shawn whatley md

Are We All Liberals Now or Has Liberalism Ended?

For some reason, physicians love this line:

“I am socially liberal but fiscally conservative.”

It sounds moderate, prudential, even sophisticated.

“Socially liberal” suggests individual choice about sex, marriage, and life in general. “Fiscally conservative” suggests spending restraint and market freedom.

Both statements come from the same philosophy. The first is social liberalism, the second economic liberalism.

In other words, “I am socially liberal but fiscally conservative,” is simply liberalism through and through.

What then do we mean by ‘liberalism’?

Liberalism

Liberal just means freedom. Most people like freedom, at least for themselves.

Libertarians make a whole political philosophy out of freedom: for example, Don’t Hurt People and Don’t Take Their Stuff – A Libertarian Manifesto.

Liberalism, on the other hand, means something more.

Francis Fukuyama is perhaps the most well-known expert on liberalism. At the end of the Cold War, he wrote, The End of History and the Last Man (1992).

Fukuyama predicted a future of liberalism without contest or equal. No more socialism, conservatism, or anything else. Nothing but liberalism forever and ever.

Given the lack of competition, Fukuyama did not need to define liberalism against its enemies. Everyone knew what he meant.

Anti-Liberalism

Fukuyama’s endless future lasted two decades. The liberal consensus is dead, and liberalism faces attack from all sides. Continue reading “Are We All Liberals Now or Has Liberalism Ended?”

Bureaucracy vs Patient Care

Bureaus and bureaucrats create bureaucracy. Together, they build their own demand and transform people into managers designed to meet bureaucratic needs.

A bureau designed to serve patients ends up serving its creators, while protecting those who work inside.

William Niskanen, economist, offered a definition. Roughly speaking, 1) bureaus contain people who do not earn income from the difference between revenues and cost, and 2) bureau revenue does not come from the sale of output per unit rate.

Squeamish About Saying “Bureaucrat”

Many people refuse to discuss bureaus, bureaucrats, or bureaucracy for fear of causing offence. The managerial and chattering classes see talk of bureau-anything as impolite, ill-defined, or perhaps unhinged.

This tactic is old. See Orwell’s, 1984. Control language; control the masses.

Forcing a word out of fashion does not remove the reality it described. Changing labels creates an endless need for new labels. Relabelling bureaucracy as management or administration does not escape the need to debate the concept.

We need bureaucracy, just like we need surgery. Surgery saves lives when nothing else will do. At the same time, there is nothing that surgery cannot make worse.

The Need for Bureaucracy

As organizations grow, they build bureaus and bureaucracy to decrease risk. Bureaucracy exists to slow things down and make us think twice.

For example, hospitals create communications departments to decrease the likelihood of bad press. Government funding relies foremost on keeping funders happy. Bad press about patient care trumps concern over care itself.

Every element of service creates its own demand for bureaucratic process.

Forms, checklists, and audits.

Computer passwords, authentication, password expiry, and mandatory sign-off.

HR credentialing… the list is endless.

Room always exists for more bureaucracy, with its imprimatur of orderliness and excellence.

The Value of Bureaucracy

Organizations and governments build teams of professional managers (bureaucrats) at significant cost.

Teams struggle to justify their own expense. They cannot point to profit or improved patient care. Given fiscal austerity, ballooning bureaucratic budgets make managers cringe in anticipation of scrutiny.

This creates an impassioned hunt for confirmation of value. Bureaucrats need something — anything — to prove their worth. Continue reading “Bureaucracy vs Patient Care”

User Fees Promote Equity and Efficiency — New Review Paper

Twenty eight countries have universal healthcare. Twenty two of them have some form of cost sharing.

User fees offer one example.

They work best as a small, flat fee paid at the point of service. Even a few dollars discourages (rational) people from booking for what they asked twice before.

User fees shorten the line for limited service. They free doctors and nurses to meet greater needs.

Some doctors rant about “skimming cream” and colleagues “stealing all the easy patients.”

Many shrug at creaming skimming. Sure, it exists at the margin, but it guarantees incompetence. Doctors need sick patients to stay sharp.

Either way if cream exists, then user fees are anti-cream.

Advocates for national pharmacare assume cost sharing must exist. Patients should share more of the cost of Viagra than Vancomycin (an antibiotic).

The same advocates often see first-dollar coverage (free meds) as outrageous for drugs but essential for doctors’ services.

Canada stands with a small group of six countries without any cost sharing in universal care. Canada stands alone in not allowing any access to medically necessary care outside the state.

NOTE: All countries with user fees have exemptions for the poor, sick, old, and very young.

Two New Reviews of User Fees

I spent several years pulling together a paper on user fees.

In July, The Macdonald-Laurier Institute published my report: Equity and efficiency vs. overconsumption and waste: The case for user fees in Canada. Check out the (shorter) press release here.

How can we protect a common good from overconsumption and waste? Everyone can access a common good. The more I use the less you get.

How can we deliver high-value care to those who need it most?

Should one person, who tries to protect medicare, and their identical twin, who abuses it, pay the same premiums (taxes) for medicare? Continue reading “User Fees Promote Equity and Efficiency — New Review Paper”