Thursday, July 23, 2009

Professor Obama's Health Care 101 Lecture

It's worth giving a careful reading to the transcript of President Obama's July 22 press conference. It can be read as the opening lecture of the course on "Health Care Economics and Ethics 101." The President is the Professor. I've done a Cliff Notes analysis of what I see as his major themes, in the form of excerpts (slightly edited) followed by my comments in bold italics.
1. "A lot of Americans may be wondering: What's in this for me? How does my family stand to benefit from health-insurance reform?"
Health policy is a form of job creation program for learned wonks. Unfortunately, the many illuminating analyses that are available are largely read only other wonks. I would guess that the distance between public understanding and expert knowledge is greater for health care than for almost any other area of public policy. Professor Obama is wise to start the course by recognizing and addressing our ignorance and skepticism.
2. "Two-thirds of the cost of reform can be paid for by reallocating money that is simply being wasted in federal health-care programs...We in the United States are spending about $6,000 more than other advanced countries where they're just as healthy...That's money that could be going into people's wages and incomes. Over the past decade we basically saw middle-class incomes flatlined. Part of the reason is [that] health care costs are gobbling that up."
Here Professor Obama is introducing us to the concept of opportunity costs. Health care is valuable. But it's only one of many values. Each of us is unwittingly subsidizing wasteful health care spending. Waste has no value for us as individuals - it's like tossing $6,000 out the window. Those who found it on the street are happy to have it, but he's asking us - do we really want to spend our money that way? 3.
Question from Steve Koff of the Cleveland Plain Dealer: "Can you guarantee that this legislation will lock in and say the government will never deny any services, that that's going to be decided by the doctor and the patient, and the government will not deny any coverage?"

The President: "No. The whole point of this is to try to encourage changes that work for the American people and make them healthier...We want to create an independent group of doctors and medical experts who are empowered to eliminate waste and inefficiency in Medicare."
The reporter invited the President to indulge in managed care bashing, but Professor Obama declined the invitation. The vision of "empowered" experts is a mechanism for managing care. As I've said in numerous posts, the best way to manage care is through global budgets for not-for-profit accountable medical organizations in which the physicians are salaried. But insofar as Medicare remains in a fee-for-service configuration an entity with some of the characteristics of the U.K.'s National Institute for Health and Clinical Excellence (NICE) is just what we need. His response to the reporter's question was politically courageous!
4. "If somebody told you that there is a plan out there that is guaranteed to double your health-care costs over the next 10 years, that's guaranteed to result in more Americans losing their health care, and that is by far the biggest contributor to our federal deficit, I think most people would be opposed to that. Well, that's the status quo. That's what we have right now. So if we don't change, we can't expect a different result...Now, I understand that people are feeling uncertain about this. They feel anxious, partly because we've just become so cynical about what government can accomplish; that people's attitudes are, even though I don't like this devil, at least I know it. And I like that more than the devil I don't know...But my hope is that when people look at the cost of doing nothing, they're going to say, we can make this happen. We've made big changes before that end up resulting in a better life for the American people."
Education is about the potential for change. In my first year philosophy class in a discussion of Nietzsche the professor asked us - "how many can refute Nietzsche's argument here?" None of us raised our hands. "Since you can't refute him, I assume you are all going to change your lives." We continued to sit on our hands. His point was even more powerful than Nietzsche's argument. We were treating education as words on a page, with no implications for action or our own futures.

I think Professor Obama is shaking us up here in a constructive manner. Like my freshman philosophy section, most of us in "Health Care Economics and Ethics 101" are sitting passively in class, listening without real engagement. Suddenly we're confronted with the consequences of our passivity, followed by a diagnosis of why we're sitting on our hands - it's because since President Reagan identified government as the problem, not the solution, our default stance has been cynical disbelief in public action (unless that action involves sending smart bombs to Iraqi targets).

Experienced psychotherapists know that the most important work is with the patient's resistance to change. Slogging through those resistances can be tedious and slow, but without addressing them therapy will be a waste of time. I think there's a chance that the political process we're seeing represents that kind of engagement with the beliefs and fears that have made change in health care so difficult.

I think Professor Obama has launched our course in an excellent way. But whether we're ready to learn remains to be seen!

No comments: