Same as the Old High

If Marx posited that religion is the opiate of the people, then we have reached a new, more clarifying moment in the history of the West: Opiates are now the religion of the people.

Andrew Sullivan

This is a plague ripping America apart from within, far greater public health crisis than AIDS ever was.

And the Presidential solution is to give it to his wife to manage.

Once again, the band plays on.

America the Unexceptional

In the United States, babies are more likely to die and high schoolers are less likely to learn than their counterparts in other affluent countries. Politicians may look far and wide for evidence of American exceptionalism, but they won’t find it in the numbers, where it matters.

American Exceptionalism”
Vaclav Smil

IEEE Spectrum

Patriotism is not seeing only the good things about your country and loving it for those things.

Patriotism is not seeing only the bad things about your country, and loving it anyway.

True patriotism is the ability to see both the good and the bad, and fighting to fix the bad without throwing away the good.

Democracy, Policy, and the Experts

The Death Of Expertise
Tom Nichols
The Federalist
January 17, 2014

The Internet has been accused of many things. It has been condemned as a destroyer of value. It has been reviled as the hiding place of gangsters and perverts. And now, in the pages of The Federalist, self-styled social science and public policy expert Tom Nichols accuses it of destroying expertise.

Nichols’ point, brutally summarized, is that by appearing to make everyone’s opinion of equal value, the Internet is slashing the value of an expert’s opinion to essentially zero. That’s dangerous, he says. To kill expertise is to reject knowledge and how we gain it. It is to raise the value of the opinions of people like Jenny McCarthy over those of doctors.

All agreed: we don’t want experts to go away. They offer tremendous value in society, and we would be lost without them.

And he is so very, very right when he notes:

People in political debates no longer distinguish the phrase “you’re wrong” from the phrase “you’re stupid.” To disagree is to insult. To correct another is to be a hater. And to refuse to acknowledge alternative views, no matter how fantastic or inane, is to be closed-minded.

All Hail the Expert

If this were as far as he took his argument, he would have won the day. Unfortunately, after a good start, Nichols goes off the rails in some important ways that hint at a larger, darker agenda.

He deems as “sanctimonious” and “silly” the idea that every person has a right to his or her own opinion. He launches into a screed against the incompetent taking part in discussions in the public arena. How dare, he suggests, that people who “can barely find their own nation on a map” have strong views on going to war? How dare those who cannot name their legislator have an opinion about how Congress handles a piece of legislation?

How dare, he asserts, anyone have an opinion on a field in which he is not an expert? Only experts, he implies, should be allowed to be heard on anything, unless, of course, the electorate become experts themselves. He doesn’t want a technocracy, mind you:

But when citizens forgo their basic obligation to learn enough to actually govern themselves, and instead remain stubbornly imprisoned by their fragile egos and caged by their own sense of entitlement, experts will end up running things by default. That’s a terrible outcome for everyone.

The threat: either people get a lot smarter about policy, or the experts are going to take over. We’ll let you have your opinions, but we control will remain in the hands of the people trained to run things.

It is sad that Nichols did not quit while he was ahead, making a case that we need to use care where we tread. In suggesting that we have a binary choice between everyone getting a lot smarter really quickly on the one hand, and letting the experts run things on the other, he is being disingenuous: the only likely outcome of those two is technocracy. And so what this article becomes is a case for the experts to take over.

Who is an Expert?

The reasons to distrust this reasoning are manifold. Let us dispose of the easy ones right away.

First, anyone who declares himself an expert is, in my opinion, immediately suspect. If someone who is in a position to know declares you an expert, you may well be one. If you declare yourself an expert, your status is suspect. Declare yourself a specialist or a professional if you must, but allow others do declare you an expert, a master, an authority.

Second, if we grant that he is an expert, his argument on behalf of the primacy of experts is self-serving, and thus suspect. In this, he is little different from the journalists decrying the Internet because it means we are reading less journalism. I feel bad for them, but the horse has left the barn, and experts, like journalists and the rest of us, are all facing a different world.

Trusting Experts

So, let us say that Nichols is an expert, and that he is being selfless. Handing over our policy decisions and our fates is a path fraught with problems. Primary among those “who gets to decide who the experts are?” Expertise is subjective, and the determination of whether someone is an expert demands other experts in that field. Who then appoints those people? This works us into a circular argument, and we wind up with a lot of people claiming expertise, but no objective way of making that determination.

I spent two decades working in China, and three decades studying it. Am any more or less an “expert” in China business than a newly-minted Harvard Ph.D. who did his dissertation on my field? Or than a journalist who has covered business in China for twenty five years? Says who? And why? You see where this is taking us. Multiply this problem by hundreds of fields, and the issue of determining expertise becomes non-trivial.

Once we have decided who the experts are, which ones do we trust? Any competent trial lawyer or white-shoe K Street lobbyist will tell you that on any issue, there are experts, but that often no two experts will reach the same conclusion, and often their conclusions will be diametric. Brookings, RAND, Heritage, CATO, and the Progressive Policy institute are all staffed by experts, but if you got all of their experts on any given issue in a room, you would have a war. Who decides among them and their recommendations?

Further, a reliance on experts implies that there are only two classes of people in any given field of knowledge: experts, and laymen, and only the former have value. This is poppycock. Apart from those with the highest level of mastery are polymaths (who are deeply conversant in multiple fields, though not necessarily expert in more than one;) apprentices, students, enthusiasts, buffs, and talented amateurs. People at any of these levels can make profound contributions to their fields.

Three examples jump to mind. Alan Hale and Thomas Bopp proved the value of amateur astronomy when they discovered the comet that was later named after them. A clerk in the German patent office turned astrophysics upside down when he wrote a short paper describing a general theory of relativity. And corporate finance executive Edward Miller, Jonathan Parshall, a software executive, and Anthony Tully, an IT support specialist each conducted research and wrote books that have forced us to reevaluate the history of World War II in the Pacific.

Broad-based Problems, Narrow Solutions

But among all of these, the biggest problem is the nature of expertise itself. Experts are expert, by definition, because they spend their lives focused on a narrow enough field that they are able to achieve a greater degree of knowledge than most others in their field. For that reason, they are excellent at answering specialized and narrow questions. Unfortunately, their expertise is of declining value as they touch on questions that have implications far beyond their narrow field of expertise, and it is axiomatic that many of the most vexing problems faced by government go far beyond an expert’s ken.

Elizabeth Coleman, who retired from the presidency of Bennington College last year after a quarter century in the role, frames the problem with experts more eloquently:

Over the past century the expert has dethroned the educated generalist to become the role model of intellectual accomplishment. While expertise has had its moments, the price of its dominance is enormous. . . . Questions such as “What kind of a world are we making?”“What kind should we be making?” “And “What kind can we be making?” move off the table.

These are precisely the kinds of questions our polity faces today.  You can substitute “nation” if you think “world” is too arrogant, but the issue stands. These are not the kinds of questions Mr. Nichols and his fellow experts are best suited to answer. They are the kind left to the rest of us.

The Tyranny of Experts

Which brings us to the final problem. Nichols contends that the idea that we all have a right to our own opinion is silly and sanctimonious. He is wrong. Giving us each the right to our own opinion, to express it, and to be proven wrong or vindicated is an essential part of the American democracy. To suggest otherwise steps beyond the arrogance of a learned man in awe of his credentials: it is to place us on the road to a technocratic tyranny where we are all the docile wards of the incredibly smart.

Aldous Huxley would have recognized what Nichols is suggesting, as would anyone who has read Huxley’s Brave New World. It is a world where because all men are not equal, their say in the way the world is run is not equal. That may appeal to the elitists. But that is not democracy, that is not the way the founders of the United States meant this country to be, and it is not a country that I would want to live in, either as an expert or a layman.

Let us keep this in mind: experts have value in that they should always be invited to inform the broader debate. Laymen need to think more critically and question the definitive statements of those who are not deeply knowledgable in the field in question. When faced with an expert versus a layman, deference should be paid to the point of view of the expert, but critical deference should be paid to all.

But experts should never be allowed to dominate that debate or, even worse, by dint of their knowledge be allowed to circumvent it. They are our servants. We shall not be theirs.

A Quick Thought on Healthcare

Responsibility for pensions and healthcare need to be taken away from employers. There is no logical reason to place companies in charge of social welfare when we no longer stay with a job for our lifetimes. It is an unfair, cumbersome burden to employers, especially those of us trying to run a small business.

We should not forget that the only reason companies are saddled with this burden today was that in the wake of World War II, a small number of very large companies decided that it would be better for companies to control the social welfare of their employees than allow unions to do so. Whatever the logic behind that approach may have been, the result has been nightmare and expense for businesses of all sizes ever since.

The system must change, if for no other reason than to ease the burden on industry and help make us competitive again. Whether Obamacare is the answer, part of the answer, or a flat-out run in the wrong direction is unclear, and has been muddied by hyperbolic promises made by its supporters and Cassandra-like prognostications made by its detractors, none of whom are left with much credibility.

What is clear is that many of us are growing weary of the debate and would like to give the initiative a chance to succeed or fail on its own merits in execution. If it fails, kill it. If it succeeds without bankrupting the nation, keep it, and let companies get out of the social welfare business.

But even that is not enough. Fixing medical care is not a matter of a single silver bullet, regardless of the Obama administration’s lofty ambitions. It is going to be a long, incremental process rather than a Big Bang, and the sooner we can begin isolating or co-opting the special interests who are blocking the process, the sooner we can go about creating a healthcare system of which all Americans can be justly proud, and from which all of us can benefit.

ACOs: Part of America’s Prescription?

“Health-care services: The good old ways”
The Economist

A fascinating look at a way to significantly improve care for those who are already getting it, all while radically reducing costs.

A major part of the long-term answer to our country’s healthcare crisis is going to be getting us all to live healthier while giving doctors incentives to prescribe tests and drugs only when necessary. “Accountable care organizations” might be a good step in that direction.

RAND: Making Healthcare Affordable

“Affordable Health Care”
Dr. Arthur L. Kellermann, M.D.
Farsighted Leadership in a Shortsighted World
September, 2012

Medicine Drug Pills on Plate
Medicine Drug Pills on Plate (Photo credit:

The issue of healthcare reform has become as divisive as any other debate in American politics today, to the point where simply suggesting that the system requires reform is enough to color you a Democrat. This is a shame, because while it would be foolhardy to set the country on the road to socialized medicine, it would be doubly so to behave as though our system does not contain serious flaws.

Foremost among those flaws is the high (and rising) cost of care, and much of that cost is wrapped up in waste and inefficiency. As physician Art Kellermann, a senior RAND policy analyst notes, “the United States has the least efficient healthcare system in the developed world.”

Kellerman notes that even with the Affordable Care Act (“Obamacare”), the health care system costs too much and will continue to get more expensive. Having spent over a decade analyzing health care costs in the U.S., he notes that the system needs changes that seem simple but that imply a massive change in the way medical care is administered, if not delivered.

  • Switch to electronic medical records at once;
  • Reduce costly and unnecessary testing and imaging;
  • Switch to a system that pays doctors and hospitals to be more efficient and effective;
  • Move to consumer-directed, high-deductible health care plans while sustaining the use of recommended care.

These are all good steps, but the most important one he identifies is the need to shift the effort in healthcare innovation from developing more expensive procedures to finding ways to deliver better care less expensively. He doesn’t offer many examples, but telemedicine, in-home care, and merging healthcare preventative care, monitoring, and healthier lifestyles are likely candidates.

Kellermann’s essay would do better if fortified with these points, and with an examination of the problem of legislative and regulatory capture by the medical professions, the pharmaceutical industry, medical equipment manufacturers, the insurance sector, and managed care providers.

Nonetheless, his rational, non-partisan approach to the problem, bolstered by his own credentials as a physician, offer an important starting point for genuinely solving America’s health care problems.

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