Star Ford

Essays on lots of things since 1989.

On racism

This is about my phases of understanding racism through life, and about structuralism vs liberalism.

  • PHASE 1 – UNQUESTIONED OPTIMISM. Ages 0-16. I believed everyone was equal and it’s best to be color-blind to race because that makes everything fair. Being autistic and faceblind, I was literally color-blind, meaning I didn’t understand where people drew the lines between “races” and didn’t get that people can even have a race identity. In high school I didn’t know my friend was black, and this phase ended when someone pointed out that she was; a line was cruelly drawn between us.
  • PHASE 2 – LIBERALISM. Ages 16-20. I learned that some people are still racist, but thought it was only a few, and still believed in the power of good will to fix it, because after all, don’t we all want justice? Seeing that black people seemed to stay poor through generations was confusing and I tried to come up with explanations that exclusively focused on what’s up with “them”, and I remember being irritated that I couldn’t understand it.
  • PHASE 3 – STRUCTURALISM. Ages 20+. Learning how social structures are maintained by profit and power, I added a structuralist layer on liberalism.

So what’s the difference? In this table, the titles are pretty abstract and it appears no widely agreed definitions exist, but “structuralism” here encompasses Critital Race Theory which is somewhat better defined. Each statement in the table is something you might believe if you generally fit into that column.

Naive/Extreme Liberalism Mix Naive/Extreme Structuralism
Each person is unique. Problems and solutions are the result of individual actions. People are unique and also products of group socialization. Racism is the result of individual actions fueled by a diseased social structure. People exist in groups. The white group as a whole oppresses all other groups. The problem is the structure.
Anyone of any race might be racist depending on if they do racist things. Any person can be racist to different degrees, plus the collective inaction by white people is also a form of racism. White people are racist by definition. People of color cannot be racist by definition.
We need laws, a justice system, and police to keep order. While we need order and justice, massive reforms are needed to actively prevent bias and racism in policing and courts. The laws are unjust. The police are part of maintaining white supremacy.
Each person is judged on their actions, not their intent or effect or associations. (So, walking around in a white cone hat is protected and not harmful.) Actions matter the most, and intent and effect also matter. Actions that constitute race-based threats can be wrong even if the same action in another context or done by a different person is not wrong. White people are guilty by association with their ancestors. People are judged by their associations and effect, regardless of intent or action. (So, humming a tune unaware that it goes back to slavery is a racist and oppressive action if a white person does it.)
Sub-criminal “wrongs” like making someone feel bad, are primarily communication issues, not a matter of guilt. Making someone feel bad through racist but protected speech is not likely to be solved by individual communication because it exists in the context of a violent history. Whtite aggressive behavior should be punishable, not protected by racist laws; POC aggressive behavior is retaliatory or protective and therefore just.
Policies that level the economic playing field matter, and race should play no part in policy. Becase of the history of racial violence and level of entreched racism, some race-informed policies need to be in place to change the course towards equality. (I have not yet found policy proposals from the structuralist side.)
Culture and language is shared, dynamic, and subcultures can mix and evolve. Cultures naturally mix and evolve, but those having a true lineage in the cultural element in question should usually be respected as authoritative, rather than white people co-opting, watering down and receiving credit and money for those things. Nonwhite cultures need to be preserved; it is wrong to appropriate elements from those cultures into white culture.
Everyone can study and understand racism; it affects all of us. While a few people directly benefit from racism, it mainly hurts all of us. White people usually have a harder time understanding it. People with privilege will be blind to the actual racism dynamics; they benefit from it and will never admit their guilt or truly understand it.
We can solve racism rationally through reasoned dialog and policy with all parties at the table. Power structures self-perpetuate unless we actively challenge them, so we cannot accept the usual players at the table. Those in power will prevent any change and so they cannot be at the table.
We should mix, not intentionally segregate anything ever. Minority and oppressed people need group identity and private space, but we should also aim to have one system that’s equal and open to all. To preserve and empower communities of color, POC need to own and control separate communities, and avoid integrating; integration always causes a loss of self.

Where do you fit? One way to identify your own position is to feel where you get energized by potential changes in power and policies, and where you feel fear. For example if you heard that a black separatist political party had won a handful of seats in the House, would you feel some fear that they would fuel a “race war” that would take away what you/we/someone worked for, or even destabilize the country? Or, would you be excited that white men have a new obstacle in their way? Noticing the fears and other feelings that come up can clarify how far you are willing to go away from the liberal side. (It should be clear that my bias is in the “mix” column.)

Woke and radical. Sometimes it seems that people are in a woke war and want to out-radical other people. But what is right is not necessarily the most extreme and simple things can be more radical than flashy absolutes. For example self-identified TERF’s have “radical” in their name but they don’t accept people; it might be more radical and less attention-seeking to accept everyone. In the same way, “All lives matter” might be more radical than “black lives matter” – but only if you really mean it, and are not just saying it to deflect the particular urgency of black lives mattering.

Culture supremacy. One of the ways racism thrives among liberals is the demand to keep white cultural patterns central – that is, ways of communicating, structuring people in groups, values, and language (spelling, word choice and everything). So POC can be invited into white-dominated space but only accepted if they conform to the culture demands; this is not a melting pot of cultures; it’s one over the others, also known as supremacy. Often it feels like the groundrules are set before the space has opened up for diversity and then anyone new coming in is secondary to the founders because some things are pre-defined to be off-topic. I’ve experienced this a lot because my disability makes it impossible for me to internalize white culture as strongly as others, and I think this is somewhat how nonwhite people can feel in spaces that are “open to everyone” but aren’t really.

Voicing. There’s a huge difference between being allowed to exist and having a voice that is heard – meaning the authentic experience of a person voiced by her own words in her way of expressing and about the topics that are important to her. If a diversity of voices is really accepted, then the demand for white culture supremacy would be set aside. If there are nonwhite authentic voices that affect how things are organized and what’s being discussed, it would feel very different and liberating.

White depowering. I’m not sure how white people would create real space for everyone else, but I’m very turned off by the rampant shame that goes along with adopting the extreme structuralist view. White people acting like we are automatically wrong and racist on everything is non-helpful, especially when it goes along with seeking validation for doing it. If we want black people to award us the non-racist prize for being allies, we are still centering ourselves. It would be better to do two things. One, be quiet and go on being liberal and just not engage with this. Two, live authentically in your cultures even if they originate from northern Europe. We need a middle way between one extreme of banding together to push out all other voices, and the other extreme of pretending to be powerless.

Structuralism as religion. Christianity has a nasty kind of internal logic that means when you don’t believe in one part of it, fundamentalists will diagnose your disbelief from within the belief system, such that the system can never be questioned. Structuralism as in the table above has the same feature – if you claim you are not racist, it proves that you are racist. The white individual is fully culpable but has no way to be non-racist. According to the logic, we have responsibility in the sense of guilt but no responsibility in the sense of agency. To me, taking it that far is the same as being a religious zealot.

Rootlessness. A lot of people in North America have tenuous links to any indigenous homeland, or none at all, even though all of our ancestors at some point lived indigenously. Dominant white culture today seems to be a remnant of some actual cultures of the past in Northern Europe, with a giant dose of colonial/capitalist thinking, idol worshiping, and civic and communication norms. I suppose we cling to idols and systems and other flat substitutes for rich culture because we’re hurting from the loss. From some observation, POC in America seem to drive culture change more than white people and don’t seem to cling as much.

Cultural appropriation. I haven’t grasped the outrage on this point, and would like to propose that mixing is mostly a good thing. Anyone who lacks culture needs it; autistic people like me can fail to integrate into a culture even if it is all around us, and I feel like the flatness of what’s left of white culture is even harder to assimilate to than a more real one. I used to do a lot of Israeli dancing before I understood that it was an element of a minority culture; I appropriated it into me and made it mine, and I think that’s the right way to spread things. But on the other hand when I call my preferences for arranging furniture “feng shui”, that’s misleading because I’ve never studied it and made it mine. In the extreme when minority-cultural elements are monetized by white people in that colonizing flattening way, it demeans the real thing. But even when a white pop star “steals” in this way and none of the original artists get the money or credit, it seems symptomatic rather than a cause of racial stratification.

Passivity. Here is a comprehensive and clear source on these topics and more. That author takes a mostly structuralist perspective but without the dogmatic absolutes. One of the points is about how white people lie to ourselves about being passive and therefore not responsible. The structuralists seem to want white people to actively identify as white in order to own the oppression that is going on and stop it, rather than just cop out. I never identified with being white and I have no idea how to purposefully adopt an identification with something when I don’t feel it, but it is an idea worth further reflection.

This is another article worth reading.

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On rationality and buffoonery

The structure of un-reason

Listening to the extreme claims made during the Kavanaugh hearings has made me consider the limits of rationality. There appears to be a structure of un-reason that we humans are stuck in, and it looks something like this:

unreason diagram

The two paths depicted are different ways of expressing why we do things or why we adopt positions, when the topic is contested. I am not attempting to explain why we do everything we do, and indeed a lot of what we do in a day is habitual or autonomic or arising just because we feel like it. This paper is only concerning those things that we make conscious verbal claims about, when we are thinking and expressing positions.

The top pathway seems to be the more common pattern and the subject of this paper. The lower pathway is the scientific version that I believe is only used in limited settings when we are able to be unusually objective.

Terms I’m using are:

  • The impetus is the actual basis for doing something, which can often be unconscious, and is self-interested. So it’s either related to a basic need (like hunger or loneliness) or resolves a state of unrest (like fear).
  • The justification is the expressed basis of the action, which we essentially make up after doing the thing, or as preparation for explaining ourselves after we have decided to do the thing. It’s retrospective of the action.
  • Buffoonery is the action-justification sequence, when viewed in the light of that retrospective order.
  • Rationality is the opposite of buffoonery, in which the reason is prospective of the action. In other words, the action is legitimately done for a known, expressed reason.
  • Buffoonery dissonance is what happens when justifications contradict each other.
  • The “cement” is all the layers of beliefs that we use to ease the buffoonery dissonance.

Examples

I will walk this through three examples – one from children in a classroom, one from a teen/adult perspective that I hope is relatable to the reader, and finally one from politicians showing an extreme case.

In the childhood example, imagine a student pleading to a teacher to relax the rules in some way – maybe to allow eating during class. “Teacher, we should be able to eat in class because we’ll be able to pay attention more!” The “reason” given is really a justification (or rationalization) – an invented basis that that the student hopes will appeal to the teacher’s supposedly disinterested sense of reason. But whatever basis is given, it is not the real impetus, which is actually more simple and direct: she’s hungry. So we have the real and self-serving impetus that happens first (hunger), and the false expressed justification that comes later (in order to pay attention more), and so far there is no rationality. The teacher might think “what principle can I apply here to make an impartial decision here” and that part could be actual rationality up to a point, but the teacher also has her own justifications for things, so the final ruling on the matter might not end up being rational.

The buffoonery of young children making up justifications for what they want is often transparent and teachers might even laugh at it. In particular they laugh when they notice the same child suddenly switches positions when their self-interest changes. Children’s lower level of sophistication allows us to see the structure. They are presumed to be less capable of reason so we do not hold them accountable. More on that below.

The second example is fictional but similar to things I have done. I love cookies and my impetus is to have them all for myself. Maybe I’m greedy or I fear a future cookie shortage, but I’m not consciously thinking of these causes. When I’m not actually hungry, I might tell others not to eat the cookies because “we should save them for a special occasion”. But when I get the munchies, I might eat them all and then say they were getting stale. The buffoonery here is switching justifications in a way that would make the other people in the house raise an eyebrow at my inconsistency and doubt my “reasoning”. If they pointed it out, I would feel the “buffoonery dissonance”, or the shame that goes with being caught.

The third example is what prompted this whole line of thought – the Supreme Court confirmation hearings on Kavanaugh. A senator supports something “on principle” one year and opposes the same thing the year later, appealing to the opposite principle. In this case, senators who made arguments for prudent and lengthy consideration of facts when Obama nominated a justice (and effectively delayed hearings until Obama was out of office) are now making arguments for quick action and not looking too hard at the nominee’s history. A staple of the workings of late night comedy shows is to search databases of footage for cases of inconsistency like this, and air the two clips juxtaposed. We all laugh at the very obvious lies, but beyond laughing is there any result of exposing them?

Responses to buffoonery dissonance

When confronted with buffoonery, people respond different ways:

  • In the case of children, they might just take stabs at whatever gets them off the hook or whatever seems to appeal to adults, and not feel the dissonance at all.
  • In the case of some senators, they appear to have developed an immunity to the shame, so they also take stabs at whatever gets them off the hook and rely on the press having a short memory. The increase of sophistication over children is only slight.
  • A conflict-avoiding person might retreat from their positions and stay safe within cultural norms, while not really facing or resolving the dilemma. (“Okay you’re probably right”)
  • A person valuing relationships over positions might soften or release principles and claims, and see multiple sides. (“It’s not so simple.”)
  • An introspective and ego-balanced person might feel the shame and admit “you got me there”. That could lead to bringing the impetus into consciousness and adjusting the position towards being rational, or having a growth moment. (However, people don’t mature in leaps like this every day, so the response would be less laudable most of the time.)
  • A person with a fighting spirit could double down and invent a more abstract justification that logically bridges the opposing ones. This is the “cement” that locks the positions in place.

Cement?

Cement is all the other beliefs that we adopt to cement in our justification after we invented it.

In the cookie hoarding example, if I was called to account for a discrepancy in expressed principles, and I was not ready to admit that the actual impetus was to have all the cookies for myself, then I would need to come up with a new all-encompassing “reason” why my two prior “reasons” were compatible. The layers of justification can get ever more intellectual until I win. A lot of politics is essentially the art of getting all the cookies for oneself, where “cookies” can be substituted by anything, such as agri-business subsidies or stockpiling for war.

A global example is slavery. The impetus for holding slaves includes greed and aggression, but that is not admitted to directly. Instead slave-holders make up a justification that makes themselves sound innocent. Those same people might also say that “all men are created equal”, and then they might be confronted with the inconsistency. They would then need to appeal to some more abstract justification that unites the inconsistency, which could be, among other things, that “slaves are not people.” In all of this, I am making the argument that the actual sequence in time is the action, then the initial justification, then the cement. When people want to sound rational, they reverse the sequence and claim that the abstract principles were first in mind, then it led to reasons which led to the action to hold slaves.

The brain is a re-sequencing machine

While I cannot prove that buffoonery (reverse rationality) is the norm, there are cousin processes in the brain that point to backwards sequencing being something that occurs constantly as a central part of consciousness.

The first observation supporting this is that hearing is faster than seeing. If you create an experimental setting where a subject has a brain monitor and a startling noise happens at the same time as a picture on a screen appears, then there are two sequences that occur in the experiment. One is what science observes: First both stimuli are detected (the light arrives before sound but that difference is insignificant at short range). Second, the sound is processed and it signals a twitch reaction in the muscles. Third, the slower visual processing part of the brain sees the image, after the muscle reaction happened. The alternate sequence is what we as subjects believe we experienced: we are really sure that we saw and heard the stimuli at the same time, and then twitched afterwards. So consciousness is subjectively sure of something that is not true. The brain is constantly re-sequencing stimuli in short term memory to align the timeline of hearing and sight and providing a false sense of being present in this exact moment, when we really are never aware of a moment until later.

The other observation is about dream recall. Freud and possibly others asserted that dreams occur as disconnected images without the usual adherence to the laws of time and space, but that we force those images into a story during the process of recall. So the sequence is imposed later upon the original dream. Even though we feel sure we “saw” the things in a linear story format, that certainty only came after the dream was already done and we were waking up.

Onlookers

What’s been bugging me about the un-reasons of the Kavanaugh supporters is the thickness of that cement, the beliefs built up to support the justifications for supporting him. There may have been some rationality exercised by the people who originally put him on a short list and then selected his name – those are the sorts of activities where, at least some of the time, we can be rational. But the millions of supporting Americans can’t be doing that most of the time – their real impetus for support could be fear of losing control by white men, or some related fear-stoked groupthink, or simply being drawn to the norms of the people around them for safety.

The easiest justifications for supporting him despite his potentially disqualifying traits are (1) There is no proof that anything happened; and (2) whatever happened was so long ago. Bart Simpson has a line that covers the bases – something like “I wasn’t there. You can’t prove it happened. I don’t know anything about it.” None of Bart’s justifications are consistent with each other, and likewise the two easy justifications for supporting Kavanaugh are like that too: It is inconsistent to argue both that nothing happened, and that it happened a long time ago.

Then to resolve the inconsistency, the cemented beliefs are constructed, and they feel dangerous. The could be abstractions like “violent assaults are inconsequential” (a way of saying it anything happened, it doesn’t matter). The only way a person can say that shamelessly is by adopting beliefs such as: rape is not a real crime, and women are not fully human in a way that makes crimes against women “real”. Possibly rape is imagined by men as not that bad, if they can only visualize themselves as the rapist. Or people have claimed the victims are fake, or that caving into the real concerns of the opposition fuels some kind of liberal conspiracy.

So the danger is that in the rush to pretend to be rational and escape buffoonery dissonance, millions of people invent and adhere to dangerous beliefs.

My guess is that the left (including me) is doing the same un-reason, and if the nominee was a Democrat with the same history, both sides might have adopted exactly opposite “principles”. One way to test the theory is to assume a hypothetical nominee 20 years in the future, and all we know is that he probably committed some misdemeanor or felony decades earlier that was not reported, but we do not know his political leanings. What would our principles be then? Without knowing our self-interest in a question like this, we usually resist answering, and when I’ve asked people questions like this, I get a lot of “it depends”. They will not say what it depends on, and I tend to think that what it depends on is self-interest at the time, which has to remain unsaid because we rarely can admit to our real impetus.

When I try to bring my own un-reason sequence into consciousness, I get some data from the introspection, but I doubt it is really possible to know oneself enough to fully escape buffoonery. I can admit that a crime in the distant past should not be a disqualifier for most any job. Relatedly, most people working to help ex-offenders re-integrate are left-leaning, but they do not want to apply that same principle to this hearing. However I also then feel drawn to the justification that the particular job of Supreme Court justice should have higher qualifications than others. Also I am drawn to the notion that he should be disqualified for lying under oath, but at the same time President Clinton did that and at the time I felt it was not consequential because the subject matter was not of national significance. To be fair I would have to admit that Kavanaugh’s probable crimes are also not of national significance. That is about as far as I can get with looking at my own un-reason.

Teaching and change

I wonder if the balance of buffoonery versus rationality could be partly influenced by culture, or if it changes in different time periods. On one hand if feels like a solid part of how the brain is wired. On the other hand there is a case to be made for buffoonish cultural patterns. For example when we want children to act rational and we ask them why they did something we do not approve of, they say something to answer the question, like “I was tired” or some other justification. When we engage with them on that level, it is as if we have believed that there has to be a lie and we can only talk about the lie, whether refuting or bolstering it, but always staying at that level. So parents can be the gatekeepers of pseudo-rationality by colluding to stay within the un-reason pattern and limit the conversation to which lie out of the many possible justifications is an acceptable one to settle on. Thus we are teaching and modeling dishonesty. But maybe that way of teaching is culturally prescribed and change is still possible. If we had a cultural pattern of not engaging in pseudo-rationality with children, we might not have a culture that appears to celebrate lying so enthusiastically.

I also wonder about the cycle of shame and revision with people who are introspective: I do not know if the cycle is really just adding so much sophistication to the lies that they really get convincing, or if we inch towards actual rationality. I worry that the more I cultivate the idea that I’m being rational myself, the more I’m building up “principles” that let me have more cookies without risking the shame of inconsistency. And that goes for all of us who feel that we are fair and benevolent.

I also wonder if the cycle of shame and revision is less prevalent in the internet age, and that could be why the Kavanaugh hearing seems to be so much more buffoonish than things in politics in the past. I cannot recall seeing that “you got me” shame in public in recent years, but I think I remember it from earlier. My memory might be limited to local settings and not national politics though. If that is a real culture shift, it could be related to the new internet-age phenomenon of people avoiding anyone they disagree with, so they can never be caught in their inconsistencies. Without ever being caught, the inconsistencies could grow larger without anyone noticing. Possibly related, the president now is someone who cannot be caught because he has no principles, therefore can rarely feel inconsistency or shame.

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On healthcare, disentangled

 

The current debate in Congress on healthcare is so hyperbolic and disingenuous that I felt it was time to actually pull out the threads and uncrumple the ball and lay it all out.

I will talk about the moral dimension, then the financial dimension, then the health dimension.

The moral dimension is simply this question: do we help each other through sickness and in health, or do we take the opposite extreme of every man for himself (women be damned)? Or do we take some middle road? Throughout most of my life, the moral choice made in the US was that middle and upper class people help each other out as a group, while we helped the working poor to a lower standard, and we essentially let the underclass die. Our sense of shame prodded us to ease the brutality of that death sentence somewhat by setting up a safety net. While that safety net was significant (medicaid, medicare, emergency services for the uninsured, for example), its moral foundation was that “we” treated “them” as inherently lower and less deserving. For generations health was never considered a right, and the debates focused on to what extent the recipients of “our” generosity were worth the expense.

The ACA fundamentally challenged that moral stance by declaring that we should take care of all of us to a more reasonable minimum standard, and it set in motion a trend towards more universal insurance coverage.

The current debate is completely hostile to that moral advance of the ACA, and I think racism and class superiority is a driving force. Some of the people who hate the ACA really want an underclass to exist, they enjoy winning, and nothing stimulates their competitive brain receptors like seeing the underclass waste away while they sip drinks by the poolside. They realize the ACA threatens to bring in more equality, so in retaliation, they ramp up their attack with an agitated fury and logical vacuum that can only be explained by the fear of the loss of their position in society. That is the moral failure in today’s debate, and it is driven by psychological forces that people experience when they lead narrow unexamined lives.

The financial dimension is a bit complex but important. Many people misinterpret the incentives of the four parties to each transaction, so I will lay them out:

  • Patients want to avoid doctors when we are well, but we also want the power to buy health-related services at only the level we need when we need it, no more and no less. It is important to see that there is not an infinite demand for services; thus patients are not the driving force behind cost escalation. But we want to be able to spend millions of dollars if needed, thus some kind of risk pooling is in our interest. It is not very relevant to us as patients whether costs are pooled by a public instrument or a private one. Like all consumer choices, we will minimize our personal costs and if insurance is not required or favorable, we will not buy it.
  • Providers (doctors, hospitals, etc) are private entities with the inventive to maximize income. Like anyone selling anything, they will do whatever it takes to make more sales – upselling, advertising, monopolistic practices, and lobbying. While the individuals involved in that system usually want to care for people at a personal level (they chose to go into that line of work), their corporate structures have the incentive to care less and charge more.

The first two of the three parties – buyers and sellers – operate just like with any other kind of financial transaction, but with healthcare, there are third and fourth parties.

  • Insurers and underwriters are private or governmental or non-profit organizations that provide the pooling of risk, taking a cut of the sales. Their incentive is to pay less out and charge more, but they operate in a market and under regulation, so they must stay within acceptable limits to stay in business. The important function of insurers is to determine what is an acceptable expense – more on that below. Many people on both sides incorrectly blame insurers for cost escalation and other problems, but insurers actually have the incentive to lower costs, so they are just a distraction from the central problems.
  • Courts are the final party involved in the money side of things, because ultimately they rule on insurance claims, if patients appeal, and thus courts ensure the insurers are following their own rules.

Costs can only be kept “correct” (not artificially low or high) if there are market forces at play, and the root reason why health costs have gone up in the last decades is that the market forces are not strong enough. Markets must have buyer choice and seller choice to be true markets, but in the US consumers cannot effectively shop around for health-related prices, so there is too little choice. Insurers commonly make deals with providers that cap prices on each procedure (more proof that insurers are on our side), but they are not allowed to cap the number and kind of procedures done.

Countries with more efficient health delivery systems (that is, all other countries) achieve that because they do fewer procedures, do them more efficiently, do not spend as much on marketing, and do not pay the doctors and CEOs outlandish salaries. Their cost savings are not achieved by pooling (insuring) differently.

The ACA changed the way the parties collude to set costs in some important ways, but it did not change the basic set of incentives. The main changes were that insurers were required to spend 85% of revenues on health costs, and they no longer could deny coverage (thus their whole business model became simpler, and they downsized). So under ACA, insurers are a less important variable in the cost equation than before.

There is an important link between the moral and financial dimensions, which is the question: what do we do if someone is not insured and they get sick and need help? They were not paying their share into the risk pool to help others, so when they need help, do we help anyway? (The same question is asked in the Little Red Hen story.) Or do we let them get insurance when they need it? Ultraconservatives say no, if they failed to think ahead, we should let them die. They are right on purely economic grounds for the same reason that if you sustain a loss of property that was not insured, you are out of luck; no one will pay you back the value of your loss. But it is clearly barbarian for us to live like that. If we really pause to consider this, we can only come to the conclusion that if we do not want to be barbaric, we need to require people to be in the risk pool. That is, either we have a public pool that automatically covers everyone, or else we require them to be in a private insurance pool. It does not make moral sense to have the “choice” to be uninsured.

The ACA was a compromise plan that favored the private pools to appease conservatives, and one of its failures was that the penalty for not being in a pool was too small; thus its adoption rate has been gradual.

The second financial dimension concerns the role of health spending as a tool of wealth distribution and equality. (I was talking about spending on health itself above, and now switching to issues of taxes and credits.)

Pre-ACA, health spending wasn’t tied in any rational way to income equality, so those expenses, being relatively equal across economic tiers, was a “regressive” type of expense; that is, one whose percentagewise impact on the poor is greater than that on the rich.

One of the most important effects of the ACA was in how it changed the distribution of wealth generally. It shifted the tax burden and entitlements on a gigantic sector of the economy such that wealthier people were paying a much larger chunk of the cost of health services for all of us, and many more people were getting those services at little or no cost. If you’re into active public management of poverty (as I am), this form of progressive taxation was a good start. Two or three more programs of that magnitide (such as in housing, food, or transport) would have made the US more like the compassionate socialist European states.

The condensed version of the way ACA was affordable is that Medicaid was theoretically expanded to include more people, and additionally, if you graduated out of Medicaid (by earning too much to qualify), then you still would qualify for credits towards premiums. Thus there was little or no gap which had existed previously. (One of the persistent failures of US social programs is that they often have a cutoff, so people have an incentive to stay poor to remain eligible.) As income goes up between around 30 to around 90,000 per year, the credits phase out.

The current agenda is being set by the uberrich, who seem to always want more money, so the brunt of their health reform proposals are to reverse the ACA taxes and entitlements. They say the ACA is broken and use terms like “choice”, but all of that is lies and distractions, and their actual motive is that they do not want to pay the taxes, along with the racist/classist motives as noted above. They propose reducing Medicaid and eliminating income-based help on premiums. Not only is the entire dimension of the health system as a tool of equality being chopped, it is even proposed to be reversed by creating a credits that the wealthy qualify for.

The health dimension includes the questions of what gets done for patients, who decides what gets done, and whether it is effective. Amidst all the noise about choice and rising premiums, these questions are not making the news. The current debate is completely missing the much larger factors of what the money gets spent on. We should be debating the finer points of who gets to decide whether to do each procedure and how much they can charge for it. Or we should be implementing more market forces to keep those prices under control. One of the ways to shift incentives is to pay for outcomes rather than procedures, so insurers only pay after the patient is treated successfully, instead of paying simply because something was done to them.

One of the big principles missed by conservatives is that people will not make good decisions about insurance in an unregulated market. Generally speaking we will under-insure ourselves if given too much choice. We might choose a plan with a 1 M$ lifetime cap, because that seems like a lot, but then need 2 M$ to survive cancer, and having made that choice when we were not thinking we might get cancer, we end up dying because of it. Or we might choose a plan that does not cover some drug that we never heard of, and then end up needing that particular drug.

We also do not know what procedures we need if we do not happen to have medical training. But on the other hand we cannot let doctors decide everything, or they would simply order every known test for every patient and drive prices up forever.

So the question of what gets done ultimately has to be a community decision – made either publicly or by insurers backed by courts. It does not make sense to make those decisions as individuals or as providers. The conservative’s notion that “doctors and patients” will decide on everything on a case-by-case basis is naive and does not contain costs. The ACA took a rational approach to that question by making those choices nationally, and putting into law specifically what had to be covered for everyone.

What do we do next? There are a lot of ways to rationally pay for healthcare costs. Here is the super-consolidated list of points that would need to be decided:

  • Who sets prices – There has to be a market force limiting the ability of providers to set runaway prices. (This point is rarely mentioned in debates, but assumed to be the role of insurers.)
  • Who decides what procedure is done – There has to be a market force limiting the ability of providers to do unnecessary procedures. (This point is rarely mentioned in debates, but should be central.)
  • What choice of doctors will you have – If insurers are allowed to control prices, they have to limit choice of providers as a way to do it. If you want to be able to go to any doctor and they can charge whatever they want, then there is no way to control runaway prices. (Republicans pretend to favor choice but have no plan that makes sense; Democrats pretend to favor choice but actually favor insurer price controls.)
  • Self-pay versus risk pooling – Only the 1%s could afford to pay full medical costs without pooling their risk, so all the rest of us need to pool risk. However, some chunk of the middle/upper income people could pay for a fairly large portion of typical medical costs if they accumulated money in health savings accounts (HSA), thus partially being their own insurer. (Everyone is assuming the combination of insurance and HSAs as far as I can tell, but Republicans want to expand the use of HSAs.)
  • Who gets included – Let’s assume that our goal is to care for everyone equally, and leave no one out. So the baseline assumption is that everyone is in a cost sharing pool of some kind. (Democrats generally favor this; Republicans generally opposed.)
  • Mandated coverage – This is really another word for who gets included; it may sound draconian to say “mandated” but it is how every other country does it. (Democrats generally favor; Republicans generally opposed but without any rational alternative.)
  • Penalty for not being covered – Pre-ACA, the penalty for not being covered was that once you developed a condition, you could not get covered for it at all, or only after a long wait. Thus in some cases the penalty was your life. Starting with the ACA, the penalty shifted to a simper tax payment. Another alternative is paying higher premiums after a coverage lapse. Another alternative is to automatically include everyone, avoiding the question of enforcing a penalty. If there is a choice in coverage, there logically has to be a penalty for opting out; otherwise the insurance market would collapse. A lot of people do not get this, but it is the main thing we need to get if we insist on using the insurance model for health costs. (Democrats generally favor the tax penalty or universal automatic coverage; Republicans favor a penalty through higher premiums.)
  • Change in coverage – Risk pools inherently require people to pay into them as a group when they are not sick, and by the same token, you would need to pay for the level of insurance that you might eventually need, before you need it. The strategy of buying minimal insurance while healthy and then switching to better insurance when you get sick undermines the whole concept of risk pooling. The ACA dealt with this problem by limiting the period of enrollment in a plan to the calendar year, which was not sufficient, since it would be economically favorable to wait out the year and then switch, for those who develop a chronic, expensive condition. Other solutions are automatic universal coverage, higher premiums (as above), and longer enrollment periods such as 3-5 years. (Democrats favor the ineffective one-year period and do not seem to have a solution; Republicans favor higher premiums.)
  • How the risk pools are grouped – There has to be a way to decide who is in a pool together, if there are going to be multiple separate pools. One way is to have the whole country in one pool. Another way is by employer. Another way is by insurer. Pre-ACA, continuously insured people were in pools by employer or by insurer if covered individually, while those who could not get insurance in the market either were in the medicaid pool or public high-risk pools. With the ACA, this mostly did not change but the ACA “exchange” established separate pools with a more transparent market. (Democrats favor a universal pool or the ACA compromise; Republicans appear to favor the tiered pre-ACA pool system.)
  • Who underwrites the shared risk pools – This is the question of insurance backing, and currently includes government, quasi-government public insurance companies, non profit and for-profit backers. (Everyone appears to be sidestepping this and is OK with the current slate of complex options.)
  • Who pays premiums – This is the question of whether consumers pay directly, through an employer, or via taxes. Pre-ACA, taxes paid for most of medicaid, most people with private insurance paid through an employer, and some paid directly. ACA did not overhaul that system, but it added a major tax credit component, such that insurers could collect part of the premiums monthly from the government and part from the consumers. (Democrats favor the current complex system or universal “single payer” via taxes; Republicans appear to favor the pre-ACA system.)
  • How is poverty handled – This is the question of how and if the health system trends towards more or less income equality. As I said above, the ACA had a system of credits and overall expansion of low-income support. (Democrats favor the current ACA system; Republicans favor a regressive taxation/credit system instead which makes it impossible to fully include the poor in the whole healthcare system, leading to countless deaths.)

 

Given the huge range of ways to do things, here is what I would do. My first choice would be single payer via taxes, automatic universal inclusion, and essentially removing the insurance component. The market forces would be created by publicly setting rates for outcomes, allowing providers to compete by minimizing the procedures necessary to achieve the outcomes.

Given that my first choice is a political non-starter, my second choice would be to keep ACA with these few changes: (1) improve the ability of insurers to negotiate prices and procedures, (2) shift to fees based on outcomes, (3) increase tax penalty for non-coverage, (4) lengthen the enrollment period to 2 years, and (4) phase out employer-sponsored plans.

Conclusion: There are complex choices to make, there is no one obvious best answer, and Republicans (mostly) are clouding the issues through a steady stream of lies to the point where meaningful real debate is possible.

 

(edited 3/11 to add more on medicaid and poverty)

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Deep Accessibility

This paper explores five levels of accessibility, extending the familiar notion of wheelchair access to the sensory and cognitive levels of accessibility. It is slanted towards autism-related accessibility, but the framework could be generalized and adapted to other kinds of people. The levels to be described are:

  1. movement
  2. sense
  3. architecture
  4. communication
  5. agency

Basically, I am looking at what makes the difference between a place or event that a lot of different kinds of people can go to and get what they need effectively, versus one that is impossible to get to, threatening, confusing, or in other ways unavailable. Autistic people avoid lots of kinds of places for a variety of reasons, but using this accessibility framework, I hope to make it easier to talk about specifically why they avoid those places, by giving vocabulary to why those places are not accessible, and to make it easier to make those places accessible.

Before I get into the levels, I need to define some abstract things, starting with this graphic explanation of inclusion versus accommodation.

Inclusion

incidence

This chart shows a bunch of people clustered on the left (without a disability), and progressively fewer people who are more disabled or at least more divergent. The three categories are those who are systematically included (the largest group; the one the system was made for), the group that is not included by design but can be individually accommodated by some adaptation, and those who are excluded. Read the rest of this entry »

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­Cost of disability

­This essay discusses the way we pay for autism, from a marxist perspective. It goes into economic reasons that certain people are disabled from participation in the economy, some models of redistribution of money, the kinds of incentives that affect behavior in each of those models, the complexities of insurance as a redistribution model, and what to do about it. I’m starting with economics background to frame disability. Even though it is probably too long and thick, I hope you will read it and discover a completely different take on costs of disability than the conventional wisdom.

1. Efficiency and exclusion from the workforce

The very rich and very poor live off the work of others, as do the old and young, all those whose work is undoing the work of others, and all those who are disabled in the quest for employment. Various wealth redistribution systems exist to maintain the imbalances, and those systems constitute the livelihood of the majority; actual economic productivity is relatively uncommon. For every one person doing economically productive work like growing food, installing windows, or teaching children, there are several operating within the economy, but just doing paperwork or fighting over money and attention, the result of which meets no actual human needs. The more efficiently industrial production is accomplished, the more inefficiency we create on purpose to soak up the excess time. So far, we are seeing advanced capitalism playing out as Marx predicted.

There was a time when we could not afford to exclude people from the workforce: people who were too weak to plow fields were still needed for other things, and generally speaking, if you could not do one thing, you could probably do something else. There was no retirement and no adolescence. With gains in efficiency, however, we can now afford to be idle; or looked at another way, we can now afford to exclude the old and young from the workforce. As efficiency marches on, we are not using the gains to better meet the needs of everyone; in fact we just become more competitive and we concentrate the wealth more, creating a large chronic underclass with no means to provide for their own needs.

Advanced capitalism therefore has two opposing effects: increasing efficiency, which tends to exclude an ever greater portion of people from the workforce; and increasing inefficiency which tends to concentrate wealth. Both opposites operate together. For example, in the food production chain, the actual farming, transport and delivery of food becomes more labor efficient over time, and the resulting wealth is distributed in the sense that the people doing that work are all getting paid and the consumer is getting a necessary product for less money over time. But there is also a growing workforce in the areas of food patents, genetic engineering, marketing and legal sectors, who are all working exclusively for the owners of the food production chain in order to increase the owner’s advantage and increase their assets, and has no benefit to others.

Adolescence and retirement were invented concepts at one time, which served the progress of capitalism by ejecting people who were no longer needed for industrial and agricultural production, and at the same time, creating a dependent class with a redistribution system around them. We now have vast budgets for schooling and social security, and whole sectors of the economy dedicated to wealth redistributing and otherwise providing for the young and old, who either may not work or cannot compete against a narrowing class of employable people. I’m not making the case that the old way is better than the new way, or vice versa, but just that a class of people have become recipients who were once contributors.

This historical pattern has not stopped with age-exclusion; capitalism demands that we continually invent new categories of exclusion, expand the pool of people who are non-productive beneficiaries, and build a distribution system for these new categories. I’m looking at disability in this context: a class of non-worker with a distribution system surrounding it to allocate money to that class. Disability is a lot of things, but this essay is only about disability in that particular economic sense.

2. Why am I writing this?­

As an autistic person, I’m focusing mainly on the redistribution system we are building today to support the neurologically disabled – including autism, so-called attention deficits and other conditions of the mind that affect interpersonal relations. This dependent class is currently undergoing rapid expansion. This affects me greatly where I am in the economy. In the 20 years I’ve been in the workforce, a lot changed. I was not considered autistic before, under the older definition of autism. Earlier in my career my particular style of social communication was a disability, but not so major, in the sense that people would willingly pay me to do things in the information technology sphere. However, over the course of two decades, autism has expanded to engulf me: the definition changed to include people like me, and at the same time, I’ve been less able to compete in the market. As I write, I’m moving into more dependence on government programs for the disabled. It is important to see this not as any change in my objective value or ability to contribute, since I have actually become more skilled over time. It is rather a change in the economy: a new criterion is being used to filter out people from productive roles. Terms like “autism” probably stay roughly synchronized over time with the set of people who have fallen out of economic favor.

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On Measurement

The empathy test

Here’s a report on some “research” that “measures” the amount of empathy people have:

Looking at their test questions, it becomes immediately clear that the test is a composite of several different things. All together, these things are labeled “empathy” and the implication is that the more of it you have, the better. Before I get into why this does not qualify as research, I’ll elaborate about their test.

Here are four of the questions from the empathy test:

  • I can easily tell if someone wants to enter a conversation.
  • I can pick up if someone says one thing but means another.
  • I am quick to spot when someone is feeling awkward or uncomfortable.
  • I can sense if I’m intruding, even if the other person doesn’t tell me.

These four questions apparently measure the ability to read what someone else is thinking or feeling, or what their motivation is. Now, here is a set of different questions, which are apparently designed to measure the extent to which a person internalizes the emotions of others:

  • I tend to get emotionally involved with a friend’s problems.
  • It upsets me to see an animal in pain.

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Getting rid of the Box – comments to DOT

Comments to RITA docket 2009-0005-0001

In addition to research on technology, case studies, and detail strategies and metrics, there also must be some more macroscopic study on waste and stagnation. There have been many attempts to describe the elements of efficient and safe macro urban designs, such as TOD, on-demand transit, integration with bike/pedestrian, coordinated land use, and so on, yet as the decades pass, we are still building primarily auto-exclusive zone-segregated places, driving more and more, and not even coming close to meeting the stated federal goals.

Clearly the way planning is carried out at the federal and state levels cements this technology and policy stagnation. Nearly all studies are scoped, meaning they define what is to be studied – a truism in government, but not a necessity. The scoping creates the box that one is to think inside of. In order to unblock the process, one must think outside the box, and to do that, one must not have a box – that is, no scoping.

Study is needed on how to remove the scoping box from government struture and let flow the natural creativity that is harnessed by the private sector, in order to make it possible to meet any of the goals. This study should include advice on the next congressional transportation authorization.

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Freedom of Information – Act 2

(letter to elected representatives)

Please introduce legislation to expand the Freedom of Information Act to a new level. The original act made transparency the rule, and secrecy the exception, in theory. But the act allows the executive branch to keep something secret just by stating a reason why they don’t want to release it, and it also gives them the ability to be noncompliant with no repercussions.

 

What is needed now is an act that directs the executive branch to operate publicly at all times, and puts the burden on Congress to determine if something should be kept secret. The order needs to be court-enforceable. The new act needs to distinguish between (1) releasing hidden information, and (2) operating in a transparent way in the first place. Transparency in operations means every piece of correspondence, email, expenditure, and audio notes from meetings is published on the web at the moment it is created. Nothing would ever be “unveiled” (a common word used in government reporting), because nothing would have been veiled in the first place.

 

What led me to this conclusion was my recent review of the WTC building 7 report from NIST, and the public comments on the report. The NIST report may or may not be plausible, and I’m not asking for a new investigation. A new investigation under the same rules of conduct would have the same result. It is useless to pretend that the government – any government – can produce an “unbiased” consensus opinion from closely guarded evidence. It is not even necessary for the government to have any interpretation of how the building was destroyed. Instead, the government simply needs to release all evidence and let the media and citizens who have an interest draw their own conclusions. The government seized footage and other evidence, and prevented media access in all the 9/11 sites, and that fact alone is sufficient grounds to disregard any government findings. The simplest and most common explanation for keeping a secret is to protect the guilty, as you may remember from childhood.

 

Under the current system allowing the executive to keep secrets at will, we have little protection from this type of terrorist activity. There are many other buildings like WTC7, and currently building owners and local safety inspectors have no new information that will keep these buildings safe. Whoever brought down WTC7 could bring down hundreds of other buildings, perhaps all in the same day.

 

If 9/11 were to happen under an expanded Freedom of Information Act, taxpayer money would go towards obtaining copies of all footage, publishing it, sending debris and all physical evidence to universities around the county and other institutions, who could collaboratively get to the bottom of it much more quickly and accurately than government can. Naturally this would be more chaotic and many false conclusions would be circulated, but that is part of democracy. Having access to just one official story is not part of democracy.

 

You may or may not believe that office fires can make steel brittle. I don’t know – I’m not a structural engineer either. But a full transparency rule is not just about terrorist investigations – it would improve outcomes on health, transportation, energy policy, and everything else. This is one important step towards keeping expanded executive powers in check and sustaining our democracy.

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Libertarian Socialist

Two main lines of thought today are libertarian and socialist. They are sometimes thought to be opposites, but actually are compatible. Libertarians believe that the free market is the best way to allocate labor and stimulate efficiency. Socialists believe we should work cooperatively and fairly, rather than allow an owning class to exploit a working class, and that a limitation on the concentration of economic power is the best way to allocate labor towards human needs.

The truth of the libertarian view can be seen easily in certain highly competitive and rapidly changing markets such as electronics, where it is fairly obvious that free competition benefits the consumer. On the other hand, highly regulated sectors like health care and public transportation do not experience a truly free market and as a result, they are stuck with rising costs and stagnating quality. In these sectors, the incentive to improve the product does not rest with those who have the power to do it – a libertarian view of that situation.

The socialist view is backed by reality in the sense that countries with the most protection against concentrated wealth have the least poverty and a high standard of living.

Those who ally with socialist thought might trust free markets in the original sense (farmers selling their wares in a marketplace), but mistrust them when they become dominated by a small number of large interests, which is also known as capitalism. Those who ally with libertarian thought might trust the general idea of protection from exploitation, but mistrust the notion that economic fairness can be legislated. Thus, both sides have a basic compatibility with the other philosophy, but mistrust the other side taken to an extreme.

A blend of these two lines of thought is what is needed today. That blend can be summarized by the rule that the public – through government – should referee the economy, but not play in the economy. To referee means to make sure the playing field is level, so a free market can thrive, and ensure it does not get dominated by monopolies. It also means the government should not be handling trillions of dollars, because you can’t both play in the game and be the referee.

Health care is a timely example of a sector that can be corrected by the combined “libertarian socialist” thinking. As aspect of the debate is whether the government should be a gigantic economic player in health care or not. One side says yes because medical decisions should not be driven by profit, and public control would give everyone equal access, and supposedly take money out of the equation. The other side says no because the free market is theoretically better at providing the best service at the lowest cost, and it keeps each person in charge of their own life, free from centralized control and possible corruption. If we think instead in terms of refereeing the economy, not participating in it, then there are many ways to create a free market system with distributed control, and also ensure fair access. Public policy would deal with transparency, fairness, truth in labeling, and upholding contracts, rather that deciding who gets paid for what. The rule that “if you insure anyone, you must insure everyone” is an example of the government playing referee – not being in the insurance business itself, but setting the groundrules for those who play. That rule helps us achieve our egalitarian objective while also remaining competitive.

As with health care, in so many other areas of the economy, the single word “referee” can help us determine the best way for the government to be involved.

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Health care: my experience of waste

(letter to the editor)

On a recent trip to a hospital, we waited and waited – and waited – for stitches. And watched as they threw out hundreds of dollars worth of supplies, and went through unneeded procedures. It was the night of “wait and waste”. My daughter didn’t need an X-ray or any other equipment. All she needed was a clean needle and thread!

If she had needed a stucco repair, she could have gotten bids, and the suppier who could do the best work the most efficiently would be rewarded, to everyone’s benefit. But instead, she needed a cut sewn up, so the supplier who could think of the most procedures to do got the biggest reward.

I hope that Senators Bingaman and Udall will work to create the kind of market competition that rewards quality and efficiency, while also ensuring everyone can get treatment. A public option that pays for results rather than for procedures appears to be a reasonable way to achieve this.

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