Please consider three quotes:
Adam Smith:
It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard of their own interest. We address ourselves not to their humanity, but to their self-love, and never talk to them of our own necessities, but of their advantage.
I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.
Saul Alinsky:
It is impossible to conceive of a world devoid of power; the only choice of concepts is between organized and unorganized power.
Smith and Berwick are on opposite sides of the choice Alinsky outlines. I am on Smith’s side. Berwick is wrong, and, as the current nominee for head of the “Centers for Medicare and Medicaid Services”, dangerous. He illustrates why leftists must not be entrusted with the responsibilities of government.
Left vs. Liberal
I believe that Alinsky captures the essential question dividing the left and classical liberals. (I use “liberal” here in the European sense; classical liberals in America are usually called “conservatives” or “libertarians”.) That question is: Which is the superior model for a society and an economy? Should it be planned, plotted, controlled, designed, and run top-down, or should it be a distributed, delegated, bottom-up, evolutionary system? In Alinskyite terms: should power (the “ability to act”) be in the hands of organized or diffuse systems?
The left comes down on the side of organization, liberals on the side of evolution. The left’s view has intuitive appeal; it seems natural that something planned must work out better than something unplanned. The liberal view has empirical evidence behind it.
Silicon Valley
Let’s look at Berwick’s quote again:
I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.
“I cannot believe”. This seems reasonable … until one considers the world we live in. Systems every bit as complex as health care are configured by choice every day. The startup ecosystem of Silicon Valley wasn’t designed: it evolved. The semiconductor industry is tremendously complex, and built by choice. The auto industry was built by choice. Name something that works in your life, and you’ll find that it was produced in response to consumer choice, not government dictates.
Just to take one example: the iPhone is a tremendously complex piece of technology. It is the result of 65 years of computer evolution. It doesn’t exist because “leaders” sat down in 1945 and plotted out the future of the “massive and complex” semiconductor, software, telecommunications, and entertainment industries. It exists because of 65 years of competition and consumer choice.
Proper
The word “proper” in Berwick’s quote is deeply, deeply problematic. The question of what configuration of health care is “proper” is likely to be a matter of dispute. In fact, the word “proper” is meaningless on its own, except insofar as it means: “something that I like”.
The essential problem with an “organized” system is that the people on the top get to decide what a “proper” organization is, and the people on the bottom have to live with it. This sort of arrangement, over time, will inevitably tend to produce a system more to the liking of the few at the top than the many at the bottom.
Whatever the failings of a bottom-up system, at least it doesn’t represent an infrastructure designed to allow the few to impose their preferences on the many. That is why I am a liberal, and why I urge the turning-out of leftists from all positions of authority at the earliest possible opportunities.
