Wednesday, March 31, 2010

The Right Kind of Political Rhetoric in Massachusetts

Against the background of overheated, duplicitous rhetoric from the Republican right/Tea Party set, a recent op-ed by Massachusetts State Senator Richard Moore, co-chair of the Joint Committee on Health Care Financing, shows what's needed to advance public learning and meaningful reform. It's his approach to policy that I want to praise, not the specific policy proposals themselves.

Senator Moore starts by identifying what Massachusetts has achieved (substantially improved access to insurance) and has not achieved (cost containment):
Massachusetts, based on our landmark health care reform efforts, has the highest rate of residents with health insurance in the country. However, it would be premature for any of us to raise the "Mission Accomplished" banner over the Golden Dome!

Our mission will not be accomplished until we can also proclaim that the health care that is delivered through that insurance lives up to our region's reputation for the highest quality care, while ending our reputation for the highest cost care and high cost of health insurance.
The policy proposal he endorses involve caps on insurance premiums and provider charges, and supports legislation proposed by Governor Deval Patrick that would create these caps (see here for the text of the Governor's proposal). Most economists see price caps as an ineffective approach that is often destructive to the wider economy. But at a time when (a) job creation is the top priority for the state, (b) small businesses are seen as the key source of new jobs, and (c) health insurance costs strangle small businesses, (d) Massachusetts is seeing a crescendo of calls for immediate action.

Here's how Senator Moore straddles the clash between wise health policy, which would not rely on price controls, and wise job creation policy, which would encourage small business:
The governor and the Senate have both proposed interim measures that would cap growth in provider costs and premium increases. Nobody has claimed that these are the best solutions, or that they are even sustainable as long-term solutions. In fact, such caps, over time, shift costs to other parts of our economy and reduce choice, sometimes compromising quality in the delivery of care. However, if we continue to force businesses to choose between paying for health care for their employees and keeping their doors open, Massachusetts will never see true economic recovery and job growth.
Moore then describes the newly instituted annual public hearings on price increases charged by doctors, hospitals and other providers and premium increases charged by health insurance companies. Unlike the Obama administration, which demonized insurers, and the Republicans, who demonized Obama, Moore takes a more balanced and nuanced approach. His aim is to increase public understanding of the drivers of health care cost increases as a basis for collaborative public action:
...we hope that all providers, which include acute care hospitals, physicians, skilled nursing facilities, pharmacies, allied health fields, and all payers, including insurance companies, health plans, government agencies, self-insured companies, and individual citizens, will work with state government to reduce the costs of care without sacrificing universal access or improvements in quality of care. Just as all health care stakeholders worked together to produce our landmark Massachusetts health reform law, we need to work together to improve quality and contain rising costs. Hopefully, we can be effective partners in achieving high quality health care at an affordable level for everyone in the commonwealth.
Now that the agony of getting federal legislation past the "just say no" Republicans, we can hope to see more thoughtful deliberation at the level of the states. Massachusetts is especially important. It provided the template for the national approach to expanding coverage. Now its job is to do the same for cost containment.

Thoughtful and civil contributions like this one from Senator Moore will foster that effort!

Sunday, March 28, 2010

Ethics, Politics, and Health Care Reform (2)

So how can we understand the virulent backlash against the health reform legislation?

I see two distinctive but inseparable sources for the remarkable eruption of hooliganism and foaming at the mouth that we're seeing.

First, the health reform process has tapped into what Richard Hofstadter called "The Paranoid Style in American Politics" in his 1964 essay. Here's the essence of Hofstadter's analysis:

I believe there is a style of mind that is far from new and that is not necessarily right wing. I call it the paranoid style simply because no other word adequately evokes the sense of heated exaggeration, suspiciousness, and conspiratorial fantasy I have in mind. I am not speaking in a clinical sense...It is the use of paranoid modes of expression by more or less normal people that makes the phenomenon significant.
As many commentators have pointed out, the Tea Party eruptions are best understood as the pre-death rattle of a demographic group that sees itself fading into the minority.

The paranoid stance is not amenable to rational discourse or political compromise. Here's how Hofstadter described the paranoid approach to politics:

Since what is at stake is always a conflict between absolute good and absolute evil, what is necessary is not compromise but the will to fight things out to a finish. Since the enemy is thought of as being totally evil and totally unappeasable, he must be totally eliminated—if not from the world, at least from the theatre of operations to which the paranoid directs his attention.
When we add to the paranoid's hypervigilance about external evil the second element - ambitious politicians like John Boehner and Sarah Palin, and ratings-hungry media entrepreneurs like Glenn Beck and Rush Limbaugh - we create an explosive mixture. It's unclear to me how much these fomenters of misinformation believe their ravings and how much they are manipulating the vulnerable Republican base for political power and personal profit.

But there's no doubt about their impact on perhaps ten to twenty percent of the population. Telling a group predisposed to seeing government as the Great Satan that our first African American President is leading a socialist conspiracy to rob us of our freedom tosses a torch of demagoguery onto the petrol of paranoia.

Hofstadter is careful to describe the paranoid style in politics as part of the "normal" spectrum, not as psychopathology. But clinical experience dealing with paranoid illness gives some pointers on how best to respond to over-the-top reaction to the middle-of-the-road health bill:

  1. Arguing with the vehement Tea Party folks won't work. Efforts to persuade zealots that they're wrong will only heighten the fears that drive the paranoid eruption.
  2. Those who see the country as endangered are correct about the risk, but wrong about where the danger is coming from. It's not "big government" that threatens us in health care. The two threats are the risk of untreated illness and avoidable death for the uninsured and the cancer of runaway costs for all of us. The administration should agree about the reality of danger but redefine where the danger is coming from.
  3. The Boehner/Palin/Beck/Limbaugh fomenters, who exploit public vulnerability to paranoia, can only be dealt with by force. They're exploiters, not thinkers. A strong, well-financed opponent to Boehner, or a boycott of the sponsors of Beck and Limbaugh, or persistent exposure of Palin's recurrent lies, is the only way to go.
Ethical reasoning presupposes openness to debate. But the virulent backlash against the health reform bill isn't debate - it's a devil's brew of political paranoia and manipulative exploitation. Sadly, once the Republicans chose to assume a "just say no" posture, the reform process lost all potential for real debate. Ethical reflection had to yield to bare knuckle politics.
Congratulations for the Democrats for taking an initial step forward!

Sunday, March 21, 2010

Ethics, Politics and Health Care Reform

Now that the House of Representatives has passed the health reform bill, it's a good moment to consider the relationship between ethics and politics.

Wider societal acceptance of the obligation to ensure access to health care for (almost) all represents the key moral achievement for the agonizing political process we've gone through. From the perspective of other economically developed countries the U.S. is late in joining this moral consensus. But at least we're heading in the right direction.

Psychotherapy can help us understand the political theater we've seen. Wise therapists tell us that dealing with resistance to change is the key therapeutic work. Resistance is where the psychological "vested interests" hide out!

The Republicans have played the resistance card brilliantly, especially in their exploitation of the paranoid component of our societal psyche (see here for a discussion of political paranoia). My guess is that a quarter of half of the Republicans believe their "government takeover" message. The rest understand it as a tactic. For the Democrats I'd guess that a similar segment believes that reforming insurance will remake the health system, with the rest understanding that focusing on insurers while making no mention of underuse, overuse and misuse, was politically effective.

In psychotherapy, when the major resistances have been wrestled to the ground, the work of therapy becomes less dramatic. It's all about "implementation" of whatever the change might be. That's where we are now in the health reform process.

At the end of Phillip Roth's hilarious Portnoy's Complaint, a novel in which Portnoy tells his salacious story while lying on a psychoanalytic couch, his therapist says - "now we will begin."

That's where we are in health reform - we've cleared away enough resistance that we can begin!

Thursday, March 18, 2010

Idaho Throws Down the Gauntlet on the Insurance Mandate

Yesterday Republican Governor Otter signed the "Idaho Health Freedom Act" - a bill whose purpose is:
"[to codify] as state policy that every person in the state of Idaho is and shall continue to be free from government compulsion in the selection of health insurance options, and that such liberty is protected by the Constitutions of the United States and the State of Idaho. The bill removes the authority of any state official or employee from enforcing any penalty which violates the policy. It also tasks the office of the Attorney General with seeking injunctive or other appropriate relief , or defending the state of Idaho and its officials and employees against laws, enacted by any government, which violate the policy."
Senator Monty Pearce, who guided the legislation through the Idaho Senate, explained the world view behind the bill this way:
“This is a sad day that we as a state need to bring forward this legislation to protect ourselves from an overreaching government. We have really changed as a nation in 220 years. People used to come into Ellis Island dirt poor, nothing but the clothes on their back. And their attitude was ‘give me freedom, that’s all that I ask.’ And they were happy for it. Today, we want the government to feed us, we want them to guarantee us medical care. I’m proud of the state of Idaho that we would consider legislation like this. We’re saying we’ll be independent. We don’t need you. We’ll take care of ourselves. And we can do a better job of doing it.”
I totally disagree with Senator Pearce's view of health care as something that individuals should provide for themselves. But I admire the spirit of frontier individuality that he evinces. I looked up New Plymouth, the town of 1,400 Senator Pearce is from. It was founded in 1895 by a group of Chicagoans who were dissatisfied with city life who wanted to live in a more natural and independent rural manner.

The spirit of New Plymouth represents what's best (the independent, can-do spirit and love of the natural world) and worst (the failure of compassion and vulnerability to political paranoia) with U.S. political culture. I've written elsewhere about in how Shane, the iconic U.S. western, the two heroes evince two ideals of frontier responsibility: Shane, the brave gun-toting defender of liberty, and Joe Starret, the brave community builder.

The U.S. at its best embraces both visions of responsibility. The tragedy of the health reform process is that they've been ripped apart and put into violent rhetorical opposition.

I continue to hope that the Democrats can pull themselves together to pass the decidedly imperfect but better-than-the-status-quo health bill. But even if that effort fails, the constitutionality of the "Idaho Health Freedom Act" could still get to the Supreme Court. If it does I hope and expect that the often polarized Court will rise to the occasion and recognize that frontier independence and caring for each other through universal health care are values that can and must be harmonized.

Tuesday, March 16, 2010

Conservatives Unwittingly Promote a Single Payer System

After reading the final sentence of my most recent post on health reform, friends asked me what I'd been smoking:
"Therefore, since health care costs must be constrained, whether through federal legislation this year or, if that fails, when the U.S. economy implodes further, the paradoxical result of the conservative anti-mandate fervor is that we will ultimately need an out-of-the-closet tax. Single payer - here we come!"
In today's New York Times, William Pewen, a former health policy advisor to Republican Senator Olympia Snowe, argues that bipartisan reform was potentially achievable, but faulty leadership from both parties blew it. Pewen is evenhanded in his critique of the parties. (I would put more blame on the Republicans, who took Nancy Reagan's injunction to "just say no" to drugs as their marching orders in relation to President Obama!)

But what interested me most was that Pewen reached the same conclusion I did about where failure of today's reform effort will lead us tomorrow:
"Should they succeed in blocking reform, Republicans should take no consolation. When Congress next attempts reform, in a decade or more, health costs and the number of uninsured and underinsured will have escalated — and the likely outcome will be the single-payer system that Republicans most abhor."
I have the privilege of directing the ethics program at Harvard Pilgrim Health Care, a non profit insurer in Massachusetts, New Hampshire and Maine (Senator Snowe's state) that currently provides health insurance to 1.1 million. (U.S. News and World Report has ranked Harvard Pilgrim first among commercial insurers for the past five years.) I know first hand that private insurers can comport themselves in an ethically admirable manner.

But if a society were creating a health system from scratch, it's hard to imagine that it would develop a hodgepodge like what we have today in the U.S. Some form tax supported universal coverage, whether single payer or the kind of system Zeke Emanuel envisioned in "Healthcare, Guaranteed," would be much more likely.

More than a hundred years ago Sigmund Freud hypothesized that repressing our true objectives would lead to "return of the repressed," in symptoms, Freudian slips, and the like. Perhaps that's what we'll see in the U.S. Conservative political discourse is trying to "repress" communitarian values by accusing communitarians of plotting "death panels" and "socialized medicine." It won't work. Pewen and I both see the rabid forms of opposition to health reform as the last gasp of a political neurosis.

As Winston Churchill said - "The Americans will always do the right thing . . . After they've exhausted all the alternatives!"

Saturday, March 13, 2010

Disney versus Campaign for a Commercial Free Childhood

I'm ashamed to say that I'd never heard of the Campaign for a Commercial Free Childhood (CCFC) or its suit against Baby Einstein, a Walt Disney company, until I learned that the Judge Baker Children's Center, an organization I admire, kicked them out.

Here's the story as I understand it.

In 1997 Julie and Bill Clark founded a company to produce Baby Einstein, a video pitched to infants. In 2001 Disney bought a majority ownership share. The company grew like Topsy despite a strong recommendation from the American Academy of Pediatrics that children under 2 should watch no television.

In 2006 the Campaign for a Commercial Free Childhood complained to the Federal Trade Commission, alleging that Baby Einstein and Brainy Baby (another producer of videos for tots) falsely described their products as educational. The companies dropped the word "educational" from their websites, but last year CCFC and a team of public interest lawyers threatened a class action lawsuit unless Disney offered to refund the full purchase price to anyone who purchased a video after 2004.

In October 2009 Disney agreed to offer the refunds for products purchased between June 5, 2004 and September 4, 2009. (The offer ended last week.) CCFC claimed victory.

But CCFC's victory came at a cost. This week the New York Times reported on what Dr. Alvin Poussaint, Professor of Psychiatry at Harvard Medical School and Director of the Media Center at Judge Baker, told them about the extrusion of CCFC:
“The Judge Baker staff informed us they didn’t want us to talk to the press, or to say anything about Baby Einstein. They suggested to me that Disney was threatening to sue Judge Baker. We’d been doing this [kind of advocacy] for 10 years at Judge Baker with no problem. We took up a thing with McDonald’s putting advertisements on report cards in Florida. The only thing that seemed to cause a problem was this Disney thing.

I asked the lawyer who had talked to Disney, point-blank, whether Disney had threatened to sue, and he said no. But I still don’t know the content of the conversations with Disney.”
Dr. Susan Linn, Director of CCFC, framed the ethics of the situation this way:
“It’s really chilling, that any corporation, and particularly one marketing itself as child friendly, would lean on a children’s center. And it’s heartbreaking that a children’s center would cave in.”
It's not unethical for a company - even the tobacco industry - to advocate for its interests. But if Disney threatened to sue JBCC it was going too far.

Today's Boston Globe editorial "Bowing to corporate America, Judge Baker Center loses face," scolded JBCC:
The Baker center clearly does not see the work of the campaign as central to its mission, the mental health of children. That’s a cramped view. So many of the problems children face today, from obesity to lack of exercise to inability to concentrate in classrooms, are directly related to the media that surround them. The Campaign for a Commercial-Free Childhood was a jewel in the Baker center crown.
I think posing the ethical challenge as a black and white "standing firm" versus "backing down" choice is too simple. Here's what I would have advised if I'd been consulting to Judge Baker:

"When I looked up your mission, here's what I found:
'The Judge Baker Children's Center promotes the best possible mental health of children through the integration of research, intervention, training and advocacy.

• Through research we identify best practices.

• Through intervention we bring those practices to children and families of diverse communities.

• Through training we disseminate skills in research and quality care.

• Through advocacy we use scientific knowledge to expand public awareness and inform public policy.'
Evidence-based advocacy is clearly part of what you're all about. And the CCFC is following guidelines from the American Academy of Pediatrics. That's as good as it can get for official sanction!

But you're a small organization. Your advocacy mission is to inform and educate, not to litigate. If you conclude that being the source of litigation exposes your full mission to too much risk it's ethically acceptable to distance yourself from it.

But you should do that in a way that "promotes best practices" and "informs public policy."

That means using the process of extruding CCFC as a source of public education. Lay out what's happening. Here's what you might say:
'We're proud of the superb work CCFC has done on behalf of children. But that work may be attacked in court. Litigation would be too costly for us. In 2009 Disney earned $35,149,000,000. Our 2009 income was $12,176,00. Disney can afford litigation. We can't.

Therefore, to protect the full range of our mission, and to keep CCFC free of any constraints we might be tempted to impose, we have arranged to separate the two organizations. In place of the support we've been giving them we will make a comparable donation to their fundraising campaign. We share CCFC's goals on behalf of children. We admire their successful advocacy. And we want to continue to work with them in the future. But without the organizational separation we'd be putting all of our other efforts at too much risk.'
Ironically, the flap over extruding CCFC makes CCFC more prominent and puts some egg on Disney's face! I know that CCFC got at least one new donor (me), and I'm sure they'll get more.

Tuesday, March 9, 2010

The Wild Rumpus Over the Individual Mandate is About to Start

The Virginia legislature is about to pass a bill that would prohibit mandating citizens to have medical insurance or pay what they call a "fine" or "penalty" (see here). The long anticipated wild rumpus over the individual mandate is about to start!

[Dear non-U.S. readers - "wild rumpus" is an episode in "Where The Wild Things Are," Maurice Sendak's wonderful book for children and their parents.]

The Virginia legislature's attack on the individual mandate rests on two legal arguments that are psychologically understandable but muddled and wrong about key facts:

  1. State Senator Fred Quayle, one of the sponsors of the bill, argues that “in the entire history of this country there has ever been any act of Congress requiring a citizen to buy anything.’’ But as Yale Law Professor Jack Balkin points out in a New England Journal article on the legal status of the mandate, the mandate is actually a form of tax that individuals do not have to pay if they have health insurance. The General Welfare clause in the Constitution ("The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States") is unambiguous about the government's right to impose taxes.

  2. State Representative Bob Marshall makes a variant of Quayle's argument: “This is a penalty for doing nothing. Hey, I’m doing nothing, leave me alone." But if Marshall elects to be uninsured he's not doing nothing. If he is injured and goes to an emergency room, the Federal Emergency Medical Treatment and Labor Act (EMTALA) mandates emergency care that his fellow citizens will pay for it he doesn't. And if he develops a curable cancer, his friends will hold a bake sale and make donations to pay for the treatment he has elected not to insure against.

But opposition to the mandate also rests on two moral arguments. While I reject these arguments as not consistent with the guiding principles for a decent human society, they are views deeply held by many Americans, not simply muddled legal thinking:

  1. While I prefer to think of the provision of basic health care as a societal obligation rather than a right, many in our society see it as neither. This is the perspective behind Senator Quayle's faulty legal analysis - that health insurance is a consumer good, like cars and computers. It would be absurd to mandate purchase of cars or computers. But for those who see health, and therefore basic health care, as of distinctive importance, taxing ourselves to provide it becomes a moral requirement, not an abominable manifestation of "socialized medicine."

  2. The article about the legislature I cited above reports that "Clint Bolick, a litigation specialist with the conservative Goldwater Institute who wants to test the mandate in the US Supreme Court if it passes, said Obama’s plan to mandate insurance coverage is nothing more than an effort to require one group of people to subsidize insurance for another." In nosing around the web to see what I could find about income redistribution I came upon "Conservapedia," a site that I - a card carrying liberal - wasn't aware of. It set forth the argument against cross subsidization this way:

    Income redistribution can be either the act of an individual's voluntary charitable giving or government mandated compulsory transfer of assets and income from one group of citizens to another group.

    Most conservatives accept and advocate voluntary charitable giving as necessary to alleviate social problems, but believe the government should not interfere, but rather should encourage personal involvement and personal giving to the under-privileged, elderly, disabled, and other hardship cases. Also, many conservatives view some forms of government redistribution as an impingement on personal rights, leading to unjust expropriation of property, fostering irresponsible social conduct and acting as a disincentive for personal involvement to alleviate social problems. Also, mandatory giving may create jobs for bureaucrats and dependent constituencies as electoral bases. By contrast better off liberals like professors are more likely to vote for political parties that favor income redistribution. Income redistribution will increase the taxation they personally pay. They show altruism by the way they vote.
Even in our fractious society, there is near universal agreement that health care costs must be constrained. There is similar near universal agreement among economists that this cannot be done without bringing the full population into the insurance pool.

Nevertheless, Virginia will pass its anti-mandate law, the governor will sign it, and a number of other states will join the bandwagon. The issue will ultimately go to the Supreme Court. Despite the anti-administration tilt on the Roberts court I am persuaded by Balkin's analysis that the anti-mandate legislation is almost certain to be rejected.

Therefore, since health care costs must be constrained, whether through federal legislation this year or, if that fails, when the U.S. economy implodes further, the paradoxical result of the conservative anti-mandate fervor is that we will ultimately need an out-of-the-closet tax. Single payer - here we come!

Monday, March 8, 2010

Health Care Trade Offs in Massachusetts

Like municipalities all over the country, Massachusetts cities and towns are going down the financial tubes. Health care costs for municipal employees is the top problem.

The quality of debate and the opportunity for public learning in the federal reform process has been pathetic. The President not been able to get us to understand the way health care costs strangle other public and private goods as a pressing moral concern. We (the public) can come to grips better with health "system" ethics and policy issues via our own states and municipalities.

In the past week the Boston Globe has run a terrific series of articles, op eds and columns that make it much harder for Massachusetts residents not to understand the opportunity costs bad health policy creates. Massachusetts cities and towns have created an economic cancer through poorly planned health insurance decisions about insurance for their employees.

In order to avoid paying higher wages, municipalities have provided health insurance that insulates employees from the cost of health care much more than other private insurance does. But what looked like a money saver for municipalities turned out to be a Frankenstein monster. Municipalities now devote, on average, 14% of their budget to employee insurance, compared to 8% ten years ago. Employees get lower wages than they could otherwise receive, and the inflated health care produces poor value for money. It's a bad deal for the towns, the taxpayers, and the employees.

Sean Murphy's articles lay out the key point. If municipalities were able to provide insurance via the Group Insurance Commission (GIC), the innovative agency that provides health insurance to more than 300,000 state employees, retirees and dependants, they could save at least 10% - 15% annually on their insurance costs.

Here's where ethics come in. These aren't just numbers on a spread sheet. If Boston could achieve what the GIC does, the savings could cover the City’s entire projected shortfall for the current fiscal year, or hire 420 new police officers, or create 32,400 additional summer jobs for youth, or double the City’s capital improvements for the schools.

These are morally meaningful tradeoffs. There's absolutely no reason to believe that the higher cost of municipal insurance produces better health outcomes than the GIC does. If this is true - and I'm sure it is - we're incurring substantial opportunity costs, without corresponding gains. That's unethical!

The municipal insurance programs are the product of years of collective bargaining, which is itself a key component of democratic society. Ideally, municipalities and unions will be able to agree that the current arrangements are harming the three key stakeholders - municipal governments, union members, and taxpayers. The Boston Globe's laying out the issues so clearly might nudge towns and unions in that direction. But if that doesn't happen it will be up to the state legislature to force an outcome that is not reached through cooperation.

A combination of our (the public's) sloppy thinking and manipulation by all those who profit from the health care cost cancer has led us to the delusion that it's immoral to think of money when we think of health care. The reverse is true. The way we've let health costs run rampantly over other public goods is a moral crime. Understanding the realities of municipal trade offs can help us move forward in our ethical maturity!

(See Sean Murphy's articles here, here, and here, Scott Lehigh's op ed piece here, and Kevin Cullen's column here.)