Thursday, September 10, 2009

Obama's Speech - Good Ethics and Good Politics

President Obama hit a home run last night. His speech brought together the three roles we need our president to take in the health reform process - educator, ethicist, and tough politician.

  1. President as educator. As a public we've been clueless about health care. How many times have we heard "the U.S. has the best health care in the world!" Many of our local settings are superb. President Obama mentioned two - Intermountain Healthcare in Utah and Geisinger in Pennsylvania. These were the right kinds of examples to give - integrated systems with strong primary care and careful attention to efficiency and cost management. We were spared from hearing another worshipful invocation of a once in a lifetime high-tech miracle as the definer of what we do best.

  2. President as ethicist. The cancer of the U.S. health system is our rampant narcissism and neglect of our common interests. Individuals are being cheated unless they receive whatever they want. Physicians are being mistreated if each individual isn't allowed to command whatever resources he believes are called for without being questioned.

    I like to use the metaphor of cancer for our health system - by letting costs explode we let health care invade and destroy so much of our capacity for creative action. President Obama used the deficit, and the specter of the depression we almost fell into - "our health care problem is our deficit problem - nothing else comes close." In other words - we choose between our thoughtless commitment to a wasteful system that produces mediocre results and a parched, deficit-ridden public life.

    Sadly, Ted Kennedy can no longer be part of the end game in health reform, but happily the president channeled him to bring out the moral imperative behind the insistence on universal coverage. Reading from Senator Kennedy's letter was a proto-religious act - a message from a loving person sent from the other world.

  3. President as tough politician. Channeling Ted Kennedy was a rhetorical triumph, but to go from rhetoric to a meaningful piece of legislation, Obama must channel Lyndon Johnson as well. He came close to naming names in his reference to "liars" with regard to the cynical efforts to manipulate the public by shouting"death panel," "government takeover" and "socialism." In the speech he evoked the persona of a don't-mess-with-me Chicago politician in an effective manner, but he'll have to emulate Johnson's combination of one-by-one persuasion and bludgeoning to move the legislature to create and pass of a bill.

It's too early to evaluate what the principles Obama laid out will look like when they take on legislative flesh. The angels and devils will be in the details of how the exchange(s) and public option are structured. I was especially interested in the president's vague reference to a commission of physicians and other experts who would identify areas of waste in our bloated system. That could mean managed care, which to me - if done well - has always seemed like the right way for a health system to go.

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