Priced Out The Economic and Ethical Costs of American Health Care Uwe E. Reinhardt; Reviewed by Christopher M. Hughes, MD

Inevitable.

As I mentioned in my last post, I am very keen on the idea of framing our political arguments and positions as inevitable. It comes from Anat Schenker-Osorio (ASO) and her argument that inevitability can overcome many cognitive psychology biases, like Status Quo Bias and others that I explore in a series of pieces here.

She believes that the success of the campaign for abortion rights in Ireland was greatly benefited by the framing around inevitability: We are eventually going to do this, why not do it now and create a better world with less suffering now instead of waiting for all of the old guard to pass on?

I believe there are many issues we can frame like this, and I am hoping some of you will help me brainstorm this. I am going to put up some issues (and my initial stab at framing) that I think are inevitably going to change in progressives’ favor as Gen Z starts voting in bigger numbers and my Boomer cohort votes less.

Gun Control. Seeing the demonstrations in Tennessee and the polling numbers on assault weapons bans, and the general unpopularity of crazy “guns’ rights” positions, makes this seem like it should be easy.
Reproductive Rights. Quashing reproductive freedom is the last gasp of religious patriarchy.
Green Energy Transition. I would like to say that the fossil fuel industries are in their last days, too, but the power they wield is still immense. But the transition is mandatory and we all know it. The longer we postpone the inevitable, the more harm we do to everyone.
Workers Rights. Union rights, fair and living wages, sharing of profits across the work force (like we did in the decades after WW II), Child labor laws, a four day work week, to name a few. Does anyone think we aren’t going to get these things as we push back against the oligarchs?
LGBTQ Rights. Also part of the last gasp of the religious patriarchy. Religious zealots gonna scream about “the gays” and continue to look the other way while their children are abused. Enough.
Universal Healthcare. Is there a universe that in 10-20 years still does not have universal healthcare? As with the fossil fuel industry, the Medical Industrial Complex will be hard to fight, but I have many thoughts on how to do it, and I am not alone.
Finally, the Big One: SCOTUS. Everything listed above can be overwhelmingly popular but if the reactionaries currently in control of SCOTUS remain in control, they can invalidate every bit of progress with the wave of their corrupt hands. I believe it is inevitable that we unpack the Court. McConnel and Trump packed it with reactionaries and religious fundamentalists, and that is not who we are as a country. It must be undone, so let’s get on it now. Mobilize to unpack the court.

There’s my list. Please contribute your thoughts and criticisms, I’m anxious to see if this can get some legs!

Reconciling Anat Schenker-Osorio, Mariana Mazzucato, Jonah Berger, Dan Ariely, Anand Giridharadas, and me.

I have been following the work of Anat Schenker-Osorio, hereafter ASO, for quite some time. But lately I’ve become more of a fan. I found an interview with her from “The Zero Hour with RJ Eskow” podcast from about three years ago. It covered a fair amount of territory for a short interview, and I thought it be worth summarizing and commenting on to help with my own clarity of thinking as I try to synthesize lots of cognitive psychology material around persuasion and changing peoples’ minds. So here we go!

First, Anat Shenker-Osorio is the author of the book “Don’t Buy It: The Trouble with Talking Nonsense About the Economy.” She is also a consultant and advisor in the field of communication and strategic communications, and the host of the podcast that was called “Brave New Words,” and is now called “Words to Win By.”

As has been said many times by many people, our choice of words when making our persuasive arguments matters. It matters a lot. She gives the example here of the difference between talking about the price of a prescription drug versus the cost of a prescription drug. She points that cost implies inherent value while price is simply an arbitrary number assigned by typically, someone trying to sell the item. Cost implies an inherent value and perhaps the cost of producing something. (She later mentions talking about insurance corporations rather than insurance companies as another example.)

This argument ties into another discussion I have recently become interested in from Prof. Mariana Mazzucato, who argues that without a clear understanding of value creation, we risk allowing value extraction to masquerade as value creation, leading to a distorted perception of productivity and value in the economy. In other words, in the same pharmacy example, there is value creation, but it lies with the underlying research, typically done in federally funded institutions, and with the actual whitecoat scientists in the pharmaceutical companies. Contrarily, the value extraction in the industry comes from the administrative and executive overload of trying to name prices that are extraordinarily out of step with the actual cost and value of a product.

ASO argues that the “way we describe these policies makes a measurable difference in terms of both who is persuaded to understand and support them, and equally, if not more importantly, how we galvanize are base to repetition so that our version of the story is the one that’s actually able to dominate” in public discourse. If there is one thing the Democrats are bad at, it’s staying on message and repeating the message ad nauseum. We have a lot to learn from our political opponents on this!

She continues that it’s not simply about convincing people that our ideas are better, but it is contending with the cynicism of the public, particularly in healthcare, that change is even possible. She notes that they are also scared to death of getting rid of the devil they know.

She then makes two arguments about this:

Describing policy and making cogent arguments will never overcome the fear of uncertainty.
Arguing for the financial and economic benefits for something that is essentially an argument about our morality as a nation is never going to work.

The uncertainty argument is critically important. Jonah Berger, in The Catalyst, Chapter 4, reviews the literature on loss or risk aversion. People really dislike uncertainty. Uncertainty undermines actively making changes and can halt the decision-making process entirely. “[W]hile uncertainty is great for the status quo, or whatever people were doing before, it’s terrible for changing minds.” “Status quo bias” or favoring something simply because it’s this certain thing that we already know and have is powerful. As Uwe Reinhardt put it long ago, “everybody’s second choice is the status quo!” Therefore, it wins. More here.

The second part of her argument is an echo of a chapter in Dan Ariely’s book, Predictably Irrational. In Chapter 4, “The Cost of Social Norms,” he describes how differently we process decisions based on whether the appeal is to “market norms” or “social norms.” He gives the example of asking a lawyer to do pro bono work for a good cause versus asking a lawyer to do work at discounted rate for good cause. They will nearly always do the former and almost never the latter. Once a rate of exchange is applied to the transaction, it becomes a market transaction and the appeal of doing something as a social good is out the window.

So ASO’s point about not making the typical liberal nitty-gritty detailed policy argument about the market benefits of universal healthcare is spot on. The argument has to turn on social justice and moral norms.

She further emphasizes that point by noting, as would George Lakoff and Drew Westen, that when you make the arguments as financial and economic you activate the parts of the brain, the neurologic pathways that favor conservative arguments of fear of the unknown. And besides, as far as energizing the progressive base, it really isn’t about the economic arguments, even as persuasive as they are, it really is about the moral argument. I know it is for me.

She gives three examples of progressive campaigns that she participated in including the fight for abortion rights in Ireland, the campaign for prime minister in New Zealand, and an anti-racism campaign in Minnesota. She points out that messaging around being against things really doesn’t work well. Progressives need to figure out how to forcefully state what we are in favor of. “Abolish ICE,” for example. It is better as an argument to “create fair immigration process that respects all families.”

One of her central points tying these three campaigns together is the idea of the inevitability of change. Rather than trying to convince people that change was necessary, argue that change is necessary and inevitable. In the abortion example particularly, this was about getting the change over with, because it painted Ireland as backwards and out of step with the modern world. I think the same argument applies directly to America and universal healthcare. We will eventually do this, what are we waiting for? It makes us look bad: selfish, uncaring and backwards. We should lean into that.

Anand Giridharadas in an appearance promoting his new book, The Persuaders, makes a good case for reframing Medicare-For-All as “FreedomCare” in a recent “Off-Line with John Favreau” podcast:

Let’s help people see themselves in Medicare for all. I would call it FreedomCare. I think it’s ridiculous that it’s that it’s called Medicare for all. Why is it named after a government program instead of a widely held American value that would be an example of sticking to the ambitious demand, but saying what are some other ways of talking about it, right?

A language of freedom is a much more resonant language in this country. Healthcare is a human right is something that people – progressives – often say about Medicare for all well that’s actually not a particularly resonant frame in America because it’s not like the people who don’t like universal healthcare also don’t like human rights, right?

What I think universal healthcare would be in truth would be a massive expansion of human freedom in this country. Like I don’t want my boss dictating whether my kid gets care if, heaven forbid, my kid gets cancer. Did you want your boss having that decision over you, right? Yeah, like I don’t want to not pursue my business idea because I have to stick to a stupid job for healthcare.

It’s amazing to me how little progressives speak in this kind of language of personal Liberty around the stuff. That’s the kind of persuasion that I think the characters I’m writing about are interested in.

But let me tell you where she really made me a fan: she wants us to name the villains! This is something I have been pushing in my circles for quite some time, so it is great to hear it validated! She talks about the positive messaging and to say what we are for, but she doesn’t discount the importance of name checking the problem and deliberately naming the villains! She uses the example of the 2009 housing crisis: people didn’t lose their homes, their homes were taken from them by Jamie Dimon and J.P. Morgan Chase and all their collaborators. We have to lose the passive construction of our arguments and assign deliberate causation to the actions of the “malefactors of great wealth.”

There are hundreds of ways that this will work in healthcare. In fact, if you ask Chat GPT who the five highest-paid health ~~plan~~ insurance corporation executives are, it’ll tell you.

1. Bruce Broussard, Humana – $17.3 million

2. Joseph Swedish, Anthem – $13.1 million

3. Stephen Hemsley, UnitedHealth Group – $12.4 million

4. Kenneth Burdick, Cigna – $11.6 million

5. Andrew Slavitt, Optum – $10.8 million

Her final point is based on a quote from Keith Ellison, Atty. Gen. of Minnesota who said, “power knows exactly what it’s doing.” The argument is that speaking truth to power is not enough. The goal is to achieve enough power and force change. FDR allegedly said to a group of activists, “You’ve convinced me. Now go out and make me do it.”

Let’s do that.

How Equal Do We Want To Be – in Healthcare?

Along my journey in Cognitive Science I came to discover Dan Ariely, and then came across a TED talk he gave called How Equal Do We Want To Be? He explores economic inequality and what we think we know about economic inequality, the reality of income inequality and finally what we would like income inequality to be. I think there are important correlations to how equal do we want to be in healthcare, and brought this here for discussion.

You can easily skip my summary of his talk and just go over and watch it, but I also wanted to capture some of the graphics, as I think with just a little imagination, they can be transformed into important questions about our healthcare system!

So, from the top! What we think is that the top 20% have 58.5% of the wealth and the bottom 40% have about 10% of the wealth.

In reality, the top 20% have 85% of the wealth the next 20% have 11% in the bottom 60% share the last 5%. He calls this difference between what we think and reality the Knowledge Gap.

Along those lines, he asks what we think the pay ratio of CEOs is to that of unskilled workers. He shows this graph showing what people think it is (Estimated), when it actually is (Actual), and our ideal notion.

Not so bad, right? Oops, he didn’t adjust the scale. Here’s the reality.

We are in Alice in Wonderland territory now. But if you are in the CEO or top 20%, it’s a very happy Wonderland, indeed!

During the talk, Ariely references John Rawls and his theory of distributive justice. He asked whether, if we could design our system, would we choose what we have? So he asks, “How should the wealth be distributed?”

Quite a different picture! The fairness is striking! Sure, those at the top do better, but those at the bottom should not be destitute, either. He calls this difference between what we think we have and what we want the Desirability Gap.

His last step is to ask us not only what do we think we know and what do we want, but what are we going to do about it? This is the Action Gap. There is much activity in the action gap of late. (Well, maybe Bernie Sanders not just lately.) But the recognition of massive wealth inequality finally seems to be making it into mainstream debates on policy in America for the first time in decades.

I will leave that larger societal question to others. My lane is the healthcare line, particularly the fairness of healthcare lane, or the social justice Lane. Ariely notes that he has done research about other areas of inequality including health, availability of prescription medications, life expectancy, infant mortality, and education. He notes that we are even more averse to inequality in these areas than we are regarding wealth. We are even especially averse to inequality when the individuals have less agency, like children. (I would be interested in extending my research to see if it also applies to people born into all lower social economic statuses.)

I do not know if there is research on what Americans think about the injustices or performance of the US healthcare system. I do know that most Americans know that we are not the best and no favor major changes or complete overhaul of the system. And of course, we do know many of the realities. We know we spend far more than any other nation and do not cover everyone. We know we have very high out-of-pocket costs. We know we have relatively low life expectancy and high infant mortality. We know our citizens are less likely to survive serious illnesses. We know that we have less physicians and our people see our physicians less frequently than other nations.

At a baseline, we do not even know what The US Healthcare Knowledge Gap is. We do not know what the public does not know. That makes it hard to get to the Desirability Gap, let alone the Action Gap.

Can we get by without knowing what the Healthcare Knowledge Gap is? Maybe. But it will be nearly impossible to move forward without knowing the Desirability Gap.

This will take some serious work. Not only do we need to do the work to educate people on the reality of American healthcare, we then have to do research to find out what we,or at least what most of us, want to do. After decades of watching progressives telling people that what they should want is single-payer, I know that telling people what they want is not the answer. We need to do some work and we need to have some conversations and we need to come up with solutions.

What Are Physicians Willing To Give Up To Achieve Universal Healthcare?

One of the things that has troubled me for more than a decade is the way the medical profession declares that we favor an equitable distribution of healthcare resources and yet do little or nothing about it. In 2002, the Physician Charter on Medical Professionalism in The New Millennium was published. I will not bore you with the details here, but 2 provisions are important. Commitment to improving access to care and commitment to adjust distribution of finite resources are clearly stated. Physicians are exhorted to “individually and collectively strive to reduce barriers to equitable healthcare” and to be public advocates “without concern for the self-interest of the physician or the profession.”

This charter was signed by essentially every medical society and specialty organization that you can think of. From the American Medical Association to the American Academy of Orthopaedic Surgeons and the American College of Radiology and on and on. And yet, apart from lip service supporting improved access to health care, we have seen essentially no action. (I will be happy to entertain examples of such action in the comment section.)

We have theoretically signed on to the principles of universal healthcare and yet we have also been adamant in opposing and successful in preventing universal healthcare adoption. As a physician, I can find many malefactors for the lack of progression to universal healthcare in America. I don’t need to name them. You know who they are. And they will fight change with a white-hot intensity. As physicians, we can, and do, say “Why should we offer up anything when nobody else is willing to?” Maybe that is fair, but then why have the Charter? Why sign on to the Charter?

I can come up with many reasons why the medical profession has failed America in this area, but I have concluded that most important is that if we are forced to have a real conversation about universal healthcare, we will be asked to give something up and we are not prepared to do that. But until the medical profession steps up, is there really any hope?

The transition to universal healthcare will involve some pain to all of us in the healthcare industry. (Well, most of us anyway. I expect nurses, respiratory therapists, and many other categories of healthcare workers to deservedly make out a bit better, at least!) The question will be about how the pain will be divided. This terrifies physicians. It especially terrifies the highest-paid physicians. It also causes angst among the lowest paid physicians and medical students. Uncertainty is deadly to health care reform.

Consequently, I have been trying to figure out a way to have a conversation about this that makes sense and is fair to everybody. As an aside, I have been telling my generational colleagues, this is not about us. If we made sweeping changes legislatively tomorrow, most of us would be retired or at least close enough to it for any significant economic damage to happen to us.

While on my journey in cognitive science, I came across the philosophy of John Rawls. Rawls was famous for his Theory of Justice, published in 1971. At its heart is this: “A just society is a society that if you knew everything about it, you’d be willing to enter it in a random place.” Rawls proposes the thought experiment in which we place ourselves behind a Veil of Ignorance, not knowing our position in society, and then construct the society.

Rawls was one of the most influential philosophers of the 20^th century and it is horribly reductionist of me to sum his work up in a few sentences, but for our purposes this will suffice. Imagine creating a physician reimbursement system and medical school tuition scheme not knowing whether you will be entering it as a radiologist, pediatrician, hospital or health plan administrator, orthopedic surgeon, or a medical student. You do not know if you will be entering at the beginning of your career or at the end of your career. How would you design the system? How much would medical school tuition be? At Georgetown? At Wright State? How much would a neurosurgeon make? How much would a psychiatrist make? What would be just? What would be fair?

I propose Rawls’ construct is a strong starting point. I can fairly confidently predict that many, if not most physicians will reject out of hand even contemplating this idea. Fear and uncertainty are potent emotions against change, or even contemplating change. But I think we can find a core of willing participants, and we can make an amazing experiment happen. We can bring these people together and have this conversation. Even if the result is just a conversation, it is a beginning. It is the beginning of a discussion of what we as physicians expect from our profession and what we expect from ourselves as professionals. Are we to “individually and collectively strive to reduce barriers to equitable healthcare” and to be public advocates “without concern for the self-interest of the physician or the profession?” Or are we to just continue to pay lip service to these ideals?

This discussion dovetails with a TED talk by Dan Ariely called How Equal Do We Want To Be? You’d be surprised. He explores economic inequality and what we think we know about economic inequality, the reality of income inequality and finally what we would ideally like income inequality to be. Please follow the link to the next portion of this writing…

Priced Out The Economic and Ethical Costs of American Health Care Uwe E. Reinhardt; Reviewed by Christopher M. Hughes, MD

Priced Out

The Economic and Ethical Costs of American Health Care

by Uwe E. Reinhardt

Epilogue by Tsung-Mei Cheng

Forewords by Paul Krugman & Sen. William H. Frist

Reviewed by Christopher M. Hughes, MD

If you are a novice to the subject of health care policy, the first few chapters of Priced Out will leave you dumbfounded at the absolute mess we have made of healthcare in the United States. Professor Reinhardt calls it a “wonderland,” and not in the pleasant sense. The wonderland is the morass of payment schemes that allow a multitude of administrators (insurers, pharmacy benefits managers, etc.) to skim just a few cents off each health care dollar spent before the remainder makes its way to those actually providing services to patients. Example after example highlight the mess we have created at the altar of “the market” or “competition” or the illusion of “choice.”

If you are in the morass, as a physician or nurse or student of health policy, you will sigh in recognition of the things you may have already known, but you will see more clearly with Prof. Reinhardt’s great ability to make the complex comprehensible. For example, the highly “popular” Health Savings Accounts, are known to be a sop to high income households, especially healthy households, but Uwe points out that they have also sprouted a cottage industry of administering these accounts, taking just a little “haircut,” as he likes to say, of the billions of dollars that flow through their accounts each year.

For me, as someone in the morass as a physician, a physician currently working in the health insurance industry and someone who teaches health policy, I was aware of most of the accretions and detritus that make our health delivery system a mess, but Uwe always manages to add this kind of level of detail to, well, just infuriate me! Other examples are the “categories” of human beings we have in the US, from the poor to the near poor to the wealthy, to those covered by Medicare or Medicaid or both or neither or those covered by employer-based insurance to those in the Affordable Care Act Marketplace – or not. He jokes that in most nations, there is only one category of human beings. We have made micro-categories a high art.

Chapters on the outrageously complex mechanisms we use to price services and how we pay the bills are head slapping. Even as one in the middle of the morass, I am still shocked to see the insane specifics of how we have passively allowed this all to go on under the banner of “competition” and “market freedom” and other euphemisms for greed. Convoluted methodologies to “control costs” by external administrative mechanisms rather than evidence-based practice infuriate physicians and have spawned the multitude of staff in doctor’s offices and hospitals to obtain “prior authorization” to prescribe medications or perform surgeries or even to determine if one is sick enough to be in the hospital.

The second half of the book focusses on the social ethic of our health care system. Uwe states it plainly: “To what extent should the better off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in healthcare?”

This is clearly more troubling to Uwe than the economics or health care and how deranged our system has become. After the failure of the Clinton Health Plan in the 90’s, he wrote a powerful article in the Journal of the American Medical Association (JAMA) called, Wanted: A Clearly Articulated Social Ethic for American Health Care. In it, he asked the precursor to the above question: “should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?” He was clearly stung by the idea that his adopted countrymen rejected this solidarity, in contrast to every other nation’s resounding “yes” to the question.

He explains that our tendency in American political life is to pretend that our disagreements on health care are due to the details and howto get to universal health care. So rather than have the broader ethical discourse that could answer the two extremely important questions he has posed, we camouflage and misdirect and devolve our discussions to the best way to bring market forces to bear or how to properly fund Medicaid in the states. We never answer the basic question of whether we should strive for universal healthcare.

He has said elsewhere, “A common incantation during debates on health reform, for example, is ‘that we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”

He spends a significant section of the book exploring his framing for this fundamental disagreement among conservatives and liberal. But he does not have an answer for us on how to get where he clearly wants us to go – as explicitly stated by his widow, TM Cheng in her epilogue – “he passionately believed in universal healthcare.”

In an exchange I had with him a few years ago, he wrote, “the problem in America is that the elite does not share a consensus on what the social ethic governing American health care should be. I am not sure it ever will reach such a consensus.”

In the epilogue by Dr. Cheng, she documents his hopes and thoughts and, surprising to me, his optimism in America. We would hobble along, he thought, and continue to figure things out as we went, and perhaps technology can improve our lot.

The book left me less optimistic about our chances to reach consensus, but more committed to trying to make it so. Profs. Reinhardt and Cheng spent decades trying to advance American healthcare and continually try to engage on the ultimate questions of our social ethic, paraphrased by Michael Moore in Sicko as, “Are we about me, or we?”

The glimmer of hope I still have rests on two foundations. Uwe’s clear-eyed articulation of the questions we have before us and their obvious answers and my faith in the doctors and nurses who provide healthcare in the trenches, as we like to say, and who have long ago had enough.

In 2002, “Medical Professionalism in the New Millennium: A Physician Charter,” was published as a Project of the ABIM Foundation, the ACP–ASIM Foundation, and the European Federation of Internal Medicine. In the Charter are calls around the Principle of social justice, Commitment to improving access to care, and Commitment to a just distribution of finite resources. It specifically charged the medical profession to “promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”

The Charter argues that “Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.”

This Charter has been endorsed by virtually every group within organized medicine, from the American Medical Association to the American Board of Radiology to the American Nurses Association. While it is not explicitly a call for universal healthcare in America, it is hard to view the principles and not see this as the logical conclusion. And in fact, at the time of its publication, there were quite a few dissenting commentators who saw it as just that, and so rejected it.

I am taking Prof. Reinhardt’s last book as the plainspoken economic and practical case to shake ourselves free from this embarrassment of a “system” we have watched become a more hideous monster than we ever contemplated. I am also taking it as the simple moral argument for whywe need to change. We must stop allowing ourselves to be pulled into discussions about what flavor of health care reform we like best, and have that knock-down, drag-out fight about who we are as a nation. Are we the nation that cheers when one of us gets struck by a car and is left to die because they chose to forego health insurance? Or are we the nation that sees ourselves in the suffering of others and wants to help?

JAMA Network | JAMA | Reshaping US Health Care: From Competition and Confiscation to Cooperation and Mobilization

In this issue of JAMA, 3 Viewpoints, by Powers et al,¹ Fuchs,² and Fisher and Corrigan,³ address problems, possibilities, and mechanisms for reshaping the US health care enterprise to better meet community needs at an affordable cost.

In their Viewpoint, Powers et al¹ grapple with a question as old as democracy: How can productive collective action, which is required for a state to succeed, emerge from the factional divisions for which protection is required for democratic principles to succeed?

The founding fathers of the United States debated this vigorously. In the most famous Federalist Paper,⁴ Madison favored a large republic in the hands of a meritocracy to counterbalance the passions of a majority “faction” that might overwhelm legitimate minority interests. Others wanted to protect states’ powers, arguing that smaller political units could be more responsive to local groups.

Madison defined a faction as “a number of citizens, whether amounting to a minority or majority of the whole, who are united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community.”⁴

Health care is ground zero for this problem, and the stakes are immense. Health care is a behemoth “faction” that controls one-sixth of the US economy and distorts the nation’s economic and political future. I recently ran as a candidate for governor of Massachusetts, and, in the course of an 18-month campaign, I saw vividly the effect of this dominating industry on the opportunities for the total well-being of a population of nearly 7 million people.

JAMA Network | JAMA | Reshaping US Health Care: From Competition and Confiscation to Cooperation and Mobilization

Robert Nozick, father of libertarianism: Even he gave up on the movement he inspired.

Thought I’d blogged this before, but this is from an excellent piece on Libertarianism’s most famous proponent and his own change in perspective later in life.

How could a thinker as brilliant as Nozick stay a party to this? The answer is: He didn’t. "The libertarian position I once propounded," Nozick wrote in an essay published in the late ’80s, "now seems to me seriously inadequate." In Anarchy democracy was nowhere to be found; Nozick now believed that democratic institutions "express and symbolize … our equal human dignity, our autonomy and powers of self-direction." In Anarchy, the best government was the least government, a value-neutral enforcer of contracts; now, Nozick concluded, "There are some things we choose to do together through government in solemn marking of our human solidarity, served by the fact that we do them together in this official fashion …"

We’re faced then with two intriguing mysteries. Why did the Nozick of 1975 confuse capital with human capital? And why did Nozick by 1989 feel the need to disavow the Nozick of 1975? The key, I think, is recognizing the two mysteries as twin expressions of a single, primal, human fallibility: the need to attribute success to one’s own moral substance, failure to sheer misfortune. The effectiveness of the Wilt Chamberlain example, after all, is best measured by how readily you identify with Wilt Chamberlain. Anarchy is nothing if not a tour-de-force, an advertisement not just for libertarianism but for the sinuous intelligence required to put over so peculiar a thought experiment. In the early ’70s, Nozick—and this is audible in the writing—clearly identified with Wilt: He believed his talents could only be flattered by a free market in high value-add labor. By the late ’80s, in a world gone gaga for Gordon Gekko and Esprit, he was no longer quite so sure.

Robert Nozick, father of libertarianism: Even he gave up on the movement he inspired.