Visions and Conflict part 3

Visions and Conflict part 3

 

In part two of his essay Sowell applies his ideas of the constrained vs. the unconstrained vision to various topics that frequently cause conflict in social discourse.  

The first topic addressed is EQUALITY.  It should be obvious that equality is viewed differently by those of different visions.  For the constrained view the important issue is PROCESS oriented.  For the unconstrained view the issue is RESULTS.  

Burke, Hayek, and Alexander Hamilton are quoted in support of the constrained vision.  Hamilton's words are apt.  "All men are entitled to a parity of privileges "but he anticipated that economic inequality "would exist as long as liberty existed". That is the rub.  Equal opportunity never guarantees equal outcomes.  When government forces equal outcomes there is a corresponding loss of autonomy and freedom.  Conservatives generally hold the constrained vision, that sees social processes that give equal treatment as fair and just, even when outcomes are NOT equal for any particular group.  In this view the words of Jesus when he comments that "the poor you will have with you always" are taken to imply that we are not able to create a heaven on earth, but must learn to accept and live with maldistributions of economic resources.  How to rationalize this comment with others such as "it is harder for a camel to pass thru the eye of a needle than for a rich man to enter heaven" has kept theologians busy for the last two thousand years.  

Conservatives would generally agree with Hayek that "irremediable inequalities" exist and will frustrate any effort to remove them.  It is the constrained vision that sees man's capability as limited.  The unconstrained vision see's no such fundamental limits and sees results as the only fair and just way to measure equality.  It assumes more intellectual and moral capacity than can be shown to exist. 

 There is a particularly significant quote from Milton Friedman that bears repeating. " A society that puts equality-in the sense of equality of outcome-ahead of freedom will end up with neither equality nor freedom.  The use of force to achieve equality will destroy freedom, and the force, introduced for good purposes, will end up in the hands of people who use it to promote their own interests."  It seems that SCOTUS ignored that wisdom in finding the mandate to purchase health care insurance constitutional.  When you have the force of the IRS, which includes the right to place a citizen in prison,  used to enforce obamacare the possibility of misuse by those in power seems all to real a possibility.

The Unconstrained vision held by most progressives sees no such fundamental limitations in man.  When results are the measure of equality the existing order is seen as unjust.  This drives the progressive to find ways of "redistributing" resources.  The small fact that the only way to do this is to steal from someone else is seen as acceptable. Providing "compensatory advantage" such as reparations or affirmative action is thus a major goal of progressives, and influences all discussions of public social policy. 

A major point made by Sowell is that causation is part of the unconstrained vision.  Some groups have so little BECAUSE other groups have so much.  The rich are seen as taking from the poor.  For this reason alone redistribution is fair.

Neither vision denies the existence of the poor.  It is how society should deal with the problem that brings conflict.  The constrained view is that capitalism and free markets bring about a rising tide that lifts all boats including the poor.  The unconstrained view is that the "ill gotten wealth" of the rich should be taken from them and given i.e. redistributed to the poor.  This is the language of socialism.  Margaret Thatcher famously said once that the biggest problem with socialism is that you eventually run out of other peoples money.  That is the dilemma facing Greece and for that matter Illinois and California.  No better example of the results of the unconstrained vision exist than in the fiscal mess of these two blue progressive states.

 

 

 

 

Physician Shortage Coming

There have been more than 60 reports in the last 10 years which point to a looming shortage of physicians in the US.  Like most problems facing society the reasons are complicated and multifactoral.  Physicians are retiring earlier than in prior years and the demand for health care goes up as does the population.  Complicating things further, the demographics show rapid growth in the older population who historically consume the lion's share of health care services.

The American Association of Medical Colleges states that the overall physician shortage will be about 63,000 by 2015.  30,000 of this shortfall will be in primary care.  Various strategies such as expanding the role of mid-level practitioners have been proposed to deal with this problem but I hear very few trying to address the underlying problem. 

 IMHO one of the biggest problems responsible is the changing  economics of medical practice.  Physician's have historically been small businessmen. They rent or buy space to practice.  They hire people to work for them, and purchase equipment and supplies from vendors.  They buy computers, and pay for consultants, in accounting, legal, insurance, pension benefits, etc.  Any business where costs go up but reimbursement goes down, will eventually fail.  The income the physician took home was what was left over after paying all the bills.  Taxes take another bite and what is left is what you have to take care of your family, and save for a retirement that arrives all to soon.  Many practices have passed the point where there is anything left.  That model is no longer the paradigm most physicians embrace.  For increasing numbers the uncertainty of private practice is not worth the struggle.  Employment is seen as safer and easier.  With this shift comes a different mind set. An employed physician is going to be more influenced by the employers concerns than an independent physician.  The employer's concern is all about saving money.  Patient advocacy can become a secondary concern when ones job is threatened. What this means is that not only is there a shortage of physicians in terms of absolute numbers, there is also a shortage in advocacy.  Which is the greater problem is difficult to ascertain.

The changing landscape in graduate medical education (GME) is also a problem. The majority of the funding of GME in the United States comes from Medicare and Medicaid (together about 83%), dept of Veterans Affairs (10%), Defense Dept and Bureau of Health Professions (6%).    The number of GME positions in the US, has been capped since the "Balanced Budget Act of 1997".  In spite of these caps medical schools are accepting more students but there are no more slots in GME programs.  

Recent proposals by the Joint Select Committee on Deficit Reduction have included a 50% reduction in Indirect Medical Education costs.  The total contribution by Medicare is approximately 9.5 Billion dollars.  Of that 6.5 Billion are Indirect Medical Education costs.  The effect on GME is certain to be further constraints on training all the while the country is facing a physician shortage.  One thing is certain.  The effect of such a reduction will be seen first in jobs.  The proposed cuts will cost about 73,000 jobs.  One can only wonder if members of either political party have the political will to lose that many jobs in the search for a balanced budget.

The American College of Surgeons has proposed several common sense GME reforms.  First is the  recommendation that IME payments be tracked instead of dumped into the general fund of teaching hospitals.  If performance measures and outcomes for each program are tracked it would go a long way to seeing that the public gets the most "bang for the buck".  Secondly GME funding needs to be separated from patient funding streams.  All stakeholders need to be at the table when alternative funding is being discussed.  The stakeholders include Medical Schools, the Biomedical Industry, Patients, Residents, Hospitals with GME programs,Federal and State governments, Private Insurers, and Non GRE hospitals.  In trying to arrive at even a conceptual framework for GME alternative funding, the issues of equity, adequacy, efficiency, accountability and feasibility must be addressed according to a RAND working paper. 

My take on this issue is that somewhere, somehow, all of the stakeholders have to find a way to increase funding for graduate medical education.  The consequences of not acting are not going to be pretty. 

Visions and Conflict part 2

Further thoughts on Sowell's book.
 How we view issues as basic as human "survival and progress" is different depending on which vision we adopt.  "According to the unconstrained vision, the patterned behavior of society is successful, just, and progressive insofar as it reflects the articulated rationality of man in general and of the most intellectually and morally advanced people in particular."
The constrained vision sees a fundamental inability for man, seen either as an individual or a collective society, to achieve success in deliberate, comprehensive central planning.  This vision sees a "moral and intellectual"  insufficiency that frustrates those attempts.  The failure of the USSR's planned  economy is seen as an example.
How should we make judgements about societal processes? What is justice?  Should judgements be made on results? Or on adherence to agreed-upon rules existent prior to the event or process being judged.  How we make those judgements reflects our vision.  If we judge a process by trying to decide if that process is right or good, we probably have an unconstrained vision.  If we judge a process as fair when all the a priori agreed on process characteristics were faithfully adhered to, and ignore the outcomes, we probably have a constrained vision. The results are subordinate to the process and the agreed upon rules of engagement.  
Just as the word "freedom"  means something different to holders of each vision, justice means something different as well.
The unconstrained vision is results oriented. The constrained vision is process oriented.

As I drive to Chicago to visit my daughter and her family I observe the tear down of the high rise "project housing" lying east of the Dan Ryan. Nearly everyone's judgement about the projects is that it represents an abysmal failure of policy.  When they were built, it was with great fanfare and hope that making good housing available cheaply would help those in poverty rise above.  Instead the projects degenerated into a special version of hell on earth.  The reasons have been debated in multiple forums.  My point in bringing it up is that the different visions are on display.  The constrained vision saw the attempt to give cheap or free housing as bound to fail, since it eliminates the personal pride of ownership, etc, etc.  The unconstrained vision saw the removal of an impediment (lack of housing) as something to be fixed with the providing of free apartments.
History has shown which vision was vindicated. 
The application of the analysis of visions as it applies to power, equality, justice, law, economics will take us further into the book.  I am now reading chapter 5.
     

Visions and Conflict

I recently read Thomas Sowell's book titled "A Conflict of Visions".  I admit I was shocked by the outcome of the last election.  It seems inconceivable that a majority of Americans would vote for more of the same economic malaise that the papers report on daily. I have been searching for an explanation that goes deeper than those offered by the talking heads on TV. Sowell's central idea is that what divides the political spectrum is a fundamental difference in visions.  He differentiates visions from interests. Interests are short term while visions "dominate history".  The insight he offers helps explain why persons of good will can come down on opposite sides of almost any policy debate. 
The definition he offers for vision is a "pre-analytic cognitive act". This was the definition originally offered by Joseph Schumpeter in his book "History of Economic Analysis".  This definition is supposed to describe what we emote about an issue before we analyze it systematically.  It precedes theory. It is the teleological backbone of theory.  Visions are about causation and set the "agenda for thought and action."
A theologian friend of mine used to say that "every ideology assumes an anthropology." What he meant was that it is our ideas about the nature of man that directs our formation of theories about society, history, law, justice, and politics.  Sowell is saying much the same thing as he lays out the contrast of the Constrained vs. the Unconstrained vision.
 The constrained vision sees man as intrinsically  flawed with many moral limitation.  One is tempted to resurrect a theological term and call it original sin.  The constrained vision seeks to make the best of a bad situation.  This is the vision of thinkers such as Thomas Hobbes, Edmund Burke, Adam Smith, Alexander Hamilton, James Madison, John Jay, Friedrich A. Hayek, Oliver Wendell Holmes, and  Milton Friedman.
The unconstrained vision sees man as perfectible with no intrinsic moral limitations.  It sees a possible utopia since there is an infinite well of goodness at the heart of man.  This is the vision of thinkers such as William Godwin, Rousseau, Voltaire, Thomas Paine, John Kenneth Galbraith, Ronald Dworkin, Saint-Simon, George Bernard Shaw, and Earl Warren.
With respect to social decisions the "marketplace" is seen as inadequate, even evil by adherents of the unconstrained vision and as the best way to achieve the greatest good for the greatest number of people by those adhering to the constrained vision.  The alternative to the marketplace for the unconstrained vision adherents is a meritocracy where an elite "far seeing" group decides what is best for society.  The fears of those who hold to the constrained vision is that this group of elites can disintegrate into tyranny very quickly.  They would point to the excesses of Stalin, Pol Pot, etc. as historical examples. The adoration of the intellectual elite by the true believers on the unconstrained vision is justified in their view since they and they alone have the articulated rationality to guide society towards the utopian ideal.
The different visions give different value to "experience vs. articulated rationality". This leads naturally to a youth vs. age debate with respect to the value of their respective insights and the attending societal value of each.  The unconstrained vision sees the institutions and existing beliefs of society holding back its progressive agenda.
Epistemology is the study of knowledge.  What it is and how it is acquired. It seems clear that language is key to the acquisition of knowledge because words have meaning.  If we cannot agree on what a word means it seems pointless to pursue knowledge of what that word depicts.  Take the word freedom for example.  The constrained vision interprets the word to mean liberty, equal opportunity and the individuals "pursuit of happiness".  The unconstrained vision can take the word  freedom to mean equal outcomes, the absence of hunger or poverty and a society free of prejudice and conflict.  Clearly trying to understand what freedom means is colored by our underlying vision. Knowledge is seen as widely distributed and broader in definition by those with a constrained vision.  It is not the province of a gifted elite as seen by those with unconstrained vision.     
The labels of conservative and liberal are inadequate in my opinion to describe what Sowell sees as a contrast of visions.  It will take me some time to digest the implications of this essay but I embark on it eagerly.