“Some of these stories are closer to my own life than others are, but not one of them is as close as people seem to think.” Alice Murno, from the intro to Moons of Jupiter

"Talent hits a target no one else can hit; genius hits a target no one else can see." Arthur Schopenhauer

“Why does everything you know, and everything you’ve learned, confirm you in what you believed before? Whereas in my case, what I grew up with, and what I thought I believed, is chipped away a little and a little, a fragment then a piece and then a piece more. With every month that passes, the corners are knocked off the certainties of this world: and the next world too. Show me where it says, in the Bible, ‘Purgatory.’ Show me where it says ‘relics, monks, nuns.’ Show me where it says ‘Pope.’” –Thomas Cromwell imagines asking Thomas More—Wolf Hall by Hilary Mantel

My favorite posts to get started: The Self-Righteousness Instinct, Sabbath Says, Encounters, Inc., and What Makes "Wolf Hall" so Great?.

Tuesday, November 19, 2013

Healthcare.gov and the Government We Deserve

No matter what changes you make to a system as large and complicated as the healthcare industry, there are going to be winners and losers. The president was wrong to claim otherwise. Republicans were wrong to make all the misleading or mendacious claims that put the president in the position of having to counteract them by overselling the Affordable Care Act. Now we’re hearing every day about how millions of people are getting the cancellation notices Obama said they didn’t need to worry about getting, and they can’t sign on to healthcare.gov to shop for new plans because the website didn’t work when it was launched. The first point to make is that those who have been opposed to Obamacare all along were primed to pounce on any issues that arose—knowing full well that issues were bound to arise. Anyone who pronounced the reform a failure before the ink was dry on the bill forfeited whatever credibility he might have expected when he later pronounces it a failure owing to complications in the implementation.

The blame for the widespread worries and furor, however, can’t be laid solely at the feet of republicans because in claiming that there would be no losers Obama was effectively handing over a bunch of perfect props for the catastrophe narrative. If you claim not a single premium will go up, everyone who sees theirs increase can expect an invitation to go on a conservative pundit’s radio show. If you say not a single person will lose their coverage, everyone who receives a cancellation notice can expect to be prodded to go on TV to brandish it. Never mind the question of whether far more premiums go down than up. Never mind that millions more will acquire access to affordable coverage for the first time than will lose cheap plans which were full of holes anyway. Stories are what sway people, not numbers. And it’s too late now to roll out counter-stories about all the people who thought they were happy with their plans—until they actually got sick.

The second important point is that it’s not all that surprising that a website tasked with integrating inputs as complicated, from sources as far-flung, relying on the cooperation of private institutions as diverse, and serving visitors as numerous as those involved with healthcare.gov would have serious issues at launch. It’s also not surprising that people would start pointing fingers as soon as those issues arise, each voicing an opinion about how the design and launch should have been managed while expressing something between longsuffering contempt and unchecked outrage that any other approach was taken. The delays and frustration with the site are undeniably unfortunate because many people are forming their first impressions of healthcare reform in general based on it—even though many of its other policies have been in place for a while. But a problematic website launch is hardly the scandal it’s been made out to be.

Which brings us to the third point that needs to be made—however bad the governance behind healthcare reform really is or isn’t, the problems are our fault. That’s right, our fault—yours and mine. I’m not making a partisan point here; the problem wasn’t caused by people voting one way or another in any particular election. The problem that has led to this and countless other government failures is that we all, as American citizens, think of government as just another consumer product. Just like when we pull up to the drive-through at Burger King, we want government services our way, right away, and beyond that we don’t want to be bothered by it. Whenever we hear an elected official saying something we want to believe or already agree with, we give him or her our support and do no further investigation. Whenever they say something we disagree with, or whenever something goes wrong, we raise holy hell, and do no further investigation. And this is why our government almost never engages in anything even remotely resembling anything a rational person would describe as a practical decision-making or problem-solving process. Instead, the only process that takes place in the federal government is a never-ending, no-holds-barred, winner-take-all campaign for votes, lobbying money, and public approval.

If our politicians can no longer govern, it’s because we force them to perform on the sleazy reality shows our media outlets have become, which value controversies and scandals infinitely more than the information and context that would empower us to make prudent decisions about candidates and policies. Why have news shows sunk so low? Because they’re pandering to our dual need for validation and entertainment. Because if they don’t tell us what we want to hear we surf the channels for someone who will. Because if we don’t see two volatile, nearly hysterical people exchanging zingers we flip to some other reality show featuring some poor souls purchasing a few moments of fame for the small price of their dignity. Educate and inform? That might make us feel ignorant, or worse, stupid. It might make us feel like we’re in school—that dreadful ego-crushing realm of anti-entertainment the industry has been doing its best for decades to make us loath. Even when news shows oblige us with daily affirmations about how smart we already are and let us feel blithely superior to the people we elect to govern us, it’s still overwhelmingly the most ideologically erect who tune in, hoping to see their guys scoring points against the other guys, points they hope to score themselves at the next family gathering or friendly debate. Is it any wonder our so-called deliberative processes look more like WWE Smackdown?

The news isn’t—at least it shouldn’t be—a consumer product any more than government is. As citizens in a democracy, it is our responsibility, our duty to stay informed. It is the role of journalists and news agencies to help us do that. But for the past few decades we haven’t let them. Instead, those of us who actually bother to watch the news have been demanding precisely the type of news we’re getting. The news has resorted to scandalmongering, insane hyperbole, personal attacks, shouting matches, and cheerleading for reality-challenged tribal ideologues—to lure us away from actual news, to rivet us to the screen. And democracy is suffering for it.

Thinking of democracy as a set of consumer goods—government services your way, right away—transforms a system whose fundamental purpose is to serve collective interests into a commodity to be purchased by individuals. We think by paying taxes we’re participating in some type of commerce, so if our taxes serve collective goals we don’t benefit from directly it sours our attitude toward government. The problem is we’re too short-sighted and take far too much for granted to appreciate how much we truly benefit. While for some Americans government is a byword for limitations on individual freedom, government is in fact a fundamental necessity of life in complex societies. Without institutions empowered with the authority to direct collective action and to make and enforce rules, any challenge or problem that arises as a result of large numbers of people living together in circumscribed regions would be insurmountable. We would have no roads, no power grids, no schools, no currency, no military to protect us from foreign invasion. We would also have no science, no advanced technology like you’re probably using to read this essay, and no scientifically advanced healthcare.

Far from curtailing our freedoms, government is actually one of the main reasons why we Americans are currently enjoying a standard of living nearly unprecedented in the history of our species, surpassed only by those in some European nations whose governments are even larger as a proportion of their economies than ours. But in America we take the benefits afforded us by our wildly successful democracy for granted. Political conservatives fail to see the contradiction in revering our Founding Fathers and our Constitution while reviling the government they established as a hostile tribe of outsiders; while liberals perversely insist that civilizing institutions like governments function as engines of oppression for everyone but the moneyed white men who found them—even as these same liberals go about trying to convince the citizenry that government is the best way to combat injustice. The impression that government has either failed to meet the challenges of a modernizing world or been commandeered by members of a rival tribe results in both widespread apathy and the election of officials who deliberately try to undermine the very institutions they serve, making our government, in the most literal way, a victim of its own success.

The fundamental point we’re missing is that we can’t escape the need for actions that solve collective problems—even though every such action will by necessity create both winners and losers. We have to accept this tradeoff because overall we’re all much better off living in an advanced civilization, with things like cars and contact lenses, that’s governed democratically. The free market is a wonderful force for freedom, but it cannot solve collective action problems. And public health is not just an individual concern. When people who can’t afford routine doctor visits end up in the ER, we all pay for that. When people can’t pay their medical bills and declare bankruptcy, we all pay for that. When people overuse antibiotics and inadvertently create strains we can no longer treat, that may in the short term benefit the individual, but ultimately we all pay for that.

Healthcare, like news, education, and government in general, cannot be thought of as a consumer product. I don’t care who you are: when you get sick, you don’t shop around for the best services—you go to the doctor and do whatever he tells you to do. If, as healthy Americans, we persist in asking, “What can healthcare reform do for me?” instead of asking, “What can we do for healthcare reform?” then we are quite simply terrible citizens, and we don’t deserve to live in this paradise that is our advanced democracy. If all we can think to ask of any government initiative is what it can do for me, then we’re nothing but parasites, sucking up all the vital force from our society, as we hypocritically stand back pointing our fingers and getting howling mad about the sorry state of our government and the ugly nature of our politics. 

For more about collective action problems read: What's Wrong with the Darwin Economy?

For more on why government shouldn't be considered an enemy tribe read: A Zero-Sum Game with Obamacare?

And to find out why civilizations, particularly democratically governed ones are too great to take for granted read: The Self-Righteousness Instinct: Steven Pinker on the Better Angels of Modernity and the Evils of Morality 

7 comments:

caynazzo said...

Nice post with some good points, especially how Obama's overcompensating promises were feeble compared to the unchecked shitwave of lies eroding ACA's credibility.

Binning your hang-ups on privilege and oppression for now, I only take issue with this:

I don’t care who you are: when you get sick, you don’t shop around for the best services—you go to the doctor and do whatever he tells you to do.

This horse sense statement neglects a large part of healthcare which is preventative care and elective surgeries, where 2nd opinions are to be encouraged I would think. And by second opinions I include shopping around for the best services, and asking how much a procedure will cost before it's scheduled and the rationale behind it. We are at our most vulnerable and open to suggestion when we're sick so maybe that's an important time to be asking questions.

Lets not forget, over-diagnosing/testing is a recognized problem and remains a huge component in rising healthcare costs.

If you haven't read this before, an interesting take on healthcare history
http://www.tobiasbuckell.com/2013/10/01/american-healthcare-was-already-socialized-by-reagan-were-just-fighting-about-how-to-pay-for-it/

Dennis Junk said...

Thanks. "Hang-ups"? Dang, I was so proud of the insight expressed in that line. ;-)
We can quibble about whether looking for second opinions is the same thing as shopping around--seems to me there are some fundamental differences--but it really doesn't affect the larger point I was making, in keeping with which I can say I completely agree with your points about preventative care and the problems of over-testing and over-diagnosing. Don't get me started on mental health.

Curtis Nash said...

Nice closing, with the spin on the famous Kennedy quote, but sadly I think the days where the common good beyond one's own immediate needs have any bearing on what is real. Most people who pay any attention to this issue, whether for or against it, know very well that many nations with lesser power or wealth, especially European nations, are able to pull off a national health care system, and that almost works against it happening here--what are we, Eurotrash? Hmph. When French President Nicholas Sarkozy welcomed the US to "the league of compassionate nations of the world," one could almost hear a collective American umbrage, saying "not so fast." Considering our history of helping other nations in time of need, it is easy to take that comment out of context as an insult, and opponents of this issue have bristled ever since at the idea that we should be more like France. How dare they, right? It seems a lot of resistance to the collective good is rooted in spite at the fact that we are not in the vanguard of caring for our own people.
But you hit the nail on the head, Dennis, its a cultural thing. Many intend no offense, but it is taking too long--its a long term thing. When the evidence you cited about how much it costs in the short term, there is rarely an answer or a counterpoint. Cultural pressures, in place because so many are struggling to survive day-to-day, in the short term, have ensured that we have been conditioned to ignore a less than immediate answer to any problem.

Dennis Junk said...

Yes, I do expect now, and have been expecting for the past few years, that the initial stages of healthcare reform are going to be rife with complications and roadblocks. Naturally, many will readily pronounce the whole endeavor a disaster and restate their opinions about how ill-conceived it was from the beginning.
But I predict two years from now we'll be wondering how we ever lived without it.
I have to take issue with your pessimism about Americans thinking in terms of the collective good. Kennedy said it when he did because it needed to be said. The 60s--as you well know--were no golden age. In every age, we need to be pushed to look beyond our own immediate self-interest. Plus it's better to light a candle and all that.

caynazzo said...

I figured. But to be clear, you're for or against Obamacare's mandatory health and maternity care?

Dennis Junk said...

I'm not completely sure which provisions you're asking about. But if you mean that insurance has to cover preventative health measures like mammograms and reproductive health costs like birth control--of course, I'm all for them. Preventative medicine is where a good deal of the cost savings will come from, as insurance companies pay less for preventable problems and pass the savings on through lower premiums.

caynazzo said...

Yes to preventative screens for say HPV for women but also counseling for HIV, STDs, domestic abuse, breast pumps, alcohol and tobacco prevention awareness during pregnancy, autism and obesity screening for children, etc.

The basic idea is that maternity and mental health care was not on par with general medical care. Now all three are being assimilated into the Essential Health Benefits rule for plans. This means psychiatrists feeding at the same health insurance trough as medical doctors, something most don't do, especially because mental illness is more widely considered a chronic lifetime illness to be managed and not curable as say an inguinal hernia.

Your "don't get me started on mental health" prompted the question.