I have no love for the lobbying efforts of H&R Block et al., but they're not the only problem here. The more social engineering gets layered onto the tax code (some advocated for by this very blog), the harder it is for the IRS to accurately calculate what you owe, and the IRS is not the most nimble IT service in the country.
Indeed. That this is an industry is a real failure. A huge anchor in terms of the opportunity cost stemming from smart people deployed in unnecessary activities and charging hilariously exorbitant fees. But then, tax avoidance is the one biggest way regular folk can do rent seeking...
Turbotax is a lot different then tax lawyers scheming with private bankers. Rich people paying tax professionals to reduce liabilities is inevitable, turbotax is not
For low to middle income wage earners, taxes should absolutely be way simpler than they currently are. But there will still be plenty of jobs in business tax prep, because there is really no good way to make business taxes simple.
I've always wondered if open source tax software could ever take off to be a feasible challenger to killing these middlemen if Congress can't or won't.
I’m more a fan of the “file our taxes on a postcard” plan, or just have everyone use the 1040EZ form. Get rid of deductions and raise the standard deduction. There is no reason we need things to be so complicated. We could lower tax rates substantially by eliminating deductions that only help a small percentage of the population. Get rid of capital gains and tax it all with the same rates, too. Withholdings would be easy to calculate so you wouldn’t have a big bill in April. We could put the accountants and tax lawyers to work doing something productive.
"The origin of American zoning is largely in efforts to uphold racial segregation."
You see this claim a lot in progressive circles and it (a) doesn't really make sense and (b) is wholly unsupported by the linked studies and historiography. The paper linked in this work examines the use of zoning to enforce Racial Segregation in Southern Cities in the early 1900s. The idea that zoning would be used to uphold a de jure system of segregation that already existed is more or less unremarkable, horrific though it may be.
But "the origin of American zoning" is not found at all in the largely rural South. The paper you link to admits this in the second paragraph (!) saying "Benjamin Marsh championed zoning in the early 1900s in an effort to combat urban congestion and thereby improve the quality of working-class neighborhoods." Not only does this progressive, urban origin of zoning happen to be true, it also makes way more sense that an idea that originated in European urban renewal movements would first present itself in large, Northern American cities as opposed to smaller Southern ones.
This claim is akin to the ludicrous 1619 project claim that capitalism was invented in America (wrong) as a way to more efficiently facilitate the trade of enslaved people (also wrong). I don't understand why people feel the need to lie about this stuff, when it seems bad enough to me that the United States spend two centuries using otherwise anodyne or progressive advancements (urban renewal, ledger books) to facilitate the bondage and disenfranchisement of human beings. That is already bad! You don't need to pretend that Central Park is Jim Crow! IMHO it devalues the entire argument to make demonstrably false claims like this.
+1 from an urban planner. It's true that zoning has been *used* to facilitate segregation, but its orgins were related to the problems associated with urban growth and industrialization that you cite. And I superlike (tm) your point about undermining arguments with disingenuous false claims!
That said, I'm broadly sympathetic to the point that emphasizing the racist history of X is not going to be a very convincing argument since it's disconnected from the material consequences for voters you might be trying to persuade.
Well said, Ray. I understand that this was more of a throat-clearing comment by MY, but I think we would all be better off and more able to make real progress if we just dropped this point from the discourse. You will not guilt homeowners into supporting upzoning with the systemic racism argument.
I think it's worth unpacking a few things here. I think overall you're right to note that the origin story of zoning places much too much emphasis on a racist origin story, especially as you note that urban zoning began in Europe and migrated here.
But I think you might be overselling the case a bit too far in the other direction. Zoning became over time a backdoor way of upholding segregation. In some ways I think it might be worth breaking up history of zoning into pre and post WWII phases. But more to the point with modern times, when someone at a local board meeting complains that apartments will bring poverty to the town, it's hard not to see the very obvious racists origins of that claim. I'm aware that people have objections to multifamily projects for all sorts of reasons, including very basic ones as "I don't like how this building looks". But it's also undeniably true that enforcement of single family zoning is at least in part about keeping "those people" out of the neighborhood.
*Also not the point of your post, but in your 1619 project note I'm assuming you're referencing the Matthew Desmond essay? I bring this up because in the intellectual honest criticism of the 1619 project (unfortunately my feeling is most criticisms are intellectually dishonest...mostly along the lines of "how dare you say anything bad about Murica and it's founding. It's UnAmerican", really center around just two essays; Nicole Hannah Jones and Matthew Desmond's essays. Given that NHJ is basically the editor/creator of the project, there is a certain amount of fairness in expanding criticism of her essay as a criticism of the project overall. And I do think Matthew Desmond's essay is kind of garbage for the reasons you noted. But it is striking to me that criticism of the other (numerous) essays is almost non-existent. Like does anyone have any solid critiques of Jamelle Bouie or Kevin Kruse's essays? I'm sure they exist somewhere, but the lack of outrage directed at any of other essays seems really telling to me. Again, I for the most part agree with your comment about 1619 (although I'd quibble with using progressive as I think you're using a very late 19th early 20th century definition of the term that may not apply today), but just thought it worth noting.
I think that the synthesis point for zoning is that it's just like a very powerful and very imprecise tool. Like, as our host likes to point out, what kind of buildings you allow where is a very big deal in both, uh, breadth and depth. That is: land and buildings are expensive, so allowing/forbidding/making changes to what kinds of buildings you can build hits people and businesses very deeply. It's not a minor speedbump that people can just sort of mostly handle and continue on with what they were doing, zoning makes and breaks ideas and projects and businesses and people. But also, it has really wide-ranging consequences, lots of important second-order effects.
And that's a dangerous combination. I think that lots of the people who supported zoning that we now understand limited the opportunities of black people probably did so without a single racist sentiment -- but because the impact of zoning is both so deep and so broad, it was easy to sneak in racially exclusionary zoning even as a second or third order consequence, and even as a second or third order consequence, its impact was deep enough that it was highly meaningful. And regardless of whether you, the hypothetical audiencemember, are personally animated by the racial framing, if it could be used that way, it can also be used to meaningfully impede goals that you do find compelling, or to accelerate projects that you personally find distasteful.
I think Matt Yglesias himself has complained when people claim that the origin of American *policing* is in the American slavery system, noting in his complaint the lack of global context -- other countries have broadly similar police systems and don't have a similar history around slavery.
It looks like he's making the same mistake himself here. (If there is some cross-country analysis that shows a strong link between housing restrictions and a history of segregation, please do correct me!)
There are a lot of things from the first three weeks of the URBS 1001: Introduction to Urban Studies curriculum that have been floating around the broader discourse for the past five or six years that could use a lot of the information from the other four years of the program...
We went over the early zoning cases in 1L Property Law. I remember at one point saying that these laws were designed to keep out poor black people and the professor correcting me with "No! These laws were designed to keep out all poor people, not just black people."
Euclidean zoning was more about anti-density and keeping the sounds and smells of industry (and the riffraff who worked in factories) away from nicer neighborhoods. Racial segregation was absolutely perpetuated by zoning, especially in the post-CRA era, but that was not the original intent.
I’m not a knee-jerk defender of the doctor’s lobby and usually disagree with my specialty organization. But US training really is much better than what exists in many other countries, and also American tourists in many countries are often told to go to “the good hospital” and don’t just visit a random rural hospital when they’re sick.
If we want to intelligently deregulate (which I agree should be a goal), we should follow the example set by other countries like New Zealand, which don’t require a full residency but still require a couple years of supervised practice and a licensing exam before doctors set out on their own. And I totally agree that expanding NP practice is good, although we also have a nursing shortage so we should probably just expand that pipeline in general
>>But US training really is much better than what exists in many other countries<<
Sure, but not *all* countries. Seems nuts to require doctors trained in Canada, UK, France, Israel, etc to do a full residency. Can't the federal government certify the products of certain countries' medical training systems for fast-track status? (I agree with your idea re: the NZ system.)
Yeah I actually think dumb deregulation would backfire, because inevitably there would be horror stories about a poorly trained immigrant doctor providing bad medical care. And then US medical societies (which I 100% agree are all about rent-seeking) would say “see, all foreign-trained doctors should do residency” and we would be back where we started. I think something like what you are describing would be a better way to sustainably make this work.
They would be if salaries didn't crater. And they would probably continue to practice in large urban areas and continue to leave the rest of the country undersupplied.
Isn't there still a cap on the number of doctors able to train in the US? Really struggle to see how that's justified amid a physician shortage (and heavy restrictions on importing medical professionals).
HHS pays the wages of doctors in training. As far as I know, nothing would stop a private hospital from deciding to fund its own additional residency spots, but hospitals are penny pinchers and don’t do that. So the number of residency slots is determined by the budget Congress will allocate for them.
While most residency spots are government funded (via many routes: CMS/Medicare & Medicaid, VA, HRSA), I have been at 3 institutions that either added residency spots with internal funding, or created entirely new residency programs from internal funding. It is pretty common.
There was a recent big boost to residency funding as well
It's not a "cap" as in a set maximum decided somewhere. It's "the number we have collectively come to" via the independent and often competitive and contradictory decisions of ~200 US medical schools (MD+DO) who graduate new doctors (who really can't do anything) and literally thousands of residency programs of all types (who train doctors to have useful skills).
I agree with the NZ comments from Mark.
Allowing foreign physicians into the US to practice unrestricted if licensed there means one thing from EU countries, and something else entirely from many other places.
There is, because that is centrally set. If we went full unregulated capitalism here, I would argue we should scrap residency and even medical school requirements in general and just let hospitals hire whoever they want and train them the way they want to.
But if we have higher standards for US grads and the more competitive foreign applicants (who will still do a US residency), and lower standards for less competitive foreign doctors from countries with much lower standards for their own residency systems, then you end up with a system where only desperate rural hospitals hire foreign-trained doctors.
This is incorrect. There is no centrally set cap on either physician grads from medical schools (AAMC, LCME), nor one for residencies (ACGME). Each program can adjust size--within existing guidelines and funding sources, which are complex--on their own.
Realistically though, programs generally only increase slots if they get Medicare funding, so we have a defacto shortage. This is exacerbated by the fact specialist residents/fellows are worth more to hospitals than generalists, so if they are going to self fund it's not for the generalists they need.
I'm in the military and have interacted with/have colleagues that interact with the European system. The consensus is that Britain's residencies are as rigorous as the US, but most European residencies don't produce doctors capable of independent practice (in part owing to hour restrictions that reduce training they can get in a set time). My boss said in Italy he'd frequently see docs 10 years out of residency deferring to a super senior doctor on management issues we'd expect a fresh grad to make.
I also was told that care east of Germany (Poland) was severely substandard to the US, even citing OR cleanliness issues.
Data on the US system shows we grade the best for most issues (trauma, heart disease cancer etc.) Controlling for health when you get in trouble. The non US advantage is better population health and management/screening that nips more issues in the bud.
Basically, you need to improve compensation for general practitioners and ramp up their supply. That will reduce the supply of train wreck patients that make our numbers look bad.
I am totally for expanding med schools, residency spots, and importing doctors with appropriate credentials--I appreciate your insights above on European training.
My colleague did months of rotations in Australia and came away horrified at their training for what that's worth....
I am not a member of the AMA, or generally a fan of most specialty society positions on "business and workforce" issues.
I only exist here to correct the misperceptions that there is a set cap of some meaningful sort in the way that people commonly use the term "cap" to mean.
I agree, there isn't a cap, the same way there isn't a cap on housing. However the way the system is set up you generate a shortage and residency is where the shortage manifests. The easiest way to fix that is probably some increased Medicare funding for primary care residencies in undeserved areas.
I'd also say a lot of mid-level proliferation is a work around on this. Whatever you think of foreign trained docs, they're better than an online NP grad heading straight into independent practice.
They are good for some things like fishing-related or farming-related injuries, but I would definitely get my cancer care (or more specialized care in general) elsewhere. Primary care is probably more or less equivalent, there are a lot of good rural family doctors
I don't know. Obviously there is selection bias skewing this but the amount of "oh my god, this medicine hasn't been the standard of care for this problem since the 90s" or "how could they have never considered to run this test or treatment when the chart indicates that the patient has been complaining of this problem for years?" I hear from my wife about patients ending up in the urban hospital she works at after having their care mismanaged doesn't make me feel great about the quality of care in a lot of rural settings.
I accept many patients transferred to the big fancy university hospital from small rural critical-access hospitals. Some for clear good reasons (complexity) some because the small hospital is just failing to do what they clearly need to do. Yes, there is often a knowledge deficit in the small places--I don't think they see enough, do enough to keep up their knowledge and practice with anything but the most very common things they care for.
For me though, my hesitation is more based on the limited resources in case of something going wrong, something new and bad found, or just general lack of 24/7 coverage for important things (it's often ~12/5).
Agreed. At the same time, NPs who aren’t doctors at all are increasingly replacing doctors. And the trend continues. Now you have nurse anesthesiologists etc. You’re telling me that an EU trained doctor would on average give you less qualified treatment than an American np? As others commented, o think a rigorous regulation that very much cuts hurdles for doctors trained in. *specific countries* only would be a good thing. Not goin as far as MY but not accepting the untenable status quo either.
US training is indeed better than what exists in many other countries, but is it better than the EU, for example? I’m very skeptical having lived both in the EU and the US. I would only go to an American doctor for an emergency, and I always wait to go back home on vacation for doctor visits I can schedule.
"I would only go to an American doctor for an emergency"
Because of the quality of the doctor or the quality of the health care system? I feel like the latter is 90% of what's important or more but doctor training only impacts that other 10% that is doctor quality.
Good question. I only have anecdotal evidence to offer. My American experience says that doctors will spend as little time with you as possible and try to do as many tests as possible so that they can charge you. I view them more as salesmen than doctors to be honest. I’m used to the doctor taking her time to listen to you before anything, and then also taking the time to explain to you in detail what’s going on, and I haven’t seen that in the US at the times I needed to go to a doctor. I also know that American residencies tend to be more brutal than the ones back home, and you end up with doctors that are more sleep deprived than normal. I don’t want a sleep deprived doctor!
However, nothing here is data. The only data I’m aware of say that the US has unusually short life expectancies for the wealth it exists here. But that could point to problems at many areas of healthcare other than doctor training.
My anecdotal experience with GPs has been really good - they've always taken a lot of time to listen and answer questions - but maybe I've just gotten lucky.
With other care I find that I have to wait a long time and barely see the doctor. It just seems like there's staffing shortages across the board, at least that's my explanation but I don't really know or have a point of comparison.
"unusually short life expectancies for the wealth" - I'm skeptical of healthcare explanations for that gap. Or at least I'm skeptical healthcare is the majority of the explanation. There's too much geographic and demographic variation in LE between counties, states and demographics within the US for healthcare to be the main driver. It could be one driver, but other cultural or lifestyle factors most be at work, too.
Why so skeptical? US stands out in western world for low and decreasing life expectancy. It also is *unique* in the terrible healthcare system and lack of any kind of universal coverage. I see no other potentially relevant factor in which the US stands out so clearly from peer countries. Why wouldn't you think this is extremely plausible a priori as at least one significant factor explaining the phenomenon?
“Together, injuries (drug overdose, firearm-related deaths, motor vehicle accidents, homicide), circulatory diseases, and mental disorders/nervous system diseases (including Alzheimer’s disease) account for 86% and 67% of American men’s and women’s life expectancy shortfall, respectively.”
As a relevant factor, I'm not quite so skeptical as I must have sounded. But I'm very skeptical that it's the major or only factor.
One part I didn't mention is that I'm just somewhat skeptical of our healthcare systems ability to treat non-acute issues. If I have an appendicitis or a heart attack, I'll be glad I live near an ER. But if I needed a plan to lose weight or eat healthy I'm not expecting a doctor to prescribe that for me. And in between the acute stuff and the lifestyle stuff there's a huge volume of elective procedures and diagnostics that I have a very skeptical view of. I just don't think they move the needle much and can do as much harm as good.
I don't have great evidence for this latter POV other than "lived experience". And I may be entirely ignorant of how much better Western Europe is on one of those 3 areas of healthcare: lifestyle, acute, elective/diagnostic. A good source of evidence that I may dig through at some point is mortality data during covid when hospitals stopped doing elective and diagnostic work: many editorials predicted people would die of cancers, etc.. due to lack of screening but as far as I can see that never happened.
The part I did state above, though, is there's so much non-healthcare variation in American Health. Non-college degreed people live many years fewer than the degreed, but in general we all go to the same hospitals for acute stuff and are left to our own devices wrt to lifestyle (and as I said I don't think the elective stuff does much anyway) so lifestyle is probably what explains the gap.
I'm glad about your GP experiences! I mostly have that type of visits when I go home on vacation, so I really only use the medical system here for relatively urgent staff. For the lifestyle conversation, check my answer to Mark below.
The time limits are set by insurance companies and the government, and probably influenced by low supply of doctors (it’s still hard to get an appointment). The excessive testing is dumb but a separate issue - lots of medical training here is based on highly conscientious people who think you need to test for every rare disease under the sun. And insurance companies/Medicare will always reimburse, so it’s never challenged.
If this was driven by doctor greed, then academic hospitals that pay on salary would have lower costs of care than community hospitals that pay more based on incentives, but we don’t see that pattern. It still leads to excessive costs either way, but assuming all doctors are bad people isn’t any more useful than saying that all academics are bad people because tuition at US universities is too high
And I think a lot of people *want* a bunch of tests/meds, so for doctors that can be the path of least resistance. I know a lot of people in my middle-aged cohort and older who are convinced that they're sick a lot of the time...
Academic hospital cost >> community hospital cost.
Academic hospital care ?? community hospital care...depends on the issue for; for some complex stuff there just isn't much comparison (since it doesn't happen at community hospitals, but for other things (particularly routine things) a great community hospital could be far better.
I'm at a big academic place and my income changes based on the number of patients I see is <10-15%, and it is not affected whatsoever based on tests, consults, whatever that I actually order/do (I am not a proceduralist).
First, I'm not saying that all American doctors are bad people! I'm saying that from my anecdotal evidence (and not data) I would describe my interactions with doctors here as mediocre at best. I said that I'm not sure that points to training issues even. The only direct knowledge of a problem with doctor training I have from the US is that the residents I know here are far more overworked than the ones back home, and I don't want a tired doctor.
However, I find it rather implausible that American doctors are such an outlier in conscientiousness. If insurers paid providers (hospitals, clinics, etc) a fixed amount of money every month regardless of the number of tests they did, I suspect that American conscientiousness would go to European levels.
Didn’t mean to imply that, but the relationship between money and healthcare implied by the salesman model is wrong. The difference between US and Euro doctors isn’t that we’re paid more for doing tests, otherwise you would see that relationship based on practice setting, and academic doctors would spend less since we are on salary. It’s that nobody tells us “no”, so we assume/feel that all tests are justified (as opposed to Europe where cost control exists). We also have a very human bias that the work we do is useful - not always true! And external cost control can fix that.
The better analogy is an overfunded bureaucracy where nobody ever says “no” to a funding request, not a sales team where our only goal is to sell a product.
If your doctor takes longer than 15 minutes in the exam, her emr system dings her for taking too long and her hospital system will penalize her for not seeing enough patients. Time is money and throughput is the only way we can get these people referred up to the real doctors who earn the hospital its money.
Also US lifestyles are bad. There are other factors in life expectancy beyond the healthcare system. I promise I don’t control how walkable anyone’s neighborhood is or set the price of junk food/alcohol.
I don't buy the junk food argument. Junk food also exists in the EU, and it is a cheaper option than healthy food there as well. However, I'm also used to having a long-standing relationship with our family doctor there with whom I have a chat every year, so if he thought my blood tests show that I'm not eating healthily, he would very forcefully let me know. (And he does do that from time to time.) Most Americans I know here don't do that type of doctor visits. (I mostly know people my age here, of course.)
I will give you the higher number of car accident deaths and the wider availability of guns as lifestyle reasons for shorter lifespans in the US though. However, I would expect you to concede that American doctors gave a lot of powerful opioids to people without appropriate supervision (my understanding is that you can't get this type of drugs with you at home where I come from) and that caused a lot of avoidable deaths here.
Fat but active is vastly better in terms of health outcomes than fat and inactive. Not quite as good as “not fat and active,” but within shouting distance.
European and Asian urban planning and transportation almost guarantee the former outcome even for people whose diets are unhealthy on the whole. American urban planning and transportation virtually assures the latter outcome for people not actively trying to avoid it.
I think its likely both sides somewhat overstate the impact here... I was doing some quick googling and it looks like Canada makes it quite a bit easier for foreign-educated doctors to practice (basically one year of residency + you have to take a test provided you went to one of the schools on their list). But Canada still has pretty high doctor salaries.
Biggest problem in the US seems like the US is overindexed on specialists vs. primary care, but that seems like a case where it'd essentially be a win-win: primary care doctors could help with the shortage but I don't think salaries would come down that much.
At least part of the specialist issue is demand, lots of people want to see dermatologists or gastroenterologists for things that might not get treatment in other countries. If we really wanted to disincentivize this we would probably need insurance companies (or the government) to deny more claims, which might be justified for things like back surgery that are expensive but useless. And even cancer screening programs are mostly controversial aside from a few clear-cut cases like colon cancer screening. But probably a tough lift politically so I think expanding supply is more realistic than telling Americans that prostate cancer screening doesn’t pass cost-benefit analysis
On the nursing shortage: a major contributor there is that a major educator of nurses are community colleges, and community college nursing instructors usually make less money than nurses who are qualified to teach.
Another way to promote growth is to add a lot more automation to seaports and freight rail. There is a lot of low-hanging fruit that automation would make more efficient. Of course that would mean fighting the unions.
Freight rail is mostly provided by (regulated) private companies who got way more profitable in recent years while quality of service has, if anything, deteriorated. Seems like regulators just got comfortable with way higher returns for the operators and that should be rethought.
By no means an expert and would love someone who is to chime in, but as I understand it one of the major issues that rail companies have pushed for over the last decade has been to have trains leave on time. Historically a lot of trains were delayed because companies wouldn't get their stuff loaded on time. Those delays required much looser scheduling to accommodate and were much less efficient. Moving to a - it has to ready on time or its not going - approach is definitely a change in the quality of service, but I don't know that its worse.
*they have also run their staff much more heavily which given that it appears the railroad workers might strike, is going to be bad for all of us.
Interesting and thanks for sharing! Be curious how that compares to historical averages. It does seem to echo what I've read elsewhere that they understaff and that has been a major driver in both poor service performance and in the labor issues where conductors are feeling overworked.
To be fair, just because management is being stupid in some way, doesn't exclude the unions from also being foolish. Tis sadly possible if not likely for both to happen.
You are correct that we should do more to expand the supply of healthcare services, but you kind of skipped over the reason why it’s so difficult to do. One reason why rent seeking is so common in medicine is because doctors are politically powerful. That’s not only because they are affluent and educated, but also because they are an extremely well trusted profession. If a doctor goes around telling their patients that some new healthcare rule is going to make it harder for them to give good care, then those patients will oppose the change, even if it’s a change that is beneficial for patients. If your doctor says something is bad and a politician says it’s good, most people will believe their doctor.
Was a big discovery when I did field work promoting ACA; that insurance companies were not actually the biggest villains in our bloated health care system. Attacking insurance companies as the "evil" ones* was probably smart politics because as much lobbying power as they had it was dwarfed by the lobbying power of doctors for the reasons you outlined.
Obama got a of flack for his "if you like your doctor, you can keep it" line as for a decent number of people it turned out to not be true. And I think it's fair for GOP (or other Progressives who want M4A) to point out that this wasn't strictly true. And yet if I could go back in time and advise Obama, I'd tell him to keep that line in his speeches and Town Halls because of the politics. You basically needed it to get it passed and I think this is one of those situations where the consequentialist framing is right (the end result justifies the "only most true" aspect of this line).
*not biggest villains doesn't mean they weren't or aren't villains. Insurance companies finding ways to deny claims that were seemingly part of someone's insurance plan was definitely a thing and they deserved the criticism that came their way.
Ah yes, Politifact's "Lie of the Year." I always wondered what the standard was for turning Obama's statement into a lie (or the Lie of the Year). If one single person hadn't been able to keep their plan, would that have been enough? Two? Thirty million? You use the term "a decent number of people" -- any idea what that translates to in actual numbers?
BTW, I agree with you on the questionable singling out of insurance companies. That has always been Bernie's and Warren's go to move, including the other villains: "Big Pharma" and hospital administrators. Somehow, there's always one group that *never* gets mentioned. On the tip of my tongue . . . rhymes with "proctors" . . .
Yeah. Doctors aren’t mentioned in those attacks because it’s really obvious that the attack would backfire. People trust their doctors, and they especially trust their doctors more than they trust politicians. It misleads people a bit but the alternative is making healthcare reform ideas incredibly toxic because most people will refuse to think of their doctor as a bad guy in the situation.
The "'If you like your *health care plan*, you can keep it" [1] line really was a lie because part of the *purpose* of the ACA was to ban many types of plans. E.g. the ACA required all healthcare plans to cover a long list of things, so plans that didn't cover contraceptives were banned, and no one could keep them. I'm guessing that the vast majority of pre-ACA healthcare plans were not up to ACA standards (lifetime limits, which were also banned, were pretty common), so arguably, basically everyone lost their plan and got a different one in its place. (Probably a more expensive one given the expanded coverage.)
I think the mitigating factor is that HMOs suck, so I doubt anyone really liked their plan. At best, they just disliked it less than the alternatives... Was anyone unhappy that they could no longer get a plan with lifetime limits? I doubt it. Lifetime limits suck. Were some people unhappy that they could no longer get plans that didn't cover contraceptives? Absolutely. See Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania; Zubik v. Burwell; and Burwell v. Hobby Lobby Stores, Inc.
EDIT: [1] has an example of someone who was unhappy about the changes. I doubt she was the only person unhappy about expanded coverage:
"One example: PBS Newshour interviewed a woman from Washington, D.C., who was a supporter of the health care law and found her policy canceled. New policies had significantly higher rates. She told Newshour that the only thing the new policy covered that her old one didn’t was maternity care and pediatric services. And she was 58."
"The chance of me having a child at this age is zero. So, you know, I ask the president, why do I have to pay an additional $5,000 a year for maternity coverage that I will never, ever need?" asked Deborah Persico.
The fact that we don't have hard numbers for the number of people who couldn't keep their doctors speaks volumes as to the absurdity of Politfact calling it "Lie of the Year". Its seems definitely more than a handful. But I can't seem to find just how many.
Regarding Bernie and Warren, I agree signaling Big Pharma or hospital administrators is mostly about politics as they make for good villains. But I'll semi-defend them in that there really are some terrible hospital administrator practices and insurance practices worth condemning. Centering your critique of the American health care system around these two entities is probably not entirely honest, but it's not entirely dishonest either if that makes any sense.
"who couldn't keep their doctors speaks volumes as to the absurdity of Politfact calling it "Lie of the Year"."
The lie of the year had nothing to do with keeping doctors. The line was "If you like your **health care plan**, you can keep it" [1]. He did often mix healthcare plans and doctors together (e.g. "If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan." [2]), but only the health care plan part was the lie of the year. Serious, read [1]. The word "doctor" doesn't appear once. [1] Also notes that about 4 million people had their plans canceled. Granted, I have no idea how many of those people liked their plans, but surely some did.
Almost any working age, non-disabled person has more to gain from growing the economy than further expanding the welfare state. Single parents of preschoolers are the biggest exception as the costs of child care swamp most younger peoples’ wages. Still, a solid 65% of adults do better by growing the economy than expanding benefits. This is the beating heart of center-right politics. The 35% who do better expanding benefits are numerically fewer and generally unproductive and often unsympathetic.
The main thing the welfare state can offer the median earner is security. I don’t trust an insurance company to take care of me if I get sick (I recall one claiming my wife’s cancer was a preexisting condition even though she’s had continuous coverage for years) and I sure as fuck don’t want my basic needs in old age to depend on the stock market.
>>Almost any working age, non-disabled person has more to gain from growing the economy than further expanding the welfare state<<
That's undoubtedly true as far as it goes, but there are clearly very large numbers of people who would benefit from both. You know, a parent who does well by getting a better job AND sees a real benefit from affordable childcare, or the 22 year old who gets good education partly subsidized by wealthier people (so no burdensome student loans) but is is also helped by a robust job market upon graduation.
Also, I've been trying for years to find evidence of a tradeoff between A) size of a country's welfare state and B) the strength of its economy. And I can't find much. I mean, Denmark's pretty freaking rich!
I agree with your general point about economic *security*.
The median parent is better off with subsidized child care as long as said care is funded by a progressive income tax. If were funded with a flat tax or a sales tax, that would basically transfer income from the median parents late career to the early, child residing part of it. That might still be a good trade off, given that most people face more income constraints at 30 than at 50.
Yes, one of the things people don't understand about the case for public funding of child care is that it's essentially a form of income smoothing (allows people to spread payment for things that are really expensive in about 5 years of their life over a longer time period), which is particularly relevant for higher income professionals in paying for child care, since most are not able to save for it as for retirement, higher ed, etc. (And is obviously also an issue for lower income families who do not have the money to save for those things in any case)
I understand why we do it, but comparing the US to Denmark or any other small country seems weird to me. Its more comparable to Virginia - about the same size, though Denmark has 30% fewer people.
Having a very large economy makes it easier, not more difficult, to fund a robust safety net. Small countries like Denmark are vastly more vulnerable to exogenous shocks. I think Finland’s early 1990s downturn was comparable to the US in the early 1930s in terms of GDP shrinkage. Moreover, there’s not as much demand for their currency (nor any other county’s currency) as there is for the dollar.
In terms of economic capacity, I would agree. However, 300+ million people are going to have a far larger spectrum of political preferences than 5 million and building a functioning system that addresses that spectrum in a meaningful way is going to be more difficult. In Denmark, if 3% of the population objects to something, then you have 150k people of whom maybe 10% or about 15k people are die hard believers. In the US those number equate out to 10 million and 1 million. Modern communications mean those 1 million people can actually unite behind something in a meaningful and forceful way so that overcoming their objections is a just politically more difficult. Its the reverse effect of there being enough people in the US to support "Slow Boring" and also a bunch of other newsletters while that isn't true in Denmark.
In practice you're actually describing current center-left politics, at least how it's practiced in the United States. Take a look at who supports expansion of the Child Tax Credit. It's Democrats and basically Mitt Romney alone on the Republican side (I know a few other GOP politicians and pundits have given tepid support, but the number of Republicans currently supporting some sort of CTC expansion is very small). In addition, I think Matt (and many others) has demonstrated that huge cuts to Medicare, Medicaid and Social Security are still very popular with GOP elites (if not voters). It's a big part of Matt's thesis why Trump won in 2016 as he essentially took off the table entitlement cuts (even if it turns out he was just lying).
I suspect too that you probably support Unemployment insurance with some sort of sunset of eligibility? I'm guessing also you may have supported the original Stimulus checks (the February 2021 stimulus seems a mistake but the previous ones I think we can classify as success). I have no idea, maybe you don't. But I'm asking only to engage with the idea that you're actually describing the policy agenda of a typical center left Democrat more than you are a typical current center-right Republican (current being an operative word here)*.
*Only thing you didn't mention as part of current welfare state is SNAP benefits. Not that important, but again curious if you support expansion, current benefits or cuts. Again, unpacking you're claim about "center-right".
Is there a way around basic needs in old age depending on the stock market? If the projected economic growth doesn’t materialize, pension obligations are unlikely to be paid. Meanwhile pensions are at additional risk from mismanagement and theft, while stock held through a regulated brokerage might fluctuate in value, it’s at no real risk of walking away.
I think you make a very good point, but it also goes the other way! In what world can the stock market have good returns but the US economy not be growing sufficient to cover SS payments?
The GOP can get control of the federal government and decide to stop or severely cut back on Social Security. We have a whole lot of regulation and insurance infrastructure to make sure nothing like that happens to your Fidelity account.
You misunderstand the potential regulatory risk with your "Fidelity accounts." It is very possible for Congress (most likely Democrats) to pass legislation that would change the tax treatment for those accounts negatively. Obama proposed several items in his budgets that would have had significant impacts on retirement accounts, including a lifetime cap on the amount that could be tax sheltered, Biden has proposed taxes unrealized gains, etc.
I hope your wife recovered well and I hope you don't mind this question that could feel a bit personal - but what happened with that insurance claim? Did you dispute it? Did it resolve in your favor?
I ask b/c I work in a different area of insurance where everybody seems to err on the side of extreme caution wrt claim eligibility. In other words you have to be grossly ineligible and basically fraudulent to be denied, at least from what I've seen. Mistakes can still happen, so maybe that's what it was, but if not, it's crazy, for me personally, at least, to hear about a situation where the insurer was so aggressive in denying the claim.
That transition, in the medical insurance industry, seems to have come about at least in part because the ACA simply blew up the entire system of preexisting conditions and the rent-seeking which had built up around it.
There are far fewer plausible justifications for denying coverage now than was the case in 2009.
It's interesting, though, to question whether we could have gone too far in the other direction. I have basically no knowledge or evidence that that's the case, partly because as I said, I don't work with medical insurance.
But in the line of insurance I'm now involved in, I've yet to see a single error of the type "denied, but was eligible". But I've seen hundreds of the "accepted, but was actually fraudulent, lying, etc..."
Preventing single cases of "denied, but was eligible" feels more important to me than preventing single cases of "accepted, but was fraud" but there's still some trade off there.
Again - I don't know much about medical insurance. I'm sure fraud existed then and exists now but you could probably tell me more about the relative levels of fraud vs rent-seeking insurance companies denying for BS and how they've changed over time.
We disputed it and they paid eventually. However, it was horribly stressful to have an insurance dispute when we were already dealing with cancer. I was 26 at the time, earned like $54k and had very few savings
And of course children, who would likely most benefit from a stronger safety net, cannot vote. (IIRC, MY has been a supporter of eliminating age limits on voting, which if I'm correct is one of my favorite of his more idiosyncratic takes)
I never understood this argument:"children don't vote, so their needs don't matter to politicians." True, children don't vote, but their parents and grandparents do. Don't parents consider their children's wellbeing when voting?
Even if we stipulate that parents' votes 100% of the time align with the interests of their children (which is a big if), a parent only gets one vote to represent both themself and the child, who are two people (or more in the case of multiple children), so the perspectives of children and their parents are still weighted less, relative to population, than those of other folks. Children are reflected in a state's or district's population for representation numbers, but don't have equivalent representation in voting.
What are your thoughts about allowing employees of large corporations, eg. Starbucks, Amazon, Apple, Walmart, to form unions? Currently employers can fire union supporters with impunity and retaliate in other ways. Do you believe that empowering workers to engage in collective bargaining would be a way to address income inequality without cost to government? (By the way "right to work" laws derive from white supremacy.)
Speaking of upward leaky buckets I’d love to see fixed, we should really be getting rid of tax deductions, and increasing the standard deduction. If something is important enough that it deserves subsidy, refundable tax credits are the way to go.
One of the few things I liked about the 2017 tax bill is the changes it made to the mortgage interest tax deduction and deduction for state taxes. Of course it was done for terrible reasons ("revenge" against states that didn't vote for Trump) but speaks to a path forward to how some of these reforms can happen. "Those fancy pants kale eating elites don't think decent hard working Americans belong in their town. That's why we need to upzone". A better speechwriter will have something better than I wrote, but I think the sentiment I put forward is a political path to upzonging where needed. It is telling to me that for all the ways I think Youngkin is terrible, he does seem to be on the right side of the housing debate.
The whole idea of NIMBYism (and anti-gentrification) is to get the marginal high income transplant to fuck off. Restricting housing supply to raise their rent is one way to do that, raising their taxes to reduce their income is another.
NIMBYs are asset rich but not high income; any collateral damage to their own tax bills are minimal and probably worth it to them.
I agree in principle but the question becomes "how?"
The timelines on which these things play out are so long, and the law obviously can't be applied retroactively, so there's no good way to untangle the ratfuck without lots of people feeling they were screwed over.
In the short term doing this would essentially be yet another transfer from young to old.
I would be opposed to it, but surely the easiest way to eliminate that would be to just reduce the contribution limit to, say, $5000 a year or whatever the median contribution amount is.
I mean that *changing the rules* would be a transfer from young (who no longer have the ability to accumulate savings with tax benefits going forward) to old (who still enjoy decades of accumulated tax benefits that will not be retroactively taken away).
"There's certain type of economist who loves to dazzle people with examples of unintended consequences or.... "
It's worth being perfectly clear here, this certain kind of economist is always a conservative trying to stand athwart history yelling "Stop" because, as we know, "It is difficult to get a man to understand something, when his salary depends on his not understanding it." It's classic Albert Hirschman in his book "The Rhetoric of Reaction." It's an unfalsifiable claim that begs the question in a certain way, because, obviously everything has unintended consequences, many of which can also be good, but we would never know unless we try. Of course these conservatives go on to then talk about "human nature" and minimize the potential intended consequences of collective action, and how it'll only ruin the incentives currently baked into the system that have gotten us where we are today.
“…this certain kind of economist is always a conservative…”
When I read that my first thought was, ‘It’s always a progressive-type, building up the case for: Market Failure, therefore my favorite form of government intervention is clearly indicated.’
There's a certain type of left winger that defaults to being very averse to any sort of major reduction in government regulation, and also averse to growth for fear of unintended side effects and externalities. It's articles like this that they need to read to understand how some of those restrictions cut against their ideological worldview.
Nice statement of what I think of as commonsense Liberalism.
I do, however think we should not overlook the elephant in the room: the federal deficit. A dollar borrowed comes mainly out of investment. A dollar taxed, even from high income people, comes somewhat out of consumption. Moreover there are ways to tax that have lower deadweight losses then the one we have.
Federal business taxes are riddled with exemptions and special treatment of one and another sector and activity that reduces the value of private investment. Taxation of income's only deadweight loss is reduced effort and entrepreneurship which is bad but I think really miniscule. So it would be a big deal to reduce business taxes and raise personal income taxes.
A capped wage tax for financing SS and even the uncapped wage tax financing Medicare fall somewhat on (reduce) savings. A VAT falls mainly on consumption, including consumption of high income and non-wage income earning people. A dollar for dollar shift would be growth promoting but of course at the shift point we could also raise revenue collections to match benefits, another contribution introducing the federal deficit.
Taxing capital gains at a preferential rate and rebasing gains on inheritance has an advantage of offsetting (more or less than) the gain coming from the inflation. We would be better off to just index the inflationary gain and tax it at the person's regular rate.
A tax "deduction" is worth more to a high marginal tax rate person that to a lower marginal tax rate person. To the extent that deductions are incentives for certain kinds of consumption (charitable giving, health care and insurance spending, owner occupied housing services) over others the incentive should be the same regardless of the consumer's tax bracket (or even greater for lower income people?) We should replace deductions with partial tax credits (which would also eliminate s lot of complicated caps and exclusions that exist to partly offset the inherently regressive nature of the deduction).
And although I'm sorry it not already popular, all right thinking elitists ought to be pushing for a revenue neutral tax on net CO2 emissions.
It’s not just the price of gasoline that’s a racial justice issue, much more important is the push to outlaw internal combustion (ICE) cars. New York and California have already banned the sale of ICE vehicles after 2035 and are phasing them out before that. I would be very surprised if other states, and perhaps the Federal government, didn’t follow suit soon. If you are upper middle class suburban dweller with a driveway and a garage, switching to a Tesla might be a bit more expensive but is definitely manageable. But if you live in a dense urban environment, in a multi family house, and park on the street, how is that going to work for you? And which racial groups are more likely to be in the second group?
I think this may an under-examined problem. I just attended a community meeting here in West Los Angeles on a proposed 200-apartment complex. The complex would have 200 parking spaces (due to reduced parking requirements -- good!) and the developer said that of those 200 only 25 would be for charging EVs. However, he said, another 65 would be wired to allow EV charging in the future. So the majority would not be built to ever allow charging. Now this building is obviously meant to last many decades, and California will forbid ICE car sales in 12 years. What are the future people parking the ~115 EVs in their apartment building supposed to do for keeping their cars charged? You might think the developer would see this as a problem but >12 years is a long time from now and I guess it's just not something he sees as worthy of increased construction costs. But it sure will be a problem down the road.
Whether having chargers at 40% of parking spaces is not enough or more than enough depends on the type of charger. If these are all L1 changers, then 40% is likely not enough. If they are mid-range L2 chargers then it's more than enough. A mid range L2 will deliver 300+ miles of range overnight, so the average car would only need to recharge overnight once(ish) a week.
I perhaps am not as trusting as you to not worry that my fellow residents won't just grab the first parking spot whether or not their car needs charging, leaving me steaming when I see that their car isn't even plugged in and my battery is almost dead.
I'm just pointing out that the capacity created by 40% is plenty with decent chargers. I don't trust your fellow residents to manage it on their own either. There will have to be some kind of process in place to prevent folks from charging to full in an hour, then leaving their cars connected all night -- Idle fees, times slots, whatever.
"if you live in a dense urban environment, in a multi family house, and park on the street, how is that going to work for you?"
Smart parking meters everywhere, with charging cords. So when you park at the curb, you plug your car into the meter and it automatically recognizes your car and bills you for both the parking space and the electrical charge.
We should in general ease off the electric vehicle subsidies/mandates over the next decade or so. They've accomplished the purpose of kick-starting the EV industry, and EVs are good enough to compete with ICEs on their own now. Phasing back to a pure market competition will help EVs continue to develop by keeping pressure on them to improve in areas that aren't at parity with ICEs yet.
I feel like there’s so much fud being spread about the climate that I genuinely don’t know how fast we need to act.
I don’t think we’re on the verge of some mad max climate collapse but because I think even 2 degrees really does seem quite bad especially if we’re counting the effects on wilderness qua wilderness and we need to move really fast. I’m open to arguments that I’m wrong but it seems that we need to say we’re not going to let people dither forever.
I want to up front admit that I haven't done a deep dive on the emissions situation here and I'm going off general principles.
My basic belief is that EVs are really great and are going to eat the lunch of ICEs even if the subsidies and mandates are slowly turned to zero, and that attacking the long tail of remaining cases where ICEs have legitimate benefits will have marginal emissions effects and some significant cost to the lives of people forced into bad EV solutions.
I also tend to believe that everything in the broad category of environmental policy has a systematic bias that leads it to overweight interventions that are create highly visible lifestyle choices to consumers and underweight invisible industrial changes, and so we should redirect EV subsidies to, say, nuclear or geothermal research.
I still have no clue how the low-end of the used vehicle market is going to develop with EVs. If they require costly battery upgrades (e.g., $22k for a Tesla replacement) ... they'll always stay in that more off-lease used segment of the market and never make it down to the Buy Here Pay Here segment that's looking for a < $500 monthly cost. I thought the solution would be to design more modular / quick swappable battery packs but the newest Tesla and Rivan designs have gone in the other direction to make them more structurally integrated.
To your point above ... I'm not sure if the "long tail of remaining use cases" is like 2% (i.e., heavy duty trucks, extreme polar climates) or more like 20% of the lowest-cost transport market.
I think one issue is that right now, with subsidies, they've kind of been able to ignore that question. I got my Bolt for a criminally low cost, partly because the government is subsidizing my high income ass, and partly because the car companies are subsidizing it because they need to build out their EV offerings. But that won't work for volumes necessary to replace the Toyota Corolla market, and the companies should have to work out how to sustainably make a sub-$20k vehicle.
“I still have no clue how the low-end of the used vehicle market is going to develop with EVs”
I would imagine with cheap, non-OEM replacement cells. You know, of the sort that burns down your house when you leave a hoverboard charging under the tree on Christmas Eve.
Western civilization seems to be zeroing in on the next 15 or 20 years or so as a time of great transition. Indeed, we are told regularly that if don’t make this transition, and fast, we are doomed. As Obama put it is Paris, in 2008, if we don’t act quickly to end the use of fossil fuels the Earth may well be uninhabitable by 2100. Many others have made similar if not more aggressive predictions. And yet, when we think of the scale of the transformation required we can see that these timetable are grossly unrealistic to say the least.
The transition from ICE vehicles to BEVs is hardly the most ambitious part of this agenda but let’s focus there for the moment. A complete transition to BEVs would require about 50% additional electrical power above what we generate now. In addition, we will have to replace the power we now generate with oil, coal, natgas, and, some say, hydropower. Could we adapt? Perhaps, at great cost and given time. Can we adapt on the timetables being demanded? No.
Just to be clear ... the EV mandates are for *new* vehicle sales. There are 285m registered vehicles in the US and just 1% are EVs. The average vehicle last 12 years. They don't outlaw existing ICE vehicles from operating. And they shouldn't - they need to be run until fully depreciated to maximize the carbon cost of production. Current projections are that - maybe - 50% of vehicles in the US will be EV by 2040. All this to say ... nothing is happening fast here and the multi family housing residents in your example will be driving ICEs into the 2050s as the existing ICE vehicles fall down their depreciation curve.
To address what is clearly the point of your comment...seems like the Cowboys are front runners to sign OBJ. But wouldn't be surprised if the Bills come in with an offer to try to match what the Chiefs did getting Kadarius Toney from the Giants.
I can remember now who was the female editor at the Times who was publicly fired several years ago but, as she was also Jewish, I was profoundly disappointed that no publication ran the headline: "New York Times Editor Fired: Woman, Minority Hardest Hit"
I'm about 85% sure that the "obj" is what is rendered when you enter a UTF character that the font that this site is in doesn't include a representation for.
In this case it appears to be one of the more exotic whitespaces (of which there are a bewildering variety).
In re the "OBJ" box, I've been seeing those occasionally for several months at least. I haven't been able to figure out any rhyme or reason to them though.
No idea what the graphic is. I've noticed Substack's been doing some weird things of late. Pretty sure that, yes, POC in the US tend (all things equal) to live in areas characterized by more serious air pollution issues. To the extent that decarbonizing the economy means one day ridding ourselves of vehicles powered by the internal combustion engine, POC should see an oversized share of the resulting health benefits.
CO2 is not a health issue. As for other air quality impacts from ICE vehicles, those have largely been minimized by various pollution control technologies. As for EVs, unless you really believe that all the electric power is going to come from windmills, then we have the pollution impact of generating all that additional power.
The pollution impact of electric power may not be zero in our lifetimes, but the amount produced continues to trend down as cleaner sources generate more power. All toxicity is about amounts, concentrations, etc.
> And which racial groups are more likely to be in the second group?
Probably more White and Asian than you'd think, because gentrification has steadily pushed richer groups into urban cores and poorer groups to the periphery
One thing not noted but I think can be included in your post is reforming the requirements to receiving a college degree and a graduate degree. What I mean is that colleges (as you have noted) are essentially designed in their structure around a world and society that existed in the 19th century. In other words, they are designed to serve only the upper crust as it existed pre-20th century. As much as I loved my college experience, I would say a lot of the classes that I had to take to fulfill my requirements for graduation were probably unnecessary and resulted in me staying in school longer than is strictly necessary. At least with state schools there should be a push to eliminate "common core" requirements and allow students to concentrate on taking classes that are needed for their major. In addition, there should be a way for students to go directly into graduate level programs as soon as they are able to. My understanding is that in other parts of the world, you can go straight into an MBA program without undergraduate classes (this may be different from country to country and it's perhaps not right out of high school, but I think I'm on pretty firm ground saying the class requirements to go to grad school are a lot less stringent). For thinks like medicine, it seems like the necessary undergraduate requirements (classes like organic chemistry) should be included in medical schools. The time spent in medical school would be strictly speaking longer, but your overall number of years spent studying to be a doctor would be shorter.
Given the huge debt loads kids need to take to finance higher education (Kevin Drum had a good post noting that the gap between Millennial wealth and Boomer wealth at the same age can be explained primary by the burden of student debt), finding ways for kids to graduate with undergraduate and graduate degrees in a quicker timeframe seems a no-brainer to me.
I love all the ideas for change in this article, but the framing and motivations were a little off for me.
1) The article asserts without evidence or limitations that redistribution is good. This is a loser of a frame -- healthy, broad middle class, sure, but redistribution has communist vibes. I’d imagine there’s some efficiency point between where we are today and equal salaries for all. The truth is, low and middle class pay some of the lowest federal income taxes as a % of income in the developed world, so there’s already a fair bit of redistribution.
I’d like politicians to align increased taxes with new benefits for all (+ some deficit reduction). It’s in line with Matt’s abundance agenda, but let’s raise taxes on higher earners to pay for things we all use.
2) Countries all over the world use zoning. It’s an overstatement to say that zoning comes from racism. (There are certainly some examples, but there were/are many motivations.)
Also, major overstatement that zoning and regulations are what makes cities so expensive. Manhattan is an island, and it just costs more to build up vs single family homes in Florida or Texas.
>>This is a loser of a frame -- healthy, broad middle class, sure, but redistribution has communist vibes.<<
That's probably right. Which is why we should never hear Democrats utter the word "redistribution." Stick with language like "fair deal" (in Australia it's "fair go") or "prosperity for all" — stuff like that.
>>It’s an overstatement to say that zoning comes from racism.<<
Following MY's link it is clearly an overstatement. The linked paper, published in 1997, says that zoning was created and used by a hodgepodge range of people for a hodgepodge of uses beginning around 1900. The very first laws were about land use and building heights. Then it says that historians have primarily focused on zoning for land while partially ignoring racist motivations for some subset of the zoning laws that were used in many cities and states across the country.
tl;dl; zoning laws were "invented" for land usage, and then used for many things, racist segregation among them, until that went out of vogue in the late 60s.
The steam engine was invented to pump water out of coal mines but had lots of other applications, eg locomotives. Zoning was invented for racist purposes but has lots of other applications.
I'm sure race had and had something to do with zoning...how much, who knows. But I would say that it's pretty clear that people with a certain level of prosperity don't want to live next door to less prosperous people, regardless of race.
I mean, we’re talking about a progressive class that feels entitled to the Hispanic vote and yet insists on describing itself as “socialist” despite this being extremely triggering language for anyone who has actually lived in a Latin American socialist country. When a Venezuelan immigrant hears the word “socialism”, they don’t think of Denmark. And even a lot of Puerto Ricans have some degree of roots in Cuba.
I don’t think just looking at federal income taxes is a good way to look at the tax burden for different parts of the income spectrum. Payroll taxes are pretty significant for low income workers, and state and local taxes are often imposed with regressive taxes like a sales tax.
You’d have to look at all of those combined to see how high the tax burden is on people. The federal income tax is a tax that particularly hits wealthy people harder, but not all taxes work like that.
Are you sure? MY had a post here about land use regulations in UK, and while I forget a lot of it, I think the takeaway was that it was really bad. The recollection that stands out the most to me is that there is a gigantic green belt surrounding London and every other major city that forces sprawl an extra 5 or 10kms out from the city center, and other zoning prevents up-zoning in the cities.
It may not play out exactly as Florida or Texas for other reasons, but it's still sprawl.
Even Amsterdam has supply and demand problems. But “zoning” around the world zones for dramatically denser and less car centric places than are typical in North America.
Well maybe that's right in the sense that zoning for density is much more prevalent in W Europe - but the MY post on UKs zoning really showed a shocking amount of green space near cities, effectively where our city outer-ring suburbs would be. And he argued in the same article that it effectively made the UK much poorer.
First, We need Democrats to register that so much regulation is counterproductive, is creating barriers to entry, stifling small business and helping to push the never-ending mergers and consolidations. Regulation needs to be really really thoughtful and Democrats are just too keen on applying it. It feels like some Democrats love all regulation, see it as a barrier to corporate power.
To help do this, and change perspectives, those of us who experience this stifling of regulation in their professional world need to be vocal but reasonable about this stuff, citing our real world experiences and demonstrate how they are counterproductive.
For example, in an effort to protect a recently endangered migratory bird, NJ moved all the oyster farming along the Cape May’s bayshore flats to one access point. Our farm was less than a mile from this point but we were mandated to move also. State of NJ wrote us a grant to make our move easier (so we wouldn’t fight them essentially) - a 4x4 vehicle to help us move, something we’d never used before and something that very obviously disturbs the same birds far more than anything we were doing previously. The whole basis of forcing our farm to move - that our no-input farming was resulting in “take” - the death of endangered birds, was absolutely absurd. But absurd will win the day when these issues become pure partisan affairs.
Meanwhile, we have literally collapsing ecosystems and we’re arguing about stinking paper/plastic straws. I wish we could get it together people.
I think the nuclear bit is key. We need an enormous push in funding for designing then building bulletproof-safe but also economical nuclear plants and just run with that as a medium term solution to climate change. We don’t have a ton more time to bicker over this and now crystal clear Saudi Arabia and Russia will blend their tyranny with their trade in oil.
We need to break the tyrants backs with energy policy.
Unfortunately, we’re just not quite able to make the renewables work as a substantial replacement for fossil THIS generation. Next one, it seems more feasible. But for now, it seems crystal clear to me nuclear is the stop gap in energy policy we need to balance our economic, environmental and geopolitical goals. Getting off the black crack from the Middle East will solve a lot of the world’s problems.
Then ending the war on drugs IS AN ENORMOUS ECONOMIC BOON. The effect of taking that economy away from the black market and putting back into legit economy is hard to overstate. Especially as so many toxic, costly effects flow downstream from the black market, those cartels, the political and economic instability they bring throughout central America. The recruitment and firepower of so many inner city gangs is crushed when they lose the monopoly on soothing substances not called alcohol. The incarceration costs, and downstream impacts of that.
And first trimester abortion as an economic freedom is very legit issue as well. If you are able to take religion out of this issue, 1st trimester abortion restrictions becomes a civil and economic freedom issue, one that is quite compelling. There is no compelling argument that an unborn fetus, too early in development to have a functional nervous system (and without stated constitutional rights) has any legitimate claims that the government should need to stand behind. Meanwhile, unwanted pregnancies often result in neglected children who often fall through the cracks.
Economy is so intimately tied to the overall health of our society and its governance.
Could we step up the push to put tax-preparers out of work?
Legislation to have the IRS calculate your taxes and send you the bill. You verify it, or don't, and send them a check, or don't.
HR Block and Turbotax have to find new jobs.
I have no love for the lobbying efforts of H&R Block et al., but they're not the only problem here. The more social engineering gets layered onto the tax code (some advocated for by this very blog), the harder it is for the IRS to accurately calculate what you owe, and the IRS is not the most nimble IT service in the country.
Indeed. That this is an industry is a real failure. A huge anchor in terms of the opportunity cost stemming from smart people deployed in unnecessary activities and charging hilariously exorbitant fees. But then, tax avoidance is the one biggest way regular folk can do rent seeking...
Turbotax is a lot different then tax lawyers scheming with private bankers. Rich people paying tax professionals to reduce liabilities is inevitable, turbotax is not
"That this is an industry is a real failure."
Every tax-prep billionaire is a policy failure.
(Much easier to agree with than the generalized version.)
Eh, perhaps...then again, too-specific can be a bit much. See: “Can we step up the push to put tax preparers out of work?”
Or improve their service. Every year the same annoying edge cases don’t get fixed. And it’s gotten harder to see the underlying tax documents.
Don’t get me started!
Any politician who proposes that is going to find that their opponent in the next election is extremely well funded though.
Though I'm also guessing the AMA would fund the shit out of opponents to Matt's second proposal.
For low to middle income wage earners, taxes should absolutely be way simpler than they currently are. But there will still be plenty of jobs in business tax prep, because there is really no good way to make business taxes simple.
I've always wondered if open source tax software could ever take off to be a feasible challenger to killing these middlemen if Congress can't or won't.
Supposedly they are considering it again, but who knows if anything will result:
https://www.cnbc.com/2022/08/30/congress-explores-free-tax-filing-program-to-cut-out-middlemen.html
I’m more a fan of the “file our taxes on a postcard” plan, or just have everyone use the 1040EZ form. Get rid of deductions and raise the standard deduction. There is no reason we need things to be so complicated. We could lower tax rates substantially by eliminating deductions that only help a small percentage of the population. Get rid of capital gains and tax it all with the same rates, too. Withholdings would be easy to calculate so you wouldn’t have a big bill in April. We could put the accountants and tax lawyers to work doing something productive.
Even better replace it with something like the Fair Tax
"The origin of American zoning is largely in efforts to uphold racial segregation."
You see this claim a lot in progressive circles and it (a) doesn't really make sense and (b) is wholly unsupported by the linked studies and historiography. The paper linked in this work examines the use of zoning to enforce Racial Segregation in Southern Cities in the early 1900s. The idea that zoning would be used to uphold a de jure system of segregation that already existed is more or less unremarkable, horrific though it may be.
But "the origin of American zoning" is not found at all in the largely rural South. The paper you link to admits this in the second paragraph (!) saying "Benjamin Marsh championed zoning in the early 1900s in an effort to combat urban congestion and thereby improve the quality of working-class neighborhoods." Not only does this progressive, urban origin of zoning happen to be true, it also makes way more sense that an idea that originated in European urban renewal movements would first present itself in large, Northern American cities as opposed to smaller Southern ones.
This claim is akin to the ludicrous 1619 project claim that capitalism was invented in America (wrong) as a way to more efficiently facilitate the trade of enslaved people (also wrong). I don't understand why people feel the need to lie about this stuff, when it seems bad enough to me that the United States spend two centuries using otherwise anodyne or progressive advancements (urban renewal, ledger books) to facilitate the bondage and disenfranchisement of human beings. That is already bad! You don't need to pretend that Central Park is Jim Crow! IMHO it devalues the entire argument to make demonstrably false claims like this.
+1 from an urban planner. It's true that zoning has been *used* to facilitate segregation, but its orgins were related to the problems associated with urban growth and industrialization that you cite. And I superlike (tm) your point about undermining arguments with disingenuous false claims!
I am not sure this is such a big distinction, how long did it take for zoning to be used for racist ends? Like five years?
https://en.wikipedia.org/wiki/Zoning_in_the_United_States#Los_Angeles,_1904-1909
That said, I'm broadly sympathetic to the point that emphasizing the racist history of X is not going to be a very convincing argument since it's disconnected from the material consequences for voters you might be trying to persuade.
Well said, Ray. I understand that this was more of a throat-clearing comment by MY, but I think we would all be better off and more able to make real progress if we just dropped this point from the discourse. You will not guilt homeowners into supporting upzoning with the systemic racism argument.
I think it's worth unpacking a few things here. I think overall you're right to note that the origin story of zoning places much too much emphasis on a racist origin story, especially as you note that urban zoning began in Europe and migrated here.
But I think you might be overselling the case a bit too far in the other direction. Zoning became over time a backdoor way of upholding segregation. In some ways I think it might be worth breaking up history of zoning into pre and post WWII phases. But more to the point with modern times, when someone at a local board meeting complains that apartments will bring poverty to the town, it's hard not to see the very obvious racists origins of that claim. I'm aware that people have objections to multifamily projects for all sorts of reasons, including very basic ones as "I don't like how this building looks". But it's also undeniably true that enforcement of single family zoning is at least in part about keeping "those people" out of the neighborhood.
*Also not the point of your post, but in your 1619 project note I'm assuming you're referencing the Matthew Desmond essay? I bring this up because in the intellectual honest criticism of the 1619 project (unfortunately my feeling is most criticisms are intellectually dishonest...mostly along the lines of "how dare you say anything bad about Murica and it's founding. It's UnAmerican", really center around just two essays; Nicole Hannah Jones and Matthew Desmond's essays. Given that NHJ is basically the editor/creator of the project, there is a certain amount of fairness in expanding criticism of her essay as a criticism of the project overall. And I do think Matthew Desmond's essay is kind of garbage for the reasons you noted. But it is striking to me that criticism of the other (numerous) essays is almost non-existent. Like does anyone have any solid critiques of Jamelle Bouie or Kevin Kruse's essays? I'm sure they exist somewhere, but the lack of outrage directed at any of other essays seems really telling to me. Again, I for the most part agree with your comment about 1619 (although I'd quibble with using progressive as I think you're using a very late 19th early 20th century definition of the term that may not apply today), but just thought it worth noting.
Not wanting apartments isn't necessarily about race.
Crime is strongly correlated with density and poverty
I think that the synthesis point for zoning is that it's just like a very powerful and very imprecise tool. Like, as our host likes to point out, what kind of buildings you allow where is a very big deal in both, uh, breadth and depth. That is: land and buildings are expensive, so allowing/forbidding/making changes to what kinds of buildings you can build hits people and businesses very deeply. It's not a minor speedbump that people can just sort of mostly handle and continue on with what they were doing, zoning makes and breaks ideas and projects and businesses and people. But also, it has really wide-ranging consequences, lots of important second-order effects.
And that's a dangerous combination. I think that lots of the people who supported zoning that we now understand limited the opportunities of black people probably did so without a single racist sentiment -- but because the impact of zoning is both so deep and so broad, it was easy to sneak in racially exclusionary zoning even as a second or third order consequence, and even as a second or third order consequence, its impact was deep enough that it was highly meaningful. And regardless of whether you, the hypothetical audiencemember, are personally animated by the racial framing, if it could be used that way, it can also be used to meaningfully impede goals that you do find compelling, or to accelerate projects that you personally find distasteful.
I think Matt Yglesias himself has complained when people claim that the origin of American *policing* is in the American slavery system, noting in his complaint the lack of global context -- other countries have broadly similar police systems and don't have a similar history around slavery.
It looks like he's making the same mistake himself here. (If there is some cross-country analysis that shows a strong link between housing restrictions and a history of segregation, please do correct me!)
There are a lot of things from the first three weeks of the URBS 1001: Introduction to Urban Studies curriculum that have been floating around the broader discourse for the past five or six years that could use a lot of the information from the other four years of the program...
We went over the early zoning cases in 1L Property Law. I remember at one point saying that these laws were designed to keep out poor black people and the professor correcting me with "No! These laws were designed to keep out all poor people, not just black people."
Euclidean zoning was more about anti-density and keeping the sounds and smells of industry (and the riffraff who worked in factories) away from nicer neighborhoods. Racial segregation was absolutely perpetuated by zoning, especially in the post-CRA era, but that was not the original intent.
Very much agreed.
And that's why I oppose density around my property
I’m not a knee-jerk defender of the doctor’s lobby and usually disagree with my specialty organization. But US training really is much better than what exists in many other countries, and also American tourists in many countries are often told to go to “the good hospital” and don’t just visit a random rural hospital when they’re sick.
If we want to intelligently deregulate (which I agree should be a goal), we should follow the example set by other countries like New Zealand, which don’t require a full residency but still require a couple years of supervised practice and a licensing exam before doctors set out on their own. And I totally agree that expanding NP practice is good, although we also have a nursing shortage so we should probably just expand that pipeline in general
>>But US training really is much better than what exists in many other countries<<
Sure, but not *all* countries. Seems nuts to require doctors trained in Canada, UK, France, Israel, etc to do a full residency. Can't the federal government certify the products of certain countries' medical training systems for fast-track status? (I agree with your idea re: the NZ system.)
Yeah I actually think dumb deregulation would backfire, because inevitably there would be horror stories about a poorly trained immigrant doctor providing bad medical care. And then US medical societies (which I 100% agree are all about rent-seeking) would say “see, all foreign-trained doctors should do residency” and we would be back where we started. I think something like what you are describing would be a better way to sustainably make this work.
I agree. But my guess would be that there aren't all that many French and British doctors who are interested in immigrating here.
They would be if salaries didn't crater. And they would probably continue to practice in large urban areas and continue to leave the rest of the country undersupplied.
Isn't there still a cap on the number of doctors able to train in the US? Really struggle to see how that's justified amid a physician shortage (and heavy restrictions on importing medical professionals).
You'll struggle indefinitely. There is no justification. It's rent-seeking, pure and simple.
HHS pays the wages of doctors in training. As far as I know, nothing would stop a private hospital from deciding to fund its own additional residency spots, but hospitals are penny pinchers and don’t do that. So the number of residency slots is determined by the budget Congress will allocate for them.
This is actually wrong.
While most residency spots are government funded (via many routes: CMS/Medicare & Medicaid, VA, HRSA), I have been at 3 institutions that either added residency spots with internal funding, or created entirely new residency programs from internal funding. It is pretty common.
There was a recent big boost to residency funding as well
https://www.cms.gov/newsroom/press-releases/cms-funding-1000-new-residency-slots-hospitals-serving-rural-underserved-communities
It's not a "cap" as in a set maximum decided somewhere. It's "the number we have collectively come to" via the independent and often competitive and contradictory decisions of ~200 US medical schools (MD+DO) who graduate new doctors (who really can't do anything) and literally thousands of residency programs of all types (who train doctors to have useful skills).
I agree with the NZ comments from Mark.
Allowing foreign physicians into the US to practice unrestricted if licensed there means one thing from EU countries, and something else entirely from many other places.
There is, because that is centrally set. If we went full unregulated capitalism here, I would argue we should scrap residency and even medical school requirements in general and just let hospitals hire whoever they want and train them the way they want to.
But if we have higher standards for US grads and the more competitive foreign applicants (who will still do a US residency), and lower standards for less competitive foreign doctors from countries with much lower standards for their own residency systems, then you end up with a system where only desperate rural hospitals hire foreign-trained doctors.
This is incorrect. There is no centrally set cap on either physician grads from medical schools (AAMC, LCME), nor one for residencies (ACGME). Each program can adjust size--within existing guidelines and funding sources, which are complex--on their own.
Realistically though, programs generally only increase slots if they get Medicare funding, so we have a defacto shortage. This is exacerbated by the fact specialist residents/fellows are worth more to hospitals than generalists, so if they are going to self fund it's not for the generalists they need.
I'm in the military and have interacted with/have colleagues that interact with the European system. The consensus is that Britain's residencies are as rigorous as the US, but most European residencies don't produce doctors capable of independent practice (in part owing to hour restrictions that reduce training they can get in a set time). My boss said in Italy he'd frequently see docs 10 years out of residency deferring to a super senior doctor on management issues we'd expect a fresh grad to make.
I also was told that care east of Germany (Poland) was severely substandard to the US, even citing OR cleanliness issues.
Data on the US system shows we grade the best for most issues (trauma, heart disease cancer etc.) Controlling for health when you get in trouble. The non US advantage is better population health and management/screening that nips more issues in the bud.
Basically, you need to improve compensation for general practitioners and ramp up their supply. That will reduce the supply of train wreck patients that make our numbers look bad.
I mean yes and no, I've been a part of entirely new and self-funded residency and fellowship programs in a large non-academic hospital system. Most of the medicare spots were basically frozen decades ago until recently. https://www.cms.gov/newsroom/press-releases/cms-funding-1000-new-residency-slots-hospitals-serving-rural-underserved-communities
I am totally for expanding med schools, residency spots, and importing doctors with appropriate credentials--I appreciate your insights above on European training.
My colleague did months of rotations in Australia and came away horrified at their training for what that's worth....
I am not a member of the AMA, or generally a fan of most specialty society positions on "business and workforce" issues.
I only exist here to correct the misperceptions that there is a set cap of some meaningful sort in the way that people commonly use the term "cap" to mean.
I agree, there isn't a cap, the same way there isn't a cap on housing. However the way the system is set up you generate a shortage and residency is where the shortage manifests. The easiest way to fix that is probably some increased Medicare funding for primary care residencies in undeserved areas.
I'd also say a lot of mid-level proliferation is a work around on this. Whatever you think of foreign trained docs, they're better than an online NP grad heading straight into independent practice.
To be honest, I *would not* visit a random rural hospital here *in* the US...
They are good for some things like fishing-related or farming-related injuries, but I would definitely get my cancer care (or more specialized care in general) elsewhere. Primary care is probably more or less equivalent, there are a lot of good rural family doctors
"...fishing-related or farming-related injuries, but I would definitely get my cancer care..."
I originally wanted to do a residency in oncology, but wound up doing five years of fish-hook removal.
When I play golf with the other docs, they make a lot of barbed comments.
I think you're trolling . . . .
And they fell for it, hook line and sinker!
I cheer all attempts at humor in SB comments. Even ones that flounder about. :-)
"I cheer all attempts at humor..."
I'm glad you liked it! I'm not above fishing for compliments.
I don't know. Obviously there is selection bias skewing this but the amount of "oh my god, this medicine hasn't been the standard of care for this problem since the 90s" or "how could they have never considered to run this test or treatment when the chart indicates that the patient has been complaining of this problem for years?" I hear from my wife about patients ending up in the urban hospital she works at after having their care mismanaged doesn't make me feel great about the quality of care in a lot of rural settings.
I accept many patients transferred to the big fancy university hospital from small rural critical-access hospitals. Some for clear good reasons (complexity) some because the small hospital is just failing to do what they clearly need to do. Yes, there is often a knowledge deficit in the small places--I don't think they see enough, do enough to keep up their knowledge and practice with anything but the most very common things they care for.
For me though, my hesitation is more based on the limited resources in case of something going wrong, something new and bad found, or just general lack of 24/7 coverage for important things (it's often ~12/5).
COVID made all this 10x worse.
I would allow primary and outpatient care. But that is not *hospital* care.
Agreed. At the same time, NPs who aren’t doctors at all are increasingly replacing doctors. And the trend continues. Now you have nurse anesthesiologists etc. You’re telling me that an EU trained doctor would on average give you less qualified treatment than an American np? As others commented, o think a rigorous regulation that very much cuts hurdles for doctors trained in. *specific countries* only would be a good thing. Not goin as far as MY but not accepting the untenable status quo either.
US training is indeed better than what exists in many other countries, but is it better than the EU, for example? I’m very skeptical having lived both in the EU and the US. I would only go to an American doctor for an emergency, and I always wait to go back home on vacation for doctor visits I can schedule.
"I would only go to an American doctor for an emergency"
Because of the quality of the doctor or the quality of the health care system? I feel like the latter is 90% of what's important or more but doctor training only impacts that other 10% that is doctor quality.
Good question. I only have anecdotal evidence to offer. My American experience says that doctors will spend as little time with you as possible and try to do as many tests as possible so that they can charge you. I view them more as salesmen than doctors to be honest. I’m used to the doctor taking her time to listen to you before anything, and then also taking the time to explain to you in detail what’s going on, and I haven’t seen that in the US at the times I needed to go to a doctor. I also know that American residencies tend to be more brutal than the ones back home, and you end up with doctors that are more sleep deprived than normal. I don’t want a sleep deprived doctor!
However, nothing here is data. The only data I’m aware of say that the US has unusually short life expectancies for the wealth it exists here. But that could point to problems at many areas of healthcare other than doctor training.
My anecdotal experience with GPs has been really good - they've always taken a lot of time to listen and answer questions - but maybe I've just gotten lucky.
With other care I find that I have to wait a long time and barely see the doctor. It just seems like there's staffing shortages across the board, at least that's my explanation but I don't really know or have a point of comparison.
"unusually short life expectancies for the wealth" - I'm skeptical of healthcare explanations for that gap. Or at least I'm skeptical healthcare is the majority of the explanation. There's too much geographic and demographic variation in LE between counties, states and demographics within the US for healthcare to be the main driver. It could be one driver, but other cultural or lifestyle factors most be at work, too.
Why so skeptical? US stands out in western world for low and decreasing life expectancy. It also is *unique* in the terrible healthcare system and lack of any kind of universal coverage. I see no other potentially relevant factor in which the US stands out so clearly from peer countries. Why wouldn't you think this is extremely plausible a priori as at least one significant factor explaining the phenomenon?
“Together, injuries (drug overdose, firearm-related deaths, motor vehicle accidents, homicide), circulatory diseases, and mental disorders/nervous system diseases (including Alzheimer’s disease) account for 86% and 67% of American men’s and women’s life expectancy shortfall, respectively.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9154274/
American Exceptionalism isn’t just the good stuff, you know.
As a relevant factor, I'm not quite so skeptical as I must have sounded. But I'm very skeptical that it's the major or only factor.
One part I didn't mention is that I'm just somewhat skeptical of our healthcare systems ability to treat non-acute issues. If I have an appendicitis or a heart attack, I'll be glad I live near an ER. But if I needed a plan to lose weight or eat healthy I'm not expecting a doctor to prescribe that for me. And in between the acute stuff and the lifestyle stuff there's a huge volume of elective procedures and diagnostics that I have a very skeptical view of. I just don't think they move the needle much and can do as much harm as good.
I don't have great evidence for this latter POV other than "lived experience". And I may be entirely ignorant of how much better Western Europe is on one of those 3 areas of healthcare: lifestyle, acute, elective/diagnostic. A good source of evidence that I may dig through at some point is mortality data during covid when hospitals stopped doing elective and diagnostic work: many editorials predicted people would die of cancers, etc.. due to lack of screening but as far as I can see that never happened.
The part I did state above, though, is there's so much non-healthcare variation in American Health. Non-college degreed people live many years fewer than the degreed, but in general we all go to the same hospitals for acute stuff and are left to our own devices wrt to lifestyle (and as I said I don't think the elective stuff does much anyway) so lifestyle is probably what explains the gap.
I'm glad about your GP experiences! I mostly have that type of visits when I go home on vacation, so I really only use the medical system here for relatively urgent staff. For the lifestyle conversation, check my answer to Mark below.
The time limits are set by insurance companies and the government, and probably influenced by low supply of doctors (it’s still hard to get an appointment). The excessive testing is dumb but a separate issue - lots of medical training here is based on highly conscientious people who think you need to test for every rare disease under the sun. And insurance companies/Medicare will always reimburse, so it’s never challenged.
If this was driven by doctor greed, then academic hospitals that pay on salary would have lower costs of care than community hospitals that pay more based on incentives, but we don’t see that pattern. It still leads to excessive costs either way, but assuming all doctors are bad people isn’t any more useful than saying that all academics are bad people because tuition at US universities is too high
And I think a lot of people *want* a bunch of tests/meds, so for doctors that can be the path of least resistance. I know a lot of people in my middle-aged cohort and older who are convinced that they're sick a lot of the time...
Good insight.
Academic hospital cost >> community hospital cost.
Academic hospital care ?? community hospital care...depends on the issue for; for some complex stuff there just isn't much comparison (since it doesn't happen at community hospitals, but for other things (particularly routine things) a great community hospital could be far better.
I'm at a big academic place and my income changes based on the number of patients I see is <10-15%, and it is not affected whatsoever based on tests, consults, whatever that I actually order/do (I am not a proceduralist).
First, I'm not saying that all American doctors are bad people! I'm saying that from my anecdotal evidence (and not data) I would describe my interactions with doctors here as mediocre at best. I said that I'm not sure that points to training issues even. The only direct knowledge of a problem with doctor training I have from the US is that the residents I know here are far more overworked than the ones back home, and I don't want a tired doctor.
However, I find it rather implausible that American doctors are such an outlier in conscientiousness. If insurers paid providers (hospitals, clinics, etc) a fixed amount of money every month regardless of the number of tests they did, I suspect that American conscientiousness would go to European levels.
Didn’t mean to imply that, but the relationship between money and healthcare implied by the salesman model is wrong. The difference between US and Euro doctors isn’t that we’re paid more for doing tests, otherwise you would see that relationship based on practice setting, and academic doctors would spend less since we are on salary. It’s that nobody tells us “no”, so we assume/feel that all tests are justified (as opposed to Europe where cost control exists). We also have a very human bias that the work we do is useful - not always true! And external cost control can fix that.
The better analogy is an overfunded bureaucracy where nobody ever says “no” to a funding request, not a sales team where our only goal is to sell a product.
If your doctor takes longer than 15 minutes in the exam, her emr system dings her for taking too long and her hospital system will penalize her for not seeing enough patients. Time is money and throughput is the only way we can get these people referred up to the real doctors who earn the hospital its money.
Also US lifestyles are bad. There are other factors in life expectancy beyond the healthcare system. I promise I don’t control how walkable anyone’s neighborhood is or set the price of junk food/alcohol.
I don't buy the junk food argument. Junk food also exists in the EU, and it is a cheaper option than healthy food there as well. However, I'm also used to having a long-standing relationship with our family doctor there with whom I have a chat every year, so if he thought my blood tests show that I'm not eating healthily, he would very forcefully let me know. (And he does do that from time to time.) Most Americans I know here don't do that type of doctor visits. (I mostly know people my age here, of course.)
I will give you the higher number of car accident deaths and the wider availability of guns as lifestyle reasons for shorter lifespans in the US though. However, I would expect you to concede that American doctors gave a lot of powerful opioids to people without appropriate supervision (my understanding is that you can't get this type of drugs with you at home where I come from) and that caused a lot of avoidable deaths here.
Fat but active is vastly better in terms of health outcomes than fat and inactive. Not quite as good as “not fat and active,” but within shouting distance.
European and Asian urban planning and transportation almost guarantee the former outcome even for people whose diets are unhealthy on the whole. American urban planning and transportation virtually assures the latter outcome for people not actively trying to avoid it.
I think its likely both sides somewhat overstate the impact here... I was doing some quick googling and it looks like Canada makes it quite a bit easier for foreign-educated doctors to practice (basically one year of residency + you have to take a test provided you went to one of the schools on their list). But Canada still has pretty high doctor salaries.
Biggest problem in the US seems like the US is overindexed on specialists vs. primary care, but that seems like a case where it'd essentially be a win-win: primary care doctors could help with the shortage but I don't think salaries would come down that much.
At least part of the specialist issue is demand, lots of people want to see dermatologists or gastroenterologists for things that might not get treatment in other countries. If we really wanted to disincentivize this we would probably need insurance companies (or the government) to deny more claims, which might be justified for things like back surgery that are expensive but useless. And even cancer screening programs are mostly controversial aside from a few clear-cut cases like colon cancer screening. But probably a tough lift politically so I think expanding supply is more realistic than telling Americans that prostate cancer screening doesn’t pass cost-benefit analysis
yeah I agree with that, create more primary care folks rather than getting rid of specialists.
On the nursing shortage: a major contributor there is that a major educator of nurses are community colleges, and community college nursing instructors usually make less money than nurses who are qualified to teach.
I like Supply-Side Matt.
If repeal of the Jones Act were on the list, this essay would be a winner.
Jones Act delenda est
Another way to promote growth is to add a lot more automation to seaports and freight rail. There is a lot of low-hanging fruit that automation would make more efficient. Of course that would mean fighting the unions.
Freight rail is mostly provided by (regulated) private companies who got way more profitable in recent years while quality of service has, if anything, deteriorated. Seems like regulators just got comfortable with way higher returns for the operators and that should be rethought.
By no means an expert and would love someone who is to chime in, but as I understand it one of the major issues that rail companies have pushed for over the last decade has been to have trains leave on time. Historically a lot of trains were delayed because companies wouldn't get their stuff loaded on time. Those delays required much looser scheduling to accommodate and were much less efficient. Moving to a - it has to ready on time or its not going - approach is definitely a change in the quality of service, but I don't know that its worse.
*they have also run their staff much more heavily which given that it appears the railroad workers might strike, is going to be bad for all of us.
The industry appears to admit service quality is bad at the moment, e.g. https://www.trains.com/trn/news-reviews/news-wire/railroads-report-on-time-performance-to-federal-regulators-for-first-time/
Interesting and thanks for sharing! Be curious how that compares to historical averages. It does seem to echo what I've read elsewhere that they understaff and that has been a major driver in both poor service performance and in the labor issues where conductors are feeling overworked.
Right...which runs pretty contrary to blaming the unions, as the OP of this little threat did.
To be fair, just because management is being stupid in some way, doesn't exclude the unions from also being foolish. Tis sadly possible if not likely for both to happen.
Freight and longshoreman unions fight tooth and nail against automation. Heck, freight unions fight against one-conductor trains.
You are correct that we should do more to expand the supply of healthcare services, but you kind of skipped over the reason why it’s so difficult to do. One reason why rent seeking is so common in medicine is because doctors are politically powerful. That’s not only because they are affluent and educated, but also because they are an extremely well trusted profession. If a doctor goes around telling their patients that some new healthcare rule is going to make it harder for them to give good care, then those patients will oppose the change, even if it’s a change that is beneficial for patients. If your doctor says something is bad and a politician says it’s good, most people will believe their doctor.
Was a big discovery when I did field work promoting ACA; that insurance companies were not actually the biggest villains in our bloated health care system. Attacking insurance companies as the "evil" ones* was probably smart politics because as much lobbying power as they had it was dwarfed by the lobbying power of doctors for the reasons you outlined.
Obama got a of flack for his "if you like your doctor, you can keep it" line as for a decent number of people it turned out to not be true. And I think it's fair for GOP (or other Progressives who want M4A) to point out that this wasn't strictly true. And yet if I could go back in time and advise Obama, I'd tell him to keep that line in his speeches and Town Halls because of the politics. You basically needed it to get it passed and I think this is one of those situations where the consequentialist framing is right (the end result justifies the "only most true" aspect of this line).
*not biggest villains doesn't mean they weren't or aren't villains. Insurance companies finding ways to deny claims that were seemingly part of someone's insurance plan was definitely a thing and they deserved the criticism that came their way.
Ah yes, Politifact's "Lie of the Year." I always wondered what the standard was for turning Obama's statement into a lie (or the Lie of the Year). If one single person hadn't been able to keep their plan, would that have been enough? Two? Thirty million? You use the term "a decent number of people" -- any idea what that translates to in actual numbers?
BTW, I agree with you on the questionable singling out of insurance companies. That has always been Bernie's and Warren's go to move, including the other villains: "Big Pharma" and hospital administrators. Somehow, there's always one group that *never* gets mentioned. On the tip of my tongue . . . rhymes with "proctors" . . .
Yeah. Doctors aren’t mentioned in those attacks because it’s really obvious that the attack would backfire. People trust their doctors, and they especially trust their doctors more than they trust politicians. It misleads people a bit but the alternative is making healthcare reform ideas incredibly toxic because most people will refuse to think of their doctor as a bad guy in the situation.
Yup.
The "'If you like your *health care plan*, you can keep it" [1] line really was a lie because part of the *purpose* of the ACA was to ban many types of plans. E.g. the ACA required all healthcare plans to cover a long list of things, so plans that didn't cover contraceptives were banned, and no one could keep them. I'm guessing that the vast majority of pre-ACA healthcare plans were not up to ACA standards (lifetime limits, which were also banned, were pretty common), so arguably, basically everyone lost their plan and got a different one in its place. (Probably a more expensive one given the expanded coverage.)
I think the mitigating factor is that HMOs suck, so I doubt anyone really liked their plan. At best, they just disliked it less than the alternatives... Was anyone unhappy that they could no longer get a plan with lifetime limits? I doubt it. Lifetime limits suck. Were some people unhappy that they could no longer get plans that didn't cover contraceptives? Absolutely. See Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania; Zubik v. Burwell; and Burwell v. Hobby Lobby Stores, Inc.
EDIT: [1] has an example of someone who was unhappy about the changes. I doubt she was the only person unhappy about expanded coverage:
"One example: PBS Newshour interviewed a woman from Washington, D.C., who was a supporter of the health care law and found her policy canceled. New policies had significantly higher rates. She told Newshour that the only thing the new policy covered that her old one didn’t was maternity care and pediatric services. And she was 58."
"The chance of me having a child at this age is zero. So, you know, I ask the president, why do I have to pay an additional $5,000 a year for maternity coverage that I will never, ever need?" asked Deborah Persico.
[1] https://www.politifact.com/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/
The fact that we don't have hard numbers for the number of people who couldn't keep their doctors speaks volumes as to the absurdity of Politfact calling it "Lie of the Year". Its seems definitely more than a handful. But I can't seem to find just how many.
Regarding Bernie and Warren, I agree signaling Big Pharma or hospital administrators is mostly about politics as they make for good villains. But I'll semi-defend them in that there really are some terrible hospital administrator practices and insurance practices worth condemning. Centering your critique of the American health care system around these two entities is probably not entirely honest, but it's not entirely dishonest either if that makes any sense.
"who couldn't keep their doctors speaks volumes as to the absurdity of Politfact calling it "Lie of the Year"."
The lie of the year had nothing to do with keeping doctors. The line was "If you like your **health care plan**, you can keep it" [1]. He did often mix healthcare plans and doctors together (e.g. "If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan." [2]), but only the health care plan part was the lie of the year. Serious, read [1]. The word "doctor" doesn't appear once. [1] Also notes that about 4 million people had their plans canceled. Granted, I have no idea how many of those people liked their plans, but surely some did.
[1] https://www.politifact.com/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/
[2] https://www.politifact.com/obama-like-health-care-keep/
Almost any working age, non-disabled person has more to gain from growing the economy than further expanding the welfare state. Single parents of preschoolers are the biggest exception as the costs of child care swamp most younger peoples’ wages. Still, a solid 65% of adults do better by growing the economy than expanding benefits. This is the beating heart of center-right politics. The 35% who do better expanding benefits are numerically fewer and generally unproductive and often unsympathetic.
The main thing the welfare state can offer the median earner is security. I don’t trust an insurance company to take care of me if I get sick (I recall one claiming my wife’s cancer was a preexisting condition even though she’s had continuous coverage for years) and I sure as fuck don’t want my basic needs in old age to depend on the stock market.
>>Almost any working age, non-disabled person has more to gain from growing the economy than further expanding the welfare state<<
That's undoubtedly true as far as it goes, but there are clearly very large numbers of people who would benefit from both. You know, a parent who does well by getting a better job AND sees a real benefit from affordable childcare, or the 22 year old who gets good education partly subsidized by wealthier people (so no burdensome student loans) but is is also helped by a robust job market upon graduation.
Also, I've been trying for years to find evidence of a tradeoff between A) size of a country's welfare state and B) the strength of its economy. And I can't find much. I mean, Denmark's pretty freaking rich!
I agree with your general point about economic *security*.
The median parent is better off with subsidized child care as long as said care is funded by a progressive income tax. If were funded with a flat tax or a sales tax, that would basically transfer income from the median parents late career to the early, child residing part of it. That might still be a good trade off, given that most people face more income constraints at 30 than at 50.
Yes, one of the things people don't understand about the case for public funding of child care is that it's essentially a form of income smoothing (allows people to spread payment for things that are really expensive in about 5 years of their life over a longer time period), which is particularly relevant for higher income professionals in paying for child care, since most are not able to save for it as for retirement, higher ed, etc. (And is obviously also an issue for lower income families who do not have the money to save for those things in any case)
I understand why we do it, but comparing the US to Denmark or any other small country seems weird to me. Its more comparable to Virginia - about the same size, though Denmark has 30% fewer people.
Having a very large economy makes it easier, not more difficult, to fund a robust safety net. Small countries like Denmark are vastly more vulnerable to exogenous shocks. I think Finland’s early 1990s downturn was comparable to the US in the early 1930s in terms of GDP shrinkage. Moreover, there’s not as much demand for their currency (nor any other county’s currency) as there is for the dollar.
In terms of economic capacity, I would agree. However, 300+ million people are going to have a far larger spectrum of political preferences than 5 million and building a functioning system that addresses that spectrum in a meaningful way is going to be more difficult. In Denmark, if 3% of the population objects to something, then you have 150k people of whom maybe 10% or about 15k people are die hard believers. In the US those number equate out to 10 million and 1 million. Modern communications mean those 1 million people can actually unite behind something in a meaningful and forceful way so that overcoming their objections is a just politically more difficult. Its the reverse effect of there being enough people in the US to support "Slow Boring" and also a bunch of other newsletters while that isn't true in Denmark.
In practice you're actually describing current center-left politics, at least how it's practiced in the United States. Take a look at who supports expansion of the Child Tax Credit. It's Democrats and basically Mitt Romney alone on the Republican side (I know a few other GOP politicians and pundits have given tepid support, but the number of Republicans currently supporting some sort of CTC expansion is very small). In addition, I think Matt (and many others) has demonstrated that huge cuts to Medicare, Medicaid and Social Security are still very popular with GOP elites (if not voters). It's a big part of Matt's thesis why Trump won in 2016 as he essentially took off the table entitlement cuts (even if it turns out he was just lying).
I suspect too that you probably support Unemployment insurance with some sort of sunset of eligibility? I'm guessing also you may have supported the original Stimulus checks (the February 2021 stimulus seems a mistake but the previous ones I think we can classify as success). I have no idea, maybe you don't. But I'm asking only to engage with the idea that you're actually describing the policy agenda of a typical center left Democrat more than you are a typical current center-right Republican (current being an operative word here)*.
*Only thing you didn't mention as part of current welfare state is SNAP benefits. Not that important, but again curious if you support expansion, current benefits or cuts. Again, unpacking you're claim about "center-right".
Is there a way around basic needs in old age depending on the stock market? If the projected economic growth doesn’t materialize, pension obligations are unlikely to be paid. Meanwhile pensions are at additional risk from mismanagement and theft, while stock held through a regulated brokerage might fluctuate in value, it’s at no real risk of walking away.
yes. it’s called social security and getting your house paid off
In what scenario is the long-term value of the stock market in the toilet, but the social security checks keep flowing?
I think you make a very good point, but it also goes the other way! In what world can the stock market have good returns but the US economy not be growing sufficient to cover SS payments?
The GOP can get control of the federal government and decide to stop or severely cut back on Social Security. We have a whole lot of regulation and insurance infrastructure to make sure nothing like that happens to your Fidelity account.
You misunderstand the potential regulatory risk with your "Fidelity accounts." It is very possible for Congress (most likely Democrats) to pass legislation that would change the tax treatment for those accounts negatively. Obama proposed several items in his budgets that would have had significant impacts on retirement accounts, including a lifetime cap on the amount that could be tax sheltered, Biden has proposed taxes unrealized gains, etc.
I hope your wife recovered well and I hope you don't mind this question that could feel a bit personal - but what happened with that insurance claim? Did you dispute it? Did it resolve in your favor?
I ask b/c I work in a different area of insurance where everybody seems to err on the side of extreme caution wrt claim eligibility. In other words you have to be grossly ineligible and basically fraudulent to be denied, at least from what I've seen. Mistakes can still happen, so maybe that's what it was, but if not, it's crazy, for me personally, at least, to hear about a situation where the insurer was so aggressive in denying the claim.
That transition, in the medical insurance industry, seems to have come about at least in part because the ACA simply blew up the entire system of preexisting conditions and the rent-seeking which had built up around it.
There are far fewer plausible justifications for denying coverage now than was the case in 2009.
Thank God.
Thank Obama. I have a lot of criticism of the guy, but that legislation was a huge achievement.
It's interesting, though, to question whether we could have gone too far in the other direction. I have basically no knowledge or evidence that that's the case, partly because as I said, I don't work with medical insurance.
But in the line of insurance I'm now involved in, I've yet to see a single error of the type "denied, but was eligible". But I've seen hundreds of the "accepted, but was actually fraudulent, lying, etc..."
Preventing single cases of "denied, but was eligible" feels more important to me than preventing single cases of "accepted, but was fraud" but there's still some trade off there.
Again - I don't know much about medical insurance. I'm sure fraud existed then and exists now but you could probably tell me more about the relative levels of fraud vs rent-seeking insurance companies denying for BS and how they've changed over time.
We disputed it and they paid eventually. However, it was horribly stressful to have an insurance dispute when we were already dealing with cancer. I was 26 at the time, earned like $54k and had very few savings
And of course children, who would likely most benefit from a stronger safety net, cannot vote. (IIRC, MY has been a supporter of eliminating age limits on voting, which if I'm correct is one of my favorite of his more idiosyncratic takes)
I never understood this argument:"children don't vote, so their needs don't matter to politicians." True, children don't vote, but their parents and grandparents do. Don't parents consider their children's wellbeing when voting?
Even if we stipulate that parents' votes 100% of the time align with the interests of their children (which is a big if), a parent only gets one vote to represent both themself and the child, who are two people (or more in the case of multiple children), so the perspectives of children and their parents are still weighted less, relative to population, than those of other folks. Children are reflected in a state's or district's population for representation numbers, but don't have equivalent representation in voting.
What are your thoughts about allowing employees of large corporations, eg. Starbucks, Amazon, Apple, Walmart, to form unions? Currently employers can fire union supporters with impunity and retaliate in other ways. Do you believe that empowering workers to engage in collective bargaining would be a way to address income inequality without cost to government? (By the way "right to work" laws derive from white supremacy.)
"(By the way 'right to work' laws derive from white supremacy.)"
This seems difficult to reconcile with the well-documented history of racial discrimination by labor unions into the mid-20th Century.
"(By the way "right to work" laws derive from white supremacy.)"
And are designed to deprive you of your right to unionize.
If a conservative position is called "right to X," you can bet it is designed to take away your rights.
“By the way ‘right to work’ laws derive from white supremacy”
But of course they do.
Speaking of upward leaky buckets I’d love to see fixed, we should really be getting rid of tax deductions, and increasing the standard deduction. If something is important enough that it deserves subsidy, refundable tax credits are the way to go.
One of the few things I liked about the 2017 tax bill is the changes it made to the mortgage interest tax deduction and deduction for state taxes. Of course it was done for terrible reasons ("revenge" against states that didn't vote for Trump) but speaks to a path forward to how some of these reforms can happen. "Those fancy pants kale eating elites don't think decent hard working Americans belong in their town. That's why we need to upzone". A better speechwriter will have something better than I wrote, but I think the sentiment I put forward is a political path to upzonging where needed. It is telling to me that for all the ways I think Youngkin is terrible, he does seem to be on the right side of the housing debate.
The whole idea of NIMBYism (and anti-gentrification) is to get the marginal high income transplant to fuck off. Restricting housing supply to raise their rent is one way to do that, raising their taxes to reduce their income is another.
NIMBYs are asset rich but not high income; any collateral damage to their own tax bills are minimal and probably worth it to them.
My favorite extremely politically unpalatable opinion is we should eliminate the retirement savings subsidy for affluent people (401k, etc).
I agree in principle but the question becomes "how?"
The timelines on which these things play out are so long, and the law obviously can't be applied retroactively, so there's no good way to untangle the ratfuck without lots of people feeling they were screwed over.
In the short term doing this would essentially be yet another transfer from young to old.
I would be opposed to it, but surely the easiest way to eliminate that would be to just reduce the contribution limit to, say, $5000 a year or whatever the median contribution amount is.
I don’t think making retirement saving more difficult is a good policy goal.
I don't either -- that's why I said I would be opposed to it.
Still basically a transfer from young to old, though?
Um, no, not all? If anything it's the opposite -- the tax benefits from a 401K go to present workers, not retirees.
I mean that *changing the rules* would be a transfer from young (who no longer have the ability to accumulate savings with tax benefits going forward) to old (who still enjoy decades of accumulated tax benefits that will not be retroactively taken away).
"There's certain type of economist who loves to dazzle people with examples of unintended consequences or.... "
It's worth being perfectly clear here, this certain kind of economist is always a conservative trying to stand athwart history yelling "Stop" because, as we know, "It is difficult to get a man to understand something, when his salary depends on his not understanding it." It's classic Albert Hirschman in his book "The Rhetoric of Reaction." It's an unfalsifiable claim that begs the question in a certain way, because, obviously everything has unintended consequences, many of which can also be good, but we would never know unless we try. Of course these conservatives go on to then talk about "human nature" and minimize the potential intended consequences of collective action, and how it'll only ruin the incentives currently baked into the system that have gotten us where we are today.
“…this certain kind of economist is always a conservative…”
When I read that my first thought was, ‘It’s always a progressive-type, building up the case for: Market Failure, therefore my favorite form of government intervention is clearly indicated.’
There's a certain type of left winger that defaults to being very averse to any sort of major reduction in government regulation, and also averse to growth for fear of unintended side effects and externalities. It's articles like this that they need to read to understand how some of those restrictions cut against their ideological worldview.
Nice statement of what I think of as commonsense Liberalism.
I do, however think we should not overlook the elephant in the room: the federal deficit. A dollar borrowed comes mainly out of investment. A dollar taxed, even from high income people, comes somewhat out of consumption. Moreover there are ways to tax that have lower deadweight losses then the one we have.
Federal business taxes are riddled with exemptions and special treatment of one and another sector and activity that reduces the value of private investment. Taxation of income's only deadweight loss is reduced effort and entrepreneurship which is bad but I think really miniscule. So it would be a big deal to reduce business taxes and raise personal income taxes.
A capped wage tax for financing SS and even the uncapped wage tax financing Medicare fall somewhat on (reduce) savings. A VAT falls mainly on consumption, including consumption of high income and non-wage income earning people. A dollar for dollar shift would be growth promoting but of course at the shift point we could also raise revenue collections to match benefits, another contribution introducing the federal deficit.
Taxing capital gains at a preferential rate and rebasing gains on inheritance has an advantage of offsetting (more or less than) the gain coming from the inflation. We would be better off to just index the inflationary gain and tax it at the person's regular rate.
A tax "deduction" is worth more to a high marginal tax rate person that to a lower marginal tax rate person. To the extent that deductions are incentives for certain kinds of consumption (charitable giving, health care and insurance spending, owner occupied housing services) over others the incentive should be the same regardless of the consumer's tax bracket (or even greater for lower income people?) We should replace deductions with partial tax credits (which would also eliminate s lot of complicated caps and exclusions that exist to partly offset the inherently regressive nature of the deduction).
And although I'm sorry it not already popular, all right thinking elitists ought to be pushing for a revenue neutral tax on net CO2 emissions.
It’s not just the price of gasoline that’s a racial justice issue, much more important is the push to outlaw internal combustion (ICE) cars. New York and California have already banned the sale of ICE vehicles after 2035 and are phasing them out before that. I would be very surprised if other states, and perhaps the Federal government, didn’t follow suit soon. If you are upper middle class suburban dweller with a driveway and a garage, switching to a Tesla might be a bit more expensive but is definitely manageable. But if you live in a dense urban environment, in a multi family house, and park on the street, how is that going to work for you? And which racial groups are more likely to be in the second group?
I think this may an under-examined problem. I just attended a community meeting here in West Los Angeles on a proposed 200-apartment complex. The complex would have 200 parking spaces (due to reduced parking requirements -- good!) and the developer said that of those 200 only 25 would be for charging EVs. However, he said, another 65 would be wired to allow EV charging in the future. So the majority would not be built to ever allow charging. Now this building is obviously meant to last many decades, and California will forbid ICE car sales in 12 years. What are the future people parking the ~115 EVs in their apartment building supposed to do for keeping their cars charged? You might think the developer would see this as a problem but >12 years is a long time from now and I guess it's just not something he sees as worthy of increased construction costs. But it sure will be a problem down the road.
Whether having chargers at 40% of parking spaces is not enough or more than enough depends on the type of charger. If these are all L1 changers, then 40% is likely not enough. If they are mid-range L2 chargers then it's more than enough. A mid range L2 will deliver 300+ miles of range overnight, so the average car would only need to recharge overnight once(ish) a week.
I perhaps am not as trusting as you to not worry that my fellow residents won't just grab the first parking spot whether or not their car needs charging, leaving me steaming when I see that their car isn't even plugged in and my battery is almost dead.
I'm just pointing out that the capacity created by 40% is plenty with decent chargers. I don't trust your fellow residents to manage it on their own either. There will have to be some kind of process in place to prevent folks from charging to full in an hour, then leaving their cars connected all night -- Idle fees, times slots, whatever.
"if you live in a dense urban environment, in a multi family house, and park on the street, how is that going to work for you?"
Smart parking meters everywhere, with charging cords. So when you park at the curb, you plug your car into the meter and it automatically recognizes your car and bills you for both the parking space and the electrical charge.
Requires cities to make a huge infrastructure investment though.
We should in general ease off the electric vehicle subsidies/mandates over the next decade or so. They've accomplished the purpose of kick-starting the EV industry, and EVs are good enough to compete with ICEs on their own now. Phasing back to a pure market competition will help EVs continue to develop by keeping pressure on them to improve in areas that aren't at parity with ICEs yet.
(I drive an EV for what it's worth.)
I feel like there’s so much fud being spread about the climate that I genuinely don’t know how fast we need to act.
I don’t think we’re on the verge of some mad max climate collapse but because I think even 2 degrees really does seem quite bad especially if we’re counting the effects on wilderness qua wilderness and we need to move really fast. I’m open to arguments that I’m wrong but it seems that we need to say we’re not going to let people dither forever.
I want to up front admit that I haven't done a deep dive on the emissions situation here and I'm going off general principles.
My basic belief is that EVs are really great and are going to eat the lunch of ICEs even if the subsidies and mandates are slowly turned to zero, and that attacking the long tail of remaining cases where ICEs have legitimate benefits will have marginal emissions effects and some significant cost to the lives of people forced into bad EV solutions.
I also tend to believe that everything in the broad category of environmental policy has a systematic bias that leads it to overweight interventions that are create highly visible lifestyle choices to consumers and underweight invisible industrial changes, and so we should redirect EV subsidies to, say, nuclear or geothermal research.
I still have no clue how the low-end of the used vehicle market is going to develop with EVs. If they require costly battery upgrades (e.g., $22k for a Tesla replacement) ... they'll always stay in that more off-lease used segment of the market and never make it down to the Buy Here Pay Here segment that's looking for a < $500 monthly cost. I thought the solution would be to design more modular / quick swappable battery packs but the newest Tesla and Rivan designs have gone in the other direction to make them more structurally integrated.
To your point above ... I'm not sure if the "long tail of remaining use cases" is like 2% (i.e., heavy duty trucks, extreme polar climates) or more like 20% of the lowest-cost transport market.
I think one issue is that right now, with subsidies, they've kind of been able to ignore that question. I got my Bolt for a criminally low cost, partly because the government is subsidizing my high income ass, and partly because the car companies are subsidizing it because they need to build out their EV offerings. But that won't work for volumes necessary to replace the Toyota Corolla market, and the companies should have to work out how to sustainably make a sub-$20k vehicle.
“I still have no clue how the low-end of the used vehicle market is going to develop with EVs”
I would imagine with cheap, non-OEM replacement cells. You know, of the sort that burns down your house when you leave a hoverboard charging under the tree on Christmas Eve.
“ But if you live in a dense urban environment, in a multi family house, and park on the street, how is that going to work for you? ”
Why do you assume the built environment won’t adapt to new technology? You as stating as fact that when X happens Y won’t be added. Why?
Western civilization seems to be zeroing in on the next 15 or 20 years or so as a time of great transition. Indeed, we are told regularly that if don’t make this transition, and fast, we are doomed. As Obama put it is Paris, in 2008, if we don’t act quickly to end the use of fossil fuels the Earth may well be uninhabitable by 2100. Many others have made similar if not more aggressive predictions. And yet, when we think of the scale of the transformation required we can see that these timetable are grossly unrealistic to say the least.
The transition from ICE vehicles to BEVs is hardly the most ambitious part of this agenda but let’s focus there for the moment. A complete transition to BEVs would require about 50% additional electrical power above what we generate now. In addition, we will have to replace the power we now generate with oil, coal, natgas, and, some say, hydropower. Could we adapt? Perhaps, at great cost and given time. Can we adapt on the timetables being demanded? No.
“As Obama put it is Paris, in 2008, if we don’t act quickly to end the use of fossil fuels the Earth may well be uninhabitable by 2100”
You didn’t believe him, did you? I mean, he lied a lot.
Just to be clear ... the EV mandates are for *new* vehicle sales. There are 285m registered vehicles in the US and just 1% are EVs. The average vehicle last 12 years. They don't outlaw existing ICE vehicles from operating. And they shouldn't - they need to be run until fully depreciated to maximize the carbon cost of production. Current projections are that - maybe - 50% of vehicles in the US will be EV by 2040. All this to say ... nothing is happening fast here and the multi family housing residents in your example will be driving ICEs into the 2050s as the existing ICE vehicles fall down their depreciation curve.
The mandate for EVs actually start in 2026 at 35% and ramp up from there to 100% in 2035. So it is happening a bit faster than you think.
Air pollution is a more serious health risk for people of color.
To address what is clearly the point of your comment...seems like the Cowboys are front runners to sign OBJ. But wouldn't be surprised if the Bills come in with an offer to try to match what the Chiefs did getting Kadarius Toney from the Giants.
What is that little text at the end of your post - I think it says OBJ, but in a strange font with a dashed line around it?
But also, "Air pollution is a more serious health risk for people of color" is it? Because more POC live in dense areas?
There’s an old joke about God announcing that he will end the world in one week. The next morning’s headlines:
New York Post, “God to Mankind: Drop Dead!”
Daily News, “Long-planned Increase to East River Tolls Delayed Indefinitely”
The New York Times, “World to End in One Week; Women & Minorities Hardest Hit”
I can remember now who was the female editor at the Times who was publicly fired several years ago but, as she was also Jewish, I was profoundly disappointed that no publication ran the headline: "New York Times Editor Fired: Woman, Minority Hardest Hit"
That is actually LOL
I'm about 85% sure that the "obj" is what is rendered when you enter a UTF character that the font that this site is in doesn't include a representation for.
In this case it appears to be one of the more exotic whitespaces (of which there are a bewildering variety).
In re the "OBJ" box, I've been seeing those occasionally for several months at least. I haven't been able to figure out any rhyme or reason to them though.
I assumed it was an attempt to add an emoji that didn't come through for some reason, but I guess not.
No idea what the graphic is. I've noticed Substack's been doing some weird things of late. Pretty sure that, yes, POC in the US tend (all things equal) to live in areas characterized by more serious air pollution issues. To the extent that decarbonizing the economy means one day ridding ourselves of vehicles powered by the internal combustion engine, POC should see an oversized share of the resulting health benefits.
CO2 is not a health issue. As for other air quality impacts from ICE vehicles, those have largely been minimized by various pollution control technologies. As for EVs, unless you really believe that all the electric power is going to come from windmills, then we have the pollution impact of generating all that additional power.
The pollution impact of electric power may not be zero in our lifetimes, but the amount produced continues to trend down as cleaner sources generate more power. All toxicity is about amounts, concentrations, etc.
> And which racial groups are more likely to be in the second group?
Probably more White and Asian than you'd think, because gentrification has steadily pushed richer groups into urban cores and poorer groups to the periphery
One thing not noted but I think can be included in your post is reforming the requirements to receiving a college degree and a graduate degree. What I mean is that colleges (as you have noted) are essentially designed in their structure around a world and society that existed in the 19th century. In other words, they are designed to serve only the upper crust as it existed pre-20th century. As much as I loved my college experience, I would say a lot of the classes that I had to take to fulfill my requirements for graduation were probably unnecessary and resulted in me staying in school longer than is strictly necessary. At least with state schools there should be a push to eliminate "common core" requirements and allow students to concentrate on taking classes that are needed for their major. In addition, there should be a way for students to go directly into graduate level programs as soon as they are able to. My understanding is that in other parts of the world, you can go straight into an MBA program without undergraduate classes (this may be different from country to country and it's perhaps not right out of high school, but I think I'm on pretty firm ground saying the class requirements to go to grad school are a lot less stringent). For thinks like medicine, it seems like the necessary undergraduate requirements (classes like organic chemistry) should be included in medical schools. The time spent in medical school would be strictly speaking longer, but your overall number of years spent studying to be a doctor would be shorter.
Given the huge debt loads kids need to take to finance higher education (Kevin Drum had a good post noting that the gap between Millennial wealth and Boomer wealth at the same age can be explained primary by the burden of student debt), finding ways for kids to graduate with undergraduate and graduate degrees in a quicker timeframe seems a no-brainer to me.
I love all the ideas for change in this article, but the framing and motivations were a little off for me.
1) The article asserts without evidence or limitations that redistribution is good. This is a loser of a frame -- healthy, broad middle class, sure, but redistribution has communist vibes. I’d imagine there’s some efficiency point between where we are today and equal salaries for all. The truth is, low and middle class pay some of the lowest federal income taxes as a % of income in the developed world, so there’s already a fair bit of redistribution.
I’d like politicians to align increased taxes with new benefits for all (+ some deficit reduction). It’s in line with Matt’s abundance agenda, but let’s raise taxes on higher earners to pay for things we all use.
2) Countries all over the world use zoning. It’s an overstatement to say that zoning comes from racism. (There are certainly some examples, but there were/are many motivations.)
Also, major overstatement that zoning and regulations are what makes cities so expensive. Manhattan is an island, and it just costs more to build up vs single family homes in Florida or Texas.
>>This is a loser of a frame -- healthy, broad middle class, sure, but redistribution has communist vibes.<<
That's probably right. Which is why we should never hear Democrats utter the word "redistribution." Stick with language like "fair deal" (in Australia it's "fair go") or "prosperity for all" — stuff like that.
>>It’s an overstatement to say that zoning comes from racism.<<
It may not be an overstatement in the US context?
Following MY's link it is clearly an overstatement. The linked paper, published in 1997, says that zoning was created and used by a hodgepodge range of people for a hodgepodge of uses beginning around 1900. The very first laws were about land use and building heights. Then it says that historians have primarily focused on zoning for land while partially ignoring racist motivations for some subset of the zoning laws that were used in many cities and states across the country.
tl;dl; zoning laws were "invented" for land usage, and then used for many things, racist segregation among them, until that went out of vogue in the late 60s.
The steam engine was invented to pump water out of coal mines but had lots of other applications, eg locomotives. Zoning was invented for racist purposes but has lots of other applications.
I'm sure race had and had something to do with zoning...how much, who knows. But I would say that it's pretty clear that people with a certain level of prosperity don't want to live next door to less prosperous people, regardless of race.
I mean, we’re talking about a progressive class that feels entitled to the Hispanic vote and yet insists on describing itself as “socialist” despite this being extremely triggering language for anyone who has actually lived in a Latin American socialist country. When a Venezuelan immigrant hears the word “socialism”, they don’t think of Denmark. And even a lot of Puerto Ricans have some degree of roots in Cuba.
I don’t think just looking at federal income taxes is a good way to look at the tax burden for different parts of the income spectrum. Payroll taxes are pretty significant for low income workers, and state and local taxes are often imposed with regressive taxes like a sales tax.
You’d have to look at all of those combined to see how high the tax burden is on people. The federal income tax is a tax that particularly hits wealthy people harder, but not all taxes work like that.
Western Europe does not zone for anything like the suburban sprawl of Florida or Texas. It would be a much poorer place if it did.
Are you sure? MY had a post here about land use regulations in UK, and while I forget a lot of it, I think the takeaway was that it was really bad. The recollection that stands out the most to me is that there is a gigantic green belt surrounding London and every other major city that forces sprawl an extra 5 or 10kms out from the city center, and other zoning prevents up-zoning in the cities.
It may not play out exactly as Florida or Texas for other reasons, but it's still sprawl.
Even Amsterdam has supply and demand problems. But “zoning” around the world zones for dramatically denser and less car centric places than are typical in North America.
Well maybe that's right in the sense that zoning for density is much more prevalent in W Europe - but the MY post on UKs zoning really showed a shocking amount of green space near cities, effectively where our city outer-ring suburbs would be. And he argued in the same article that it effectively made the UK much poorer.
found the post, see if you agree or not:
https://www.slowboring.com/p/the-uk-really-needs-better-housing
First, We need Democrats to register that so much regulation is counterproductive, is creating barriers to entry, stifling small business and helping to push the never-ending mergers and consolidations. Regulation needs to be really really thoughtful and Democrats are just too keen on applying it. It feels like some Democrats love all regulation, see it as a barrier to corporate power.
To help do this, and change perspectives, those of us who experience this stifling of regulation in their professional world need to be vocal but reasonable about this stuff, citing our real world experiences and demonstrate how they are counterproductive.
For example, in an effort to protect a recently endangered migratory bird, NJ moved all the oyster farming along the Cape May’s bayshore flats to one access point. Our farm was less than a mile from this point but we were mandated to move also. State of NJ wrote us a grant to make our move easier (so we wouldn’t fight them essentially) - a 4x4 vehicle to help us move, something we’d never used before and something that very obviously disturbs the same birds far more than anything we were doing previously. The whole basis of forcing our farm to move - that our no-input farming was resulting in “take” - the death of endangered birds, was absolutely absurd. But absurd will win the day when these issues become pure partisan affairs.
Meanwhile, we have literally collapsing ecosystems and we’re arguing about stinking paper/plastic straws. I wish we could get it together people.
I think the nuclear bit is key. We need an enormous push in funding for designing then building bulletproof-safe but also economical nuclear plants and just run with that as a medium term solution to climate change. We don’t have a ton more time to bicker over this and now crystal clear Saudi Arabia and Russia will blend their tyranny with their trade in oil.
We need to break the tyrants backs with energy policy.
Unfortunately, we’re just not quite able to make the renewables work as a substantial replacement for fossil THIS generation. Next one, it seems more feasible. But for now, it seems crystal clear to me nuclear is the stop gap in energy policy we need to balance our economic, environmental and geopolitical goals. Getting off the black crack from the Middle East will solve a lot of the world’s problems.
Then ending the war on drugs IS AN ENORMOUS ECONOMIC BOON. The effect of taking that economy away from the black market and putting back into legit economy is hard to overstate. Especially as so many toxic, costly effects flow downstream from the black market, those cartels, the political and economic instability they bring throughout central America. The recruitment and firepower of so many inner city gangs is crushed when they lose the monopoly on soothing substances not called alcohol. The incarceration costs, and downstream impacts of that.
And first trimester abortion as an economic freedom is very legit issue as well. If you are able to take religion out of this issue, 1st trimester abortion restrictions becomes a civil and economic freedom issue, one that is quite compelling. There is no compelling argument that an unborn fetus, too early in development to have a functional nervous system (and without stated constitutional rights) has any legitimate claims that the government should need to stand behind. Meanwhile, unwanted pregnancies often result in neglected children who often fall through the cracks.
Economy is so intimately tied to the overall health of our society and its governance.