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Health care innovation, did Dems rig the primary, and fetal stress

2016-05-27

Health care innovation, did Dems rig the primary, and fetal stress: Sarah, Ezra, and Matt look at a specific case in America's great productivity slowdown, assess Bernie Sanders' complaints, and examine some exciting Swedish administrative data.

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This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
This we support, is also sponsored by Nature box, good nature, backstop com, slash weeds for fifty percent off your first order. The following podcast contains explicit language content ray. I had so much content for the new order, contravene hello. Welcome to another. So did the weeds boxes, policy, Pakistan, the penalty network, a method, glazier sat with his usual, my colleagues here cliff and as replying pumped, we got great episode for humped answer is promising doubled the content of irregular pursued. But I don't think we want to make it twice as long as we can just try to speak, really really big ideas. Real information density is gonna, be amazing, off the charts in short, it wanted and fed energy, so less Jitchu more count more weeds.
I'm excited about this episode of the weeds because it comes out on the day of a peace have been working on for months about productivity and algae and the economy and and and basically, why isn't all of the technology we see around is changing the way we work closely, We know that we did an episode of productivity technology couple months ago to try to not repeat, we said there and I really want to talk about a different part of this, not the this measure hypothesis about whether or not cavities really super high or does not noticing it. I don't think that's true. I think we explain why it is untrue. Honour lost up, You can read my article four more in it. I want to talk about what would be required at this point for all this technology to sharpen economy. What would be required for us to see an economic boom that matches our intuitions about what's going on around us and that the idea for this article for me, was
she triggered by something Larry Summer said he gave a speech at a twenty fifteen Hamilton Project or twenty thirteen and Hamilton project event. Any basically said this is great mystery to him that we see all this technology all around us, but we do not see it in our economic statistics, and so I began looking into this in some detail, talking a lot of economists, steady productivity, talking a lot of Silicon Valley types who think that everything we're doing great darkness Silicon Valley types who think that actually work not inventing anything. It is really changing our lives that the numbers here pretty cool that the big thing you want to look at a summit in total factor productivity, and this is basically how much we make if you hold labour and capital constant. So it is a closing. We have an equinox to a measure of our ability to work smarter of building use, innovations and technology to do more. with the same amount that we already have an the twentyth century, total factor productivity behind this tremendous boom and for the last forty years,
been growing at about a third of that rate. So that's a real drop, the good Whitehouse economic Report about a year ago. That said, if productivity broadly had been going at the same rate. It did in the end the twentyth century, the average american family would have two thousand more per family. Now, that's a big number. That's more than as Matt. You pointed out in a in another article, that's more than if you sort of restructured our inequality, statistics they would get about nine thousand if we too much more equal society, thirty thousand is, is a really big gained. So this matters to the fact that we are not push. economy, for it is fast on in terms of how much you make really matters. This is into a very long and someone interesting argument about whether the invention and we are seeing now and party- are going to see in the future matter as much as a tremendous step of innovation in the twentieth century, Robert Gordon, who wrote the rise and fall the market which is a really interesting book, makes your commitment they're not, and he talks about how
Essentially, we had really all at once, electrification, about my optics indoor plumbing cars skyscrapers, Ino tremendous advances in education, tremendous, advancing communication technology, telephones, sailboats him the arab steamships, I'm sorry there so much that we created at once that he just thinks we're not gonna, see that again, I am going to just dodge that argument. Entirely I don't think we have any real way of knowing what a high and driverless cars and advances in material sciences and bioengineering, and your crisper again hacking out an old ever think. We know what that's going to mean in fifty years, the thing that I've become really instead and is more the kind of ten year fifteen year, time frame, which is at hand to that. People need help in right now, anyway, and there I ve come to believe that we are not being held back by technical, We are being held back by our ability to implement technology telecom economists
but this pretty well to me when I was reporting the peace. We said that as he sees it, the information technology revolution, a party the internet is just beginning in the economy. He thinks we kind of how to face one where we are The internet begin ip capabilities as an add on so phase. One is like best by getting a website where you can buy things or businesses. We're getting you and adds on Facebook it's what they are already doing, but have added, and I t component face too. In his view, is. You have companies that are built from the ground, up around the around I capabilities that everything about them their organizational structure there, personnel, the though Bina their business model. Everything is built to take advantage of this stuff and they even get much our productivity gains out of that in here you think of something like Amazon like a you, can imagine but if we are able to create real telemedicine, things that are
in very fundamental ways cannot have existed within that the previous scenario, and that is very hard and it just beginning and there's a lot of really. Frankly, I think interesting the evidence in and work around this at at the andreasen Horwitz, which is a big venture capital from they began talking about this idea of funding full stack, start ups for law Tom. What their funding were companies. It went in and said that they were going revolutionise one little piece of an industry, so they're going to come in and give taxis over like technology, but leave the driving to the taxis or they're going to come in and give retailers a website but they're, going to leave the actual logistics and fulfilment of orders to the retailers and that the future is gonna, be these full volstead start ups that are from owned up vertically integrated around a run information technology on this the price for that reason? This is really hard is that it turns out Technology often is not the hardest problem. When you're trying to rebuild industries its workflow
status quo bias. It is regulatory barriers, it is what customers have come to understand and expect care, which we talk about a lot on the shows, a really good example. This is a huge part of the economy. We really- we need to see some big productivity improvements. Therefore, gonna be seeing the economy driven forward, you know, but we and we ve also solve some really big technical problems. There is no doubt that we have the technical capacity to have electronic health records. There is no doubt that we have the technical copies. She did up telemedicine. My iphone does face time that could easily replaced fifteen or twenty percent of doctors visits the one is that we have very big regulatory barriers in this area. We have very big various in terms of customers and what they expect, what they want. They want to see a doctor in person we ve a lot of doctors should own under and how to use a lot of. technology and see, see that there is the raw material for for some big gains, but the actual work of making this technology into real cool
beneath it can revolutionise industries is really difficult. The thing I do. Talk about it all in the article is what we would. Actually. who, on a policy level if we wanted to pushes for if we really wanted to increase productivity and increase the building of you no company, to try to use technology to push their industries forward faster, and so I think that's the gosh I wanted to raise here on the wheats. So I want to pick up on their healthcare space. Unsurprisingly, I have shocked that allow, if trail, both somebody's braids about health and as someone who has unfortunately getting a lot of healthcare dealing with a foot injury for the past year and one of things like because I'm a healthcare nerd I've been thinking about, is just a lot of the issues you raised at this lack of technology that I know exists but clearly does not exist in my doctor offices as we know it exists. I would think of, is online scheduling for Well, I know there are systems you can do online scheduling. I can do online scheduling at my yoga studio.
Technology seems to exist or another example be technology to download a record. I know when I go on my bank, for example. I can get my time forms that I want to day. I d have to wait for them, come in the mail and I dont think and someone correct me if I'm wrong. This is especially expensive technology. I don't think this is like you know. Proprietary are hard to get, but the lack of a doctor in the space is just incredible and one things I've those I've been thinking about this lot. It seems to me that there would be an advantage for You know the medical system to adopt these technology is because I spent a lot of time on the phone calling people, so they all these people who set up front tasks- and I call them because I need a record, then I call them back because it and send me the record- and I spent a lot of time just calling people in talking to him on the and I don't really like it, and these well. Don't really seemed like me, bothering them all the time, so there's a clear problem think- is costing doktor offices money. They caught the medical system, money, paying all these jobs for people to answer,
phone calls and millions of other people's phone calls. Yet there hasn't that, doesn't seem to be enough to push towards adopting something different and that the two then sent it doesn't seem to be there and I've been trying to think about why that is running of something specific to the structure of the healthcare system. Where allows times you don't shop for health care, a lot we're going, you knew I the number, I probably won't need one for, hopefully a good long while so you- dont shop around and see who has like online scheduling and who has downloadable records. I just go wherever my doktor tat: me to go, and that's kind of where I end up. So you know maybe there's incentive. They don't see me as a repeat customer, but there are a lot of people do use the healthcare system a lot, and you see this happening elsewhere. Health care. You know it's just one. Sixth of the american economy, its just like not taken hold all ends No, if there'll be a consumer driven push towards that are, like you said, Azra like this.
Something that will have to happen. If you read nations, even though you know? I see these reasons. I would think these says would want to change, but don't actually The change happen, so I feel, like I've, actually seen more change in this I mean this is anecdotes, can get can get tricky here, but I've gone over over the past several years. Health care at the retail clinic in Walmart down in Chinatown. A is just like that's a substantial organizational innovation at all like Walmart. Has these nurses on staffing come see them they do online scheduling. They do pretty good you now stuff about, like emailing information around things like that. My dentists off Do online scheduling they send me text messages to remind me that I should actually show up to the to the office stuff like that. So you know.
Instances wet with this kind of adoption is happening. I do think that the small scale of a lot of healthcare providers holds back in terms of technology. Adoption that, like infamously, like restaurant websites, are terrible, whereas, like a big national chain, read like a puppet johns dot com is a pretty good piece of technology infrastructure like regardless of what you think about the pizza, like it's a good way to get some pizza to come to your house using the internet, and I think dominoes has economic Oji based ordering system, but a small practice. That's like a handful of doctors operating in one city doesn't necessarily have the not so much I recognise that it would be good to build some new idea infrastructure, but I feel like they have someone who knows how to find the guy who's gonna not rip them off, to go, build it, but
What strikes me, though, is that when we talk about productivity of the health care sector, we don't really want a larger want to tee of health care to be provided with a greater volume of efficiency. Will we want is for our elements. To be cured more rapidly. That's the way that, like penicillin right was like a technique Gee driver of health care, because you had infections than he would take this medicine. And then you wouldn't anymore, what's disappointing to me about about health care and technology raided site. So might my knee hurt and I had to get some treatment for it and I feel like I've got, that treatment me reasonably idee intensive way, but the answer turned out to be that what I needed to do for my knee was like stretch more continue,
exercise regularly, but do it with really really careful form. So I wasn't hurting my knee and also try to lose weight, unlike blah blah blah blah blah blah blah blah blah it turns out, I could have found out all that information with no doctors. Interventions right it just like in general life, health advice, But what I want is like a star track. You no doctor crusher would come with her little magic wand and would actually make my need better and we seem to have made very little progress on like helping people with some of these underlying issues and and The kind of communication window dressing that we can get telemedicine right, but if the doktor can't fix you, then like how does that faced time color, I think you're, giving the healthcare system slightly too little credit we do still see breakthrough drugs like one the ones I would mention, is the cure for HIV ever appetite to see which was introduced onto the market like two years.
that's really revolution guided in curious. They don't. We know what we re, making some vague and whose here and that we, as you know, you did see a habitat to seek here, there's a debate about how much it costs and, I would argue unification window dressing does matter, because if you're liquid, the magic wand exists. But you know you have two facts. Your records around to get access to the MAX Magic wand, and I was like it appears to me and my experience the medical industry is keeping the fax machine in three alive. I have never been asked for a fax number as much as they have dealing with medical offices. but here the communications window dressing it matters for as to the want of matters if you're actually going to get there if you're going to be here, get the appointment of you're gonna, be leaving these judges and in boxes, and not hearing back or you're gonna, be like faxing documents back and forth. In my view, it is window dressing is actually part of making the healthcare system work for people will obesity, two things got you think you're both right on this one
of it really do good. What Sarah said that one of the places where we could have some real advances are in the low touch access. They could be given just very basic diagnostic advice I think that one of the things that you begin to believe, if you study Healthcare of a longer time, is that a lot of the biggest gains come from the simplest advice that a nurse practitioner can get you. I think, basically, eighty percent of what our healthcare system can really get. You partake in terms of things like prevention and so perfectly. in areas that are more world parental leave for people who you know maybe donor, regular doctor, I'm a really big fan, like the Walmart, I don't remember if it's taking the minute clinic, but the sort of Walmart clinics, the target clinics, I think that's enough, is really good for that. That same reason of that, Yes- and I do think that can lead to leaders are millions and health. The other thing you're talking about which is I'm a bit more and on your side of this and that action on your cell right administering isn't, there has been a decrease
action in a number of blockbuster drugs or seeing in recent years, certainly were getting fewer, effective antibiotics and is a very worrying rise in drugs. Dense, receive less gains and life expectancy than we did in much of the twentieth century, and people really argue back and forth about what or not. We are in a sort of period before things like gene b and bio hacking and all these other sort of nouveau technologies end up later some really begins or not. But but your point mad about productivity in the health sector. I do think this is that this is important and because it's an important part of this whole argument, whether we're talking about health care, not a lot of big game, for economy wide productivity end up having deflationary aspect on a very specific sector, so you could definite magic in a world in which we invented a health pill and that health pill who cares you all elements and make sure you have a healthy life into ninety five, that pill, Cassandra's olives,
and so all this may be a lot less money and in health care sector, and you would look at that and say well. This must go the GDP you're. Having allows people to jobs but in theory what happened, then is run spending a lot of money and a lot of time on useless need treatments and waiting around talking to receptionist doctors offices we would end spending a lot of time and a lot of money on other, more productive thanks, a lot of the productivity advances and not showing up so much in one sector, is a contribution to GDP as they do in overall GDP. That's one way to think about these broader: it's about Miss measurement of arms and it comes up. The people talk about. Is Google How you know when you garments, gps system that showed up in the productivity statistics because, like that was a cash transfer, I use Google maps all the time, it's in credit valuable to me, but I don't pay directly. For it at all. Let me Google's tracking advertising out. I mean they're getting something out of it, but it is clearly a lotta consumer surplus there, but Google MAPS is in theory, getting
places faster, beginning places more reliably, that's show up in other kinds of productivity. In theory, I'm doing more meetings or I'm making a connection I wouldn't otherwise made her or whatever it might be that the great the recent cars and aeroplanes was so good for them. me wasn't just because we built and sold cars in aeroplanes, but because of other things, have happened and we're not seeing a lot of that happening. So I do think it right to point out that you dont want to focus too much on industry, specific productivity. You wanna be thinking about economy wide productivity and when we are not particularly sympathetic to the argument that you were not seems give it a gains, because all the stuff is free. It is true that thing Google on Facebook and sums communication technologies are very low cost or they are are, or they are free, but there by doing so much for the fact that we can knee cautiously com, decayed and collaborate the drug research in Amerika can so easily communicate with a jerk researcher in Shanghai should be like Two more new drug discovery is a fact that it's not suggesting that the FAO,
ending. These things has become an waterways more difficult, but I do not want to put a bit of upon a table lit I really came way believing as we do not think hard enough in a macro economic way, about organizational cos sure we do not like it. I dont think I very much I don't feel like. I have a good handle on regular. In the health care of space or really and in any space, you hear a lot of complaining about them. and then some of your good responses. Those complaining, but I dont, know, there's something that any of us great handle on- and this is a real question. me of whether or not there are ways of government can actually be productive here or there Just gonna be a extended period of time. As you know, one generation of of workers retires one generation of consumers ages out and the next nation you know has companies and workers and see egos and customers who are more friendly to the Kinds of products and innovation? As you know, to go back to the healthcare example, I think a lot of the reason. A lot of these doctors
do not do heavy, I t is it the doctors themselves, how to do a lot of their customers, don't know how to do it and nobody wants to switch you. I had a sort of a question about dad. Sarah is like home. My impression is that a lot of health care is going to like old people right who probably dont really one to use cutting edge technology while these- yes Alot of Healthcare- is going to be here, but I think it sounds like an accurate assessment. in terms of their use of technology that, but I'm not sure about on us I don't know how much opportunity there being given to adopt Technology high mean in general, though you know, if you look at like what's the demographics of vocs readers you're, like you not surprised to see like a drop off in the Sixtys and Seventys well due to pray right, we don't sit around being like what's going on. Well, while all people like old ashore, Thank you.
grandmother has an Iphone. That key is a smartphone that he can like someone. you so you know, I wouldn't right after thing or healthcare for all people like that's, why it's not being adopted- and you do have a you know not. What we do here is more health care, but, like a sizeable like, vulgar under the doktor like you know, your new staff, and I have my foot staff and that there is unison if you look around like a waiting off as unlike downtown DC, you see a lot of young people use it. healthy water, vocs, reader, eight people using the health care system, yeah I'm interested in you know, as are the other. What is the policy response? For this I mean so far, it's been canvas, regulation scheme on electronic medical records. If you also talked about on an episode of the week three essentially have, gold meaning for use which is kind of the standard. The federal government use to measure you know how good are hospitals and Doktor it using electronic medical records and theirs.
It is and meaningful use. I don't exactly remember what the associated with each stage, but you know you ve Meaningfully- is one to three: it's a program that on for a number of years and like when you look at church on you see kind of life going up of adoption of electronic records, but one of the things you know, I think you might see it on the back and the patient facing side is a part. That's not really as as their so. Doctors can like enter stuff in. They can put their record when you get there, but your ability to kind of log into that record and, like a doctor's note or get a scan, is less diffuse This is all through incentives, programs, you gotTa Medicare bone. Essentially, if you can meet these targets- and at some point start getting dark from your better care payments and that's it. By the way and in health care, with the centipedes things we kind of paid for performance. We pay you, you know if you adopt its own technology, if you your patients healthy, there's a lot of paper performance schemes, but there's
what really mixed research on if that's actually working- and I think it does. suggest a space. I will know exactly what the right response is poor thing, about the way we push technology change, I think most about health care, but maybe it's applicable to other places. We were finding paper performance doesn't always work as strongly as we'd like to suggest a need for other ways to think about. How do we encourage this behaviour? We want people engage in, but you know is not defusing, is in line with what one specific policy thing that was done relatively recently. That strikes me as a little counterproductive in this regard. Is the the medical loss ratio rule which is that basically insurance companies, the interpreter cap on the profitability of health insurance companies under the affordable care, acted says
they have to pay out Africa to what is at eighty five percent to eighty five percent. So eighty five percent of incoming revenue to health insurance company has to go out in terms of like billing play in terms of metal, couldn't get God in terms of administration or advertising relating it had it has to go as payments out to providers and to the policy rationale for this I think it's pretty clear. I think the political upside is very clear, but if you think in thy cold, hearted economic terms right about like why do big players really do the hard work? That, as we are talking about wait if technology was magic, then it's like something new comes you'd say like let's adopted its better but but it's not magic. It's hard. It's it's hard to get people to use new technology in ways that really do like DR efficiencies and drive say eggs and the reason you might do all that hard work is to cut your costs and increase their profits.
In the way society as a whole. he's. The benefits is like. First, one company comes in cuts, costs and increase its profits, but then one of their competitors also has to adopt it and prices start to go down and, and the public starts to gain by making it difficult for insurance companies to raise their profitability. I think you have blunted Some of that the instinct to do that and then there's a thing that I dont understand at all called accountable care organizations, Asia. We should do in episode and one that I ever think sounds meant to accomplish, I'm saying the medical loss ratio hurts really understand what it is, but the idea that somehow some other aspect of the legal and regulatory system is supposed to do. Push insurance but he is to become more integrated and more thoughtful, but it seems to me that
The main way you would do that is by saying, if find a way to become much more efficient. We will be much more profitable and we ve kind of aid that elite, but to focus on one thing you said, which is about new entrants coming in and out, compete basically incumbents and then other forcing the commons to respond with by by updating where they do their work or by actually going to business. So one thing that's been influential. My Give us is child cyber centres, an economist it at Chicago you, VE, Chicago and, and others have noted- that we ve seen patterns like this before explification. Era had appeared of time when electricity seem to be the sudden everywhere, but wasn't showing up in productivity. Then there was about a decade, long productivity burst, is it the sort of initial corporate and business in commercial use has got into it. Then there is enough. lag so so far its showing almost exactly the same pattern. As I t
but then you saw another gigantic burst and that that second burst came when companies. Basically, build themselves or founded themselves based off that, instead of just putting electric motor into something rebuilt, your factory around electricity, like one more thing about that was the compared to steam factory say you could build horizontally, suppose, judges vertically- and they're all things it than all kinds of things. It emerged that one thing they let you do see people talk about here, is whether there are reasons to believe that it has become harder for new players to two competing. hundreds in some of these industries, and it was it at other points in economic history. So you know practically when we talk about health and education. These are really really really highly regulated sectors. To summary, for that there are a lot of others like that, but those are so big. I think it really matters a point you ve made me mad is that we have different regular the scheme as in other countries, and it's not like we see very different productivity, a number
in other countries is kind of slow down. Wherein appears to be something missing across all most advanced economies, pretty much all events, economies, I believe, and so that is a reason to think it isn't regulation, but I guess ignore the broad question is: do you think there reason to believe that it is hard to start a company that the grows into real player now than it was at other points. I could really, I feel like make that argument. the ways and a lot of these sectors means the ability for people to know your company exists is tremendously greater than never was before the ability for people to some Try it out and low Friction Way party when its digital is higher than ever, but or, but you also have these blockades. You also have the floor, switching things and- to me to be the mechanism you would be looking for and of that, in his miss breaking down and we do see in parts of the economy there is less new firm formation. There has been at other times, then I think that should make us pretty worried,
yeah one? I actually think you should look at health care and education separately in this regard, because, even though it is true that the for more education sector is very rarely did the close We adjacent sector of telling people information about things and helping them know how to do things is not regulated at all. So I think you would actually notice if there was some like awesome, rogue teaching operation, That was like kicking ass, an a million times better than the official schools right by like in a really clear way and to some extent it is ready, I give developing is great. You also like today. I can look up anything I want on Wikipedia right. Twenty years ago, you couldn't write so like that's pretty clear, cut kind of advance in the like learning space right units goals are different, but health lake I mean there's just a fixed number of
new doctors minted every year right, fixed number of new doctors, but you see like more nurse practitioners, more Pierre right. I actually see when I look at the primary Kara space. I feel it gives you a lot of new entrants. There are like the retail clinics now talked about You have a kind of this sort of concierge light service. One matter call that's been like popping up and most urban areas and there really that their one They ve been impressed with what they really seem to be like almost like this idea, like a false stack, start up where they think about primary care very differently. A lot of their technical. Exists in like a mobile app, you download, I will. I guess I should disclose I'm a one medical I've used their services, and I am to the most press recital really so now you know we're not being paid by one. We also of complaints, but I have been impressed with you know online scheduling that I get email down. I test results that I can text my provider, if I want to that stuff, all feels very smooth
that's when I think this divide that I see in health when you step up a level above that basic primary care where you for some years, see as much new entrants. If you don't see someone like trying to disrupt the world, like, like or like, like Orthe P Orton, exert surgery or something by offering like using new technology with patience that almost a split, and maybe it has to do with people using care. More regularly is more of a reason to shop you kind of like using services more than once. You decide in what you like your tell your friends about it. Whereas if you look a special day care, there's probably less space for like word of mouth, referrals you're not using it- is much too maybe you're not as interested in kind of finding the best. experience. You just defined experience once verses use it repeatedly. I think it is really noticeable in medicine,
The surgery space is incredibly fast food out new technology, like therefore confine proton beams at you, and somebody was riding down what they did on a sheet of paper, putting it in Manila Folder and giving it to your mother and, in fact, out at some see it's just so. did you just say I find it really weird the difference in like the people who We were sitting at avenue, surgical tool. Yes, your address the question there Right is like it does show. There's a difference between like new technology in the sense of here is a thing that is different from the previous and productivity gains in the sense of like here is a new thing that is clearly and demonstrably superior to the old thing in a lot of ways, and this goes back to what I was saying about about cures, and I we see there have been some genuine advances in in surgical techniques. But like what we haven't seen is the new. medical instrument. That means that certain
for lower back pain, is now really effective and reliable and, like that's a big problem on a lot of people, suffer from low back pain. A lot of people spend money on medical treatments for low back pain. The treatments are not very effective, they are not very well ball, because there's a lot of money in that space, there is investment and, like quote, unquote, innovation. But there is an by progress toward the world in which people have back pain and end. As I was saying, I think you would expect to see. Not just you know, sales of the low back pain cure driving gdp, but actually you would have liked more people in you have a wider range of things. People could do, you would have fewer people. I love ruined by allowing manufacturing spending because people about together that way but like but like, I would think, like a
jubilee better worlds, as is quite widespread. Medical problem, that is, it doesn't kill. People leads to people no longer being able to work in being a disability and just like not working as as effectively as they could. And while we see a lot of like new surgical kind,
gizmos we're not like breaking through those barriers, speaking to break into those barriers that we should take a break and then come back to talk a little bit about the political revolution. Put a revolution if you're anything like me, you know sometimes you wanna snack end. If what's allowed snack on his junk food, you gonna eat junk food and it's it's not great. So if you want a short and live a healthier life, he did start snacking healthier with nature box. It makes next that actually taste great and their better for you to create with high quality ingredients that are free from artificial colors flavors of sweeteners. She can feel ok about snacking. I like some their dried fruit, static, great apples. It got great pairs, they also have some in a slightly more indulgent, principally things in their that that I also ask for, and they recently made this I was even better. You can order as much as you want, as often as you want with no minimum perched required. Any can cancel it at any time. I so it's really simple. You gonna nature by
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I think you ve seen a including on vocs allotted debunking of sort of a strong versions of these clients. and they are wrong, I mean Sanders simply has fewer votes than Hillary Clinton, and if you look at some of the things that that centres. People are really fired up about, like that they were pretty substantial number of people still from that the voting rules in Brooklyn, but before the near primary booklet, missing very, very heavily pro Clinton count, one of the most heavily proclaimed counties in the north, and so that was genuinely bad thing. That happened election administration error, but it probably hurt her rather than helped her Similarly, the super delegates strike me as a weird idea, but in point of view, are the only reason centres is still in the game, not not selling, that's that's rigging and against him. But I wanted to look at a sort of that in our more generous view of where this sentiment comes from front from centres.
people and and with that co worker, add Jeff Stein who is younger a little a little closer to the the emotional centre of gravity of of Bernie broke, and you know what came down on is back in in the wild days of twenty fifty and when it was widely thought that party elite, controlled domination processing is, it would have seemed unsurprising to say that, like look, what happened here is that a network of party elites like including the elected officials and super delegates, but also importantly, including interest. Group leaders- and you know, actors in left of centre. Politics had decided that Hillary Clinton was going to be the nominee and were acting in a coordinated way to make that happen, and that that meant that Sanders has been fighting on an unlawful Plainfield. Does this whole time which are really thing
he is, and I could go a really key example of that is things like the Labour Union essay. I? U, whose policy agenda Bernie like supports loyally, always has at same thing with the American Federation of teachers. These are two of the biggest labour unions in America and even more critically to the most politically active unions in America, and they have been out their active we campaigning for Hillary Clinton, not really on the basis of any kind of issues, disagreement with Sanders, but as part of their own big picture political gain that leaders of those organisations and end there, ask me
as well the same local government workers union and you saw a more sort of media. Prominent example of this when the plane parenthood went vocally, endorsed Hillary Clinton. Even though Sanders is a hundred percent rock solid plan, parenthood voting record. So then Sanders gets asked about the assets like how complaint parenthood is against you. So then he has to say something and when he up with, is well. You know their part of the political establishment, which I think is true in any common sense reading of it. But then you have all these people up in. like he's attacking this important feminist organization is the establishment and it was like a like a bad news cycle for four sanders. Not because Sanders is like not weighing on abortion rights, but just because you know the people who matter had gotten together and decided they can do what it takes to make Hillary Clinton the nominee that's not to say anyone cheated
I mean you are entitled as the head of Labour Union or the head of an interest group organization. Did you know, do what you think is right to advance our issues in advance, your agenda happens to be the case that what the heads of major labour unions, feminist groups, Djibouti groups, think, will help advance them is to not have sanders, be the democratic nominee. Even though Bernie Sanders has it good voting record on their issues. They don't think he would be the strongest stub person in that job you can understand how grass roots supporters, particularly the highly engaged ones, who can like see what's going on, but are not significant enough to stop it or in any way participate in the decision. Making process find it very very very for us so I think everything you say here is broadly correct, but I want to offer a different interpretation of this, That's because I think this is a really important point and is something that speaks in very deep ways to
politics of condemning Sanders and is worth, I think, interrogating little bit more? I would frame this differently. I would say that the Democratic party establishment they constituency. It's a constituency really like any other constituencies, that it is different powers, but it has, but it s people and you went over those people. You try to get them to vote for you and you do that by the promises and by displaying elect ability and by building relationships and all the other things that that that build a political support. This concern you will see that in a million ways, Hillary Clinton has been campaigning to win over for a decade now she's in out are raising money for them. She's been working with them, she's been showing up their events. She's been they she she's, been speaking of em she's, been building keep relationships. She's been doing all the things said that that, when you are, which has been understanding how to talk about their issues,
Bernie Sanders has, while he has been in any case, supportive of democratic party policies. Of a lot of these interest groups. Agendas he has it not just not campaigned for their support over the course of his career. He is actively rejected them. his brand is being a political, independent. He famously join the Democratic Party until this election cycle he has made a big deal, including in interviews vocs of the fact that he's not a democratic uses that, as a very key selling point for him, he will go out and say that he is I'm going to do. What passed democratic president's like Bill Clinton, like Brok, Obama, have done I'm kind of sell you out, because he is not in hock to the Democratic party establishment, is corrupted by money and spent time with Wall Street, you know Billy as millionaires millionaires and end and generally has so disappointed. So many liberals- and so independence and SAM
this is not a dumb move. His game a tremendous amount of value from being able to death straight: his independence from the Democratic party establishment, it is, one reason he so appeals to liberals and enter independent entered the liberal, leaning independence. I don't think that's unfair but by the same token, the flip of that that, as part of rejecting the democratic establishment he doesn't have much supported them also does not feel to me to be unfair and, I think it's really matters because I don't think this is just a popularity contest and I, and with the exception of the way Debbie one in short, is run the dnc during this period, which I think is really problematic and certainly the way their limited debates and and other things. I think this is pretty deplorable actually, but but putting that aside, that that the question of endorsement of you know.
The influence of interest group. You know backing that. That's of his all, I think, very much on the level and the reason I think the different passed they took mattered is this your ability, president's ability to attract and build wheel. Real coalitions in deep coalitions of support among allies is actually a really important skill for that President have Jimmy Carter famously had a very our relationship with congressional Democrats and it really hamstrung his agenda by the by the opposite way: Brok Obama. Despite being a real newcomer to two to politics, he had staffed himself with a lot of talk congressional staff from Tom Daschle and it kept arts offices and he was able to those relationships to get unprecedented party loyalty. things like Obamacare, which is you only reason they passed, and so one thing one quest
and I think that the Sanders campaign really raises the pollute. The theory of political revolution really raises is how important do you think the ability to play that inside game is part of Bernie Sanders argument? Is it he's not gonna, be he's not gonna play the inside, he's not can be corrupted by the inside game and he's gonna leave an ex he's. Gonna led lead an external political revolution, though accomplishes goals. Hillary Clinton argument as demo, great, which he demonstrates in terms of building this broad based support. Is it she'll be excellent? Working with key power players and that's why she will be able to accomplish our goals, and so I'd ever get to your point about why it it. It feels unfair to something the supporters. But to me when I look at this, it is a strategic choice. Bernie Sanders and Hillary Clinton have made they made opposite choices. Those opposite choices, actually tell you a lot about how they would govern and help clarify the choice here, and it feels very fair and the fact that you know if he's got its choice pays off more than Bernie Sanders. Did I
think that's actually telling and and sort of part of the gamble they were both making not not not some sort of way in which the primary was was unfair should be seen as a gentleman and I think you see another version of this on the republican side, where you have kind of almost in a way making the same that the tenders it and seeing that that pay off ends United that anything Andrew Programme on our side has written a lot of great stuff about. This is kind of decent, are evident in Obama's own campaign and two thousand aid a unit of the ability to kind of brake. But even though there are barriers, credit upstart candidates that there are certainly not insurmountable in ways, we might have thought them to be maybe be new threats for election cycles. Ago you, you know you had Trump saying You know earlier in this election cycle of the processes reg that I won by this much that you know. I didn't and then I think this was in one
videos. Maybe you where you know he said he. You know why don't say that anymore. It's because our eggs, I won, because I have the nomination at this point. And you know it was, I think, for someone like Trump. Certainly an uphill. well to end up at denomination of his party. But you know he found there was the political support for that he has won. The most votes in the Republican Party he's so far and sin has not demonstrated same level of political support, which is why I have more trouble with credit rigged argument and think I fall slightly more towards Ezra side of truck was able to fraud. the outside kind of get this grounds or support. He doesn't have. Canada want behind him- get, but maybe their fathers Y know. Maybe it doesn't, but he was able to sure that, even with the system kind of putting these barriers- and there are suggesting the possibility of
so it s kind of a similar way, but Obama did it in two thousand eight with Clinton running. I can't believe I need to be the Sandy defender, I think, a particular area, If this is striking to me- and I guess this- this will be my my neoliberal sellouts defence of Bernie Sanders. Whining. It is really the role of these large national labour union swayed because I think a lot of what you guys set about. This makes a lot of sense like if you ask on a day when there isn't a presidential campaign going on red, like if you ask Brandywine Weingarten like what is your organization, she will not say like. I am. The democratic parties like designated representative to control the teacher unions, and then we have this other guy ones. The waterfront right
she's saying that she represents the interests of teachers as a collectivity, and you see in act that the way these organizations Mitt made their decisions right exactly as were said right like Hillary Clinton very assiduously corded, these leadership groups, who then without a canvas of their members or really without Without what I would even call like a pretence of like an open process of deliberation, we just like oh yeah hashtag, I'm with her right now, I mean to me in part. This raises some questions about the deeper logic of Bernie Sanders: Social, democratic politics.
An end. I will say at the end that, like the big problem with all of this process, stuff from Sanders is that, outside the context of the democratic primary it, there is no question in my mind that the system is rigged against massive expansion of the welfare state. Right like the bee constitutional order of the United States was constructed by wealthy property owners who feared that popular participation in government would lead to massive income region pollution, so they tried to create a system that would make it hard to enact income redistribution subsequent centuries of research indicate that they chose pretty well that the United States we distributes much less than most other countries, primarily because of its political institutions. Sanders entire campaign is premised on the idea that he has a mechanism that can over
this problem known as political revolution, quoting quote in which I think he has described it- We can be people with signs near minimum camels window yelling at him and was going to make this happen. I think that that is incorrect I think you Bernie Sanders is seeing in the Democratic Party primary that, like even a much much lighter finger on the scales can make it really really hard to do things and that work rules and structures and system design matter quite a bit, but that would continue to be the case. He was the nominee even if he was the President ride like you have to operate in the system that exists or you have to have a plausible theory of how to change the system. It has always been at the heart of Hillary Clinton sort of bummer of a message, this kind of like no, we can kind of thing like it sucks it's a shitty slogan like she lost in two thousand, eight Tuesday fared. No, he kept it
Actual slowly ensure agree will be a very bad, but I believe it is the message particularly her, like reposted Bernie Sanders. Like sorry, no none of this happened, but she's she's right, you know and like good Bernie has been showing this whole time. With this, like, oh, my god, it turns out that in New York you have to be registered, devote in last October. Like you do, you do have to be registered. Eliza gonna, like I don't think it's a great system either but like it is what it is, and you either have the tools to change it. Else. You have a way to work within it, but he has instead is like some viral content about how it isn't one is a lot of other people fired up about this I mean something that I think is is true. One of the things is very hard. I think in a debate like this too do well is to simultaneously be able to talk about it, as it exists and also like reckon,
It is odd that a lot of people don't like the system as it exists. I do not like the system as it exists. I think in this is a really interesting contracts to be drawn between the Bernie Sanders and Brok, Obama campaigns go back to obey a bomb is running against hello Clinton likened to those in sixteen. She also begin to the massive massive establishment of vantage huge doubles. Endorsements everybody thinks it's more or less a foregone conclusion that she's going to win she's up in the polls by think twenty five thirty point she's a bit more dominant this year when it began, but but but you is a really they had and then to an Obama like Sanders and on a message it is fundamentally about the car. Option and inefficiencies and disappointments of the political system, but he doesn't think Sanders doesn't do which is it. He combines a theory of the outside game in the end a game, and so one thing Obama does and- and I think this is one reason that I'm a little lesson, but that this Anders case here is it here-
this shows the system can be won over? He takes a lot of endorsements away from Clinton. He gets but like TED Kennedy and Jean Louis who everyone expected would would go to Clinton. He gets a lot of your unions at the April ceo to sit on the sidelines into very late in the primary when they eventually endorse him, really is able to disrupt Heller, contains winning over the system in part and that's an important in a way part of his message like he actually says that he is a theory of how to make the system work and that theory has to do with partially with mobilizing people on the outside, but partial, with compromise part It was listening partially being able to think up. Waste division and look at policies for from a different perspective, and I think the critique Bernie Sanders would make of of of Ababa. Is that that willingness and try to created an inside game approach to winning a corruptive? What centres when Caesar came ends up corrupting or at least trimming Obama's ambitions, and he ended, and he has too many formal,
bias in his administration- and he does not break up the big banks and healthcare doesn't have a public should I think Obama would say that he he no makes the best compromise account with reality, but ends up getting a tremendous amount. Consequential legislation that makes the best deal you makes it necessary. Could I just showing the coalition is more flexible than you might expect examined? This shows up alive into doesn't is with women's health, where narrow very antics Did the the proportion rights group endorses Obama over clean and put her to just hold off to the under the primary to endorse. I think this was the first time they ever adverse. Anyone during the primary process that you see women's Health Reno space, that generally, you might expect to align with the female candidates specially when is the establishment candidate, essentially throw its weight. You know and subtle must settle ways behind Obama Edam, and when it seems I dunno starting off Hilary would have been the kind of establishment pick that that he was you know, maybe
Bernie Sanders would offer worse off for doing this, but able to break up some of these groups. nutritional traditionally align with a female establishing Canada, game and I think that's right and then and then I think that the way you seek Bernice Energy savings really different here in this primary, where I think Bernie Sanders Belize to some degree that that inside game itself. The problem I mean his critique of the system is more thoroughgoing. When Obama's was Obama's critique was about how people operate within this come on, I think centres? Could it is much more about the system itself and its always it's a very inspiring critique, but the problem I would really so is it he is not offer a persuasive counter to your point, Matt of how he change that, and so I think that one workplace I've had a lot troubled. The sandwich campaign, is it there's a I like in his diagnosis and then I actually don't stand. That, though the political there, I don't think it, I don't think it fundamentally holds up, and I think that he's got a lot of people in it position now, where what
Persuading them of it is a kind of rejection, it's a sort of its bordering increasingly on an anti politics and its so interesting what centres will do when the primary is over those aversion where he actually begins to war? on Sunday systemic challenges and you can see a little bit beginning with the people is named, the platform committee any talked about your being upset about he. His take tend to have set about primaries a bit disadvantage him. So he likes Caucasus, but you're quite undemocratic, but does not lie close primaries, but but you know he could be really take. Things like money in politics, in the filibustering building, a movement around them or he Thirdly, a lot of his people to just say: well, fuck it like the system, is corrupt people never gonna, make it in it. And you know this is a reason not to be involved and to know which one he will choose, but I do think that that the Obama centres contrast is
The interesting in that way, and- and it's why think what's image did Here- was make a choice: Obama made a different choice and ended a winning over a lot of establishment support. I think Sanders ultimately does not want to play that game. But that's very again, like I dislike, that's very relevant to the kind of president. He would be it's not it's not a feature of the primary. So much feature of his political approach and one that would have for better or for worse consequences in a sandwich white house. For research trappers, yes or research. Paper research paper, this one's doozy, it's it's! It's a methodology, nickel wonder in which the the very narrow conclusion is is is pretty narrow but its, but it's a really cool sort of experiment. So this these papers called family rupture stress and the mental health The next generation by Petra person and Maya Rosson Slater, and what you're trying to investigate here is a question that sort of people have
thought for a long time. They ve known that the stress hormone cortisol has an impact on our brain development in young kids. They, they ve, seen this so it seems like it, should also have an impact in utero and break pregnant women but it's hard to design methodological rigorous elements involving pregnant women, you can't inject them with stress hormones and- and you really can just like Let's deliberately have something awful happened to a random sample of pregnant women and see how that turns out bread. Ethics are troubling So they use a rich set of swedish administrative data to look at which Sweden has much more camp
my complete records of gotta love and semi. It at any rate, is data data immediately. Data is great, which is is amazing on its own terms, but so they look at pregnant women who have had relatives die and their able to look at a fairly large set of relatives, not just parents but like, other kids and spouses and like brothers and sisters licking construct at a whole, like relatedness variable of the dead person. And then they could do a discontinuity design and look at kids whose moms had arrived. to die like shortly after baby was born versus shortly before so you know you really isolating the effect of the like pre birth environment, and they also have data in in Sweden that you can get on which prescription drugs people are taking years later and you can and you can match them up. So
ethically what they show credible data. Very swedish administrative data, swedish Minister dad is fantastic, so they show that Since Sweden, if a relative of your mother's died, while she was pregnant with you. You are more likely to wind up taking Anti AIDS age d and an anti depression medicines later in life, and that the closeness of the relationship between your mother and the dead relative is related to the likelihood that that you have here so on its own terms, as obviously of finding of limited social relevance and so one that clearly has no policy implications, because we already knew his bad for people to die and to avoid that, but the the implication and is that other kinds of stressful situations, including like the general stresses associated with living in poverty or having a shitty,
or whatever else are going to have similar effects that this death of a relative happens to be something that you can study and are in a well quantum. I kind of way. But the general phenomenon of like stress in life is that we understand separately from the pregnant situation and now we're seeing a link to veto, kids and and later life outcomes of of some kind in a way that that's kind of fascinating No, I ain't so so, there's a broad, although hard to define exactly what the implications are and just at a cool mythological bring. I've ever is a really interesting finding but almost like Wales, swell fighting about stress where they do you see this and one I was in clear and that, obviously this is one paper and a large body largely bought a research busy we're talking about like one stressful and that's out of your control that the relative end. What things I was with a curious about you coming
this is. How is that similar or different lake? Constant stress is it this bike? That's the thing that's happening. It was For me to know, I thought is a really interesting finding also one where I can have looked at those like well, we will do what do we do with that? Here's this terrible thing we found- I dont know if it's as applicable to I'm kind of a constant low levels. Ass might be curious to see more research on that. But what do we do with? This really can have terrible thing that we find also man if I were a pregnant woman, I would not want to know about this paper. Railway jeer, at year, end, woman and, tragically your brother dies, and then you have to sit here. King about how you're hurting your child, because your grievously, often thanks whether world ends up cheating pregnant women in is just so fucking unfair? But I I take your points. I really like the question of you know how
measure constant stress versus by verses, episodic stress. You know that said. I do think that there are some reasonably clear policy implications here, not another. We want to go to them, but we really could do a lot to make people's lives easier when the pregnant also you know, I think we ve good evidence that the beginning of other matters, so you know when they of young children. I mean when you go back to the beginnings of. Ok, you you're dealing with a programme that really was about pregnant mothers, young and and and young mothers, and a single one is particularly- and I dont think Medicaid should have remained in a specific to that group, and it hasn't, but I do think was probably a lot. We due to to make life easier there. You know you can imagine all kinds of anti poverty. Pro am said- are that are well targeted. You can match alot whether we can do to generally for children, but what we do for children could begin with pregnancy right if we did that like the children's allowances at our own idea. Here people talk about that could begin
when mothers are pregnant, doesn't have actually wait for birth Annie, I you get into questions of incentives and gaming, but bribing bozos can be digital or they're, not as bad as as as running this gone so complete. Great you. I feel like bad pleaded this that we are putting this finding out into the world, but you know I also we could do recognising how, in itself, We're too says, but so obviously recognising home poured into the work. Is that people are that women are for the country when they go through the incredibly hard experience of of having a child. We could really do what more to support- and it suggests a different like space to wriggle out of the debate we have right now is about like I'm like parental leave like what you get after you have the baby. I think that's a fair enough point that you know it suggests a wider space for policy debate that, like also goes to the inn you'd, or else he would make sense yes,
yeah, I should say you know some some context for this paper, because obviously thinking of this as a finding about how like it's bad for your relative to die, is, I think, a little unproductive. But but this is so papers, bye, bye, Clancy Blair and no other related user papers by your Highness House, half hour that look at poverty and cortisol level swayed, and they just show that living in poverty is associated with increased cortisol levels. Some of that is is observational data that can be called into question, but there is some pretty good experimental and an quays experimental evidence from like whether she son peasants in Kenya. I mean it's always difficult to get like a really really really on the nose experiment, but it seems to be the case that, like these sort of bond force of getting some more economic resources can make your life less stressful, which
seems intuitive and that you were seeing here that the experience of going through the stressful situation of living in relatively deprived circumstances has an intergenerational component and the fact that the that defining is is applicable. Please, earth, I think, is important too, because one line, you don't see, this argument made like above board in politics alive, but in the sort of intellectual space I see a lot of people, leaning on genetics and inherit ability, findings about intergenerational transmission, of of poverty, to raise doubts about possible solutions but it is worth noting that there are these. Not genetic mechanisms of inheritance, of which uterine environment is, is definitely a prominent in and in full.
No one. So you know what you're seeing what this finding an and some other related ones about very early childhood environment in and brain development are just ways in which you know relatively crude resource transfers. You know, could make life easier for people which will then make life easier for their children and so on and so forth with possibly more, click it in fact seen over them the very long term, unfortunately it but it's an unfortunate, but it would take several generations for like really really huge impact, stick to show up but in that sense unity it strikes me that the policy world has not fully come to terms with the fools, Scope of things that we know about biology right that that ie, nah, makes and sort of economics influenced realms of the policy universe like to take a very sort of blank slate approached to human behaviour and is very invested in like incentive,
you know I like levers and and nudges and things like that and does not pay as much attention to like the the raw material out of which people are our crafted. But there's like a big Julian findings about different sorts of biological feedback loops either through these hormone causa mechanisms or through like hemispheric contaminants set and things like that and in the policy space. You know targets these things. is like a notion that we should not have pregnant women starving is like a little program to help them get food, but there is not, I think, a lot of thoughtfulness in the design of those programmes like will this help people be more relaxed about their food security, or is it going to be a crazy hassle to sign a brave? We have a lot of interest in creating crazy hassles because God forbid one person like fraudulent
obtaining in a court of milk truly entitled to- and you know AIDS like when you think about the noise of real tradeoff, obviously like there is fraud in programmes, though when you're thinking, but that the costs and benefits of of different kinds of program, designs, understanding the role that stress plays in life. I think changes the way you you think about. What's really important here, I think what I think is also becomes mean we one area Don T, much debate about women who are pregnant, verses, women who have had kids, it becomes a little bit politically challenge. for you know this is part of origin rates to be navigating display, So you see a lot of legislation by push by abortion rights opponents that kind of train establish the feed a person. You know, there's no law, Utah passed earlier this year that requires doctors to, Mr Medina Ortega, for long term abortion which abortion fighters their say, make the process quite complicated in some. says impossible. So I think it is
somewhat challenging of the guinean Prohibitive, challenge, but it somewhat challenging space for life I too am to navigate where I think is on some sense. You know a worry of am encroachment. Fetal person had this idea that eaters, question the anti abortion side of establishing personal rights for the fetus, which would make abortion much more difficult to obtain. And so I think this is one area policy. Why You do see liberal struggle with little bit of veto on how to regulate better programmes for pregnant women about the fetus in utero audit unit grapple with the fact that one happens in utero can matter for, Are you not childs entire life, but also it worried about going into that policy space where you have a lot of argument about person who can feel rights, good weeds, appoint end as that, our aim
didn't we got twice the content and to link is critical to straighten out what are we expressly? Thank you returning to the weeds, a box, our common panoply podcast. Thank you. Tar producer, a famous Shapiro, is joined us and were excited up. And we will see you next week,
Transcript generated on 2021-09-14.