? He’s not saying: “this is how much workers would like to get paid”. He’s saying: “this is the bare minimum of how much workers must be paid in order to sustain their work over multiple generations which is my theory of how much they will get paid in certain types of economy in which they have no bargaining power and are simply a commodity”. And it certainly doesn’t require that the elderly be taken care of.

Anyhow, the idea that just because socialized health care could benefit the capitalist doesn’t mean it shouldn’t be regarded as utopian. That is just cutting off your nose to spite your face.

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Henri Vieuxtemps 09.07.11 at 10:11 pm

Steven, sure, since empirically we don’t observe GM lobbying for a socialized scheme (at least not openly), there’s gotta be something else, some explanation. All I’ve been saying here, from the beginning, is that socialized health care is not, logically, antagonistic to the interests of the elite.

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James 09.07.11 at 10:57 pm

The NHS has some upper limit on how much cash it is willing to spend in treatments that result in 1 year of extra life (approx 100,000 pounds – 130,000, if elderly, per life year granted by the treatment). This may have changed from the last time I looked into it. This limit on costs seems to be the real savings between US and UK spending. I am not sure how you sell this limit to the Elderly voters in the US.

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Steve LaBonne 09.07.11 at 11:15 pm

This limit on costs seems to be the real savings between US and UK spending.

One of them, but far from the only one. The US also has doctors who are paid too much, and insurance and hospital executives who are paid far, far too much, and an army of insurance and hospital bureaucrats who shouldn’t be employed at all, and overuse of expensive and dubiously effective treatments apart from the last year of life.

67

Steve LaBonne 09.07.11 at 11:18 pm

Steven, sure, since empirically we don’t observe GM lobbying for a socialized scheme (at least not openly), there’s gotta be something else, some explanation.

If I may chime in- ideology and class solidarity, I would guess. Yes, I agree that objectively it would seem to be in their interest. And GM of all companies should know this well because a lot of their production is in Canada.

But they prefer to force down wages, and have been very successful at that.

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Chrisb 09.07.11 at 11:44 pm

Surely one part of the explanation as to why GM is not lobbying for socialised health schemes is that, as Thatcher famously said, “There’s no such thing a a company: there are only executives.” The interests of the upper executives, as we have seen, are best served by them arranging circumstances where they are grossly overpaid until the company collapses in a screaming heap, when they take their loot and go home; it’s certainly difficult to extract any other drivers from their practice. And this means that their planning timelines are in the order of two to three years, which means that they can afford to disregard any long-term damage to society.

69

Lee A. Arnold 09.08.11 at 2:23 am

This just in from the U.S. Republicans’ first debate: Rick Perry does not believe Social Security should exist.

John, I though you were wrong in saying that Romney would get the nomination, but I may have to take it back.

70

gordon 09.08.11 at 2:32 am

hartal says (at 50): “Elsewhere in the book Wright claims that a disciplined labor movement could work with the state to ensure full employment. But offers little in the way of analysis of the grave difficulties in getting such an outcome”.

In Australia from 1983 to 1996 there was a very deliberate and (to my mind) pretty successful effort at getting “such an outcome”. It was called The Accord. A very brief summary of that adventure by Peter Cook, a Fed. Govt. Minister at that time, is here (Note: .pdf):

http://cep.lse.ac.uk/pubs/download/occasional/OP001.pdf

Maybe Prof. Quiggin, who is also an Australian, could provide more comprehensive references if commenters are interested.

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StevenAttewell 09.08.11 at 4:41 am

Gordon – it’s also a bit weird in that labor-state cooperation in wage restraint as quid pro quo for full employment is one of the key ingredients in the “postwar miracle” in pretty much every country in Western Europe. Hell, we even had a ramshackle version of same in the U.S.

There may be grave difficulties, but apparently it’s achievable for 25-year plus periods.

72

ajay 09.08.11 at 8:52 am

A very brief summary of that adventure by Peter Cook, a Fed. Govt. Minister at that time, is here

He went into politics after failing to become a judge. He didn’t have the Latin, you see.

73

Chris Williams 09.08.11 at 10:29 am

Can anyone point me in the direction of research (the more abstracted and reliable the better…) on how the VA’s managed demand (through ‘death panels’, QUALYs, whatever) for heath care in the last few decades?

74

Alex 09.08.11 at 11:41 am

Steven, sure, since empirically we don’t observe GM lobbying for a socialized scheme (at least not openly), there’s gotta be something else, some explanation. All I’ve been saying here, from the beginning, is that socialized health care is not, logically, antagonistic to the interests of the elite.

Well, way back in the late 40s, Walter Reuther actually made them an offer – join us in a joint campaign for national healthcare, and we’ll let you off putting lifetime health benefits in the contract between the UAW and Detroit. They were willing to essentially sign a blank cheque rather than be seen to agree with the UAW.

Spite and bullshit explain a lot.

Chris: at least some of it must be down to the VA’s homebrew open-source case management software that the NHS wasn’t allowed to use because Bill Gates got at Blair back in 2001.

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John Quiggin 09.08.11 at 12:06 pm

The Accord worked very well in its early years, and among other things formed the basis for the (re)introduction of our single-payer* health insurance scheme. Essentially, the original accord implemented a gradual winding down of inflation, with workers taking slow real wage growth in return for improvements in the social wage. Although it continued in formal terms until 1996, it was effectively abandoned by the late 1980s. Like the Wassenaar agreements in the Netherlands, it provides a model that may be useful in some circumstances. Preconditions include a strong, and fairly centralised, union movement.

* We have private insurers who cover extra services, private hospitals etc as well, and high income earners are effectively compelled to insure with them. As always with health policy, it’s complicated.

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Emma in Sydney 09.08.11 at 12:21 pm

JQ, high income earners are not compelled to insure with private insurers. We have to pay a slightly higher tax rate (1.5%) if we don’t have private health insurance. But when you do the sums (or at least when I do) you come out ahead paying the tax and saving the premium, for what is a really crappy product (private health insurance). Because if you are seriously ill in Australia, you *really* want to be in a public teaching hospital, not some private set up where they will just send you to the public hospital when things go wrong. And for lots of ‘elective’ things, it’s actually cheaper to pay the doctor and use the public hospital (as I found for gall bladder surgery last year — $380 to the surgeon, no waiting, great public care). Private health insurance, like private schools, is really for signalling wealth, rather than actual utility.
And the Medicare levy is the only bit of my taxes that I actually get to direct to a worthwhile cause (unlike, say, helping the Americans obliterate Afghanistan or Iraq). I positively enjoy paying it every year.

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SamChevre 09.08.11 at 12:47 pm

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Chris Williams 09.08.11 at 1:18 pm

Cheers Sam: it looks like about half of US households have an income which is above the VA ‘thresholds’, although it’s not clear from the VA site whether these refer to individual or household income. On the other hand, I’d imagine that a majority WW2 veterans would have entered the system aged 65 or more, and census data suggests that a far higher proportion of households headed by over-65s have an income below those lines.

79

Pete 09.08.11 at 1:24 pm

Back to “people don’t want other people getting healthcare”:
http://blogs.telegraph.co.uk/news/timstanley/100103658/republican-debate-showcases-romney-the-centrist-perry-the-conservative-and-paul-the-maverick/

In contrast, when Perry was asked if he was ashamed that a quarter of all Texans have no healthcare, he implied that he most certainly was not. “I’ll tell you what the people in the state of Texas don’t want,” he said. “They don’t want a health care plan like what Governor Romney put in place in Massachusetts. What they would like to see is the federal government get out of their business.” He then launched an attack upon Medicaid.

80

guthrie 09.08.11 at 6:47 pm

I find your initial contention a little confusing:

“Turning to health care, we could start with a utopian ideal where everyone got all the health care that could benefit them. But that would be utopian in the pejorative sense – the scope for expanding health services is effectively infinite, and the resources available to society are not.”

For starters, a finite number of humans cannot exactly consume an infinite amount of health care. Secondly, it hardly benefits someone to be kept alive hooked up to a machine despite being brain dead, which I understand is a rather expensive operation. So I think we can safely say that as long as you include the caveat which you did include, i.e. it benefits them, there’s no way healthcare costs will tend anywhere near infinity.

Anyway, don’t mind me, I’m just disgruntled because the bastard tories are destroying the NHS and giving it away to their rich pals to play with, and no political party has the balls to do anything about it.

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gordon 09.08.11 at 10:29 pm

ajay, I must say I’m glad that Peter Cook’s Latin was so poor; I would have great difficulty reading his Accord summary if it had been in the language of Cicero.

82

Salient 09.08.11 at 11:22 pm

This just in from the U.S. Republicans’ first debate: Rick Perry does not believe Social Security should exist.

Also in from the U.S. Republicans’ first debate: Rick Perry is apparently really awesome specifically because he signed orders to get a lot of people killed. 234! Including someone who was never found guilty of murder or even accused of a murder charge (Robert Lee Thompson), someone who was blazingly obviously not mentally fit to stand trial (Kelsey Patterson), and someone whose convictions relied on evidence that was later called into question and found to be deeply faulty, meaning the prosecution’s case could plausibly have been utter bullshit (Cameron Todd Willingham). Those people plus 231 more! It’s a record! I think Rick Perry also holds the elite status of being the very last governor to refuse commutation to a minor. He’s proud of that: he even faced off with the Supreme Court over the right to let juries assert the mental fitness and competence of someone facing the death penalty and overrule professional medical assessments. How courageous. And he, by his own admission in that video clip I just linked, hasn’t ever felt worried about potentially executing the innocent!

Rick Perry is a man proud to grant his approval to executions against the advice of his Texas Board of Pardons and Paroles (his because he has sole authority over the people who comprise the board, as all members are his appointees). So I can say, completely literally, that Rick Perry approves of death panels, but only if those panels almost always approve death.

(Thank you, I needed a chance to say that.) I’ve known Perry was slime for quite a while; no news there. But how the audience responded to his boisterous remarks just knifed me in the fucking chest. Click the link, scroll down to the 71-second video clip from the debate, watch it. Know this man is one of the top contenders for the Republican party’s choice of President, and could quite plausibly receive the support of half the voters in this country, and easily a third of those would’ve applauded in that audience if they had been there on that day. Despair.

It’s feeling like a couple decades from now Restrictions on the state’s right to authorize executions as feasible utopia will be a coherent blog post title.

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ScentOfViolets 09.09.11 at 3:31 am

I’ve known Perry was slime for quite a while; no news there. But how the audience responded to his boisterous remarks just knifed me in the fucking chest. Click the link, scroll down to the 71-second video clip from the debate, watch it. Know this man is one of the top contenders for the Republican party’s choice of President, and could quite plausibly receive the support of half the voters in this country, and easily a third of those would’ve applauded in that audience if they had been there on that day.

Yep. I probably know some of those people. This is what I’m talking about when saying that running as a “populist” (i.e., an economic liberal) makes a lot more sense than a generic run to the left that so many seem to think is the ticket.

No. A lot of these people think that “enhanced interrogation methods” are just fine and dandy – would probably in fact, pay good money to see something like that on T.V. (Why not? It would never happen to them.) More rights for gays, women, immigrants, suspected criminals, etc? No, they’re definitely not down with that. And so on and so forth.

But talk about jobs, about sticking it to the banksters (code for having the banksters face exactly the same consequences everybody else does for poor job performance and other, perhaps shadier deeds), etc? Well on that front, most of those chuckleheads cheering for Perry would definitely become “liberals”.

Which is of course why the non-economic fissures between “liberals” and “conservatives”, Republicans and Democrats, are so heavily played upon.

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Norwegian Guy 09.09.11 at 4:05 am

Pete @37 & OCS @51: While that could perhaps sound reasonable, Sweden is a good counter-example. They had rationing during WW2, but not bombing or a US-style military mobilization. Still, they built a welfare state, despite not having been at war since 1814.

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Josh G. 09.09.11 at 4:33 pm

ScentOfViolets @ 83: “No. A lot of these people think that “enhanced interrogation methods” are just fine and dandy – would probably in fact, pay good money to see something like that on T.V.

The problem is that they do see it on primetime TV, almost every week. Torture always shows up in TV and in the movies, and it is almost uniformly portrayed as effective. I blame popular culture for the shameful popularity of torture in the U.S. over the past 10 years.

It’s easy to understand why this happens. It’s much easier to make a torture scene look dramatic than a good professional interrogation, although we know in real life other interrogation techniques are far more effective. It provides an opportunity to play the “cowboy” cop or agent off against his by-the-book superiors. And it provides an opportunity for some dramatic hand-wringing by the protagonist and others over whether his actions are justified or not. (It’s interesting that Law & Order resisted this for years, showing the cops routinely using legitimate investigation and interrogation techniques, and often featuring suppression of evidence when they bent or broke the rules, but its spinoff SVU has almost entirely done away with this and is now little more than a conventional cop show with Stabler beating up “perverts” every week.)

I understand why Hollywood loves putting torture in films and TV shows, and perhaps I can forgive them for that. What I find much harder to understand, and impossible to forgive, is how many of my fellow citizens seem to think that real life is like ’24’ or a summer action movie.

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engels 09.10.11 at 6:37 am

Engels, you don’t seem to care much what kind of utopia it is, just so it’s utopian.

I’m not really sure what this means, but I’m sure it means you’ve won the argument.

Pleased to hear that in Utopia the hard-working and productive classes will be doing the school run in solar-powered 4x4s.

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Watson Ladd 09.11.11 at 2:50 am

@ajay at 9: We are a long way away from the ultimate in health care spending. While no one wants to get cancer, in the 1970’s they would get a lot less then they would now. Monoclonal antibodies do not come cheap.

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Peter T 09.11.11 at 10:10 am

I take JQ’s point to be that “socialised” health care works reasonably well (and demonstrably better than more market-based alternatives) and the basic approach could be extended to other areas. Whether this could work or not can be debated but, in an earlier post, JQ pointed to the need to inspire people with something more than a technocratic recipe for somewhat greater welfare. I don’t see advocacy of a more mixed-economy approach to, say, housing, as meeting this need.

It’s worth reflecting on how we got to social democracy – a seventy-year civil war, sometimes full-on, sometimes simmering, over the restoration, in a different economic setting, of the basics of community provision that had been lost with the changes from agrarian to industrial economies. Social democracy emerged as a response to a challenge. Is more equal access to decent housing the real challenge now?

I’d see the broad range of environmental issues (and the concomitant need to downsize our impacts on the planet with the minimum of distress) as the major challenge. Surely one could come up with a social democratic response to this that would inspire people?

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StevenAttewell 09.12.11 at 4:00 am

Peter T – I think inequality is a major challenge; access to decent housing (which, have you been watching the protests in Israel or the cuts in the U.K or…foreclosures in the U.S one might suggest?) is a means of dealing with that end. The problem with environmental issues as an inspirational politics is that they can be a bit elitist and ascetic – which tends to mean that environmental political types tend towards a certain monochromatic, upper-middle-class, dudely constituency.

90

Tim Worstall 09.12.11 at 11:03 am

“and, on the other hand, markets perform very badly.”

That really doesn’t sound quite right.

A pure free market, turn up with your chequebook to get treated, works badly, certainly. The US private insurance market has many well known problems too.

However, within the various government backed social insurance schemes ranging from Singapore’s health savings accounts plus catastrophic illness insurance, through to the UK’s near monolithic NHS (both govt financed and directly govt run) with the various Swiss, Sweidish, German, French etc variants in between the performance of markets seems to be rather good.

The French system for example, was regularly said by the WHO to be the finest one in the world (and the evaluation was based on impeccable social democratic measurements, like equity of access, equity of financing etc as well as standards of treatment) and that has competing providers, govt owned, charitable, for profit, even if largely govt financed.

So the statement that markets perform badly in health care would seem to be too broad. Markets in the financing of health care, yes, it does seem that they work badly there. But markets in hte provision, supply of it, well, they seem to work just fine.

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Peter T 09.13.11 at 1:07 am

Environmental issues as “elitist and ascetic”? Like floods in Pakistan, heatwaves in Russia, droughts in Texas and Australia, floods and snowstorms in Australia and the eastern US….(taken together, manifestations of climate change). Or loss of fishing industries worldwide, or deforestation and accompanying mudslides through shanty towns, or….

Do these things really only affect elites? Is there no narrative about greed, re-distribution of the fruits of the earth, need to share the costs of adjustment, need to take local control of one’s local patch that might appeal to all those being run over by various juggernauts driven by financial elites?

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StevenAttewell 09.13.11 at 2:38 pm

Elitist in the sense that the preferred policy option in dealing with these issues is often a call for regressive taxation or a rather blithe attitude about how the “costs of adjustment” might affect blue-collar jobs (combined with a distaste for “dirty” manufacturing), or a tendency to be more interested in Other People’s Poverty than the home-grown variant. Ascetic in the sense of looking down on materialism and consumerism, which rather rankles people who can’t afford to shop at Whole Foods or buy all-hemp clothing and who could use some more material security.

It’s not that there can’t be a green politics that does class well, but at least in the U.S, environmental politics tends to attract an audience that’s whiter, maler, and in some cases richer than even the GOP.

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