An Alt-left?

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What is it with James Burnham? I associate him — via Curtis Yarvin — with the alt-right. And Burnham is the founding text of what I call the Alt-centre (of which I am the founder and which I’m hoping to parlay into world domination if only I can get some time away from the keyboard). And here is Burnham and the Marxist left. Well, Burnham was a Marxist, but his big contribution was the two books he wrote as he emerged as Trotsky’s best American mate and headed rightwards —  The Managerial Revolution and The Machiavellians. And they’re the texts discussed in the video.

Anyway, I can recommend the first presentation. It addresses Burnham’s concerns well. The only telltale sign that it’s from the Marxist left is the occasional creepy reference to where Burnham fails to be ‘dialectical’ in his thinking. I recall the phrase from Czesław Miłosz’s descriptions of the Stalinist intelligentsia in The Captive Mind. I hadn’t realised before then the imperative that Marxist regimes felt to ensure that all serious thinking to be done by the intelligentsia be ‘dialectical’.

Apart from that, the talk seems very thoughtful and unflinching about the current state of the Marxian left (it’s in roughly the same state as the star of the parrot sketch). Following the links I discover The platypus Initiative no less — it’s a good name for putting reality ahead of thought (fancy that!) via this story.  And here’s its premise:

Platypus contends that the ruin of the Marxist Left as it stands today is of a tradition whose defeat was largely self-inflicted, hence at present the Marxist Left is historical, and in such a grave state of decomposition that it has become exceedingly difficult to draft coherently programmatic social-political demands. In the face of the catastrophic past and present, the first task for the reconstitution of a Marxian Left as an emancipatory force is to recognize the reasons for the historical failure of Marxism and to clarify the necessity of a Marxian Left for the present and future. — If the Left is to change the world, it must first transform itself!

The improbable — but not impossible — reconstitution of an emancipatory Left is an urgent task ….. To abdicate this or to obscure the gravity of past defeats and failures by looking to “resistance” from “outside” the dynamics of modern society is to affirm its present and guarantee its future destructive reality.

That seems an excellent platform for developing an alt-left, one not weighed down by historical commitments and the sentimentalism that has so marred the left and its politics in the past.

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Universal basic income: notes of an agnostic

I got this list from Google Images. It’s a good checklist though some may quibble with some of it.

Michael Haines, who has previously posted on Troppo, is campaigning for universal income funded from the adoption of sovereign money — which would yield a large amount of seigniorage like revenue to government. Geoff Croker is campaigning for something similar from the UK. I responded to this by email which I reproduce here.

As far as I understand it, you’re both arguing that you generate all this free money with sovereign money and then you spend it on UBI.  They’re two separate policies that need to stand or fall on their own merits. 

Thus for instance, I’m in favour of green taxes and wealth taxes and some move towards greater sovereign money (I don’t think I’m so clever that I know what would happen with full sovereign money so I’d like to take some substantial steps in that direction and then reassess). But the case for each is a product of their cost-effectiveness, distributional impacts considered in the context of the political economy of each measure. (If you’re not sure what I mean, the last two dot points of this post relate to political economy questions). 

The case for UBI likewise needs to be made on the merits. 

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Posted in Democracy, Economics and public policy | 6 Comments

Gruen: detox democracy through representation by random selection

I use Troppo to make various notes for file as it were for reference in future. And on wanting to record something I found that I hadn’t reproduced this post — which was originally at The Mandarin — here. So here it is, with some notes to file below.

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Posted in Cultural Critique, Democracy, Political theory, Politics - international, Politics - national, Sortition and citizens’ juries | 3 Comments

Some thoughts on fixing the Australian health system

This is an edited version of an article that first appeared in Crikey on 3 June 2022.

As I see it, the four most pressing challenges for the new Minister for health and ageing concern: 1. promoting health (not just treating disease); 2. addressing the disconnect between care settings (particularly hospital, primary and dental care), 3. fixing the private sector; and 4. addressing the national disgrace that is aged care.

‘Health’ is much more than medical interventions

 Firstly, the portfolio needs to encompass health, not just healthcare. The distinction is important. Health is more than the absence of disease. Healthcare is mostly concerned with treating illness. It has little to say about promoting health and avoiding illness unless it involves medical interventions (part of the problem is how we pay for care… but we’ll get to that).

The most pressing issue is the pandemic, which is far from over. The new government needs to listen to experts and work with, not against, the states and territories on containing it. In fact, COVID-19 perfectly demonstrates the value of public health interventions. They suppress spread (distancing, masks, periodic restrictions) and severity (vaccination).

Beyond that, we need to invest more in promoting health especially in tackling “upstream” risk factors. We have a pedigree here. Australia led the world in reducing tobacco use — a globally recognised public health success despite a determined campaign opposing it. Nicola Roxon, the health minister at the time, did a very good job standing up to vested interests.

The minister was less successful at adjusting the cataract surgery rebate to align with the cost-effectiveness of Medicare reimbursement for other procedures. To be fair, this was a harder sell than tobacco but it nevertheless illustrated Machiavelli’s timeless observation that:

“…nothing is more difficult to plan, more doubtful of success, nor more dangerous to manage than a new system […] for the initiator has the enmity of all who would profit by the preservation of the existing ways and merely lukewarm defenders in those who gain by the new ones.”

It also confirmed the golden equation of health care: every $ of spending = a $ of income (sometimes a very good income indeed.)

It’s now well established that the most powerful determinants of health (and disease) are social and economic. Inequality is especially harmful. It reduces everyone’s health, not just those at the bottom. The government has the levers controlling many of the factors affecting our health: education, tax, housing, social services and welfare.

Public housing — neglected over the past decade — can deliver some quick health wins. Unsurprisingly, improved housing availability and quality has been shown to reduce hospital admissions and re-admissions. We need health in all policies across the relevant portfolios and through the Council of Australian Governments (COAG).

Sorting out health care

What we call the health system in fact covers mainly medical care. It’s an illness system and, to be honest, it’s a stretch to call it a system at all; it’s more like patchwork, a marble cake that’s increasingly struggling to address modern demands of chronic, non-communicable disease, multi-morbidity and mental ill health.

Some serious changes are needed to improve how the current arrangements work for patients and consumers as well as those for those who toil every day to deliver care (who have really copped it throughout the pandemic).

Mental health care is probably the biggest illustration of the problems and challenges we have . We need to listen to patients, consumers and experts about how to invest in the prevention and treatment of mental ill health. The current ‘system’ is broken – and the current disconnect between primary, community and hospital care is a major contributor.

Hospitals are expensive and at times dangerous places. We must do everything we can to keep patients out of them, and if not, to ensure that their stay is as short and as safe as possible. I concede that this is difficult under a funding model that rewards activity and I caution against simply throwing more money at public hospitals. Inflating the balloon won’t reduce the pressure.

While the states run our public hospitals, the Commonwealth is responsible for primary care. Rising levels of chronic disease mean that our GPs and allied health professionals are on the frontline in helping people manage their health problems and keep them out of hospital. It also gives them a landing pad after they leave acute care, freeing up beds faster and helping reduce wait times at the front door.

(Most states need sub-acute beds and more social care for people who may have trouble coping at home — there are massive savings on offer by reducing the number of ‘boomerang’ patients.)

But we have a GP shortage in areas of greatest need (the inverse care law). Many patients don’t see their doctor because of high out-of-pocket costs (bulk billing data is a sham). Little wonder that compared to those living in other OECD countries, Australians are almost twice as likely to be admitted for respiratory conditions, most of which should be managed out of hospital.

SOURCE: OECD.STAT

We can bolster primary and community care in several ways. We should ensure that electronic medical records used in public hospitals can exchange information with those used in other settings, especially GPs and pharmacies. My Health Record isn’t working. The privacy risks can be managed. The benefits of integration can be considerable.

In the long term, we need a discussion with our medical colleagues about changing the training, socialisation and culture of medicine to value generalists as highly as specialists. Doctors are human so part of that is about money and a career in general practice (a specialisation in its own right) should be a financially attractive option.

Among OECD countries that provide this data, Australia has the second-lowest GP income rates relative to their specialist colleagues.  We need to change this by increasing how much GPs earn.  (Reducing the amount specialists earn is not a fight I would advise anybody to pick – see the cataract example above and what Nye Bevan had to say).

SOURCE: OECD.STAT

Follow the money … FFS

Many of the problems we have boil down to how we pay for health care. We don’t pay for health, nor can we because we’re hopeless at measuring it. So the prevailing approach fee-for-service (with the apt acronym of FFS) with the implicit assumption that the service produce health. Aside from the fact that this assumption often incorrect, FFS is probably the worst way to fund care that seeks to provide joined-up services for the growing number of people with multiple morbidity and complex health and social care needs. (Those suffering from mental ill health are a prime example).

In the interim, we should at least structure FFS to reflect various levels of patient complexity. Providers must have an incentive to invest the time to help their most vulnerable patients. A good start would be to raise the Medicare rebate for general consultations. This should at least begin to improve access for our poorest (and sickest).

But some point, we need to discuss ways to fund care that rewards value, not volume – both in general practice and hospitals. There are calls to unify the funding source for both. This would be the perfect solution. Given their overall vastly superior performance in managing COVID-19, I’d argue that the states would be better placed to manage and fund a unified health system in each jurisdiction. But I suspect that convincing any government to relinquish control of health care is highly ambitious.

A national health reform commission, however, could begin drawing up transition in funding to deal with this and other challenges we face. There’s plenty of alternatives to FFS. Perhaps we could try paying providers a lump sum per patient based on their level of health need (Gonski for health). We could incentivise people registering with primary care providers. We could encourage more care integration by bundling payments across the entire care cycle rather than pay for each individual component as if the patient were a product on an assembly line (albeit a very inefficient assembly line that would have Henry Ford spinning in his grave).

This commission — comprising representatives of patients and consumer experts as well as the usual suspects from the clinical world and academia — would be well placed to begin incorporating dental care in the health system. This is a much-needed reform that can 1. alleviate a lot of immediate suffering, 2. improve overall health, and 3. reduce pressure on other parts of the system.

‘Private’ health needs a major rethink

Most Australians receive elective procedures in the private sector. “Private” healthcare in this country is a cosy arrangement between insurers and providers, all propped up by billions courtesy of the taxpayer each year. The truth is that private health diverts resources away from the public sector, rather than taking pressure off it. The result is a two-tiered arrangement where those who can afford it get care (sometimes excessive and unnecessary care) while those who can’t go without, languishing on waiting lists. Little wonder the industry is in real trouble.

We can have a private sector (we will continue to have one regardless of what anybody thinks or says) but it must be designed to serve consumers — not providers and insurers. Several things can be done. Stronger regulation on fees and charges, including better transparency and limits. Also, why not publish provider outcomes so that patients can assess the quality they’re getting for their money?

We need to press on with efforts to modernise the Medicare Benefits Schedule, which is full of items that are obsolete or do not reflect effective, high-value care. And maybe giving more say to health funds in how care is delivered could improve efficiency and value in the sector.

Markets: a good servant, poor master — just look at aged care

The most fundamental tenet is this: health isn’t a commodity, and healthcare is fundamentally different to any other service or product. Market forces can play a role (note the health systems of Israel or the Netherlands) but they must be carefully guided and regulated. Relinquishing it all to the invisible hand will simply result in paying more for worse health outcomes. For evidence, just look at the USA.

In fact, we need not look abroad at all. Australian aged care is a prime example of what happens when we leave it to all to the market. It’s a complete mess, and a taskforce to implement the Royal Commission findings is needed as soon as possible. In a nutshell: more regulation, outcomes data, consumer protection and better pay for care staff. (We often hear ‘you pay peanuts you get monkeys’. Well, if this is true it applies equally here just as it does for executive remuneration.)

We shouldn’t waste a day.

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The case for greater use of secret ballots in parliament

If we want politicians to actually represent their constituents, we need to free them from the pressure of toeing the party line.

A week or so ago someone tweeted this to me.

It was a response to my Crikey! article of February last year. I had forgotten I’d written such a concise summary of my ‘hack’ to save our entertainocracy, but it’s a good summary of what it is and the way it could prevent our politicians damaging the country by voting against their consciences.

Because the truth is that the most disastrous moves Western democracies have made in the last decade have all been the result of politicians being unable to vote for what they think is the right course for the country and still remain in politics.

So I’m reproducing the column over the fold. Continue reading

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The case for more secret ballots within our legislatures

This is a piece I did for Crikey I’d forgotten I’d written and hadn’t put it up here. So now I have. The article was spotted by someone who has been exposing just how much damage opening up Congressional committee deliberations to the public has done. It’s a very interesting take.

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Fast foodification: what is it, what’s driving it, how do we stop it?

In this discussion, Peyton Bowman and I discuss my term ‘fast-foodification’. I coined the word trying to describe modern politics. The techniques used by politicians and their professional enablers are optimised to attract votes in the same way that McDonalds and KFC optimise their food with salt, sugar and fat to attract sales.

We also discuss other areas characterised by fast-foodification.  And we look at the question of what psychologists call ‘primary’ and ‘secondary’ preferences — namely what we want as compared with what we want to want. Growing as people involves a process of schooling tastes to acquire better ones. We might want to get fit, find going to the gym a chore for a while as we get used to it, but once we’re habituated to it we don’t want to miss our session.

Many things in human flourishing are like this as we school ourselves and habituate ourselves to better tastes and better behaviour.   Finally, having both agreed that capitalism and competition for votes tends to reinforce primary preferences — we discuss what institutions might encourage a culture in which secondary preferences might be nurtured. The audio is available here.

Posted in Cultural Critique, Democracy, Ethics, Philosophy, Political theory | 1 Comment