I felt compelled to watch Obama's "Prescriptions for America" meeting the other night (transcript available here), where he talked about America's health care system and what he wants to change about it. I was curious about what he was going to say, especially after his speech to the AMA, where he said he would not put caps on malpractice rewards. For this post, I think I'll focus on the things that I didn't agree with during his meeting, and I'll leave the things that I agreed with for another time.
One of the first things mentioned during the introduction to the program was that Obama supports a health care system that resembles today's medicare, where the government handles the financing but patients still have the freedom to choose their doctors and hospitals. Now, don't get me wrong, I like the idea of universal health care. I don't mind government involvement at all, especially if it can get care for those millions of Americans that can't afford medical treatment. Like it or not, however, there is some benefit that insurance companies provide: they spread out patients to various providers, and they make people stick with their choices. People have a few doctors to choose from on their plan, and because of this they have to stick with their doctor. You might be thinking that this is horrible--what if you have a doctor you absolutely hate? Well, the good news is that you can usually switch a couple times until you find one you like. When we eventually get universal healthcare, there are going to be 50 million or so people looking for a primary care provider to call their own. The health care system will be much more stressed, and I feel that we need at least a few ways to organize the people entering the system, rather than allowing for a blind clusterfuck to occur. I already thought that primary care physicians would be specializing in the future, to where there would be divisions in primary care based on age, disease type, or even gender. This may provide the necessary stabilization to the program. Who knows. There is also something to be said about establishing a relationship with your patients, something that frequent doctor-shopping does not allow. We have to consider if too much of a good thing (freedom to choose a health care provider) is a bad thing in this situation, especially with such a large population entering the system.
There was also some discussion on private vs. public health insurance, but I think that a lot of people are missing the point. A lot of people believe that public health insurance will, in itself, lower costs for everyone. It's the simple fact that we have insurance for health care which is driving up costs. Looking strictly at costs, it won't matter what kind we have. A simple car insurance analogy illustrates this pretty well.
A while back, I was in a small car accident with an emo teenage girl bitch, probably talking to her friends on the phone about how her parents hate her, her boyfriend dumped her again, or someone left a nasty message on her myspace (I might be bitter). Anyway, she hit my stationary car in a parking lot while talking on her phone, causing a surprisingly significant amount of damage to my back bumper. I went to the repair shop, where the first words out of their mouths were "is her insurance paying for it?" When I said yes, they instantly put on a big smile, and we walked out to the car to see what the damage was. You would be amazed what these guys said needed to be fixed, all because her insurance was paying for it. They pretty much wanted to replace (or order the parts to replace) the entire back end of the car, when they obviously didn't have to. The mechanic even said that, if I was paying for the repair myself, I would be paying only $700. But the bill to her insurance company was $3400. In turn, this girl's rates are going to go up (ha! fuck her...sorry, I'm still bitter), and she'll be paying a lot more for any other accidents she inevitably gets into. Guess what? The same thing happens with health insurance. *Gasp*
Though it isn't as obvious in health care, and there are many more checks to make sure this doesn't happen...it does. In some instances, it is even encouraged. A skilled doc can tell when his patients have pneumonia when they walk through the door. They have an unmistakable cough, and their histories and physical exams confirm the diagnosis. Docs really don't need x-rays to diagnose it, but they have to. They're required to. By the insurance companies, no less. Otherwise, they won't pay the doc for the patient's treatment. Because they weren't there to examine the patient, the insurance companies need visual confirmation of the disease. So the docs get paid for the x-rays and the treatment, fucking over the patient in the process (because their rates may or may not go up, but they can still get points on their record for that x-ray) and wasting money. That's why health care costs so much. Will public health insurance fix the problem? Maybe, but why would it? Docs will still have to answer to the insurance companies, so "covering their asses" with needless procedures will still be the norm. Insurance is insurance...and it sucks.
So why do docs have to "cover their asses?" Well, Mr. Obama, it's because the pointy stick of malpractice is always about to ram them in the ass. It's why docs pay over $100,000/year in malpractice insurance (which, based on the previous paragraph, also sucks). High malpractice claims do cost the healthcare system money, and they cost patients money. Malpractice is one of the main reasons why costs are so high (and why docs are often grumpy). Fuckin' a, Obama, fuckin' a.
One of the last things I wanted to talk about was Obama's statement that more people need to be encouraged to enter medicine, especially family medicine, through loan forgiveness etc., etc. I hope Obama gets to the realization that the problem isn't that people don't want to go into medicine. The problem is that there are not enough medical schools and thus not enough people graduating from medical school. If all of these students went into primary care, we would probably still not have enough docs for the millions of people about to enter the system. I have dozens of friends who didn't get into medical school for one reason or another, but I know they'll be excellent doctors, just by knowing their study habits and their desire to help people. More than likely, they'll just apply and get in to medical school next year or the following year. It's not like we weed out everyone who doesn't get into medical school...we just delay their entering if they don't get in (40,000 people every year don't get into medical school--20,000 do. In the next year, over half of those who do not get in will apply again, and the cycle continues). It's been proven that students only need a 20 on the MCAT (out of 45) and a GPA of 3.0 to do well in med school. There aren't many people applying who don't get above these scores. Let's reconsider how we educate our physicians, and maybe a few pieces of the puzzle will naturally fall into place.
Hopefully I've shown a bit of my stance on national health care in this post--I think it's important to consider all of these things in the establishment of a new system. I'll probably end up doing more about this in the future, especially as more ideas get tossed around in D.C. about the topic.
Jim
Sunday, June 28, 2009
Friday, June 26, 2009
Political Nihilism
It's been nearly two weeks since I received a $184,178 piece of paper declaring that I have some negligible amount of expertise in the nebulously defined field of "Public Policy Studies." The most common question about this area--one I freely admit to not having a complete answer to--is straightforward: what the hell is public policy? The very close runner-up is probably "is that like political science?" I'm going to indulge myself by ruminating on these questions for a bit.
To understand what public policy is, it is necessary to tackle politics first. Let's consider two kinds of thinkers: Politicians and Utopians. The difference between the two is the difference between what is and what should be. The Politician has the unenviable task of facing the harsh realities of today. Politics is invariably ugly and unpleasant because it is the mirror society holds up to itself. The Politician is responsible for representing the views of his constituents--sometimes ugly, sometimes irresponsible--well enough to get re-elected. The Utopian is tasked with envisioning the Good Society and outlining its structure. Unconcerned with constraints, the Utopian is preoccupied by possibilities, meticulously constructing elegant solutions to intractable social problems. Rough caricatures that these labels may be, they do an adequate job of making the distinction clear.
Public policy, in an ideal world, is the bridge between the world of the Politician and the world of the Utopian. Not quite myopic enough to appease only the Politician and not quite bold enough to satisfy the Utopian, public policy is a tiptoe--perhaps a half-step in extraordinary times--toward a goal envisioned by the Utopians. Thus public policy is borne of a collaboration between the Politicians and the Utopians of the world. It is a program or course of action--or inaction--to which the government commits itself with some purpose in mind.
Of course, one likes to think that few pure Politicians or Utopians exist in the world. We prefer to believe that our elected officials serve with some purpose and some vision and that those academics, policy analysts or advocates, and long-shot candidates who help to shape our discourse are not completely divorced from reality. Übercynics and ivory tower buffoons would make strange bedfellows indeed. But only the shrewdest of operators can successfully navigate both worlds to produce good policy.
The question of what constitutes "good" policy is, of course, the great unresolved social question that occupies us every two years. "Good policy" is often--erroneously, I believe--assumed to lie in the purview of the Utopian; the Politician merely mucks up the implementation of the Utopian's pristine plans. "We know what works but the political system will never let us do it," a friend majoring in political science once complained to me. The fatal flaw in this logic, of course, is that it ignores the purpose of a representative democracy. The questions at the heart of public policy are philosophical: what is important to us? How should the world be? What is the role of government in society? And so on. The Utopian assumes certain answers to these questions and proceeds to prescribe antidotes to the problems he diagnoses in society.
Therein lies the paradox. As any public policy student can attest, identifying a problem is the first step toward developing a policy solution. But problem definition is an inherently political process: there are no "right" answers, only consensus answers. And we have elected not to leave the decision-making to a select group of Utopian oligarchs. Instead, we are all afforded a say in making the value judgments underpinning the public policy process: we get to elect representatives of our views. This is why the idealistic view of public policy-making as a strict matter of quasi-scientific problem-solving best left to the Utopians is untenable. This view forgets that the philosophical questions underlying every step of the policy process from problem definition to the formulation and implementation of solutions can be answered only by the body politic. We can be idealists or democrats but not both.
But once we accept--not grudgingly but enthusiastically--the key role the political process must play things become very murky. Complexities begin to pile on top of complexities. Elected officials are more than just representatives of districts; they are not simply vessels through which the will of a constituency is done. They lead and follow at the same time, they manipulate the masses as they are manipulated by the opinions and passions of their districts. Policy-making becomes more than just a contorted sort of problem-solving in which palatable solutions are developed to address problems identified by consensus. Solutions can be decoupled from problems; indeed, problems can be conjured to fit pre-existing solutions. The distinctions between "campaigning" and "governing" begin to blur and no longer can each be identified simply by noting whether it happens to be an even or an odd numbered year.
The noble vision of policy-making and governing fades into a less gratifying image: that of a game. A grave game with enormous consequences but a game nonetheless. The culprit, I suspect, is, in part, uncertainty. The dissolution of the Absolute--the Good Society toward which we strive--leaves us rudderless. We--the collective public--drift between political persuasions with the ebbs and flows of popular opinion often dictated by events seemingly beyond our control. Compare the political climate of 1920 with that of 1932 or the prevailing political winds of 1980 with those of 2008. "Right" answers are elusive. Some people grasp onto an ideology that contains the philosophical precepts that offer a guide to formulating public policy (i.e. contain an implicit picture of what the Good Society will look like), while others prefer a more pragmatic and less ideologically-anchored approach.
A participant in the policy process who becomes unmoored from ideological preferences and personal passions finds himself in a dire situation. The loss of faith leaves him with only the cold embrace of cynicism. He can be little more than a "hired gun," choosing a side and playing to win by any means necessary. Politics and policy-making become solely about the acquisition of power or a simple love of the game. The notion of identifying desirable social goals and using policy to launch us in the direction of the Utopian's dream becomes quaint and, if anything, simply a tool in the political manipulator's arsenal. This sense of purposelessly drifting through the political landscape is what I'll call political nihilism (a usage of the phrase that differs a bit from what Wiki tells me is usual). It isn't any more endemic to society than is religious agnosticism but I suspect--as with religious agnostics--there are many adherents among us. However, this might be getting a little simplistic and less coherent so I'll stop for now. More to come, I think.
To understand what public policy is, it is necessary to tackle politics first. Let's consider two kinds of thinkers: Politicians and Utopians. The difference between the two is the difference between what is and what should be. The Politician has the unenviable task of facing the harsh realities of today. Politics is invariably ugly and unpleasant because it is the mirror society holds up to itself. The Politician is responsible for representing the views of his constituents--sometimes ugly, sometimes irresponsible--well enough to get re-elected. The Utopian is tasked with envisioning the Good Society and outlining its structure. Unconcerned with constraints, the Utopian is preoccupied by possibilities, meticulously constructing elegant solutions to intractable social problems. Rough caricatures that these labels may be, they do an adequate job of making the distinction clear.
Public policy, in an ideal world, is the bridge between the world of the Politician and the world of the Utopian. Not quite myopic enough to appease only the Politician and not quite bold enough to satisfy the Utopian, public policy is a tiptoe--perhaps a half-step in extraordinary times--toward a goal envisioned by the Utopians. Thus public policy is borne of a collaboration between the Politicians and the Utopians of the world. It is a program or course of action--or inaction--to which the government commits itself with some purpose in mind.
Of course, one likes to think that few pure Politicians or Utopians exist in the world. We prefer to believe that our elected officials serve with some purpose and some vision and that those academics, policy analysts or advocates, and long-shot candidates who help to shape our discourse are not completely divorced from reality. Übercynics and ivory tower buffoons would make strange bedfellows indeed. But only the shrewdest of operators can successfully navigate both worlds to produce good policy.
The question of what constitutes "good" policy is, of course, the great unresolved social question that occupies us every two years. "Good policy" is often--erroneously, I believe--assumed to lie in the purview of the Utopian; the Politician merely mucks up the implementation of the Utopian's pristine plans. "We know what works but the political system will never let us do it," a friend majoring in political science once complained to me. The fatal flaw in this logic, of course, is that it ignores the purpose of a representative democracy. The questions at the heart of public policy are philosophical: what is important to us? How should the world be? What is the role of government in society? And so on. The Utopian assumes certain answers to these questions and proceeds to prescribe antidotes to the problems he diagnoses in society.
Therein lies the paradox. As any public policy student can attest, identifying a problem is the first step toward developing a policy solution. But problem definition is an inherently political process: there are no "right" answers, only consensus answers. And we have elected not to leave the decision-making to a select group of Utopian oligarchs. Instead, we are all afforded a say in making the value judgments underpinning the public policy process: we get to elect representatives of our views. This is why the idealistic view of public policy-making as a strict matter of quasi-scientific problem-solving best left to the Utopians is untenable. This view forgets that the philosophical questions underlying every step of the policy process from problem definition to the formulation and implementation of solutions can be answered only by the body politic. We can be idealists or democrats but not both.
But once we accept--not grudgingly but enthusiastically--the key role the political process must play things become very murky. Complexities begin to pile on top of complexities. Elected officials are more than just representatives of districts; they are not simply vessels through which the will of a constituency is done. They lead and follow at the same time, they manipulate the masses as they are manipulated by the opinions and passions of their districts. Policy-making becomes more than just a contorted sort of problem-solving in which palatable solutions are developed to address problems identified by consensus. Solutions can be decoupled from problems; indeed, problems can be conjured to fit pre-existing solutions. The distinctions between "campaigning" and "governing" begin to blur and no longer can each be identified simply by noting whether it happens to be an even or an odd numbered year.
The noble vision of policy-making and governing fades into a less gratifying image: that of a game. A grave game with enormous consequences but a game nonetheless. The culprit, I suspect, is, in part, uncertainty. The dissolution of the Absolute--the Good Society toward which we strive--leaves us rudderless. We--the collective public--drift between political persuasions with the ebbs and flows of popular opinion often dictated by events seemingly beyond our control. Compare the political climate of 1920 with that of 1932 or the prevailing political winds of 1980 with those of 2008. "Right" answers are elusive. Some people grasp onto an ideology that contains the philosophical precepts that offer a guide to formulating public policy (i.e. contain an implicit picture of what the Good Society will look like), while others prefer a more pragmatic and less ideologically-anchored approach.
A participant in the policy process who becomes unmoored from ideological preferences and personal passions finds himself in a dire situation. The loss of faith leaves him with only the cold embrace of cynicism. He can be little more than a "hired gun," choosing a side and playing to win by any means necessary. Politics and policy-making become solely about the acquisition of power or a simple love of the game. The notion of identifying desirable social goals and using policy to launch us in the direction of the Utopian's dream becomes quaint and, if anything, simply a tool in the political manipulator's arsenal. This sense of purposelessly drifting through the political landscape is what I'll call political nihilism (a usage of the phrase that differs a bit from what Wiki tells me is usual). It isn't any more endemic to society than is religious agnosticism but I suspect--as with religious agnostics--there are many adherents among us. However, this might be getting a little simplistic and less coherent so I'll stop for now. More to come, I think.
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