Saturday, December 19, 2009

Crunch Time in Health Care Reform

We're in the end game of health care reform.

As I said in my last post, we're seeing real debate in the Senate, but - unfortunately - only among the Democrats, since the Republicans have united around their goal of preventing the Democrats from passing a bill.

Yesterday two of our best commentators - David Brooks and Paul Krugman - discussed whether Senators should support the bill. Brooks (here) agonizes over the choice, but ultimately concludes that he would vote no. Here's why:
"...if this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we’ll never come back to the spinach."
Krugman (here), I believe, would agree with Brook's analysis of the pluses and minuses in the bill. But he ends up encouraging a "yes" vote:
"With all its flaws, the Senate health bill would be the biggest expansion of the social safety net since Medicare, greatly improving the lives of millions. Getting this bill would be much, much better than watching health care reform fail...Bear in mind also the lessons of history: social insurance programs tend to start out highly imperfect and incomplete, but get better and more comprehensive as the years go by. Thus Social Security originally had huge gaps in coverage — and a majority of African-Americans, in particular, fell through those gaps. But it was improved over time, and it’s now the bedrock of retirement stability for the vast majority of Americans."
For three reasons I think Krugman got it right:

  1. The perfect is the enemy of the good. No matter where one falls on the spectrum from single payer advocate to market hawk, the Senate bill is hard to love. The legislative sausage moving through the reform process won't satisfy anyone's dreams. But the right comparison is with the status quo, not the ideal. It's been 16 years since the last serious effort at health reform. Senators should ask - "would we rather tinker with the status quo for the next 16 years or work with the framework created by the bill?" Imagining a better bill isn't a reason for voting "no." We're not going to see a better bill. Only those who (a) genuinely believe that tinkering with the status quo is the better course to follow from 2009 to 2025 or (b) expect that when we go further into economic hell in our health system handbasket we'll be readier to pass a better bill should vote against the bill we have.

  2. Wishful thinking won't control health care costs. The bill is rightly seen as doing little to contain costs. But many of those who make this attack are the same ones who shouted "evil rationing" and "death panel" when costs were dealt with more directly. We've made progress as a body politic in understanding that health care cost containment is a moral and economic necessity, but we haven't grown up enough yet to dig in to the cost problem openly, honestly and vigorously. In 1914 Freud introduced the concept of "working through" a "neurosis" - clarifying the elements of a conflict, identifying the basis of our resistances to change, and moving forward as best we can - as the pathway to change. It's a sloppy and slow process - "an arduous task for the subject of the analysis and a trial of patience for the analyst" - is how he described it. As it was with Freud's patients trying to cure neuroses in 1914, so it is with our population trying to cure the health system through political action in 2009. Alas, knowing that our system is profoundly wasteful and unjust doesn't create the will to to make bold choices any more than knowing the source of our neuroses erases our quirks. We have to take baby steps - working through!

  3. It's time to retire Reagan's sound bite that "government is the problem." In his inaugural speech in 1980 President Reagan said "Government is not a solution to our problem, government is the problem." It's still the central tenet of Republican theology. (See here for a video clip of Reagan's speech.) Because of our pervasive distrust of government, proposals like single payer insurance or a "public option," which would be mainstream ideas in most other developed economies, are seen as "radical" and "socialist" in the U.S. Our readiness to believe that support for doctor-patient dialogue about appropriate care for the elderly meant "death panels" showed just how powerful the grip of the perspective Reagan articulated so forcefully is in our national psyche. (See here for a discussion of the "paranoid style" in American politics.)

    Atul Gawande's characteristically insightful article in the December 14 New Yorker draws an analogy between the federal government's creative role in catalyzing development of U.S. agriculture at the turn of the 20th century to the potential impact of the many pilot programs promoted in the Senate bill. His argument won't convince the right wing mullahs, but I think anyone with even a partly open mind will see the many ways public action could foster positive change.

The Senate bill, and whatever comes out of the Senate-House conference, is the best option for change we're likely to have before 2025. It will be VERY imperfect. There will be LOTS to criticize. But voting it down and endorsing the status quo would be the wrong course for the country to take.


Anonymous said...

Thank you so much for your wonderful post on health care reform. An ethical dilema is similar to working through a neurosis. It is interesting to watch Howard Dean and others soften their stance on the Senate health care reform bill as the days go on. I am so fortunate to be living in this era.

Jim Sabin said...

Dear Anonymous -

I'm glad the concept of "working through" and the comparison to "neurosis" made sense for you. People who work in the area of ethics are often frustrated when lucid argument doesn't change public attitudes or policy. 20+ years ago I asked Dan Callahan, who'se been a pioneer in medical ethics, about the apparent impotence of argument. He reminded me of how long it took to change attitudes and policies about civil rights and women's rights. That's what put me on to the comparison to the "working through" process in psychotherapy and psychoanalysis.



Debra J.M. Smith said...

Staying Focused On The Main Issue of Federal Health Care
Debra J.M. Smith -
December 08, 2009

Though we can use the details of government ran health care plans, to show just how far off the beaten path many in our federal government have gone and how severe the need is to replace them, we must keep to the fact that any federal government ran health care is unconstitutional.

If someone broke into our homes to steal from us, we would not stand there and debate with them, what they could and couldn't take or in which way they can and cannot carry out the job. We would call the police to get their rears out of our homes!

We would not debate with a would-be rapist, as to what he could and couldn't do to us.

We would not debate with a murderer, on what method he could kill us by.

Why on earth, would we debate with Congress over what way they can go against the U.S. Constitution and take over our health care?

We must keep focused on the fact that it is all wrong to begin with! And we must use this to educate voters and to remove those people in government who are not upholding and defending the U.S. Constitution.

For those citizens, who do not appreciate and do not wish to defend the U.S. Constitution, we need to point them in the direction of Canada. Let them move to a country that allows for such a thing.

Jim Sabin said...

Hi Debra -

Thank you for sharing your passionately held thoughts. I disagree with virtually everything you say about health care, but I appreciate your expressing yourself forcefully but civilly. We've had an absence of civility in our national dialogue, which has impeded the political process.

I don't see any basis for concluding that "any federal government run health care is unconstitutional." Medicare, which is our most well received program, is government run health insurance. The Veterans Administration, which provides some of the best health care in the U.S., is government run care. I think the strongest argument against government involvement is made by those who invoke the effectiveness of market forces (even though I think these arguments are largely wrong).

I actually see federal assurance that every citizen has access to good health care as a responsibility of the government. We were founded on the view that "life, liberty, and the pursuit of happiness" are God given rights, and without access to effective care when we need it, all three are impeded.

Again, thank you for your contribution to a discussion that we need to be having throughout the U.S. The capacity to debate and disagree in a civil manner is a foundation of democracy!



Anonymous said...

While I can understand that passing the "imperfect" bill and then "tinkering" with it may be better than status quo, I have a real problem with Reid's provision that parts of the bill cannot be repealed or otherwise changed for perpetuity. This is wrong on so many levels...

Jim Sabin said...

Dear Anonymous -

My understanding of what you're referring to is an amendment that was presented for up or down vote, but not for revision. In my view the legislative process we're seeing - much like the making of sausages - is ugly, but probably the best that could realistically be expected. Health reform has been an untouchable area for U.S. policy. In the context of "deliberation" all the actual debate has been within the Democratic party. The Republicans appear to have coalesced around the objective of defeating the Democrats, not seriously engaging with health issues. So closing an amendment to debate, was, in my view, a necessary evil.

Any legislation can be revised or overturned in the future by the legislature. It's only the Constitution that has the kind of prohibition of change (except by the demanding process of amendment) that you fear has been attached to the health bill.

Thank you for entering the discussion. And - happy New Year!