The Decline and Fall of the American Empire
bloomberg.com
bloomberg.com
If you were going to do one thing to extend American prosperity, it would be disruptive structural improvements to our healthcare system. That's structural reform, not new biotech (except as allows you to disintermediate care). The fact that our total expenditure is so high relative to other countries with similar quality of care is evidence that the economic models, not the technology available, are to blame.
How long are you willing to go without medical care just to make a political change? Not sure that geriatric politicians will be skipping their monthly appointments.
US doctors apparently earn about 2x the average for other comparable nations. That's not a small number, but doctor's salaries in toto are only about 8% of US healthcare spending. A 50% reduction would bring our salary spending in line with everyone else, but only save $100 billion out of a $3,300 billion cost.
Meanwhile, outright waste in medical supply spending costs $765 billion per year. That's drugs discarded at expiration dates which are known to be too restrictive, spending on combination drugs which are identical to the sum of cheaper components, and supplies thrown away by hospitals for non-sanitary reasons (e.g. vendor change, or drugs allotted for a patient but never issued or opened). Changing some parts of this would involve challenging the profits of drug companies, but in many cases not even that would be required. A handful of regulatory changes could save enough to offset the entire cost of paying doctors.
The situation with unnecessary or ineffective medical treatments is comparable. Some of the most common surgeries performed are known not to work, suspected not to work, or known to be more risky than inaction for standard patients, but they're still carried out at enormous expense. Adjustments to medical publication standards, physician statistical training, and and malpractice risk profiles could massively reduce the number of unnecessary and even net-harmful surgical procedures performed every year, cutting costs while directly improving care.
Framing medical expenses as a conflict between consumer expenses and doctor's salaries is false and harmful. It literally can't solve the problem, but it's excellent at derailing the work that could.
https://www.propublica.org/article/the-myth-of-drug-expirati...
https://www.propublica.org/article/what-hospitals-waste
https://www.theatlantic.com/health/archive/2017/02/when-evid...
Should patients be consigned to disability immediately without even attempting some procedure, simply because the chance of success is too small in your arbitrary definition?
You have never been seriously sick.
For a comment arguing that I'm being dismissive of sick people, this is a genuinely insulting and exceedingly false assumption to make. Yes I have, yes I am, and those experiences absolutely support my point.
> Who are you to decide what level of risk should a patient accept? ... Are they presumed to be too dumb and must obey your decisions? ... Should patients be consigned to disability immediately without even attempting some procedure, simply because the chance of success is too small in your arbitrary definition?
I did not say any of this at any point. I did not say anything remotely resembling "people should be consigned to disability because some procedures rarely work". None of what I am proposing is about denying patients treatments they make informed requests for.
Please actually read that Atlantic article. It is not in any way about denying medical care to a sick patient who wants it because "doctors know best". It is exactly the opposite - a patient was being railroaded into major heart surgery that made sense as a malpractice precaution but not as patient care. He did his own research, obtained multiple opinions, and independently decided to what should be done with his body.
That is what I want more of. In a discussion of cost-cutting I focused on the straightforward case of expensive treatments being pushed on patients without giving them full information, but over-treatment and under-treatment both happen. If it would make you happier, I can list some of the ways I think we can get better care at lower costs by providing more treatments and emphasizing patient wishes over current medical consensus.
I'm painfully aware that the 'patients are clueless' attitude you're attacking exists. I mean that literally, as a result of that attitude I'm in pain right now. But you read an entire worldview into one sentence, in the face of examples that specifically disagree with it. The thing you're objecting to is terrible and deserves opposition, but you're picking a fight with someone who already agrees about that.
It's easier to get appointments with CEOs of SP500 companies than with your own doctor sometimes.
As an outsider getting occasional (and highly combative) tidbits of the last american health system debate... It seems like a tall order. Doesn't seem possible to make a reform that (a) half the people don't think is the devil's work and (b) works in theory, which is important to Americans and (c) works in practice.
Seems to me that governments, including American Federal and State governments, do it all the time. In fact, it's so common, that I wonder if that's the main function of government.
Excluding ethics / philosophy of that kind of seizure, it's just a hard computational problem to orchestrate a centralized reform of something so complex. It becomes impossible when the system being reformed gets involved, buying politicians on both sides to impact the future and influencing public perception. And how could they not? It's hard to even fathom the stakes: a highly centralized industry capturing 10% of US GDP.
That's why, at the risk of being a tech culture charicature, I think business innovation from outside the industry is more likely to make a dent than politics.
For a 'clean tale of hypothetical decline' this really seems to undersell the climate problem. As of the weekend along the Norther American West coast there was almost continuous forest fire smoke from southern BC to near the middle of the Central Valley. It's not implausible we will see a sizable percentage of the Western US forests destroyed by fire in the next couple of decades. For anyone who has observed the ecosystems over the past few decades the changes are starting to become quite alarming.
So the climate problem is pretty big. At least at the national level the US is basically ceding responsibility for developing technologies to address it to other nations. This looks like a big future opportunity loss in addition to the actual costs imposed by climate changes.
What is (for the purpose of this article) "American Empire" anyway?
If it's relative economic & military power, than the writing is on the wall. China is matching and surpassing the US now.
Is it "Empire of the Mind" where the US leads the world in terms of political ideas, holds the torch of civilization and such? That's a whole different discussion.
Is this an article about upcoming disasters of a political-economic kind?
Military wise China is still very behind and does not have projection capability (as USN has port calls that covers 90% of the coast lines).
Economic wise China is in frail shape as it's built on mountain of debt that other countries like the US can recall. The US is unique since they can always print more and let other countries eat the costs.
The American empire is far from gone and since we aren't going to be speaking Mandarin anytime soon here in North America I'd say keep dreaming the dream.
US has:
- situations leadership cannot (ie no immediate benefit for them) or will not (ie blind tradition) correct the rules of the current system in a way founders, whom understood human-nature, could adjust to make it work better.. instead the ship is falling apart:
- essentially unlimited private campaign financing.. resulting in corruption metastasizing into all three branches, from POTUS down to sheriff and district attorneys, which leads elected officials to dismiss the public good to mostly consider the rich’es and their good.
- disengagement through manufactured consent, learned helplessness, divide-we-fell polarized animosity and non-participation.. yes, and celebrity chefs.
- mass-media oligopoly.
- insane student debt bubble, just the latest bubble.
- largely morally- and ethically-unmoored, unregulated market chicanery leveraging complexity, obscurity and trade volume speculating to alter the worth of real capital.
- large, diffuse official workforce participating in inverted totalitarian wage-slavery and living in their vehicles. more co-ops employee ownership, shorter work weeks, higher pay relativr to the cost of living and workers on boards-of-directors are needed.
- “excess” labor due to automation and outsourcing. those “better jobs elsewhere” rarely materialized, hence opioid crisis.
- opiod crisis.
- undocumented workforce which subsidizes costs of many essential goods for the lower-income classes with their cheap labor.
- complex geopolitical situation in an ever-flattening, connected and population-stabilizing work (sans Africa).
Maybe in a million years Bezos will be the first quintillionaire Morlock and feast on the marrow of the Eloi while paying for everyone’s UBI since there’s no jobs left except Scruffy, the Janitor.
Certainly the pax americana is at the end of its road, because of e.g. the costs of upkeeping the military, but will USA somehow implode and shrink to irrelevance and vanish completely? No, I don't think so.
China is emerging as the next big power. However, I am not so sure it will stay as a cohesive whole during this development as it reaches its peak. I believe technological advancements and ever-increasing interaction with other, continuously developing and changing cultures are incompatible with an increasingly tighter grip of the population (via e.g. the social credit system). Free flow of ideas & communication and an ever tighter "police state" in the physical world do not mix and will eventually collide, destructively. From extreme to extreme, then balance.
Long story short, I think in the future the world will be a multipolar one and this will be the "low energy state" of the global system. All of the current top players will eventually take a hit of some kind, and become different from what they are today, but not disappear nor sink into a Mad Max style world full of oblivion and despair.
And, no offense, but relative to the rest of the world Americans are kind of old and kind of fat.
So: probably not.
[1] Sources:
https://www.forbes.com/sites/jerrybowyer/2013/07/18/youth-in...
https://www.fragilestates.org/2012/11/25/causes-of-revolutio...
Just ask this question of any society, past or present, and tell reliably whether it's in rapid decline or not: democracy, empire or otherwise.
Accumulating enemies, losing friends, having trouble with rainfall amounts, not adjusting to internal human needs and wishes, insisting on obsolete techniques? Then you have a problem whether Mayan, Roman, Soviet or other.
Please provide actual examples.
Here’s the first three sentences from the actual article:
“So what would the decline of America look like? I don’t ask the question because I think it’s happening (yet?), but because even the most inveterate optimist should be interested in the dangers, if only to ward them off.”
These articles are a dime a dozen in the age of Trump and most of them are shortsighted and factless.
The American economy is pretty much at 100% right now, as any chart could tell you has been the result of almost 10 years of growth since the financial crisis. Which is why it is shocking and startling that it is coupled with extraordinary deficits approaching a trillion dollars. This is the time when the government is supposed to be eliminating deficits, not blowing them up.
The US debt is simply grotesquely unsustainable, and when even the anti-deficit right has ceded the fight...bad times are ahead.
So yes, the US economy is a "terror" movie of sorts. It is so profoundly irrational that it has some serious jump scares coming up.
As an aside - Trump is boasting about a steel maker making record profits. Ignore that it cost $12B in taxpayer money to farmers in a single year, and will cost billions more, and that it dramatically increased the prices for US consumers and threatened a wide swath of manufacturers...at least US Steel is making money, right?
[1] https://twitter.com/paulkrugman/status/1022913401167720454
[1] Measured in quality of cheese and wine [2]. [2] Suck it, Italy.
And of course the US almost in it's entirety owes its size and natural resources to very real "empire building" in the 19th and 20th centuries.
Admittedly the territorial expansion of the US has slowed/stopped in the past 100-200 years, but it's not hard to understand how for someone belonging to a group that lived in a given place for many, many multiples of that duration, the current situation might feel, even today, like occupation. (see: hawaii sovereignty movement, native american reservations)
I suppose the question is "when does an empire stop being an empire?" Is it the day it stops expanding? 100 years later? When nobody remembers how things were "before"? I think it's an interesting question.
From merriam-webster:
1 a
(1) : a major political unit having a territory of great extent or a number of territories or peoples under a single sovereign authority; especially : one having an emperor as chief of state
(2) : the territory of such a political unit
b : something resembling a political empire; especially : an extensive territory or enterprise under single domination or control
2 : imperial sovereignty, rule, or dominion
3 capitalized [Empire State, nickname for New York] : a juicy apple with dark red skin that is a cross between a McIntosh apple and a Red Delicious apple
Since the US does not have a single authority controlling it (i.e. "is a democracy") it cannot be an empire. They are mutually exclusive according to the dictionary.
If you really squint hard you could argue that the rest of NATO are military tribute states giving soldiers to the US empire but that's a very strained interpretation. Japan is currently pretty dependent on US military protection but that doesn't seem to have turned into economic exploitation. Certainly American efforts to get Japan to open up to more US exports isn't something Japan has just rolled over on.
But the current international system does have the US at its center and colloquially people call this the American Empire, and we know what they're talking about even if it isn't really an empire.
That's what happens when economists write, they make the coolest topic boring af.
Boring,and a world worse than today in many ways, if we don't get out ahead of the failure modes.
Let's take a look at education for an example: USA ranks pretty low on global education rankings despite the fact that we have some of the best schools in the world across all levels, its hard to think why that may be the case but when you consider the inequality in school systems due to property tax law and de facto segregation it makes a lot more sense.
Look at the criminal justice system: we have over 1 million prime aged men who are basically frozen out of achieving economic prosperity and contributing to this countries success because of bad policing and disproportionate enforcement of law.
Look at healthcare, there is a huge gap (although closing) of life expectancy between races.
India and China are not utopias by any means, but they have 1B+ people: these countries are growing larger and larger in influence and will create a middle class that contains hundreds of millions of people. The US is getting more and more in-equal and at a certain point we will reach an inflection point where we are too damn lopsided for our own good. People want to talk about lower productivity and lower wages, when you have 1.5 missing men from the workforce what do you expect?[0]
0: https://www.nytimes.com/interactive/2015/04/20/upshot/missin...
Would America's racial inequality not be an issue if we had 3x the population?