So if you are the big tree
We are the small axe — Bob Marley and the Wailers, Small Axe
“The market state,” which Phillip Bobbitt introduced in The Shield of Achilles: War, Peace, and the Course of History (2002) is a supremely evocative phrase more often cited than defined or critiqued. But “market state” is so suggestive, so evocative of “goodness of fit” for present circumstances, that I can’t help but think “That’s the market state in action!” when curating material on such seemingly disparate subjects as charter schools, nudge theory, ObamaCare, the end of the rule of law (at least as we have understood it), and blood donation. So I’m going to try to think through the implications of Bobbitt’s work, 11 years on, in a series of posts of which this is the first.
I should also issue a disclaimer: This critique should have been written by a political scientist who’s mastered the literature and can distinguish the likely from the plausible, rather than by a vituperative foul-mouthed blogger of the left who, moreover, has begun a series not yet having discovered how he is to end it. (And readers, if any of you have resources to share, please do so in comments!) Here’s the tentative plan for the series:
- Some Approaches to the Market State. Case study: Waupaca County Non-Emergency Medical Transport.
- The Market State and Changes in the Constitutional Order. Case study: ObamaCare.
- The Logic of the Market State. Case study: The Foreclosure Crisis.
- The Market State and Civil Society. Case study: The Food Chain.
- The Market State and Legitimacy. Case study: TBA.
I think that if I am lucky and right, the market state, as a fully fleshed-out concept, will subsume “neo-liberalism,” “privatization,” and perhaps even “kleptocracy,” as well as tropes like “mercenaries” and even “prostitutes” (descriptive and accurate though those concepts may be). See under Elephant, Blind people and the. We shall see!
The portion of Bobbitt’s work that concerns us today can be simply stated, although the terms are going to take a lot of unpacking, the concepts must be critiqued, and (critically) Bobbitt’s work generally should not regarded as descriptive but as a work of elite prefiguration. That thesis:
The constitutional order of the United States is now in transition from nation-state to market state.
Now, I’m not sure this thesis is true, and I’m also not sure it’s true in the way that Bobbitt — who is, after all, a cigar-smoking Episcopalian imperial über-insider thought leader with a smile like a crocodile’s — means it to be true, or would prefer it to be true. However, I am sure that if the change in the constitutional order that Bobbitt theorizes is coming true, it can have no legitimacy as we understand the term: The people who, even in Bobbitt’s view, are sovereign, have not been consulted, or even informed.*
Case study: Waupaca County Non-Emergency Medical Transport
Here’s the example where I first thought “That’s the market state!” (Our UK readers will recognize the market state features displayed here in the Cameron government’s ongoing demolition of the NHS.) I’m going to use this example as a paradigm that shows the nature of the market state, the transition from nation-state to market state, and some of the issues raised by the transition. (Again, if I speak of “transition” in any one instance, that doesn’t mean I regard the change as complete, as universal, as inevitable, as irreversible, or even as fully understood. I hope to come to a better understanding as I go deeper into the series.)
For years, Jim Barry relied on Waupaca County’s volunteer drivers to take him to his medical appointments.
The 67-year-old Weyauwega man needs dialysis three times a week. He is struggling with cancer and can no longer drive himself to his health care providers.
“The county drivers were never late and I never missed an appointment,” Barry said. “Since the new guys took over, I have missed seven appointments. Their service leaves a lot to be desired.”
In the past, the local program for non-emergency medical transportation (NEMT) was run by the Aging and Disability Resource Center, using local volunteer drivers recruited by the Waupaca County Department of Health and Human Services (DHHS). The drivers provided elderly and disabled Medicaid recipients rides to their medical appointments. [nation state]
On July 1, LogistiCare, a private, for-profit corporation based in Atlanta, Ga., became Wisconsin’s sole broker for NEMT. [market state]
Pat Enright is the aging and disability resource manager for Waupaca County DHHS. He has logged dozens of complaints from patients who have missed their medical appointments due to their rides arriving late or not showing up at all.
“These people don’t understand that I get really sick when they’re late picking me up,” Barry said, noting that being late for an appointment can result in his being at the clinic for eight hours as he waits for the dialysis equipment to become available again. And missing his dialysis treatment means toxic wastes are not being removed from his body. A Logisticare driver also failed to pick Barry up for a scheduled ride to the clinic for a CAT scan.
“I feel like they’re trying to kill me,” Barry said. “Yesterday, I made my funeral arrangements.”
You feel like that because they are. And for profit, too.**
Barry said his problems with LogistiCare began the day the company took over the program.
“It took me an hour and a half just to get my first three appointments,” Barry said.
To schedule a ride, callers have to obtain a confirmation number from LogistiCare.
Callers are questioned about whether they have a car, whether they are able to drive and whether they have relatives or friends willing to drive them to their medical appointment without reimbursement. They can be denied rides if they answer yes to any of the questions, according to a copy of logistics call script obained by the County Post.
If callers do not have their doctor’s phone number at hand when they call LogistiCare, they will be denied a ride and told to call back later with the number.
“They are trying to talk the callers out of getting a ride,” Enright said.
That’s because they profit by denying care.
After LogistiCare repeatedly failed to send a driver to Barry, he and Enright attempted to make a conference call to the WMR number.
“I called their number and the phone was not answered after 35 minutes,” Enright said. “I called again and waited 20 minutes.”
After finally getting through to LogistiCare, Enright was assured that Barry’s rides would arrive on time in the future.
“They then missed four rides in a week and a half,” Enright said.
Complaints with LogistiCare are being reported across the state, according to Carrie Porter with the Greater Wisconsin Agency on Aging in Madison. She said Barry’s problems making it to his dialysis appointments are not uncommon.
“It’s not an isolated case,” Porter said. “Just missing one appointment is a huge health concern for a dialysis patient.”
Porter added that missing dental appointments are especially a problem “because there are few dental clinics willing to take Medicaid patients. If they miss an appointment, they are at risk of losing their providers.”
“LogistiCare does not provide the transportation, they just broker it,” Enright said.
LogistiCare contracts with vendors to provide rides, then receives calls for rides and schedules the rides with vendors.
“They are not paid by the ride, they are paid a per capita rate based on the number of Medicaid clients who are eligible for rides,” Enright said. “A cynical person might wonder if they’re making their profit on every one of those rides that they don’t provide. This is privatization at its finest.”
No, it’s not “privatization.” Or it is, but it’s also something larger: A change in the constitutional order. If we treat LogistiCare in Waupaca County as a paradigmatic case, we have:
1. Nation-state: The role of the state is to provide services for its citizens. In this case, its role was to provide a space for volunteer drivers to coordinate delivery of non-emergency medical transportation, to meet the requirement that their appointments not be missed.
2. Market state: The role of the state is to determine which provider shall collect rents for delivering a service to consumers. In this case, its role was to select a broker to co-ordinate paid drivers for non-emergency medical transportation (Here’s more linkiness on Logisticare).
Caveat: These are my definitions. They are close to, but not the same as, Bobbitt’s definitions (note plural), which we will look at in Part II, along with the term “Constitutional order.”
Judging by performance, we can conclude that human life is not the uppermost concern for the provider collecting the rents in a market state regime.*** If the Waupaca NEMT example is truly paradigmatic, that would have interesting policy implications, especially for disciplines like MMT that take “public good” as an object of study.
NOTE * One might, however, regard Obama as the custodian or manager of some of the key threads that make up the transition. There’s a very good reason why ObamaCare “mandates” participation in a market. Eh?
NOTE ** LogistiCare provides a more heightened, transparent, and vicious example of the business model that health insurance companies also use: They profit by taking payment for services they later deny. And yes, it’s still going on.
Appendix I: Some sources
Here are a few of the sources on Bobbitt I looked at when developing this series. The Archbishop of Canterbury is especially good. Readers, feel free to add more in comments!
2002: The Richard Dimbleby Lecture, The Archbishop of Canterbury, Dr Rowan Williams
2002: A world reshaped by war, John Keegan, The Telegraph (review)
2002: Bobbitt on Bobbit, Open Democracy (interview)
2004: Philip Bobbitt: The Thought Leader Interview, strategy and business (article)
2006: Everything we think about the wars on terror is wrong, The Spectator (interview)
2008: Onward to a Hollow State, John Robbe, Global Guerrillas (blog post)
2008: Uncommon Knowledge: Philip Bobbitt, Hoover Institute (video interview)
2009: All the presidents’ man, Guardian (article)
2011: Market States, Sell on News, Macrobusiness (blog post)