An American Health Service?

A progressive idea that could win conservative support.

hand, care, medicine, healthy, health, product, hospital, clinic, nurse, doctor, medical, medic, healthcare, disease, diagnosis, stethoscope, clinical, health care, general practitioner, diagnostic, stetoscope
Image under CCO Public Domain license

While I reject the premise that Joe Biden needs to move left to court disappointed supporters of Bernie Sanders, Jordan Weissman’s actual policy proposal in “Here’s How Biden Should Move Left on Health Care and Court Sanders Voters” is worth considering.

Biden should propose creating an American Health Service, an expansive network of federally funded, locally run primary care providers and hospitals that would offer more affordable treatment and help coordinate public health responses. It would build on the thousands of community health centers that already serve low-income and rural communities, which Sanders played a key role in growing, but cater to middle-class patients, as well. And it would all come wrapped in some stirring patriotic branding.

Given the long setup, I was prepared to simply dismiss this as a classic case of “this situation calls for enacting my pre-existing policy preference. But he makes a good argument.

Why an American Health Service? First, and most important, it would be good idea on the merits that would address some of the glaring shortcomings of our current medical system. Most discussions about health care reform in this country tend to focus on the insurance side of the equation, for the obvious reason that we’re the only advanced country in the world that doesn’t have universal coverage. But many corners of the U.S. suffer from a basic lack of health care services, too. More than 77 million Americans live in federally designated Health Professional Shortage Areas, where providers are in short supply for part or all of the community; the dearth is especially acute in poor and rural areas, which leads people to rely on expensive emergency rooms for essential care.

The U.S. also fares poorly in international measures of health care capacity. Despite spending a bigger share of our economy on health care than anyone else, we have far fewer doctors, hospitals, and hospital beds per capita than many of our peer nations. Meanwhile, we’ve got a rural hospital closure crisis that’s threatening to make these issues worse. We overspend, yet we’re under-resourced. And while it’s too hard for many Americans find a doctor even in normal times, now we’re fighting a plague that has left us all worried about literally running out of hospital rooms.

One straightforward way to address these shortages would be to publicly fund more providers, the tried and true method used across much of the globe. In the U.S., public hospitals provide just 15 percent of beds, according to the Commonwealth Fund. In Australia and France, by contrast, they provide about two-thirds; in Germany they provide almost half; and in even in heavily privatized Japan, they provide more than 20 percent. I’m not exactly suggesting that we try to replicate the United Kingdom’s National Health Service, which directly employs most of the country’s doctors and cares for the vast majority of patients. But if we want hospitals to survive in, say, rural Oklahoma, it seems like we should take a cue from our international peers and just pay for hospitals in rural Oklahoma.

Indeed, one of the criticisms of Medicare for All was that, while it would ensure that all Americans would be able to pay for healthcare, it did nothing to ensure they had access to it. Given how expensive they are, the private sector simply isn’t going to build hospitals in sparsely populated areas.

And, yes, the current crisis demonstrates the value of surge capacity. And, again, the market is unlikely to provide it, given that empty hospital beds and unused equipment are very expensive to maintain.

Is building publicly-funded hospitals in rural areas “socialism”? Sure. But no more so than building publicly-funded hospitals for veterans. Nor is it unprecedented otherwise in our system.

We also already have a successful model to work from: Community Health Centers, which provide primary care and services like mental health, dental, and drug treatment to around 29 million patients across the country. For that, we can largely thank Sanders, who convinced Democratic leaders to ramp up federal health center funding during the negotiations to pass Obamacare. These clinics receive federal grants, along with state and local dollars, to treat residents in underserved communities and charge on a sliding scale based on income (people in poverty pay little or nothing). Almost half their patients use Medicaid, while another 23 percent are uninsured, according to the National Association of Community Health Centers. These are not, for the most part, government-run operations—the vast majority are private nonprofits. But they have to abide by strict operating and reporting rules, including a requirement that patient representatives make up the majority of their governing boards, which keeps them focused on their public mission. And research suggests that they are very successful at providing high-quality care to patients while also lowering costs.

I’m only vaguely familiar with the program but it seems like a reasonable system. Then again, I went to Army doctors from infancy to my mid-20s.

And it turns out they’re pretty cheap, to boot.

Sanders is widely seen as the patron saint of the Community Health Center program, and he has proposed boosting its funding as part of a wide-ranging effort to increase access to primary care in the U.S. But the centers are now widely popular within the Democratic Party; Hillary Clinton wanted to expand them in 2016. Joe Biden is currently calling to double their funding, which reached $5.6 billion in 2019.

But why not go bigger? An American Health Service could include the more than 1,300 Community Health Center organizations that already exist, which ran 11,744 care sites in 2018. Biden could triple or quadruple their funding over time, with the goal of expanding the number and size of clinics, while providing subsidized services to more middle-class patients. He could then take the basic health center grant model and apply a version of it to hospitals in underserved areas. Last July, Sanders proposed a large bailout fund to help states and counties buy distressed local hospitals. Biden could do him one better by a creating a continuous source of funding, with strings requiring hospitals that participate to keep charges affordable and serve needy populations. Nonprofit and public hospitals could both apply. And there could be additional funding for states to build new hospitals (or reopen old ones) in areas that currently lack enough beds.

Weissmann argues that it would be good politics, too:

Aside from being good policy, creating an American Health Service would probably be a popular idea that would fit with Joe Biden’s moderate image. Americans don’t love being told to give up their private insurance. But they do like public (or quasi-public) services. The Community Health Center program in particular enjoys overwhelming support from Democrats, as well as significant backing from Republicans, who understand that it’s a crucial source of care for their rural constituents. When its funding lapsed in 2018, 105 House GOP members signed a letter to then-Speaker Paul Ryan urging him to reauthorize it. Slapping a catchy name on the program and supersizing it to include more clinics and hospitals is an idea that moderate Democrats should be able to get behind. It would also cost a fraction of other ambitious health policy ideas. Again, the current Community Health Center program costs about $5.6 billion per year. You could go an order of magnitude higher and it’d still look modest compared to the policy ideas that have been kicked around this campaign cycle; plus, it could save money for programs like Medicaid by reducing patient costs.

Again, I don’t have the expertise to know whether this would work on a larger scale. But $5.6 billion is a tiny chunk of change in a $4.7 trillion budget.

I don’t know that running on this plan would make that much of a difference in winning Sanders supporters or swing voters. But this actually is a time when the current crisis demonstrates the need for a pre-existing preference.

FILED UNDER: Health, US Politics
James Joyner
About James Joyner
James Joyner is Professor and Department Head of Security Studies at Marine Corps University's Command and Staff College and a nonresident senior fellow at the Scowcroft Center for Strategy and Security at the Atlantic Council. He's a former Army officer and Desert Storm vet. Views expressed here are his own. Follow James on Twitter @DrJJoyner.

Comments

  1. Teve says:

    I would argue that the military is socialist, and the post office is socialist. Nobody lives in a purely capitalist system which would be horrible, or a purely socialist system, which would also be horrible. We’re all arguing about exactly which things to make socialist and which things to make capitalist. I think that national health, like national defense, should be a socialist system, At least for the basics. It’s the same with the military. You can buy machine guns and fortifications and have your own Super Duper personal defense, and you should be able to do that with your own health care.

    13
  2. Mu Yixiao says:

    That sounds like a reasonable proposal, and a good use of tax money. (Though the key wouldn’t be the funding as much as the management). I don’t think anyone would be opposed to getting more healthcare in the places that need it.

    Oddly, this is something that WalMart has been doing with their retail clinics. They take care of all the little, preventative stuff–at a cheap price–and let people know when they need to go to an MD and/or hospital (they use Nurse Practitioners).

    Add fully-staffed and equipped local clinics to the equation, and you’d get a lot more people taking advantage of the opportunity instead of being afraid of the “big scary hospital”. I have access to several big hospitals in the area (the closest being about 15 miles away), but there’s a clinic up the street where I go for pretty much everything. I see a PA rather than an MD. I’ve known him since I was a kid and feel really comfortable talking to him about anything.

    2
  3. Sleeping Dog says:

    When we look at US healthcare there are 3 broad issues that need to be addressed

    Coverage: which gets the most attention with M4A and Obamacare.
    Cost: Gets talked about a lot, but little gets done to actually do any thing about them. Too many wealthy ox’s to be gored.
    Supply: As Weissmann points out there aren’t enough healthcare providers. Additionally those that exist, aren’t very well distributed.

    3
  4. steve says:

    Sounds good but I dont have much hope for it. It is really, really hard to get doctors, decent ones, to work in rural areas. Partly it is the pay since rural pts tend to have crappy insurance or none at all. The other part is schools and living conditions. Let say you get a doc from a really good program like the U of Michigan. Good chance they grew up in the Midwest. Might be willing to live in a rural area you think. Then the doc and spouse look at the local schools. Kills the deal right there. Ok, they can live an hour or more away and commute. That can work for ED docs or primary care but anyone who needs to take call and live closer to the hospital? Not happening. So you either staff those hospitals with docs who have failed at other places, usually many times, or pay them a fortune. (Yes, yes there are exceptions. People who grow up in an area and want go back to be with family, or they are fishing addicts, but they really are exceptions.) Then how do you afford specialists at these low volume hospitals? Critical care? (We have to pay bonuses to get our nurses and mid-levels to work at some rural places. )

    Steve

    8
  5. Lounsbury says:

    @Teve: Calling the Military socialist or a postal service socialist is nonsense. By such fuzzy headed definitions, socialism has always existed, rather rendering the term meaningless.

    Now of course yes, no economy in the world has ever operated in an American Libertarian Free-Market-as-Bolshevism mode, but really this is largely an American Libertarian lunatic fringe (or Ayn Rand based understanding of market economics).

    2
  6. Mu Yixiao says:

    @steve:

    It is really, really hard to get doctors, decent ones, to work in rural areas.

    What about a debt-forgiveness program like they have with teachers? Encourage young doctors and nurses who’ve recently graduated to staff the clinics for X years (5?) in exchange for paying their student loans. Or even just “the government will make your loan payments as long as you’re at one of the qualified clinics”. Toss in a little social engineering (You’ll be in charge of the clinic, rather than a little guy at a big hospital) to make it sound better.

    It’ll still only appeal to a small portion of medical staff, but it could help get the numbers up.

    8
  7. Michael Reynolds says:

    And now the one word reason this won’t happen: abortion.

    18
  8. Scott says:

    I am for Universal Healthcare and I don’t particularly care how we get there. There are 20+models around the developed world (and even in less-developed countries) that we can choose or adapt for our healthcare system.

    I spent the last 40 years in the military healthcare system and I like it. I don’t deal with bills or paperwork. I just get care. And guess what? I don’t find myself abusing it or overusing the services.

    So much of our healthcare system is geared to preventing the utilization of services whether it is high deductibles or insurance middlemen or making people, mostly poor, jumped thru hoops like circus animals to make sure they are worthly and not lazy layabouts (See Laffer).

    11
  9. Michael Reynolds says:

    And in addition to abortion making this politically impossible because: Republicans, @Steve makes the point that people with education, people with a future, do not want to raise their families in Oshkosh, Nebraska. At best you can use debt forgiveness and subsidies to get them to do a tour, a couple of years, like Peace Corps for goobers, but actually spend 30 years in some freezing town where the nearest sit-down restaurant is an Applebees twenty miles away at a dying mall?

    Ask yourself what it would take to convince you to go. My answer would be: there is literally no amount, no, not a billion dollars a year. No. Nebraska? Unh unh. Ditto Mississippi and Arkansas and West Virginia and . . .

    Best bet would be locally-raised nurse practitioners. Maybe. People with MD’s? Nah. There’s a reason everyone in this country lives in cities and suburbs and no one lives out where the combines roam.

    6
  10. Stormy Dragon says:

    Is building publicly-funded hospitals in rural areas “socialism”?

    Last thing we need is another way for rural areas to vote for Republicans who impoverish them, then expect urban areas to ball them out from the consequences while those Republicans fight to keep the urban areas from enjoying the same benefit.

    9
  11. OzarkHillbilly says:

    Is building publicly-funded hospitals in rural areas “socialism”?

    2 words: Farm subsidies.

    10
  12. Gromitt Gunn says:

    There are already programs in place that pay for the schooling for medical professionals in exchange for a certain number of years of work in underserved areas. It’s not a new thing, either.

    3
  13. Sleeping Dog says:

    @steve:
    @Mu Yixiao:
    @Michael Reynolds:

    Debt forgiveness, a pay premium and few other bennies could get new Docs to move to the boonies and provide care. If it is for a 5 year commitment, we don’t need to ask them to make living in the woods a career. The image of old Doc Flanagan, seeing patients in what was the music room of his 19th century mini mansion in Palookaville isn’t what we need to provide.

    And as @Mu Yixiao: mentions above, the vast majority of rural medical needs wouldn’t require a Doc as a PA or even an RN would suffice.

    Another way to approach it would be to make medical education free for all but you will go where you are assigned for X years. Sort of like being in the military.

    4
  14. Michael Cain says:

    @Mu Yixiao: In some places this has been a problem for so long that everything’s been tried at least once.

    I recall sitting in a bar in Lincoln, NE when I was about 22. One of the people at the table was a young man who had reached the point where he was beginning to think seriously about where he wanted to practice medicine. We were all listening closely, and his story went something like this:

    “I’ve spent the last several years in cities, from the size of Lincoln up to Chicago, getting a complicated education. I grew up in a Great Plains town, so I know small towns. Forget about amenities, like a competent dentist. If I go to one of those towns, there will be almost no one my age and few of those have more than a high-school education. The middle-aged folks are insular — if you haven’t lived there for 20 years you’re an outsider and get treated that way. The old people are worse. The Old Ladies Club — and every town has one, the widows who have moved to town after their husbands died, because ranching is a hard dangerous way to make a living — will gossip incessantly about you, most of it wrong and some of it malicious. You can’t pay me enough to put up with it.”

    I’ve got my own set of small-town memories. You can’t pay me enough to retire back there, let alone work.

    5
  15. Michael Cain says:

    @Sleeping Dog: It’s been a problem for decades. Everything you suggest — except possibly the military-style approach — has been tried. None of them work. Trust me when I say, “There is no small town in America that can’t chase a freshly-minted doctor out in less than two years.”

    4
  16. steve says:

    I grew up in small towns mostly, and my experience was better than Michael’s above. I wouldn’t mind living in one if I were young again. The problem would be telling my wife that her son (who she actually loves, she just tolerates me) would have to go to a rural school that would pretty much eliminate his chance of going to a decent university.

    Mu- I think that has some merit, but will get expensive. I think the idea here, if I understand James correctly, is that this will provide an affordable alternative for rural areas. If it worked you would probably get a few to stay after their repayment time was finished (inertia is a law of nature after all) but you could end up with rural systems staffed almost exclusively with new grads. You could do what the military does and have short hours but then you need more staff, pretty low efficiency.

    Steve

  17. mattbernius says:

    @Michael Reynolds:

    People with education, people with a future, do not want to raise their families in Oshkosh, Nebraska.

    Honestly, I think you might be surprised at the number of people who actually would be into that. I write that as someone who lives in a small city and has very bright colleagues and friends who’ve opted to live in far more rural areas. That life definitely isn’t for everyone, but it is far from unheard of.

    The children’s education thing @steve raises is a real issue — but I also think we’re about to see some major shifts in post-secondary education.

    1
  18. James Joyner says:

    @steve:

    It is really, really hard to get doctors, decent ones, to work in rural areas.

    Yes. This would have to be accompanied by either significantly increasing the size of medical school classes, which has always been a sound policy but opposed by the AMA cartel, or further importing foreign docs/keeping foreign students trained in US medical schools here. The latter has extreme negative externalities for the losing countries, so I’d vastly prefer the former.

    @Lounsbury:

    Calling the Military socialist or a postal service socialist is nonsense

    I tend to agree, although that’s really a matter of expectations. Long ago, armies were indeed privatized; we’re just used to them being government agencies now. And, aside from ordinary mail—which is a dying thing—we’ve flipped the script on delivery such that the private sector is now better/more efficient. (Although that’s partly because USPS has to subsidize rural delivery.)

    @Michael Reynolds:

    [M]ost people with education, people with a future, do not want to raise their families in Oshkosh, Nebraska.

    While that’s largely true, the exception is a lot of people who grew up in Oshkosh. A lot of those folks can’t imagine putting up with the hustle and bustle of a major metropolitan area. My high school valedictorian stayed in Alabama, although she moved to a slightly larger community. So, if we stop artificially constraining the available medical school slots—there are a lot of straight-A students who can’t get one—you could largely end this problem. Especially if we give them loan forgiveness so they’re not forced to go to the big city to earn enough to pay off debt.

    @Michael Cain:

    Forget about amenities, like a competent dentist.

    Having spent a lot of my life living in small towns in the South, this really isn’t an issue. There’s a dearth of specialists but I’ve never had a problem finding dentists or optometrists.

    5
  19. Mu Yixiao says:

    @Michael Reynolds:

    @Steve makes the point that people with education, people with a future, do not want to raise their families in Oshkosh, Nebraska.

    I agree with @mattbernius. You’d be surprised at how many “big city” professionals move out to the countryside. They are, however, usually not the young kids. They’re people who have already raised their families and are tired of the expense and hustle of big cities.

    The small town I’m in has quite a few people who’ve left NY, Chicago, LA, etc. and moved into the area. When they realize that they can sell their $2M apartment and buy a 5-bedroom Victorian*, or 3-bedroom lakeside home, or a 40-acre wooded spread with a 5-bedroom farmhouse–and have $1M – $1.5M leftover, it gets a lot more appealing.

    * The 5-bedroom Victorian across the street from me sold for $300k last year. It sits on a 120×79-foot corner lot and includes

    a gorgeous 2-story carriage house.

    1
  20. Mu Yixiao says:

    @James Joyner:

    This would have to be accompanied by either significantly increasing the size of medical school classes, which has always been a sound policy but opposed by the AMA cartel, or further importing foreign docs/keeping foreign students trained in US medical schools here.

    Agreed.

    There’s also a small pool of medical professionals who have immigrated to the US, but aren’t allowed to practice medicine here. There should be a simple way to get them certified to practice in the US.

    Additionally, there’s the problem that medical licenses are issued by the states, and only 29 states have a reciprocity agreement (and from what I can tell, it’s not active in all of them–the map key is a bit confusing). Even then, only 80% of medical professionals who hold a license qualify to work in a different state.

    I can understand requiring lawyers to re-certify in order to work in a different state. State laws vary widely, and what they’ve learned about California laws won’t apply in Wyoming or Wisconsin (and let’s not get into the red-headed stepchild, Louisiana). But… Medicine doesn’t change when you step across a border. A short course on relevant medical laws for the new state should be enough (especially since most of that is administrative and frequently handled by administrative staff).

    It’s ridiculous that a doctor from LA or Orlando can’t move to Ohio or Alaska and easily start practicing. Not to mention the fact that it completely destroys the premise of Northern Exposure. 🙂

    3
  21. Mu Yixiao says:

    Okay… I’m not sure what happened with the formatting at the end of my previous post…. I blame gremlins.

  22. Michael Reynolds says:

    I’d need to see some actual numbers before I believe significant numbers of MD’s would live out in Mayberry.

    Using my clan as a reference, there’s very little reason for a writer (other than TV people) to live in a city. I’m doing fine in LA, but I could move to South Dakota and live like a real rich person. I could have a butler. Don’t know WTF he’d do, but I could have one. Anyone free-lancing is better off financially in the boonies. So where do writers live? Bargain destinations like NYC, LA, the Bay Area, places where they hang on by their fingernails because they figure a one bedroom walk-up with no yard and a view of a muffler shop, is better than a five bedroom McMansion on ten acres out in the sticks.

    Every few years I see stories about urbanites moving out to be near the soil or whatever, and yet in real life? Not so much. The state losing population fastest is Wyoming, and unlike California, it’s not because the rent is too damn high.

    2
  23. Andy says:

    While well-intentioned, this proposal suffers from a very common defect – the idea that policy proposals exist on their own in isolation, as if it’s just one drawer among many in an apothecary cabinet of policy choices.

    But it doesn’t work like that. Policy proposals need to deal with the world as it is, and not make rosy assumptions. It’s an idea that can work, but only if many other areas of health care are changed or reformed to enable it to work. It will require a lot more than throwing federal dollars around and creating a new bureaucracy.

    Several people have already brought up the more obvious problems. The biggest one, IMO, is that we don’t have enough doctors and medical professionals thanks to federal government policy. Is the AMA going to get out of the way and encourage Congress to create more medical professionals? History says no. The VA, for example, has a perennial provider shortage, even in urban areas.

    That’s even before dealing with the very real problem of enticing providers to work in these areas – a problem that education has yet to solve and may not be reasonably solvable.

    It’s simply wrong to assume that tripling or quadrupling funding will bring sufficient personnel and capacity to realize the program’s goals.

    This also wouldn’t solve anything with a future Covid-19 as this is a proposal for community clinics and not full-up hospitals with ICU’s and the requisite specialists. The problem with ICU access in rural areas is a different problem. Community health centers are great for many things, but they can’t provide every medical capability in every community. There are always going to be regional centers that provide higher-level and specialty care in rural areas.

    The other annoying thing about this and similar proposals is they assume the President has powers the office doesn’t have:

    Biden could triple or quadruple their funding over time, with the goal of expanding the number and size of clinics, while providing subsidized services to more middle-class patients. He could then take the basic health center grant model and apply a version of it to hospitals in underserved areas.

    No, Biden, or any other President, cannot do any of that. All that must come from Congress. Biden can say what he wants and, if legislation is passed, his administration could write the rules and run the program, but that’s it. Obamacare wasn’t written by Obama or his administration, it was mostly written by (as I recall) the Senate Health and Finance committees. Telling people that Biden could do something he obviously lacks the power to do is, at the very least, counter-productive.

    Still, I think this is an idea worth exploring and it seems like there is room to scale things up at least somewhat. But there are fundamental structural problems and factors in our healthcare system that need to be addressed for major healthcare proposals to work in the real world.

    3
  24. steve says:

    “This would have to be accompanied by either significantly increasing the size of medical school classes, which has always been a sound policy but opposed by the AMA cartel, or further importing foreign docs/keeping foreign students trained in US medical schools here.”

    You realize that if this was accomplished our total medical spending would skyrocket dont you? First, provider induced demand is real thing. Second, there is tons of pent up demand in these areas. If they have a supply of medical care suddenly available and some way to pay for it that will bye a lot of money.

    Steve

  25. gVOR08 says:

    @Michael Cain: I was born and raised in ND. I’ve said for decades that if the last engineering job in the country was in ND, I’d sweep floors in a city.

    4
  26. Kurtz says:

    @Teve:

    I would argue that the military is socialist, and the post office is socialist.

    This is exactly the point, which is one of the two big reasons the Right’s socialism messenging is stupid.

    As an extension, from what I can tell, the government contracts that suffer from the highest cost-overruns are military projects. This is intuitive, given the technology (immense research costs) involved.

    But it exposes the hypocrisy of the GOP in two ways. First, separating national defense from the definition of socialism is disingenuous. Second, it shows that centralized research programs produce advanced technology quite well, even if it is expensive.

    The second point is worthy of a little more discussion. Basic science research is only profitable for private companies in certain industries, e.g. pharma. But that cost gets added to the end-user.

    I can’t imagine the internet developing how and when it did without government/University research, because what private individual would pour money into a project that had no clear path to profitability within a reasonable amount of time.

    3
  27. gVOR08 says:

    @Mu Yixiao: Gah. Thank you. Northern Exposure. I was trying to remember that name.

    1
  28. Kurtz says:

    @James Joyner:

    would have to be accompanied by either significantly increasing the size of medical school classes, which has always been a sound policy but opposed by the AMA cartel, or further importing foreign docs/keeping foreign students trained in US medical schools here. The latter has extreme negative externalities for the losing countries, so I’d vastly prefer the former.

    The limiting factor is residency slots, not medical school enrollment.

    4
  29. Nightcrawler says:

    Parts of what is now the U.S. will get universal healthcare … after this country splits into several new ones.

    Likely, one of those countries, perhaps two (one in the South, one in the West) will be a pure capitalist “Galtland” conservative “paradise.” Another might be a pure socialist extreme-left wing “paradise,” although I think fewer people really want that really want pure capitalism, so it might not happen.

    The other countries will be somewhere in between, much like Canada and current EU member countries.

    The purely socialist country, if it exists, and the in-betweeners will all have various versions of socialized healthcare. The purely capitalist country or countries will have a system that’s like what we had pre-Obamacare on steroids, meaning no Medicaid, no Medicare, no EMTALA; you pay up or you die, just like you pay for everything else (fire, police, K-12 schooling, etc.) or too bad, so sad.

    Conservatives will never, ever, ever support socialized healthcare. They’re actually willing to die to prevent it from happening. They worship money and rich people like gods, so to them, dying for those things is a form of martyrdom.

    There’s no difference between them and religious nuts who are willing to die for a sky fairy. You cannot reason with people like that.

    4
  30. Nightcrawler says:

    @gVOR08:

    I was born and raised in ND. I’ve said for decades that if the last engineering job in the country was in ND, I’d sweep floors in a city.

    I work for myself, from home. Do does my husband. In our household, high-speed internet access is not a luxury, but a necessity. We couldn’t live in a rural area, even if we really wanted to, because those places don’t have high-speed internet access. We would be unable to support ourselves.

    That said, even if high-speed internet were brought to rural areas, I still wouldn’t want to live in one. Those states are run and populated by Branch Trumpidians, and I do not want to live in a state run and populated by Branch Trumpidians. This is actually one of the reasons why we’re leaving Florida, and it’s a reason that has significantly grown in importance since the world ended.

    The people who live in places like that hate people like me anyway, meaning anyone who doesn’t worship Trump. They wouldn’t want me living there in the first place. They want to live only among their own kind, that “kind” in this case being other Branch Trumpidians.

    7
  31. Michael Cain says:

    @James Joyner:

    While that’s largely true, the exception is a lot of people who grew up in Oshkosh. A lot of those folks can’t imagine putting up with the hustle and bustle of a major metropolitan area.

    The population of Oshkosh peaked in 1940. With the exception of the 1960s, the population has declined every decade since then. A majority of the 93 counties in Nebraska are losing population. Take out the Omaha and Lincoln metro areas and the total state population would be shrinking.

    I admit that I’m somewhat biased because when I hear “rural” I think of the Great Plains, which is the extreme example. There’s a 300-to-500 mile wide piece of the US, stretching from the Mexican to Canadian borders, where the population is slowly but steadily shrinking back to the edges (eg, Omaha) and the few transportation corridors (eg, I-80). The population density in 60% of the Great Plains counties has dropped below the 1880s “seven people per square mile” definition of frontier.

    1
  32. gVOR08 says:

    My primary care doc has set up some sort of telemedicine setup. Her clinic is discouraging in-person visits, as is the walk-in clinic associated with it. I expect this is quite common around the country right now. When I do see a doctor, most of the work is done by techs and nurses. My wife had ankle surgery some weeks ago, which left us not going anywhere before it became fashionable. The doc did the diagnosis and the surgery, but also stuck his head in while nurses put on the cast and removed the cast. I’ve read that most scans are being read in India. I once asked an allergist a question and he endeared himself to me by saying he didn’t know, he’d look it up and let me know. There’s no reason doctors need to work so heavily from memory. IBM’s Watson was developed for medical diagnosis.

    My point in all this rambling is that part of the solution has to be 21st century technology and further redefinition of what tasks really require an MD.

    I’ll add an aside that in the communities upriver from Cincinnati, the hospital, the clinics and offices, and the assisted care and nursing homes were the second largest employer in town, after the school system. “Nothing but the dead and dying back in my little town.” Back in ND there was a line that after ag products, and lately shale oil, the biggest export was educated kids.

  33. Andy says:

    @Kurtz:

    I think a big part of the problem is definitional – people have very different ideas about what “socialist” means. If people can’t accept a common definition then they just end up talking past each other.

    6
  34. Kurtz says:

    @James Joyner:

    One more thing on that. The following is from Michael Huemer’s The Problem of Political Authority. Note that he goes through this list twice. I’m omitting the first run of them, for brevity’s sake.

    As these examples illustrate, legal paternalism is quite widespread in modern Western society. All of these are unjustified laws.

    Rent seeking is behavior designed to extract wealth from others, especially through the vehicle of the state, without providing compensatory benefits in return.
    The most straightforward example is a company lobbying the government for subsidies. But many of the policies that exemplify legal paternalism are also motivated partly by rent seeking. Consider the following.

    Prescription drug laws. These laws transfer money from consumers to doctors and pharmacists. If a person wishes to buy a prescription drug, he must first pay a doctor to see him and give him permission to buy it.

    –Subsidies for college education. These increase the demand for college education far above the market level and thereby transfer resources to colleges and universities. (The author is grateful for the funds that you have provided him.)

    –Social Security. I said above that Social Security could be looked upon as a program of forcing people to save for retirement. It can also be viewed, perhaps more accurately, as a system of transfer payments from the young to the old.

    Licensing. Licensing laws place an obstacle to entering a given profession, thus decreasing the competition faced by current practitioners. This raises prices and benefits existing practitioners at the expense of both consumers and those who wish to enter the profession.

    This exemplifies one of the problems I see in Libertarianism and the GOP. The former tends to view it as a moral issue; the latter, a matter of efficiency.

    But the prior for both is that the government enacts laws solely to exercise power. But that ignores the fact that the vast majority of laws pass to solve a problem.

    Huemer is an example of a highly intelligent, well-educated person who atomizes complex social and historical phenomena to the point that what he is analyzing doesn’t resemble the whole object.

    I’ll tweak an analogy Guarneri used a few months ago. It would be like analyzing modern art by only focusing on brushstrokes without looking at anything else.

    To be fair to Huemer, there are some absurd licensing laws eneacted as a result of rent-seeking.

    But including Physician/Pharmacist licensing is worthy of a whiplash-inducing eyeroll.

    One need only look at homeopathy and anti-vaxxers to see why it’s important to maintain strict criteria for practicing medicine.

    Restricting antibiotics is a genuine concern for the public, because widespread overuse would quickly reduce the efficacy of drugs designed to kill harmful pathogens. Not to mention the need to restrict the use of powerful psychatric medicines.

    Both of those examples are not just cases of the government trying to protect people from themselves or “cartels” trying to maintain a high price floor. Rather, they exist to reduce moral hazard.

    If you need an antibiotic, you are better off with those laws. Without them, at some point in the future, you are likely to find that the treatment won’t work. The pathogen will have evolved a resistance to the medicine, not because of anything you did, but because of the irresponsible actions of others.

    Pretending that these legal regimes exist for the sole purpose of one negative aspect of them serves only one thing: ideology.

    4
  35. gVOR08 says:

    From Wiktionary:

    1. Any of various economic and political theories advocating collective or governmental ownership and administration of the means of production and distribution of goods.

    I think you’d have to say the military and the USPS are owned and administered by the government. There is some irony in the military attracting so many conservatives to about the most socialist possible organization. They even dictate what you wear.

    I’m often reminded of reading an article about sex trafficking. A commenter objected to referring to the girls as “prostitutes” because they were forced into it. Yes, they were forced into prostitution. George Lakoff talks of conservatives seeing everything through a frame of simple morality. I think conservatives attach a lot of fuzzy moral baggage to words, then have difficulties when others use a word in a way that doesn’t conform to their baggage. If I say to a gun enthusiast that 30,000 Americans are shot dead every year, he will immediately respond that that’s wrong, most of them were suicides. He’s attached a whole moral worldview to “shot” beyond that a bullet struck. When politicians say tax cuts don’t raise the deficit, they’re lying. But the base believe it because without really thinking about it they go tax cut is good, deficit is bad, a good thing doesn’t make a bad thing.

    The Army may not be your mental picture of socialism, but I don’t see how you can say it isn’t socialism.

    9
  36. Kurtz says:

    @Andy:

    Yes, they do. A good example: when the Left discusses gender, they are talking about social norms, but the Right hears “genitalia.”

    Relatedly, I’ve heard from friends of mine who happen to be on my side of the aisle say bizarre things. I’ve heard a couple of them say, “Republicans want poor people to die.” (I’m using this example rather than bullshit from a Republican voter, because it’s important to recognize that it happens on both sides of the fence.)

    Phrasing like that bothers me, because it’s obviously not true. Well, maybe with the exception of someone like Steve King or Stephen Miller, assuming said poor people are black or brown. 😉

    The point being, most political discussion is like a married couple in their 90s. Both of them simultaneously yelling at the other with the TV tuned to Andy Griffith, volume at 100–a cacophonic stew of insolent white noise with no risk of intelligibility.

    2
  37. Kurtz says:

    Those states are run and populated by Branch Trumpidians, and I do not want to live in a state run and populated by Branch Trumpidians. This is actually one of the reasons why we’re leaving Florida, and it’s a reason that has significantly grown in importance since the world ended.

    Two things:

    –how the eff do so many of us live in Florida? I live in Florida. So does Teve, Guarneri, and gVOR08. I’m sure there are others that I am forgetting.

    –What would Waco look like for this particular cult?

    1
  38. Blue Galangal says:

    @Andy: What’s really funny is seeing James claim that

    we’ve flipped the script on delivery such that the private sector is now better/more efficient. (Although that’s partly because USPS has to subsidize rural delivery.)

    when the USPS is now basically subsidizing Amazon/UPS by providing postal delivery to individual doors in cities, suburbs, and of course rural areas. Yes – that private package delivery sector is so efficient they won’t deliver their packages the last part of the chain – it’s cheaper to farm it out to the socialized postal service.

    7
  39. OzarkHillbilly says:

    Most of the doctors who work at our rural hospital and clinics are not born and bred Americans. I would say 90-95% of them. My doctor is from SE Asia (I would guess Indonesia) The one before was from the Philippines. Before her, a Pakistani. The general surgeon is from Poland (he has cut on me several times and damn, is he good. Cut my face up and the only sign is that the wrinkles are horizontal on that side instead of angled like the other)

    Most of our specialists make the 1-2 hr drive out from STL and environs for weekday appts (some 1/week, some 1/2 weeks, some 1/month) My last colonoscopy was done by an Afghani. The pulmonologist is from the ME. The psychologist is from India. And on it goes.

    One of the hallways at the hospital is lined with the pictures of all the doctors who practice there. Only 2 are American, the other 12 or 14 look like the world.

    ETA Years ago, Bill McClellan wrote an article about taking his daughter to the ER. He walked in saying “NOBODY IS TOUCHING MY DAUGHTER UNLESS THEY CAN’T SPEAK ENGLISH!”

    Once when I was poor and unemployed, I collapsed a lung. Went the ER at the public hospital. The ER doc was Indian, the radiologist was Phillippino, the surgeon was Pakistani. The person who actually did the cutting and inserted the chest tube? Was a scared half to death young white boy who had a definite tremor in the hand holding the scalpel.

    3
  40. Slugger says:

    @Michael Cain: I agree with this analysis. My wife grew up in a small midwest agricultural community of 4500. On Saturdays the “downtown” was bustling, but it is deserted now. Farming employs fewer people than before, and the retail stores were killed by Walmart. It is within commuting distance of some manufacturers, but those corporations have moved most work overseas. The population is now 3700, and the median age is probably 50+. Nursing homes are the main industry. The only new business is a mortuary! The county gave its votes to Trump, and he will win there this year.
    Would you start a business there? Going to medical school costs $100,000 to $200,000. Would you invest that much money to start a business in a shrinking market?
    Now if we think that distribution of goods should be based on peoples’ needs rather than on the providers’ economic considerations, then we can restructure the way we allocate things. However, this would require a big change in the way we do things.

    4
  41. Michael Cain says:

    @Nightcrawler: When the states are partitioned — and I believe they will be — I think people will be surprised by where the major east-west split falls, and how “the West” turns out. But our good hosts’ blog is not the place to have that discussion :^)

  42. Mu Yixiao says:

    @Michael Reynolds:

    I’d need to see some actual numbers before I believe significant numbers of MD’s would live out in Mayberry.

    What you have to do is understand that not everyone likes what you like. Not everyone wants to be in the big city. Not everyone wants the pressure of working in a major hospital.

    You like living in the city. Great. About half the US does. But you have to understand that the other half aren’t living in rural areas because they “can’t get to the city”. A lot of us actually like living in small towns. There’s a whole list of reasons that rural communities are attractive–maybe not to you, but to others.

    As for the numbers:

    Wyoming may have slow growth, but rural states are growing.

    Utah, Texas, and North Dakota lead the pack (all rural).

    Idaho, Colorado, Nevada, Arizona, North and South Carolina, Montana, Georgia, and Virginia (all rural) all have higher gains than California. And New York State is at the bottom of the list (Wyoming has about 3 times the growth that NY does–Montana has over 8.5x the growth).

    There’s no way to tie those numbers to MDs, but the idea that nobody wants to move to rural states just doesn’t hold up. And where there’s people, there’s a need for doctors.

    1
  43. Michael Reynolds says:

    @Mu Yixiao:

    What you have to do is understand that not everyone likes what you like.

    I actually imagine other people’s desires and preferences all day long. You could say it’s my job.

    But here’s the problem with the proposition: a one bedroom apartment in San Francisco costs what a five bedroom house in Bugtussle costs. A commodity – an apartment – which is more desired is more expensive, one less desired tends to be cheaper. So in crude economic terms it’s undeniable more people want to live in SF than in Bugtussle.

    Put it this way, imagine that a beachfront home in Malibu and a beautiful home in Muleshoe, Texas cost exactly the same amount, and indeed the cost of living was exactly equal as was pay. Tell me which home would have the long line? I’m sure someone would pick the Muleshoe home, but not a lot. If California was cheap we’d have a population of a hundred million by the end of the month. Whereas Wyoming is cheap and there’s no one there.

    But sure, not everyone likes cities, or culture, or a wide choice of diversions. It’s just that those people aren’t likely to be doctors because doctors make a nice paycheck and are educated and want their kids to be educated and exposed to culture and diversity and all that stuff.

    5
  44. DrDaveT says:

    @Mu Yixiao:

    and Virginia (all rural)

    Granting for the moment your larger point, the growth in Virginia is focused in the few counties around DC. Indeed, what has turned Virginia purple-then-blue is the inexorable shift of electoral weight from Sarah Palin’s “Real Virginia”, which is still deep red, to the DC exurbs and suburbs and satellite cities.

    Here’s a sortable table of Virginia county population growth from 2018 to 2020. The top of the table is dominated by Northern Virginia exurbs (like Loudoun County) and independent cities. New Kent County (Richmond/Williamsburg exurb) and King George County are the only real exceptions. The Hampton Roads cities (Norfolk, Newport News, Hampton, Chesapeake) are losing population, but not nearly as fast as the northern cities and exurbs are gaining. The largest (in population) chunk of VA that lost significant population over that period was the Danville / Pittsylvania County area, SE of Roanoke on the North Carolina border.

    So, Virginia contains a lot of rural land, but by population it is no longer a rural state. Fairfax County has more people than the 70 lowest-population counties and independent cities of Virginia combined. Of the 8.5M people in Virginia, 2.5M live in independent cities, and another 2.5M live in counties in the shadow of DC.

    2
  45. steve says:

    I live in a small town/rural area about 20 minutes away from our tertiary care hospital. It is easy to find people who will do that. Our school district includes part of the “suburbs” of the local small city in which that hospital is located. It is well rated. I can hire people to work in this kind of setting. When I try to hire people to work at the small hospitals an hour away in the real areas where the schools are poor it is hard. I am not speculating as this is something I have done over the last 15 years I have run a private practice group of specialists. If being on call was not an issue so that people didnt need to live within 30 minutes of the place it would be easier. That said, even ED has trouble hiring and they have no limitations on where they live.

    The other problem is that most people coming out of training dont really want to work at a small hospital, at least in my and a number other specialties. You dont see the breadth of cases you need to finish developing. There just isn’t enough population to support a larger hospital. It’s a real conundrum.

    Steve

    2
  46. JohnSF says:

    @Kurtz:
    Michael Huemer:

    “legal paternalism is quite widespread in modern Western society…these are unjustified laws”.

    My jaw rebounds off the floor.
    I google.
    He is a professor of philosophy.

    Well, of course he is.

    Only a (modern) philosopher could say something so superficially erudite and at the same time quite stunningly daft.
    It is quite astoundingly ahistorical.

    Offhand I cannot think of ANY society ANYWHERE, EVER that has a legal system above the level of tribal tradition that does not include elements that could be considered legal paternalism.
    Anarchists might say protest the law is “theoretically unjustifiable”; society replies “don’t care, do as you’re damn well told.”
    Some libertarians really are as infuriatingly ungrounded as communist or religious fundamentalists.

    Functioning societies are not abstract philosphical constructs, dammit.

    I blame Plato…

    2
  47. rachel says:

    @Mu Yixiao:

    Utah, Texas, and North Dakota lead the pack (all rural).

    The Wasatch Front is not rural, and (leaving out leisure class playgrounds like Park City, St. George and Moab) that’s where the growth is.

    1
  48. Kurtz says:

    @Mu Yixiao:

    First, your qualitative analysis is no different from Michael’s. If his is flawed, so is your view for the same reason.

    Yes, you are correct that some people prefer living in rural areas. But it requires significant work to argue that people who become physicians desire to live in rural areas, as they are not anywhere near the average American.
    If there were a bunch of doctors finishing residency who wanted to work in a rural setting, the shortage would not exist to the extent that it does.

    Other bits:

    You point out Wyoming, but its growth rate in your link is below the median for the 50 states.

    Identifying Texas, Georgia, Arizona, and Colorado (DrDave already mentioned Virginia) as rural requires a look at county-by-county growth rates, as they all have at least one major metro. Ditto Utah.

    North Dakota’s population boom is tied to shale oil production, and as such is likely to be somewhat elastic based on the price of oil.

    You also have to look at birthrates. If there is a large enough gap between urban and rural birthrates, that could explain a significamt portion of higher rural growth rates.

    A higher percentage of women living in rural areas had two births (25.7%) compared with women living in urban areas (20.9%). A higher percentage of women living in rural areas had three or more births (24.8%) compared with women living in urban areas (19.0%).

    Source: CDC, 2018

    A handy chart.

    All of this is to say that there is a better way to check your analysis. Pew did it.

    Likewise, recent U.S. population growth also has been uneven. Urban counties have grown at roughly the overall national rate of 13% since 2000. Suburban and small metropolitan areas have grown more briskly. Rural counties have lagged, and half of them have fewer residents now than they did in 2000.

    According to a Pew Research Center analysis of census data, since 2000, U.S. urban and suburban populations have grown at least as much as they did over the prior decade. But the total rural population has grown less than it did in the 1990s, when rising numbers fed hope of a modest “rural rebound.” As a result, a somewhat smaller share of Americans now live in rural counties (14% vs. 16% in 2000).

    More recently, the Census Bureau’s population estimates for 2017 show a one-year uptick in the nation’s rural population, though not enough to make up for previous declines. Analysis by demographer Kenneth M. Johnson attributed the increase to gains in rural communities on the edge of metropolitan areas, while more remote counties continued to lose population.

    You’re way behind here.

    5
  49. Kurtz says:

    @JohnSF:

    Haha. The book is actually worth a read, if you can avoid throwing it with great force every few pages.

  50. Teve says:

    Active physicians per 100,000 population by state.

    Massachusetts: 449.5

    Maryland: 386

    New York: 375.1

    Rhode Island: 370

    Vermont: 367.1

    Connecticut: 352.1

    Maine: 330.2

    Pennsylvania: 320.5

    New Hampshire: 315.1

    Hawaii: 314.1

    New Jersey: 306.5

    Oregon: 303.4

    Minnesota: 302.7

    Ohio: 292.7

    Michigan: 287

    Colorado: 285.7

    Delaware: 284.6

    Illinois: 284.4

    California: 279.6

    Washington: 278.8

    Alaska: 276.9

    Missouri: 273.1

    Florida: 265.2

    Wisconsin: 264.9

    West Virginia: 263.4

    Virginia: 263.2

    Louisiana: 260.3

    North Carolina: 255

    Tennessee: 253.1

    Montana: 247.1

    New Mexico: 244.8

    Arizona: 242

    South Dakota: 240.4

    Nebraska: 239.2

    North Dakota: 237.6

    Kentucky: 230.9

    Indiana: 230.8

    South Carolina: 229.5

    Georgia: 228.7

    Kansas: 227.6

    Texas: 224.8

    Iowa: 218.2

    Alabama: 217.1

    Utah: 216.2

    Nevada: 213.5

    Wyoming: 207.9

    Arkansas: 207.6

    Oklahoma: 206.7

    Idaho: 192.6

    Mississippi: 191.3

    No surprise doctors aren’t idiots and they don’t want to live in garbage states.

  51. de stijl says:

    Every other developed capitalist nation has some form of a national socialized health system but us. Misguided hubris.

    It’s embarrarassing.

    Bulgaria has a more rational and equitable health system than us.

    What must, must, must stop is linking your health insurance to your employer.

    It is ineffective during a downturn and creepily Calvinistic.

    5
  52. Lounsbury says:

    @James Joyner:

    I tend to agree, although that’s really a matter of expectations. Long ago, armies were indeed privatized; we’re just used to them being government agencies now. And, aside from ordinary mail—which is a dying thing—we’ve flipped the script on delivery such that the private sector is now better/more efficient. (Although that’s partly because USPS has to subsidize rural delivery.)

    Re Military, of course one can find in history examples of ‘private’ armies, if we give the label private to warlords who did not have a formal government position or mercenaries paid by the

    However, the history of formal military right back to the bronze age is one in which in organized military was something organized – often ad hoc of course – by what passed as the central government. Of course in an area where the division between ‘private’ and ‘goverment’ was less or even not formalized as such it is

    Overall, if we look merely to the modern era, it’s pretty clear that militaries organized off of a national central government funding are at the core of the modern nation state. Calling military socialist in this context empties the word socialist of any meaning (other than being ‘government’ which is nonsensical as it turns any government funciton into ‘socialism’ which is something only the lunatic Libertarian bolshies of the Americas think makes sense).

    If one militarized non military functions (thinking of Egypt where the military actually runs production plants and services aimed at non-military end-users) for non-military end-use, then that would be military socialism.

    The Postal Services model I would say if one goes back to the origin of Post services is a central government service for individual mail that has always been economically marginal. Package and light freight services certainly are not core to its conception prior to say the 19th century. It strikes me that to call basic postal service ‘socialism’ means one is giving credence to the extreme fringe Libertarians from USA in their economic views (if I can force myself to call it economic).

    @Blue Galangal: on what basis do you assert there is subsidy to such delivery?

  53. James Joyner says:

    @Kurtz:

    The limiting factor is residency slots, not medical school enrollment.

    Interesting. I know I’ve read of this issue before but thought it was an adjunct to the problem not the main bottleneck.

    It looks like we’ve increased the number of medical school students by roughly a third since 2002, despite opening new medical schools and we’re still turning away a huge percentage of qualified applicants because there’s been a surge of interest. But it doesn’t matter if they can’t get a residency and certified to practice.

    Then again, there are apparently more total residencies available than there are med school graduates. But it gets back to a problem Michael Reynolds and others pointed to upthread:

    According to data analysis published by The New England Journal of Medicine, the number of medical graduates has indeed begun catching up with the number of available residency positions, but the gap is narrowing very slowly. The report examined recent and projected U.S. medical school enrollment alongside the rate of increase in residency program positions, concluding that in 2024 the inventory of available residency slots will still exceed the number of U.S. medical school graduates by around 4,500.

    It’s easy to deduce where the notion of a residency shortage took root, as not all residency positions are equally competitive. Students who are interested exclusively in the trifecta of highly competitive specialties in the most prestigious programs located in metropolitan cities do indeed discover that there are more applicants than there are seats. It is imperative, however, that both students and the academic leaders who counsel them recognize the opportunity that exists to serve the most acute healthcare needs of the country.

    The Association of American Medical Colleges (AAMC) forecasts a physician shortage as great as 94,000 doctors by 2025. But this shortage is not evenly dispersed across geographies or specialties. The need is most severe within primary care and in rural and diverse urban neighborhoods. According to the AAMC, our country is already grappling with a deficiency of 8,200 primary care physicians.

    In a country with such need of physicians, it is critical that the industry stop burdening students with this false residency anxiety – even frightening some pre-med students away from the field entirely.

    Instead, medical professionals and educators must do a better job of encouraging and fostering an interest in meeting the country’s need for doctors who care for the underserved and specialize in primary care. While competition grows among specialties, residency slots in primary care are steadily increasing and have grown 2%-3% on average each year.

  54. wr says:

    @Mu Yixiao: “Idaho, Colorado, Nevada, Arizona, North and South Carolina, Montana, Georgia, and Virginia (all rural) all have higher gains than California”

    People aren’t moving to Arizona to live among the cacti — they’re setting in Phoenix and its suburbs. Rural Virginia has lost its political power as the DC suburbs grow in population. There are plenty of spaces of empty sand in Nevada, but it’s Las Vegas and (to a lesser extent) Reno that are seeing population growth. The rural population of Georgia has declined substantially as a portion of that state’s total. Denver is bursting at the seams.

    People aren’t leaving NY and CA to escape from urban living — many of them are fleeing despite their desire for urban living because they can’t afford the most desirable cities. They are cashing out and recreating their old lives in smaller places.

    1
  55. grumpy realist says:

    Random thoughts:

    I have a very soft spot in my heart for Nebraska, having lived there for a few years after my stint in the U.K. Whatever else, Nebraska has sunshine. Yeah, the weather can be cold, but sun sun sun and lemme tell you that was very heartily appreciated after two winters in London.

    The major reason that people don’t want to move into the middle of Bumfuk, Arkansas no matter what the cost of living is: lack of things to do, lack of services, and lack of, well, anything. With the advent of Big Ag the number of family farms has been dropping and it’s getting harder and harder for the secondary population (teachers, doctors, dentists, service providers, lawyers) to earn a living. They’re gasping for opportunities and will finally go under. This just chases out any non-Big Ag farmer plus family (the offspring of who move to urban areas because, well, opportunities.) This is why I call the Big Ag-dominated states “green deserts”. About the only locations that have managed to avoid this vicious circle are places that are university towns or other places that have sufficient diversity in businesses that the economic ecosystem can be maintained.

    (And yeah, rural mail services are about as socialist as can exist. If Libertarians actually believed what they expounded, they would scream bloody murder about the “same mailing cost to rural and urban addresses” and insist that rural inhabitants pay for the actual cost of getting packages from Amazon out to the middle of nowhere, rather than free-ride off the “last mile” delivery service of the US Mail and the surplus cash contributed by urban addresses mailing letters to each other.)

    2
  56. Kurtz says:

    @James Joyner:

    Ah, thanks.

    I do remember there was a proposal years ago to reduce med school for family practice to three years. That may help in terms of overall cost reduction and as an enticement to get out of school slightly earlier.

    One solution may be to allow nurses with terminal degrees (NP and PA) to practice family medicine without the supervision of a physician. That’s just a spitball though. And it probably would do little to solve the rural shortage.

    1
  57. gVOR08 says:

    @JohnSF:

    Only a (modern) philosopher could say something so superficially erudite and at the same time quite stunningly daft.
    It is quite astoundingly ahistorical.

    Thank you. I have been struggling through Nozick’s Anarchy, State, and Utopia. That he did not see brevity as a virtue would be an understatement. If you don’t object, I’ll steal your phrase to describe it.

  58. Kurtz says:

    @gVOR08:

    You ended up trying with Nozick huh? Last time we discussed this, you were lamenting the slog.

  59. JohnSF says:

    @gVOR08:
    @Kurtz:

    After reading some recent commentary, and having been aware of its influence for some years, I thought I might finally try reading Anarchy, State, and Utopia .

    *several hours later*
    “Sweet virus, take me now…!”

    Currently having fever dreams of Karl Popper engaging Nozick dialectically with the aid of a baseball bat.

    Back to Gibbon’s Decline and Fall… I think.

    2
  60. JohnSF says:

    @gVOR08:
    Actually my crack re. modern philosphers is iffy, on reflection.
    As my other snark of “blame Plato” indicates, ahistoricism and utopianism have periodically tempted philosophers since BC.

    But at least earlier utopians (including Marxians) and “state of nature” speculators had the excuse of not knowing what we now do about pre/early history, anthropology, human evolutionary biology and hominid ecology etc.
    To carry on with this stuff these days is equivalent to trying to ground modern physics on Mayan cosmology.

    2
  61. Kurtz says:

    @JohnSF:

    John, let me ask you this. I’ve been thinking about a question for a little bit. Do you think it is appropriate to assign systems themselves a moral value?

  62. Nightcrawler says:

    @Kurtz:

    how the eff do so many of us live in Florida? I live in Florida. So does Teve, Guarneri, and gVOR08. I’m sure there are others that I am forgetting.

    That’s interesting. I’m in Jacksonville. We moved here for kind of a stupid reason, the weather. We decided to move back to Delaware sometime last year, for reasons that are only tangentially related to politics. This isn’t the right place for me to be career-wise. My situation has changed dramatically since we came here five years ago.

    What would Waco look like for this particular cult?

    Damn. You see thought exercise; I see writing prompt. When I’m not writing about smart shit like infosec and cloud, I write X-Files fan fiction.

    Now I’mma think about that in far more detail than a normal person would.

  63. Nightcrawler says:

    @Kurtz:

    I used to think that prescription drug laws should be abolished as well. Then, I realized what you did, that abolishing all of them just isn’t workable or conducive to a civilized society.

    I still think a lot of prescription drugs, particularly birth control pills, should be sold OTC. Maybe even most prescription drugs.

    Maybe we could sell antibiotics “behind the counter,” like Plan B is. Maybe.

    There is no way chemotherapy drugs could be sold OTC. I always wonder how people who support that think it would work. First, most of them are delivered intravenously. Secondly, the dosage has to be very carefully controlled, or the patient will die. The dosages, frequency, and “cocktails” are highly dependent on cancer type, grade, stage, and a host of other factors. Often, patients have to be given a bunch of other drugs to control really serious side effects.

    But idiots think they’re smart, and they can Google, and they can just figure all this out on their own.

  64. Nightcrawler says:

    If Libertarians actually believed what they expounded, they would scream bloody murder about the “same mailing cost to rural and urban addresses” and insist that rural inhabitants pay for the actual cost of getting packages from Amazon out to the middle of nowhere, rather than free-ride off the “last mile” delivery service of the US Mail and the surplus cash contributed by urban addresses mailing letters to each other.

    Yeah, about that…

    https://www.nytimes.com/2020/04/09/us/politics/coronavirus-is-threatening-one-of-governments-steadiest-services-the-mail.html

    Looks like we’re about to become the only developed nation without a government postal service, too. By killing off USPS, the GOP will be effectively killing off vote-by-mail, because private carriers will charge, like, $8 to mail a letter. More than that in rural areas.

    I don’t see any other option other than splitting this country up. If this is what the GOP wants, let them have it. I want to go live in one of the sane, modern, civilized “in between” countries.

  65. Nightcrawler says:

    @Kurtz:

    One solution may be to allow nurses with terminal degrees (NP and PA) to practice family medicine without the supervision of a physician. That’s just a spitball though. And it probably would do little to solve the rural shortage.

    I’ve been in favor of that for years. It would cut costs, too. Granted, NP’s and PA’s couldn’t treat serious illnesses that need highly specialized treatment, like cancer, but they could certainly help people manage high blood pressure, diabetes, and so on. I think PA’s can even do simple, in-office surgeries like mole removals, but I’m not 100% on that.

  66. Kurtz says:

    @Nightcrawler:

    Damn. You see thought exercise; I see writing prompt.

    I write to think. But if you do come up with something on this, hit me with the link.

  67. Kurtz says:

    @Nightcrawler:

    Sure, some prescription drugs could be OTC. But in addition to the aforementioned problem of overuse of antibiotics and the dangers of OTC psychiatric drugs, I would be concerned about drugs that significantly alter hormone levels.

    I’m sympathetic to the desire to eliminate gatekeepers. But I’m skeptical of the inclination to reject the idea of expert knowledge in general.

    Granted, NP’s and PA’s couldn’t treat serious illnesses that need highly specialized treatment, like cancer, but they could certainly help people manage high blood pressure, diabetes, and so on.

    From what I understand, PCPs usually refer serious chronic diseases and illnesses like cancer to specialists. In the case of many chronic diseases, after a few visits, the PCP then monitors the treatment and only refers the patient back to the specialist if the patient’s status changes.

    So when I argue for NPs or PAs practicing family medicine, I’m more thinking in terms of that style of workflow.

    Another interesting facet of this debate is something I have read several places. That AI could eventually replace many physicians, but would have trouble replacing direct care from nurses.

    1
  68. gVOR08 says:

    @JohnSF: @Kurtz:

    After reading some recent commentary, and having been aware of its influence for some years, I thought I might finally try reading Anarchy, State, and Utopia .

    *several hours later*
    “Sweet virus, take me now…!”

    I feel your pain.

  69. Lounsbury says:

    @Nightcrawler:

    Looks like we’re about to become the only developed nation without a government postal service, too.

    No, that is not true. Japan, Germany, the United Kingdom all have privatized in whole or in part their postal services. Deutsche Post was privatized in 1995 (fully completed by 2000). DHL is actually a division of Deutsche Post. Royal Mail was progressively privatized from 2011. Japan Post is largely now privatized. Correos Portugal also.

    While not expressing a direct opinion on the shambolic and bizarre ideological Republican position on US Post, developed and European country examples indicate that it is in the modern world possible to execute a postal service privatization in a well organized way. Not that I would particularly expect a rational, well-designed and executed privatization driven by US Libertarian ideology but one shouldn’t be pig ignorant on the subject.

    1
  70. JohnSF says:

    @Kurtz:

    Is it “appropriate to assign systems themselves a moral value?”

    Interesting question.
    A better scholar and writer than I could get a whole book out of that!

    First response:
    No, the moral value comes from the experiences of the persons involved, not from any set of abstracted absolute (and arguably arbitrary, for added alliteration!) values.
    Though in retrospect we may be able to consider that what has been accepted as good or at least inescapable, was not so.

    It is a sad historical fact that all (?) human societies have been based on ethically questionable predicates.
    But to expect otherwise is to start from the wrong place; one might as well complain that lion prides, wolf packs, chimpanzee bands etc. are morally flawed.
    To mutilate Marx: humans have hitherto only inherited the world in various ways; the point is to change it.

    OTOH (speaking with my conservative hat on) to go from there to proposing a radical reconstruction of society in the pursuit of a utopian justice, whether it be communist, libertarian, religious or other, is unrealistic, dangerous and probably arbitrary.
    Radicals would, of course, disagree.

    There might be certain baselines of ethical absolutes modern humans can agree upon.
    e.g. against slavery, genocide, de-humanisation of categories of persons etc.

    But within those bounds there is room for considerable difference in what are viewed as acceptable political/economic/social/cultural systems.

    For instance, a lot of American might regard a political system including monarchic elements, a politically privileged corporate bodies and hereditary aristocracy, an established church, limits on freedom of political speech, etc. as intolerable.
    I, along with a lot of Britons, find them perfectly acceptable.

    What is viewed as morally acceptable or normal is probably contingent on history.
    Within that contingency, it is possible to work for improvement; but also to be aware that there a lot more ways for a system to be disordered than for it to be ordered.
    And political chaos is not a good thing. (Usually)

    Again, good question.
    Need to think on this.
    🙂

    1
  71. Nightcrawler says:

    @Kurtz:

    Whether bcp’s should be sold OTC is something reasonable people could debate. The people who think that anyone who has “common sense” could self-prescribe and administer IV chemo drugs, tho…

  72. Nightcrawler says:

    @Lounsbury:

    Thanks for the correction. I obviously have knowledge gaps on this particular topic. I think my concern is what you referred to in your last paragraph: I cringe when imagining the “privatization” of the USPS being done by the GOP.

    For one thing, from what you just said, those other countries privatized their postal services gradually, not suddenly and all at once.

  73. Kurtz says:

    @Lounsbury:

    They don’t have as large a land area to cover. That changes the cost basis significantly.

  74. Kurtz says:

    @JohnSF:

    Thank you for the thoughtful response. It helps that you’re from a related, yet different, society. For example:

    For instance, a lot of American might regard a political system including monarchic elements, a politically privileged corporate bodies and hereditary aristocracy, an established church, limits on freedom of political speech, etc. as intolerable.
    I, along with a lot of Britons, find them perfectly acceptable.

    I try not to fall prey (with varying degrees of success) to something that is common in America, even among the intelligent, thoughtful group we have here: grouping half of politically engaged people into two dimentional, low-resolution images.

    I say this because everything you listed describes American socioeconomic and political cultures even if the mechanisms that get us there are different. One other reason will become clear in a moment.

    Politically privileged corporate bodies? Yes. I don’t know how it works in the UK, but corporations are, from a legal perspective, p-zombies here. For systemic reasons, politics more or less guarantees that some portion of the voting public will defend that position regardless of whether it benefits them or not. Their political allies may not be comfortable with that, but accept it if the issues they find salient are addressed by the same platform.

    Restricted political speech? Much less so now than in times past. Institutions of government may not legislate such things, but other institutions do a damn good job of it, whether through in/direct economic coercion or via rabble-rousing media.

    Establishment of religion for a significant voting block is limited to Christianity. There is even a subset of that group who only conisder particular denominations to fit their definition of Christianity. We have a cottage industry of people who rewrite American history to support this view.

    Hereditary aristocracy doesn’t exist via titles of nobility, but it does exist in economic terms. The American view of class is a little different from it is in the UK. For most Americans, class is defined by finances and lifestyle rather than a cultured manner. For the most part, Americans who share the British concept of class are old money dynasties–the same ones that excluded Trump from entry into high society. His boorish, crass manner didn’t fit.

    To less well-off Americans outside of the coasts, he is the image of a rich person. To old money, he is no different from the unwashed masses in Bumfuck, Arkansas. His resentment of Manhattan elites is arguably the key to his populist appeal to middle America.

    Similarly, we don’t have monarchic elements. But we do have political dynasties at every level of government. Again, it may not be official, but there is an element that is willing to reject Constitutionalism here.*

    There are dramatic differences in views between Trump supporters and nearly everyone else. Roughly two-thirds (65%) of Trump supporters agree that America needs a leader who is willing to break the rules, while fewer than half of Cruz supporters (40%), Kasich supporters (43%), Clinton supporters (46%), and Sanders supporters (40%) agree.

    Source

    Anyway, feel free to continue it later here or in another thread. I haven’t found the words to really get where I want to be on it yet. But your post helped me get a little closer, I think. So thank you.

    *My memory of this poll was a little different from what it actually is. I remembered it as splitting by Dem/GOP voters, rather than by candidate. But there may be another poll. Also note that Cruz suppprters and Sanders (!!!) were less likely to agree that we need a leader to break the rules.

    Apparently, this view exists in the UK as well.

  75. Nightcrawler says:

    @Kurtz:

    Thinking about this more, the U.S. postal service is already partially privatized. Anyone can choose to send packages or even letters through private carriers such as FedEx, UPS, and DHL. Sometimes, especially when dealing with larger packages, the private services are a better option than USPS. For letters and smaller packages, they’re not. For example, it’s cheaper to ship things like hard-copy magazines, tee-shirts, and prescription medications through USPS than the private carriers. As it is, the private carriers frequently partner with USPS for “last mile” deliveries that fit certain criteria.

    To my knowledge, the private carriers haven’t expressed any desire to get into the daily mail business. It’s not profitable. However, it is a public good, which is why the Constitution gives specific permission for the government to establish and run a postal service.

    The problem is that the GOP insists that the postal service turn a profit. It looks like they’re about to destroy the USPS once and for all. When that happens, we can kiss daily mail service (and things like vote by mail) goodbye. It’s just not profitable for private carriers to provide daily mail service.

    Shipping costs for smaller, lighter goods are going to skyrocket, and those companies are going to pass that cost onto consumers. Vote-by-mail will be dead in the water. It’s going to cost several dollars to send a letter, and envelopes will have to be taken to the private carrier’s dropoff point. In rural areas, delivery either won’t be available at all, or the costs will be astronomical, similar to what it would cost to send an overnight letter overseas right now.

    I don’t know why we can’t just keep things the way they are right now until we can figure out a better solution. Oh, I know why. Because the GOP wants to kill vote-by-mail, and they’re willing to destroy the USPS to do it, just like they’re willing to throw a monkey wrench into the healthcare system just to get rid of Obamacare.

  76. Kurtz says:

    @Nightcrawler:

    The problem is that the GOP insists that the postal service turn a profit.

    This.

  77. JohnSF says:

    @Kurtz:
    When I spoke of privileged corporations, I was thing not in the modern (American derived) sense of business companies but the older sense of chartered corpora e.g. the City of London, the old university colleges, City livery companies, the Inns of Court and the Bar, cathedral chapters etc
    Though at times in the past there were chartered corporations that also fitted the modern sense e.g. the East India Company.

    In fact, the privileges of these bodies have dwindled in recent times.
    Your argument for the growing power and (effective if not formal) privilege of business corporations is a good point.
    The granting of legal personhood including full protection of freedom of speech is one obvious, and damaging, development.
    It is also interesting to see how anti-monopoly laws in the United States are increasingly ineffective, compared to the more robust regulators in Europe.

    Similarly your points about the effective power of social elites and dominant religious groups.are sound.
    I’m trying to recall the American commentator I read some years ago about the need for the US to be vigilant against the tendencies of elites and institutions, ,even if meritocratic or popular in origin, to entrench themselves into effective hereditary dominance.

    Indeed, one argument for the British system is the inequality is less pernicious when plainly visible covert.

    I would still argue though, that there is a basic difference between informal inherited dominance, and it’s formal legal, openly acknowledged status.
    For instance on established religion, the monarch MUST be an Anglican; the Upper House includes 25 Lords Spiritual i.e. Anglican bishops, the coronation is an Anglican ceremony etc.

    Similarly, even though the wealth and political power of the peerage is not what it was, with their decline in relative dominant wealth, and the dilution of the House of Lords by “life peers” i.e. political appointees, they are still in a very enviable position.
    Imagine one of the Manhattan elite having a fair chance of being able to take a seat in the Senate based on inherited position with no need for the vulgarity of an election!

    I suppose my basic point is that what different peoples accept (and note far from all British accept such aspects of our systems) is historically contingent.
    See also the inherited party political and constitutional arrangements of various countries.

    I think your point might be that the underlying similarities of modern states and societies impose similar basic arrangements regardless of the superficial differences in traditions and norms.
    A good point ineeed.

    It’s the difference perhaps between a historical/antropological examination and a sociological/philosophical one?

  78. JKB says:

    Knowing what I know of the Indian Health Services, I’m going to say no, unless there are ways to escape the system. And in 1990s, they finally closed the last PHS hospitals, which were fine edifices, such as the one that overlooked Seattle, but on par with the VA hospital quality of the time.

    Indian Health Service

    The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally-recognized Tribes grew out of the special government-to-government relationship between the federal government and Indian Tribes.

  79. Kurtz says:

    @JohnSF:

    Indeed, one argument for the British system is the inequality is less pernicious when plainly visible covert.

    This is important.

    The founders of the US were concerned with those formal structures of hereditary privilege. Any power exercised within government would flow from legitimate means, with a usurper being constrained by those guarding their own authority. Of course, they could never conceive of what the future would bring in terms of technological development, population growth, and the raw influence of provate entities.

    But it’s also possible to see it as being actively unconcerned about power earned through private production. This, I think, is how many Americans see their society–largely fair and those who make it deserve it. But many of them, without realizing it, are engaging in a collective delusion.

    Your point about visible and formal vs. covert power structures is true, essential to examine, and what enables that delusion.

    The thing about delusions: they metastacize until no object can be seen without mediation by tumorous faith. Anyone whose interest relies on mass delusion has the incentive to encourage that growth.

    As far as my original query, it’s borne from the emphasis by American Libertarians who assign moral values to the system.

    This strikes me as the same as the common misreading of Dawkins in The Selfish Gene. In fact, you can point to the specific interview in whcih Dawkins expresses regret for the metaphor, because people assign human characteristics to entities without agency, but it will not keep people from using the metaphor as if it is observed truth.

    The RW Libertarians make the same mistake by extending a framework intended to evaluate the morality of human action to an entity that has no agency on its own. It’s like calling an electric sander immoral for injuring its user.

    Stay healthy, my friend.

  80. Kurtz says:

    @JohnSF:

    I think your point might be that the underlying similarities of modern states and societies impose similar basic arrangements regardless of the superficial differences in traditions and norms.
    A good point ineeed.

    It’s the difference perhaps between a historical/antropological examination and a sociological/philosophical one?

    Yes. This is the point. Though, you put it succinctly–I probably wouldn’t have crafted a sentence that effective.