Tag Archives: policy debate

There Are Bubbles..And Bubbles

In a recent opinion piece in the Washington Post, Perry Bacon penned a very thought-provoking defense of the geographic “bubble” he inhabits.

Bacon lives in a very Democratic area of Louisville, Kentucky. But he strongly rejects the notion that he is sheltered from diverse opinions. As he notes, it has become fashionable to assume that neighborhoods dominated by voters of one or another political party are filled with people who are participating in a “prejudice” akin to religious or racial discrimination.

Bacon was originally from Louisville, so he was aware of the political tilt of the neighborhood into which he was moving. His motives, however, weren’t political–they centered on such things as walkability and other attractions of urban life.

I didn’t move here in 2018 because I was explicitly looking to live near others who voted for Hillary Clinton. I was moving from Washington, D.C., and I wanted to keep some parts of my old life, so my wife and I sought out a home within walking distance of restaurants and coffee shops. And here’s the thing: Our current political polarization is about urbanization and attitudes about diversity and cosmopolitanism as much as issues such as tax policy. A person who says they want to be able to walk to bars and coffee shops is essentially saying that they want to live near a lot of people who voted for Clinton.

He writes that he had initially hoped to come across at least a few neighbors who supported Donald Trump because he thought they would offer insights that would improve his political writing.

On the other hand, I was becoming increasingly alarmed and frustrated at Trump’s conduct as president. I wasn’t sure that I actually wanted my nonwork hours to include people who would rave about the then-president.

Bacon writes that, by 2020, his experiences in his overwhelmingly Democratic urban neighborhood had  brought him “to a different place”–that he now embraces being in a heavily Democratic area. (For one thing, his friends and neighbors are all vaccinated, so they can “hang out” together.)

But the really important insight he shares is one that many of us still find it difficult to recognize–the fact that our current political polarization differs–dramatically– from previous political differences.

A lot of the discourse casting polarization and partisanship as bad assumes that the two sides both want a free and prosperous democracy, but just disagree on how best to get there. But that’s not what American politics is about today…

I am not against living near Republicans; I just don’t want to spend a ton of time with people trapped in Trumpian thinking, which right now is a lot of Republicans. I would have been more conflicted living in a heavily Democratic area a decade or two ago, when the parties weren’t so firmly divided into a reality-based party and a reality-skeptical party.

But that doesn’t mean I am opposed to living around people with different views than my own. Our two-party system leads to the idea that there are two and only two sides — Democratic or Republican — to most issues. But that’s not how life really is. I disagree with my neighbors on a wide range of things. We just aren’t debating whether you should wear a mask, or whether Joe Biden won the 2020 election.

I have reluctantly come to the same conclusion.

When I first became involved in politics and political philosophy, the arguments in which I participated were about means, not ends. Everyone I knew (now, of course, I realize there were a lot of people I didn’t know), for example, claimed they wanted poor families to be able to feed their babies. The debates were about what sorts of economic policies would achieve that goal without inadvertently destroying innovation or discouraging incentive.

Those disputes were real and heated, but they were different in kind from the wacko ugliness emanating from the Trumpers.

I realize now that there have always been plenty of people who really didn’t want all babies to have enough to eat (especially if they were Black or brown babies). But until Trump gave people who felt that way permission to voice their actual views, most Americans–even those who may have harbored similar bigotries– pretended (or believed) otherwise.

Today, political arguments between Trump Republicans and the rest of us are like arguments between sane Americans and flat-earth-believers or members of Heaven’s Gate. As Bacon concludes,

Democratic-leaning people moving to areas or states with lots of other Democrats isn’t a rejection of diversity or free thinking. It’s a way to ensure that they can live out the values that they assumed we all had until millions of Americans embraced Trump.



This is Not a Bill

I’ve been following the Sunday series in the New York Times in which Ezekiel Emanuel—vice-provost and Professor of Medical Ethics at the University of Pennsylvania, and former White House advisor—has been explaining high healthcare costs.

I particularly appreciated this week’s discussion, “Billions Wasted on Billing.” My husband and I are at the age when doctor’s visits become more frequent, and I have weekly opportunities to open envelopes to read incomprehensible jumbles of medical and financial jargon under the heading “this is not a bill.”  Anyone having experience with mailings of any sort—bills, invoices, reminders—knows that it is impossible to generate and mail anything for less than $5-$7 dollars, once you account for clerical time, stationery and postage. I’ve never understood why the same not-so-informative information can’t be included when the actual bill is sent.

Emanuel’s column was not just about billing, but about all the other repetitive, duplicative paperwork that characterizes our current health care system. How many times do we fill out patient forms with the identical information? How many insurance claims must be completed in different formats by all those white-haired ladies in colorful smocks sitting behind the glass partitions in your doctor’s office?

What does all this cost, and how much of it is really necessary?

According to Harvard economist David Cutler, electronic billing and credentialing could save the system upwards of 32 billion dollars a year. Transitioning to electronic record-keeping would pay other dividends as well: it would allow medical providers to use existing anti-fraud detection methods currently used by credit card companies, and it would minimize the errors that are inevitable when data is manually entered. (No longer getting “this is not a bill” mailings would also have a salutary effect on my blood pressure.)

What Emanuel’s column did not address is the question why medical insurers and providers have been so slow to adapt to the electronic age. I think a part of the answer is the complexity of what passes for a medical system in the U.S.—a complexity that also bedevils efforts to conduct reasonable policy discussions about health care in general.

We’ve all joked about the senior citizen at the Town Hall meeting who shouted “keep government’s hands off my Medicare.”  It’s true that most Americans do know Medicare and Medicaid are government programs. We know that taxpayers fund the (much-lauded) Veteran’s Administration. But how many of us understand the extent to which government currently funds pharmaceutical and medical research? Or how much state governments contribute to the cost of medical education? To public health programs? How many of us know what local government units spend for everything from ambulance service to charity care?

I like to think of myself as informed, but I certainly don’t know the answers to those questions. I was astounded a few years ago when, serving on an academic committee dominated by healthcare professionals, I learned that government at all levels currently funds between 60% and 70% of all healthcare costs.

The real question isn’t whether we should have a government system or a private one. We haven’t had a private, market-driven system for decades, and for good reason. Markets require a willing buyer and willing seller, each of whom has the necessary relevant information and the ability to exercise choice. The real question is how to identify the measures that will reduce healthcare costs and improve patient care and access. Right now, we pay 2 ½ times what the next most expensive country pays for a system that ranks 36th in the world.

That’s a bill we shouldn’t have to pay.