mfioretti: welfare*

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  1. Two years ago I wrote about my experience in a London emergency department with my son, Victor. That post has since been viewed more than 450,000 times. There are over 800 comments with no trolls (a feat unto itself) and almost all of them express love for the NHS. I was in England again this week. And yes, I was back in an emergency department, but this time with my English cousin.

    My cousin loves high heels. As a former model she makes walking in the highest of heels look easy. However, cobblestone streets have challenges not found on catwalks and so she twisted her ankle very badly. Despite ice and elevation there was significant swelling and bruising and she couldn’t put any weight on her foot. I suggested we call her doctor and explain the situation. I was worried about a fracture. I hoped to arrange an x-ray. If it was broken we would arrange the needed care and if it wasn’t broken I could bandage it just as well at home.

    “No,” she said. She’d have to ring for an appointment. It was Friday around 11 am. The chance of getting into her GP by the end of the day was apparently non-existent. She would have to wait until Monday. Even if she were lucky enough to be seen that day there was no x-ray in his office so it would be a trip to see him and then a trip to the hospital. She was shocked when I suggested she call and just ask if he could order the x-ray. Apparently, that’s not how it’s done.

    As a gynaecologist I will admit feet are not my strong suit, but no medical degree was needed to confirm that she needed an x-ray. She also has some health issues that could impact healing from a break or the timing of surgery (hopefully that wouldn’t be needed, but you never know), so a timely diagnosis was important for her.

    “We’re going to the emergency department I said,” and off we went to Sunderland Hospital.

    Getting to the actual emergency room (ER) from the parking area required a background in orienteering. There was loads of construction and we had to go down hallway, after hallway, with Hogwarts’ worthy twists and turns. I managed to find a wheelchair, an unwieldy apparatus that only works in reverse - on purpose. This is to stop wheelchair theft, which is apparently a serious problem at Sunderland Hospital.

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    Owen Smith on the NHS

    My cousin was triaged immediately. Within two minutes a nurse checked her ankle, gave her codeine, and then sent her off to an urgent care clinic. She wasn’t even registered in the ER. A porter wheeled her to the urgent care clinic in another building some distance away, which required a trip outside.

    “What if it rains?” I asked the porter.

    “We get wet. This is the North,” he said. “Of course it rains. Almost every day.”

    Apparently no one complains.

    The urgent care clinic had a few people ahead of us. It took about 10 minutes to check in and then no more than 15 minutes to be seen. A lovely nurse named Leslie triaged my cousin and agreed an x-ray was in order and made the arrangements. My cousin did not need to see a doctor or a nurse practitioner to get an x-ray. I’m not sure I’ve ever seen that happen in the US.

    The x-ray and radiology report took 10 minutes. Then a nurse practitioner (also very nice) did an appropriate history and exam. The diagnosis was a torn ligament (sprain) and possibly a small fracture of the lateral malleolus (outside ankle bone). An orthopaedics consultation was needed. She could either wait and be squeezed into fracture clinic that afternoon, or she could have a cast and come back to Saturday fracture clinic. The clinic didn’t start until 2pm and we were done in urgent care by 1pm, so she opted to wait. She was seen around 2.15pm. An orthopaedic consultant did an exam and recommended a tight support bandage and gave her exercises and guidelines about how to follow-up if she wasn’t meeting milestones.

    My cousin was at the hospital for four hours, one hour of this was an unavoidable wait for the fracture clinic and about 30 minutes of transport back and forth between the ER, urgent care, and fracture clinic.
    UK news in pictures

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    To receive this care all my cousin had to do was provide her name and birthdate. No co-payments, no pre-authorisations, no concerns about the radiologist or orthopaedic surgeon being out of network. The nursing triage was wonderful and actually doing nursing (I hate seeing nurses relegated to charting). The nurse practitioner clearly knew what she was talking about and had reviewed the films with the radiologist.
    Tags: , , , , by M. Fioretti (2017-01-09)
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  2. Already a fourth of the adults actually employed in the US are paid wages lower than would lift them above the official poverty line – and so a fifth of American children live in poverty. Almost half of employed adults in this country are eligible for food stamps (most of those who are eligible don’t apply). The market in labour has broken down, along with most others.

    Those jobs that disappeared in the Great Recession just aren’t coming back, regardless of what the unemployment rate tells you – the net gain in jobs since 2000 still stands at zero – and if they do return from the dead, they’ll be zombies, those contingent, part-time or minimum-wage jobs where the bosses shuffle your shift from week to week: welcome to Wal-Mart, where food stamps are a benefit.

    And don’t tell me that raising the minimum wage to $15 an hour solves the problem. No one can doubt the moral significance of the movement. But at this rate of pay, you pass the official poverty line only after working 29 hours a week. The current federal minimum wage is $7.25. Working a 40-hour week, you would have to make $10 an hour to reach the official poverty line. What, exactly, is the point of earning a paycheck that isn’t a living wage, except to prove that you have a work ethic?

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    But, wait, isn’t our present dilemma just a passing phase of the business cycle? What about the job market of the future? Haven’t the doomsayers, those damn Malthusians, always been proved wrong by rising productivity, new fields of enterprise, new economic opportunities? Well, yeah – until now, these times. The measurable trends of the past half-century, and the plausible projections for the next half-century, are just too empirically grounded to dismiss as dismal science or ideological hokum. They look like the data on climate change – you can deny them if you like, but you’ll sound like a moron when you do.

    For example, the Oxford economists who study employment trends tell us that almost half of existing jobs, including those involving ‘non-routine cognitive tasks’ – you know, like thinking – are at risk of death by computerisation within 20 years.

    So this Great Recession of ours – don’t kid yourself, it ain’t over – is a moral crisis as well as an economic catastrophe. You might even say it’s a spiritual impasse, because it makes us ask what social scaffolding other than work will permit the construction of character – or whether character itself is something we must aspire to. But that is why it’s also an intellectual opportunity: it forces us to imagine a world in which the job no longer builds our character, determines our incomes or dominates our daily lives.

    What would you do if you didn’t have to work to receive an income?

    In short, it lets us say: enough already. Fuck work.

    Certainly this crisis makes us ask: what comes after work? What would you do without your job as the external discipline that organises your waking life – as the social imperative that gets you up and on your way to the factory, the office, the store, the warehouse, the restaurant, wherever you work and, no matter how much you hate it, keeps you coming back? What would you do if you didn’t have to work to receive an income?

    And what would society and civilisation be like if we didn’t have to ‘earn’ a living – if leisure was not our choice but our lot? Would we hang out at the local Starbucks, laptops open? Or volunteer to teach children in less-developed places, such as Mississippi? Or smoke weed and watch reality TV all day?

    I’m not proposing a fancy thought experiment here. By now these are practical questions because there aren’t enough jobs. So it’s time we asked even more practical questions. How do you make a living without a job – can you receive income without working for it? Is it possible, to begin with and then, the hard part, is it ethical? If you were raised to believe that work is the index of your value to society – as most of us were – would it feel like cheating to get something for nothing?

    We already have some provisional answers because we’re all on the dole, more or less. The fastest growing component of household income since 1959 has been ‘transfer payments’ from government. By the turn of the 21st century, 20 per cent of all household income came from this source – from what is otherwise known as welfare or ‘entitlements’.

    you will say – along with every economist from Dean Baker to Greg Mankiw, Left to Right – that raising taxes on corporate income is a disincentive to investment and thus job creation. Or that it will drive corporations overseas, where taxes are lower.

    But in fact raising taxes on corporate income can’t have these effects.

    Let’s work backward. Corporations have been ‘multinational’ for quite some time. In the 1970s and ’80s, before Ronald Reagan’s signature tax cuts took effect, approximately 60 per cent of manufactured imported goods were produced offshore, overseas, by US companies. That percentage has risen since then, but not by much.

    Chinese workers aren’t the problem – the homeless, aimless idiocy of corporate accounting is. That is why the Citizens United decision of 2010 applying freedom of speech regulations to campaign spending is hilarious. Money isn’t speech, any more than noise is. The Supreme Court has conjured a living being, a new person, from the remains of the common law, creating a real world more frightening than its cinematic equivalent: say, Frankenstein, Blade Runner or, more recently, Transformers.

    But the bottom line is this. Most jobs aren’t created by private, corporate investment, so raising taxes on corporate income won’t affect employment.

    When we place our faith in hard work, we’re wishing for the creation of character; but we’re also hoping, or expecting, that the labour market will allocate incomes fairly and rationally. And there’s the rub, they do go together. Character can be created on the job only when we can see that there’s an intelligible, justifiable relation between past effort, learned skills and present reward.

    Securing ‘full employment’ has become a bipartisan goal at the very moment it has become both impossible and unnecessary. Sort of like securing slavery in the 1850s or segregation in the 1950s.


    Because work means everything to us inhabitants of modern market societies – regardless of whether it still produces solid character and allocates incomes rationally, and quite apart from the need to make a living. It’s been the medium of most of our thinking about the good life since Plato correlated craftsmanship and the possibility of ideas as such. It’s been our way of defying death, by making and repairing the durable things, the significant things we know will last beyond our allotted time on earth because they teach us, as we make or repair them, that the world beyond us – the world before and after us – has its own reality principles.

    Think about the scope of this idea. Work has been a way of demonstrating differences between males and females, for example by merging the meanings of fatherhood and ‘breadwinner’, and then, more recently, prying them apart. Since the 17th century, masculinity and femininity have been defined – not necessarily achieved – by their places in a moral economy, as working men who got paid wages for their production of value on the job, or as working women who got paid nothing for their production and maintenance of families. Of course, these definitions are now changing, as the meaning of ‘family’ changes, along with profound and parallel changes in the labour market – the entry of women is just one of those – and in attitudes toward sexuality.

    When work disappears, the genders produced by the labour market are blurred. When socially necessary labour declines, what we once called women’s work – education, healthcare, service – becomes our basic industry, not a ‘tertiary’ dimension of the measurable economy. The labour of love, caring for one another and learning how to be our brother’s keeper – socially beneficial labour – becomes not merely possible but eminently necessary, and not just within families, where affection is routinely available. No, I mean out there, in the wide, wide world.
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  3. Milton Friedman, the influential ‘free market’ ideologue and economist, supported a guaranteed income as a way for the state to fulfil social obligations without interfering with the market, arguing that it ‘should replace the ragbag of specific welfare programs’.1

    Business website FastCoExist suggests, ‘A basic income could replace multiple types of public assistance – from healthcare to earned tax credits – with a single payment.’2 One of the largest trials of a basic income to date is the $22.4-million experiment planned by the rightwing Finnish government – who are also cutting health, education and welfare.3

    Increased talk of a basic income comes at a time of the voucherization, marketization and decimation of public services. Sweden, Chile and New Orleans have introduced schemes where parents are given vouchers to pay for either state or private schooling.4 In England, ‘personal health budgets’ and large-scale outsourcing are being forced on the health service, while Spain has introduced ‘co-charges’ for healthcare.5

    The policy could give the Right the justification it wants to eviscerate the social state further, and would make it harder to argue for an expansion of public services. The payment could easily be eaten up by the cost of paying for previously public services, and as, depending on the implementation, the basic income does not necessarily redistribute more money to the poorest, a rightwing programme that introduced a basic income amid cuts could leave many worse off. In Britain, the cost of a degree – previously fully funded – would take several decades of basic income to repay at the level proposed in 2013 by the Citizen’s Income Trust.6

    Many services are best provided collectively. For example, in Britain, the National Health Service has provided excellent comprehensive healthcare, free at the point of use, for many decades. It provides a better service at a lower cost than many insurance-based systems, and at around half of the cost of the disastrous free-wheeling market that is US healthcare.7

    Free-marketeers see a basic income as the perfect excuse for their wet dream of an antisocial state; introduce it in place of public services, and abandon the rest to the market

    The same goes for housing. Public investment can provide good quality housing in much larger quantities than the private sector.8Subsidizing accommodation in the private rental sector is more expensive than providing state housing and encourages private landlords to inflate their rents. A ‘basic income’ risks a similar effect.9 And, crucially, in an unregulated private market there is little security for most people in that vital thing – home.
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  4. A 40 anni dal manifesto Familjen i framtiden - en socialistisk familjepolitik l'utopia svedese si è rivelata una desolante emancipazione regressiva. Si nasce soli, si vive soli, si muore soli. Come nota Gandini nel Docu-film: “Ognuno va per la propria strada ma non c'è nulla che li tenga insieme”. Quest’ultimo fenomeno è talmente aumentato negli ultimi anni che lo Stato svedese ha dovuto creare uffici appositi che si occupano di tutte le incombenze legali e burocratiche legate alla scoperta di un morto senza legami, nel disinteresse di figli e parenti.
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  5. I think many of us assumed that the Scandinavian welfare state just appeared out of the sky one day, a natural outgrowth of cold weather plus a small and homogeneous population.

    I actually attack the phrase “welfare state” in my book. Americans imagine that “welfare state” means the U.S. welfare system on steroids. Actually, the Nordics scrapped their American-style welfare system at least 60 years ago, and substituted universal services, which means everyone—rich and poor—gets free higher education, free medical services, free eldercare, etc. Universal totally beats the means-testing characteristic of their dreadful old welfare system that they discarded and that the United States still has.
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    So, properly speaking, in the U.S. context the Nordics should be regarded not as welfare states but as “universal services states.” Nobody has gotten rid of poverty through charity, philanthropy and welfare, whereas poverty can be abolished through universal services.
    Tags: , , by M. Fioretti (2016-07-24)
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  6. Prima del 2000 l’incidenza della povertà relativa riferita agli anziani era di 5 punti superiore a quella dei minori, oggi quella dei nipoti è quasi raddoppiata e ha raggiunto il 19%, mentre i nonni restano 10 punti sotto. Queste cifre spiegano bene la ragione per cui il legame tra bambini e anziani è andato rafforzandosi con l’avanzare della crisi: come una stretta di mano sempre più necessaria per non lasciare affondare il futuro rappresentato dalle giovani generazioni. Contemporaneamente denunciano però anche tutto il limite del welfare italiano.

    Basta poco a mettere in luce l’origine dei problemi. Il quadro che emerge dall’analisi del sistema di protezione sociale italiano – per l’Istat «uno dei meno efficaci in Europa», con «la spesa pensionistica che comprime il resto dei trasferimenti sociali» aumentando il rischio di povertà – è impietoso: non solo è aumentata la disuguaglianza nella distribuzione del reddito, ma è diventato più difficile riuscire a migliorare la propria condizione. Il cosiddetto "ascensore sociale" è fermo al piano terra: chi sperimenta condizioni di svantaggio da giovane ha alte probabilità di restare ai margini anche da grande. La povertà, insomma, ha preso di mira i minori, ed è ereditaria. E lo scenario in cui questo si manifesta è quello di un Paese nel quale risaltano le emergenze indicate con forza anche dall’ultima assemblea dei vescovi italiani: lavoro, famiglia, demografia.
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  7. sono i cambiamenti incredibilmente veloci dei servizi, della produzione e del lavoro stesso, imposti dallo sviluppo tecnologico, a far apparire poco realistiche le previsioni di pensionamento da qui a 40 anni dei nostri giovani. Siamo sinceri: il problema non è quanti anni di inoccupazione sconteranno i ragazzi del 1980 e quanti contributi eventualmente mancheranno loro in futuro, ma se lavoreranno.

    E come e dove. Con quali contratti e quali retribuzioni. Gli addetti di interi settori – ad esempio quello dei call center – sono destinati a scomparire nel giro di meno di un decennio, sostituiti da software con nomi accattivanti come 'Amelia' della Ipsoft. Altri verranno soppiantati dai robot, i nuovi 'dipendenti non umani' delle fabbriche 4.0. Le ricerche delle università di mezzo mondo ci dicono che la metà almeno dei nostri ragazzi avrà un lavoro che oggi neppure esiste o immaginiamo. Preoccuparsi se – nel 2056 – i trentenni dovranno attendere 2 o 3 anni in più per la pensione ci pare proprio l’ultimo dei pensieri. E poi per chi ha solo il contributivo non bastano forse 20 anni di versamenti per la pensione di vecchiaia? Una maggiore flessibilità in uscita verso la pensione è auspicabile e, come scrivevamo due settimane fa, sarebbe bene aprire subito un confronto serio e documentato sulla questione.
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  8. f you’ve been to a conference in the past 12 months – you’ll almost certainly have seen the slide above, or a version of it.

    Mentioning “disruptive innovation” adds a sprinkle of sophistication to otherwise ordinary presentations. It’s a sit up and take notice slide that says: ‘Better listen, or you could be history.”

    However – it doesn’t always hit its intended target. A significant portion of the audience at a couple of events I’ve been to recently have looked at each other as if to say ‘that couldn’t happen to us’.

    The reason for this seems to be the comfort blanket that can come with extended working in the public and social sectors.

    The thinking can go like this.

    We are different.
    We deal with people who are highly complex with multiple needs and vulnerabilities.
    No tech outfit could hope to understand the extent of the personalisation involved in our services.

    It’s optimistic thinking – probably the same that was held by some taxi firms pre-Uber and hotels before Airbnb.

    It’s going to take radical change a lot closer to home before many managers recognise how profoundly the rules of business have changed in the digital age.

    Arguably though , it’s already happening. I’ve made a slide of my own that might be more relevant to the public sector.

    Far from fantasy – we are at the beginning of the end of one size fits all health, housing and social care monopolies.

    Some examples:
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  9. It could end well or it could end badly, depending on how we act now.

    To understand the argument, the first thing we need is a bit of context. So before the robots take over, let’s look at how we got to where we are.

    The material conditions of what we in a country like Australia, (or the US, or Iceland) think of as a normal, decent life, are largely an artefact of a particular set of social and economic circumstances that arose in the West from about the end of World War II. The hours we work, the money we earn, the things we can do with that money, the age at which we retire — the very notion of ‘retirement’ — the services that we expect from our government, were, by and large, formed within this period.

    Broadly, those circumstances are: a manufacturing-based economy that directly and indirectly employed large numbers of skilled and unskilled people in such a way that they were able to enjoy a reasonable level of financial security and had the means to afford a given standard of material comfort.

    All of this was underpinned by a welfare state in which government managed the major risks and needs associated with an economy based on capitalist growth. Health and education, financial support when you were unable to get work, and an income when you retired were its major pillars, and these were not “entitlements” as it is now fashionable to label them, but the material expression of what most citizens saw as the whole point of government.

    This had nothing to do with any particular affection for government per se, let alone with a national commitment to collectivism. It was rather the practical realisation of a belief in positive personal freedom. It held that there is such a thing as society and we are all better off, and freer, when the state aims at some basic level of equality of opportunity and outcome.

    Growing prosperity brought with it challenges to key social institutions and practices. As the writer Ellen Willis has said, the sixties were mythical but they were also consequential. They launched genuine changes to notions of family, religion, women’s role, race, and recreation, (especially as the latter related to drug taking). Willis notes:

    The expansion of the American economy after World War II produced two decades of unprecedented prosperity, which allowed masses of people unprecedented latitude in making choices about how to live….

    As a result a growing minority — particularly among the children of the upper middle class — felt free to question the dominant social arrangements, to experiment and take risks, to extend student life with its essentially bohemian values into adulthood rather than graduate to professional jobs, nuclear families, and the suburbs….

    What most counterculture opposition to capitalism amounted to was this minority’s anger at the majority for refusing to make the same choice.

    This “liberation” was always contested, especially by those who had the most to lose from the new, freer social arrangements. But it took a halt in the growth of economic prosperity to allow the forces of conservatism to push back with any force. That is to say, the backlash against “the sixties” and the liberation it represented were in part driven by the sort of white, male privilege that drives much of Australian Prime Minister Tony Abbott’s current social agenda, but it was also tied to the retreat of prosperity.

    As ever, as economic circumstances changed, so too did social relations. As industry globalised, a professional layer of managers and technocrats arose, a group Milovan Dijas and others have called “the new class”, and they insinuated themselves into the heart of these industries. This prosperous strata of managers, because of their professional, international focus, started to weaken, or even break the bonds of commitment between themselves and their countries of origin. Why, they asked, should I pay taxes for services I don’t use (health education, transport et al) in a country where my roots are shallow?

    By the time of Reagan and Thatcher, and in Australia, of Hawke and Keating, government itself was being redefined as the problem. We were being told there was no such thing as society and that freedom equated to choice in a marketplace. Industry regulations, unionisation, government ownership and the services government provided were recast as dead weights upon the alleged entrepreneurial hand of business and the alleged aspirational values of the middle class. A narrative was born — or more accurately, reanimated — and it was powerful, sweeping up not just the conservative parties of the world, but those of the centre-left too. Indeed, for those on the left who had eschewed the notion of living in or raising traditional families, and who had abandoned religion as any sort of unifying social force, work itself became the lingua franca of middle-class acceptability. The obvious ties between the centre-left of politics and the labour movement reinforced the tendency to latch onto work and employment as a unifying mantra. In recent times, this was particularly noticeable in the person of former Australian prime minister Julia Gillard, who, along with education, elevated work to the top of her list of personal values:

    …I believe in the importance of hard work; the obligation that we all owe to ourselves and others, to earn our keep and do our best.

    Life is given direction and purpose by work. Without work there is corrosive aimlessness. With the loss of work comes a loss of dignity.

    Market, market uber alles became the chant. With it came a rebirth of the sixties counter-culture, but this time it was firmly lodged within a market and consumption framework.

    What we have been living through since about the seventies, then, is a massive realignment of the philosophical and material conditions of Western civilisation. To call this a transition period is to presume that there is some sort of end in sight, that there is some sort of rest point looming, a settlement where the questions posed by the present are answered. I doubt very much that it makes sense to think in those terms. It is transition all the way down.

    And the nature of the transition is structural; that is, the changes that are happening are built into the very fabric of how wealth is created and how work is done, and it is this fact that we have to get through our heads.

    This is why what is to come is different to what has happened before. The worldwide economic stagnation flowing from the 2007 global financial crisis is not simply another trough in the usual economic cycle, but a break from what has gone before, from what we think of as “normal”. The essence of the way we construct work — the sort of paying work that underpins all our discussions and presumptions about “standards of living” — is fundamentally changing. In part this is to do with the shift in wealth creation from manufacturing-type industries to finance and technology — neither of which need much in the way of paid labour.

    given what we are about to go through in terms of automation, robotics and artificial intelligence, the elevation of work to the centre of the centre-left’s philosophy is likely to cause something of an existential crisis.
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  10.  Things happened very differently in Norway. There, feminists and sociologists pushed hard against the biggest obstacle still standing in the path to full democracy: the nuclear family. In the 1950s, the world-famous American sociologist Talcott Parsons had pronounced that arrangement—with the hubby at work and the little wife at home—the ideal setup in which to socialize children. But in the 1970s, the Norwegian state began to deconstruct that undemocratic ideal by taking upon itself the traditional, unpaid household duties of women. Caring for children, the elderly, the sick, and the disabled became the basic responsibilities of the universal welfare state, freeing women in the workforce to enjoy both their jobs and their families.

    Paradoxically, setting women free made family life more genuine. Many in Norway say it has made both men and women more themselves and more alike: more understanding and happier. It also helped kids slip from the shadow of helicopter parents.
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