On radical reform

A lot depends on how radical we are willing to be. I believe we can go far beyond "sensibly trim defense and run less of a global empire" and fundamentally do without empire and its expense altogether. The savings that would result from radical rethinking of our place in the world are potentially enormous. It is interesting that we seem to be on a path for energy independence that seemed unimaginable as recently as a decade ago -- which removes a major excuse for aggressive foreign policy. Actually, we have been at least from the early 20th century a very large and resource rich country which always had the option to be very self-sufficient if that is what we really wanted.

Medical care is begging for fundamental reform that addresses its cost structure, not merely availability of insurance. When it was discovered in the 80s that the frequency of certain medical treatments varied more by geography than outcomes there developed a growing interest in outcomes research -- basically cost-benefit analysis. However, the results are basically advisory and using it effectively has been politically difficult. "Death panels" anyone? I was reminded how in the legal profession practitioners sometimes charged contingency fees where payment was due only in the case of delivering a promised outcome. Why doesn't this occur in medicine? Probably there are some laws or regulations that stand in the way. If it were the practice, however, it would powerfully direct medical providers, individuals and organizations, to make best use of outcomes research and empower patients to bargain intelligently without giving up control of their care. The role of patents in the cost structure of medical care also needs radical review.

Perhaps our main problem is that we have been a comfortable and prosperous nation too long and institutional sclerosis has set in. We have many special interests that don't want to have their boats rocked and radical solutions, like political third parties, are rejected out of hand in favor of thoroughly inside-the-box thinking.