doctors

Toward a positive vision of the future

PNRJ current events, ethics, inequality, politics, tribal paradigm , , , , , , , , , , , , , , , , , , , , ,

Jun 22 JDN 2460849

Things look pretty bleak right now. Wildfires rage across Canada, polluting the air across North America. Russia is still at war with Ukraine, and Israel seems to be trying to start a war with Iran. ICE continues sending agents without badges to kidnap people in unmarked vehicles and sending them to undisclosed locations. Climate change is getting worse, and US policy is pivoting from subsidizing renewables back to subsidizing fossil fuels. And Trump, now revealed to be a literal fascist, is still President.

But things can get better.

I can’t guarantee that they will, nor can I say when; but there is still hope that a better future is possible.

It has been very difficult to assemble a strong coalition against the increasingly extreme far-right in this country (epitomized by Trump). This seems odd, when most Americans hold relatively centrist views. Yes, more Americans identify as conservative than as liberal, but Trump isn’t a conservative; he’s a radical far-right fascist. Trump recently gave a speech endorsing ethnic cleansing, for goodness’ sake! I’m liberal, but I’d definitely vote for a conservative like Mitt Romney rather than a Stalinist! So why are “conservatives” voting for a fascist?

But setting aside the question of why people voted for Trump, we still have the question of why the left has not been able to assemble a strong coalition against him.

I think part of the problem is that the left really has two coalitions within it: The center left, who were relatively happy with the status quo before Trump and want to go back to that; and the far left, who were utterly unhappy with that status quo and want radical change. So while we all agree that Trump is awful, we don’t really agree on what he’s supposed to be replaced with.

It’s of course possible to be in between, and indeed I would say that I am. While clearly things were better under Obama and Biden than they have been under Trump, there were still a lot of major problems in this country that should have been priorities for national policy but weren’t:

  1. Above all, climate change—the Democrats at least try to do something against it, but not nearly enough. Our carbon emissions are declining, but it’s very unclear if we’ll actually hit our targets. The way we have been going, we’re in for a lot more hurricanes and wildfires and droughts.
  2. Housing affordability is still an absolute crisis; half of renters spend more than the targeted 30% of their income on housing, and a fourth spend more than 50%.Homelessness is now at a record high.
  3. Healthcare is still far too expensive in this country; we continue to spend far more than other First World countries without getting meaningfully better care.
  4. While rights and protections for LGB people have substantially improved in the last 30 years, rights and protections for trans people continue to lag behind.
  5. Racial segregation in housing remains the de facto norm, even though it is de jure illegal.
  6. Livestock remain exempted from the Animal Welfare Act and in 2002 laboratory rats and mice were excluded as well, meaning that cruel or negligent treatment which would be illegal for cats and dogs is still allowed on livestock and lab rats.
  7. Income and wealth inequality in this country remains staggeringly high, and the super-rich continue to gain wealth at a terrifying rate.
  8. Our voting system is terrible—literally the worst possible system that can technically still be considered democracy.

This list is by no means exhaustive, but these are the issues that seem most salient to me.

2 and 3 both clearly showed up in my Index of Necessary Expenditure; these costs were the primary reason why raising a family of 4 was unaffordable on a median household income.

So it isn’t right to say that I was completely happy with how things were going before. But I still think of myself as center left, because I don’t believe we need to tear everything down and start over.

I have relatively simple recommendations that would go a long way toward solving all 8 of these problems:

Climate change could be greatly mitigated if we’d just tax carbon already, or implement a cap-and-trade system like California’s nationwide. If that’s too politically unpalatable, subsidize nuclear power, fusion research, and renewables instead. That’s way worse from a budget perspective, but for some reason Americans are just fanatically opposed to higher gas prices.

Housing affordability is politically thorny, but economically quite simple: Build more housing. Whatever we have to do to make that happen, we should do it. Maybe this involves changes to zoning or other regulations. Maybe it involves subsidies to developers. Maybe it involves deploying eminent domain to build public housing. Maybe it involves using government funds to build housing and then offering it for sale on the market. But whatever we do, we need more housing.

Healthcare costs are a trickier one; Obamacare helped, but wasn’t enough. I think what I would like to see next is an option to buy into Medicare; before you are old enough to get it for free, you can pay a premium to be covered by it. Because Medicare is much more efficient than private insurance, you could pay a lower premium and get better coverage, so a lot of people would likely switch (which is of course exactly why insurance companies would fight the policy at every turn). Even putting everyone on Medicare might not be enough; to really bring costs down, we may need to seriously address the fact that US doctors, particularly specialists, are just radically higher-paid than any other doctors in the world. Is an American doctor who gets $269,000 per year really 88% better than a French doctor who gets $143,000?

The policies we need for LGBT rights are mostly no-brainers.

Okay, I can admit to some reasonable nuance when it comes to trans women in pro sports (the statistical advantages they have over cis women are not as clear-cut as many people think, but they do seem to exist; average athletic performance for trans women seems to be somewhere in between the average for cis men and the average for cis women), but that’s really not a very important issue. Like, seriously, why do we care so much about pro sports? Either let people play sports according to their self-identified gender, or make the two options “cis women” and “other” and let trans people play the latter. And you can do the same thing with school sports, or you can eliminate them entirely because they are a stupid waste of academic resources; but either way this should not be considered a top priority policy question. (If parents want their kids to play sports, they can form their own leagues; the school shouldn’t be paying for it. Winning games is not one of the goals of an academic institution. If you want kids to get more exercise, give them more recess and reform the physical education system so it isn’t so miserable for the kids who need it most.)

But there is absolutely no reason not to let people use whatever pronouns and bathrooms they want; indeed, there doesn’t really seem to be a compelling reason to gender-segregate bathrooms in the first place, and removing that segregation would most benefit women, who often have to wait much longer in line for the bathroom. (The argument that this somehow protects women never made sense to me; if a man wants to assault women in the bathroom, what’s to stop him from just going into the women’s bathroom? It’s not like there’s a magic field that prevents men from entering. He’s already planning on committing a crime, so it doesn’t seem like he’s very liable to held back by social norms. It’s worthwhile to try to find ways to prevent sexual assault, but segregating bathrooms does little or nothing toward that goal—and indeed, trans-inclusive bathrooms do not statistically correlate with higher rates of sexual assault.) But okay, fine, if you insist on having the segregation, at least require gender-neutral bathrooms as well. This is really not that difficult; it’s pretty clearly bigotry driving this, not serious policy concerns.

Not exempting any vertebrate animals from anti-cruelty legislation is an incredibly simple thing to do, obviously morally better, and the only reason we’re not doing it is that it would hurt agribusinesses and make meat more expensive. There is literally zero question what the morally right thing to do here is; the question is only how to get people to actually do that morally right thing.

Finally, how do we fix income inequality? Some people—including some economists—treat this as a very complicated, difficult question, but I don’t think it is. I think the really simple, obvious answer is actually the correct one: Tax rich people more, and use the proceeds to help poor people. We should be taxing the rich a lot more; I want something like the revenue-maximizing rate, estimated at about 70%. (And an even higher rate like the 90% we had in the 1950s is not out of the question.) These funds could either provide services like education and healthcare, or they could simply be direct cash transfers. But one way or another, the simplest, most effective way to reduce inequality is to tax the rich and help the poor. A lot of economists fear that this would hurt the overall economy, but particularly if these rates are really targeted at the super-rich (the top 0.01%), I don’t see how they could, because all those billions of dollars are very clearly monopoly rents rather than genuine productivity. If anything, making it harder to amass monopoly rents should make the economy more efficient. And taking say 90% of the roughly 10% return just the top 400 billionaires make on their staggering wealth would give us an additional $480 billion per year.

Fixing our voting system is also quite straightforward. Ranked-choice voting would be a huge improvement, and has already been implemented successfully in several states. Even better would be range voting, but so far very few places have been bold enough to actually try it. But even ranked-choice voting would remove most of the terrible incentives that plurality voting creates, and likely allow us to move beyond the two-party system into a much more representative multiparty system.

None of this requires overthrowing the entire system or dismantling capitalism.

That is, we can have a positive vision of the future that doesn’t require revolution or radical change.

Unfortunately, there’s still a very good chance we’ll do none of it.

PNRJ core principles, market failure, public policy , , , , , , , , , , , , , , , , ,

There should be a glut of nurses.

Jan 15 JDN 2459960

It will not be news to most of you that there is a worldwide shortage of healthcare staff, especially nurses and emergency medical technicians (EMTs). I would like you to stop and think about the utterly terrible policy failure this represents. Maybe if enough people do, we can figure out a way to fix it.

It goes without saying—yet bears repeating—that people die when you don’t have enough nurses and EMTs. Indeed, surely a large proportion of the 2.6 million (!) deaths each year from medical errors are attributable to this. It is likely that at least one million lives per year could be saved by fixing this problem worldwide. In the US alone, over 250,000 deaths per year are caused by medical errors; so we’re looking at something like 100,000 lives we could safe each year by removing staffing shortages.

Precisely because these jobs have such high stakes, the mere fact that we would ever see the word “shortage” beside “nurse” or “EMT” was already clear evidence of dramatic policy failure.

This is not like other jobs. A shortage of accountants or baristas or even teachers, while a bad thing, is something that market forces can be expected to correct in time, and it wouldn’t be unreasonable to simply let them do so—meaning, let wages rise on their own until the market is restored to equilibrium. A “shortage” of stockbrokers or corporate lawyers would in fact be a boon to our civilization. But a shortage of nurses or EMTs or firefighters (yes, there are those too!) is a disaster.

Partly this is due to the COVID pandemic, which has been longer and more severe than any but the most pessimistic analysts predicted. But there shortages of nurses before COVID. There should not have been. There should have been a massive glut.

Even if there hadn’t been a shortage of healthcare staff before the pandemic, the fact that there wasn’t a glut was already a problem.

This is what a properly-functioning healthcare policy would look like: Most nurses are bored most of the time. They are widely regarded as overpaid. People go into nursing because it’s a comfortable, easy career with very high pay and usually not very much work. Hospitals spend most of their time with half their beds empty and half of their ambulances parked while the drivers and EMTs sit around drinking coffee and watching football games.

Why? Because healthcare, especially emergency care, involves risk, and the stakes couldn’t be higher. If the number of severely sick people doubles—as in, say, a pandemic—a hospital that usually runs at 98% capacity won’t be able to deal with them. But a hospital that usually runs at 50% capacity will.

COVID exposed to the world what a careful analysis would already have shown: There was not nearly enough redundancy in our healthcare system. We had been optimizing for a narrow-minded, short-sighted notion of “efficiency” over what we really needed, which was resiliency and robustness.

I’d like to compare this to two other types of jobs.

The first is stockbrokers.Set aside for a moment the fact that most of what they do is worthless is not actively detrimental to human society. Suppose that their most adamant boosters are correct and what they do is actually really important and beneficial.

Their experience is almost like what I just said nurses ought to be. They are widely regarded (correctly) as very overpaid. There is never any shortage of them; there are people lining up to be hired. People go into the work not because they care about it or even because they are particularly good at it, but because they know it’s an easy way to make a lot of money.

The one thing that seems to be different from my image may not be as different as it seems. Stockbrokers work long hours, but nobody can really explain why. Frankly most of what they do can be—and has been—successfully automated. Since there simply isn’t that much work for them to do, my guess is that most of the time they spend “working” 60-80 hour weeks is actually not actually working, but sitting around pretending to work. Since most financial forecasters are outperformed by a simple diversified portfolio, the most profitable action for most stock analysts to take most of the time would be nothing.

It may also be that stockbrokers work hard at sales—trying to convince people to buy and sell for bad reasons in order to earn sales commissions. This would at least explain why they work so many hours, though it would make it even harder to believe that what they do benefits society. So if we imagine our “ideal” stockbroker who makes the world a better place, I think they mostly just use a simple algorithm and maybe adjust it every month or two. They make better returns than their peers, but spend 38 hours a week goofing off.

There is a massive glut of stockbrokers. This is what it looks like when a civilization is really optimized to be good at something.

The second is soldiers. Say what you will about them, no one can dispute that their job has stakes of life and death. A lot of people seem to think that the world would be better off without them, but that’s at best only true if everyone got rid of them; if you don’t have soldiers but other countries do, you’re going to be in big trouble. (“We’ll beat our swords into liverwurst / Down by the East Riverside; / But no one wants to be the first!”) So unless and until we can solve that mother of all coordination problems, we need to have soldiers around.

What is life like for a soldier? Well, they don’t seem overpaid; if anything, underpaid. (Maybe some of the officers are overpaid, but clearly not most of the enlisted personnel. Part of the problem there is that “pay grade” is nearly synonymous with “rank”—it’s a primate hierarchy, not a rational wage structure. Then again, so are most industries; the military just makes it more explicit.) But there do seem to be enough of them. Military officials may lament of “shortages” of soldiers, but they never actually seem to want for troops to deploy when they really need them. And if a major war really did start that required all available manpower, the draft could be reinstated and then suddenly they’d have it—the authority to coerce compliance is precisely how you can avoid having a shortage while keeping your workers underpaid. (Russia’s soldier shortage is genuine—something about being utterly outclassed by your enemy’s technological superiority in an obviously pointless imperialistic war seems to hurt your recruiting numbers.)

What is life like for a typical soldier? The answer may surprise you. The overwhelming answer in surveys and interviews (which also fits with the experiences I’ve heard about from friends and family in the military) is that life as a soldier is boring. “All you do is wake up in the morning and push rubbish around camp.” “Bosnia was scary for about 3 months. After that it was boring. That is pretty much day to day life in the military. You are bored.”

This isn’t new, nor even an artifact of not being in any major wars: Union soldiers in the US Civil War had the same complaint. Even in World War I, a typical soldier spent only half the time on the front, and when on the front only saw combat 1/5 of the time. War is boring.

In other words, there is a massive glut of soldiers. Most of them don’t even know what to do with themselves most of the time.

This makes perfect sense. Why? Because an army needs to be resilient. And to be resilient, you must be redundant. If you only had exactly enough soldiers to deploy in a typical engagement, you’d never have enough for a really severe engagement. If on average you had enough, that means you’d spend half the time with too few. And the costs of having too few soldiers are utterly catastrophic.

This is probably an evolutionary outcome, in fact; civilizations may have tried to have “leaner” militaries that didn’t have so much redundancy, and those civilizations were conquered by other civilizations that were more profligate. (This is not to say that we couldn’t afford to cut military spending at all; it’s one thing to have the largest military in the world—I support that, actually—but quite another to have more than the next 10 combined.)

What’s the policy solution here? It’s actually pretty simple.

Pay nurses and EMTs more. A lot more. Whatever it takes to get to the point where we not only have enough, but have so many people lining up to join we don’t even know what to do with them all. If private healthcare firms won’t do it, force them to—or, all the more reason to nationalize healthcare. The stakes are far too high to leave things as they are.

Would this be expensive? Sure.

Removing the shortage of EMTs wouldn’t even be that expensive. There are only about 260,000 EMTs in the US, and they get paid the apallingly low median salary of $36,000. That means we’re currently spending only about $9 billion per year on EMTs. We could double their salaries and double their numbers for only an extra $27 billion—about 0.1% of US GDP.

Nurses would cost more. There are about 5 million nurses in the US, with an average salary of about $78,000, so we’re currently spending about $390 billion a year on nurses. We probably can’t afford to double both salary and staffing. But maybe we could increase both by 20%, costing about an extra $170 billion per year.

Altogether that would cost about $200 billion per year. To save one hundred thousand lives.

That’s $2 million per life saved, or about $40,000 per QALY. The usual estimate for the value of a statistical life is about $10 million, and the usual threshold for a cost-effective medical intervention is $50,000-$100,000 per QALY; so we’re well under both. This isn’t as efficient as buying malaria nets in Africa, but it’s more efficient than plenty of other things we’re spending on. And this isn’t even counting additional benefits of better care that go beyond lives saved.

In fact if we nationalized US healthcare we could get more than these amounts in savings from not wasting our money on profits for insurance and drug companies—simply making the US healthcare system as cost-effective as Canada’s would save $6,000 per American per year, or a whopping $1.9 trillion. At that point we could double the number of nurses and their salaries and still be spending less.

No, it’s not because nurses and doctors are paid much less in Canada than the US. That’s true in some countries, but not Canada. The median salary for nurses in Canada is about $95,500 CAD, which is $71,000 US at current exchange rates. Doctors in Canada can make anywhere from $80,000 to $400,000 CAD, which is $60,000 to $300,000 US. Nor are healthcare outcomes in Canada worse than the US; if anything, they’re better, as Canadians live an average of four years longer than Americans. No, the radical difference in cost—a factor of 2 to 1—between Canada and the US comes from privatization. Privatization is supposed to make things more efficient and lower costs, but it has absolutely not done that in US healthcare.

And if our choice is between spending more money and letting hundreds of thousands or millions of people die every year, that’s no choice at all.