Victor Fuchs on health reform

I've never met Victor Fuchs, but I've admired and learned from his writings for years. His article in this week's JAMA on "How and Why US Health Care Differs From That in Other OECD Countries" is a gem. Here's a summary:

US expenditures differ from the average OECD country in three ways:

1. As a percentage of GDP, US expenditures are twice as high.
2. The share of expenditures funded by government in the US is 46%, compared to a 75% average for other OECD countries.
3. The mix of services differs substantially - intense focus on technology vs more basic care.

Here's how Fuchs explains the difference, again in a series of three:

1. The US population has a much more distrustful attitude towards government - a trend with deep historical roots.
2. The US population is much less committed to equal outcomes through redistributive policies.
3. The US political system provides many "choke points" that allow special interests to block or reshape reform efforts.

Finally, Fuchs draws three practical conclusions for future reform efforts:

1.  "[G]overnment's role should be limited to what is necessary, not just desirable."
2. "[P]rovision of basic coverage for all should not require equality for obtaining additional coverage...individuals should be free to purchase more than basic care."
3. "[R]eform should have features that would appeal to some special interests, or to some elements within each special interest group."

Fuchs, who is presumably in his mid 80s (he graduated from NYU in 1947), is giving us the gift of his wisdom. His two page JAMA piece ends this way:

Comprehensive health care reform in the United States is necessary to avoid a financial disaster, but enactment of such reform will require attention to US history, values, and politics."

Fuchs' analysis is relevant for liberal critics of the Affordable Care Act. In the eyes of single payer advocates and other progressives, the ACA is a disappointing flop. But by Fuchs' three practical conclusions, the ACA was the best that could be achieved in 2010. The right approach for progressives is to do all we can to make it work.

Paranoid Style in the ACA Dissent

My wife and I are in Vermont with two of our grandchildren visiting, so I've only just now finished reading the 193 page Supreme Court decision about the ACA.

Throughout the health reform process I've tried to understand the virulent opposition to the ACA in terms other than "stupidity" and "demagoguery." Stupidity is real, as when Senator Breaux's constituent pleaded "don't you let the government get hold of my Medicare." And demaguguery is all too real, as in Sarah Palin's death panel lies and Mitt Romney's sucking up to the Tea Party and running away from his constructive role in Massachusetts health reform. But the dissent written by Justices Scalia, Kennedy, Thomas, and Alito (that's the sequence of their names on the dissent) offers a uniquely clear insight into hatred of the ACA.

I'm not a scholar of constitutional law, but I found Justice Ginsburg's argument that the individual mandate was constitutionally justified under the Commerce Clause persuasive. But I also found Justices Scalia, Kennedy, Thomas, and Alito's argument that the Commerce Clause does not justify the mandate strong in logic.

It may be the psychiatrist in me, but I believe the conclusion the four dissenters reached (and the virulent hatred of the ACA that some of its opponents express) reflect the dissenter's fear of a slippery slope more than the nuances of interpretation of precedents. The dissent has a framework of logic, but the driving force is emotion. I've highlighted the emotional content of three representative excerpts from the dissent:

...to say the failure to grow wheat (which is not an economic activity, or any activity at all) nonetheless affects commerce and therefore can be federally regulated, is to make mere breathing in and out the basis for federal prescription and to extend federal power to virtually all human activity. (p 129)

...If congress can reach out and command even those furthest removed from an interstate market to participate in the market, then the Commerce Clause becomes a font of unlimited power, or in Hamilton's words, "the hideous monster whose devouring jaws spare neither sex nor age, nor high nor low, nor sacred nor profane." (p 134)

But if every person comes within the Commerce Clause power of Congress to regulate by the simple reason that he will one day engage in commerce, the idea of a limited Government power is at an end. (p 138)

The dissenters see the ACA as unleashing a hideous devouring monster. Their outlook reflects what historian Richard Hofstadter called the paranoid style in American politics. 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 a member of the avant-garde who is capable of perceiving the conspiracy before it is fully obvious to an as yet unaroused public, the paranoid is a militant leader. He does not see social conflict as something to be mediated and compromised, in the manner of the working politician. 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.

The dissenters see the ACA through the lens of the paranoid style. This is what leads them to the crucial slippery slope argument - that if we allow the individual mandate we allow the government unlimited power to coerce us. The end result is the image of the body politic as an infant, being forced to eat broccoli by a controlling mother:

All of us consume food...But the mere fact that we all consume food and are thus, sooner or later, participants in the "market" for food, does not empower the Government to say when and what we will buy. That is essentially what this Act seeks to do with respect to the purchase of health care. (p 139)

The slippery slope argument - from the health insurance mandate to total government control and forced feeding with broccoli - depends on the emotion, not logic. Justice Ginsburg makes a powerful argument that health care, representing more than one sixth of our national economy, is a distinctive case, not just one stop on a slope leading to broccoli. But from the perspective of the paranoid style, giving an inch is giving a mile.

Hofstadter is clear that the paranoid style doesn't mean that the views being asserted are wrong. In my view the dissenters make cogent arguments about Commerce Clause precedents but, again in my view, the arguments don't trump those advanced by Justice Ginsburg. But for those who see the world through the paranoid style lens, the associated emotions add the necessary weight to arguments that in themselves are not decisive. 

The paranoid style isn't a logical conclusion - it's an emotional predisposition. As a result, logic won't alter it. Between now and November we'll see how the Republicans will seek to fan paranoid style flames and how the Democrats will seek to counter it. Stay tuned!

(The full Supreme Court decision is available here. And for a strong argument as to why the health sector is distinctive and the slippery slope argument fails, see health law professors the amicus brief from 104 health lawyers here.)

Six More States Join the Anti-Mandate Suit

The Associated Press reported today that Iowa, Kansas, Maine, Ohio, Wisconsin and Wyoming, all with Republican Attorneys General, have joined the Florida suit that claims the individual mandate is unconstitutional.

At this point, 25 states, all but one with Republican leadership, are suing the mandate provision!

This is a fascinating piece of U.S. politics. My guess is that when historians and political scientists delve into the issue 10 - 20 years down the road, the suit and the Republican repeal effort in the House of Representatives, will look like a combination of: (1) the latest manifestation of what Richard Hofstadter called the "paranoid style in American Politics" (see here for a post on Hofstadter), triggered by the fact that the individual mandate is an intrusive piece of legislation; (2) theological belief that market solutions are always best; (3) reluctance to embrace the communitarian values the law embodies; and (4) a hefty dose of cynical political opportunism.

There's no way to contain runaway health costs without bringing the entire population into the risk pool and, one way or another, creating an overall budget for health care that we - the body politic and our health institutions - must learn to live within. The highly complex health reform law is an effort to do that without paying for health insurance collectively through taxes. If the Supreme Court ultimately rules against the mandate, or if a Republican sweep in 2012 leads to its repeal, we'll have to look for a new way to broaden the risk pool and create a health care budget.

If the mandate bites the dust, I would predict that politicians may turn to the kind of proposal Ezekiel Emanuel made in Healthcare, Guaranteed. Emanuel envisions a tax supported system that provides individuals with vouchers for purchase of insurance. While a tax is as intrusive as a mandate, we're accustomed to paying taxes, but not to being penalized for not making a purchase. A dedicated health tax may be more politically acceptable than the mandate mechanism. And vouchers that individuals use to purchase health insurance from independent entities make use of market mechanisms. This would reduce concern about "federal takeover" of healthcare and "creeping socialism." (See here and here for Maggie Mahar's excellent 2008 discussions of Emanuel's proposal.)

The process we're seeing is a combination of ethics (a civilized society should ensure that all citizens have access to good health care), economics (a prudent society doesn't let one sector consume disproportionate resources), and politics (the way the problem is addressed must be compatible with public beliefs and values). There's no way this can be a tidy, settle things for once and all, process!

Health Care and the Campaign

A New York Times editorial on "Health Care and the Campaign" summarizes nicely the lies, distortions and disinformation about health reform the Republicans are purveying:

1. Lies. Here's John Raese, Republican candidate for Senator in West Virginia, on health reform: "From here on out under Obamacare, you're going to have a patient-bureaucrat relationship, because the first person that patient has to go to is a bureaucrat. That is called a panel."
   
   There's simply no truth whatsoever to Raese's claim. Zero. Nada. But since the lie coincides with the widespread distrust of government that is at the heart of American political culture, it confirms a preconception. Wariness and skepticism about authority are good, but they can be turned into paranoia by Raese's lies and Palin's "death panel" nonsense. (See here for discussion of the paranoid style in American politics.)
   
2. Socialism. The Republican play-book calls for high frequency repetition of the "Obamacare is socialism" and "government takeover" mantras. As the Times points out: "What is true is that the law relies heavily on private insurers and employers to provide coverage. It also strengthens regulation of those insurers and provides government subsidies to help low- and middle-income people buy private insurance on the exchanges. Those exchanges will promote greater competition among insurers and a better deal for consumers, which last time we checked was a fundamental of capitalism. "
   
   Billy Wharton, co-chair of the Socialist Party USA, agrees with the Times: "This is not a healthcare reform bill. It is instead a corporate restructuring of the American healthcare system designed to enhance the profits of private health insurance companies disguised with the language of reform."
   
3. Cost increases. The out-of-control cost trend is a key reason we need health reform, and premiums continue to go up well beyond the general rate of inflation. This gives Republicans a rhetorical meatball - "look, Obamacare is already driving costs through the roof the way we warned about!" (See here for a videoclip.) But as we teach medical students in their introductory courses, correlation doesn't establish causation. The primary harm of the Republican distortion is that it contributes to lack of public understanding of the primary drivers of the cost trend: excessive administrative costs, high prices for medical services, and inefficient provision of care.
   
4. Medicare scare tactics. Efforts to scare seniors is an election year ritual. When the Democrats were out of power they did just what the Republicans are doing now. Both parties understand that Medicare (a) is a crucial social program, (b) is very popular, but (c) is economically unsustainable as the baby boom ages. Clinicians who care for the elderly, adult children involved with their parents' medical care, and many seniors, recognize that Medicare needs to move away from uncoordinated fee-for-service treatment, through a combination of better integrated care (through medical homes and accountable care organizations) and wiser CMS oversight. This particular piece of Republican rhetoric is part of political silly season. Democrats are just as profligate in their use of Medicare scare tactics.

From Socialists to the Tea Party, no one loves Patient Protection and Affordable Care Act. Given the intensity of political passion, the enormous economic interests at stake, the complexity of health care, and the dismal state of public and political understanding, passing a comprehensive bill was a remarkable achievement. It's a last ditch effort to make a health system governed by market forces viable. The only alternative is some form of single payer system. If the Republicans succeed in tearing down the health reform process they'll be advancing their own nightmare vision!

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!

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.

The Paranoid Style in American Politics

In the course of trying to understand the eruption of rage against the non-existent "death panels" in the emerging health reform bills I went back to historian Richard Hofstadter's 1964 essay in Harper's Magazine - "The Paranoid Style in American Politics." The opening sentence reads "American politics has often been an arena for angry minds." How true!

Here's the essence of Hofstadter's argument:

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.

Hofstadter cites examples in U.S. history going back to a wave of fear in the late 18th century that the Bavarian Illuminati - a group that espoused Enlightenment rationalism "spiced with the anticlerical atmosphere of eighteenth-century Bavaria" - were plotting to overthrow Christianity. Other examples include the anti-Masonic movement, anti-Catholic and anti-Mormon movements, late 19th century beliefs about a conspiracy of international bankers, and of course the fulminations of Senator McCarthy.

While Hofstadter emphasized that the paranoid style was not exclusively right wing he discerned a continuing belief in a "sustained conspiracy, running over more of a generation, and reaching its climax in Roosevelt's New Deal, to undermine free capitalism, to bring the economy under the direction of the federal government, and to pave the way for socialism or communism." Hofstadter's words in 1964 could be applied unchanged to what was being shouted at town meetings and broadcast on Fox in August.

Hofstadter's analysis offers an explanation for the intractability of public and political debate we are seeing in the health reform process:

As a member of the avant-garde who is capable of perceiving the conspiracy before it is fully obvious to an as yet unaroused public, the paranoid is a militant leader. He does not see social conflict as something to be mediated and compromised, in the manner of the working politician. 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.

Hofstadter acknowledged that the term he chose to use for the style of mind he was describing was judgmental: "Of course this term is pejorative, and it is meant to be: the paranoid style has a greater affinity for bad causes than good." I'm not sure that he's right on this. Many people (like Hofstadter) on the liberal-left would admire whistleblowers like Ralph Nader, to whom the term "paranoid style" could certainly be applied.

In my clinical practice I thought of paranoid style as an accentuated version of the vigilance regarding external threats that has been hard wired into our nervous systems over millions of years. I sometimes said to patients - "when our ancestors in the forest hundreds of thousands of years ago heard a rustling sound, some probably paid no attention and went about their business, and others thought 'that's a tiger' and climbed a tree...if it was a tiger we know who natural selection favored..."

I don't know whether the likes of Newt Gingrich, Charles Grassley and Sarah Palin believe the nonsense they've spouted about death panels (paranoid style) or are cynically appealing to their political base's hatred of government (duplicitous manipulation). I'd guess that it varies from person to person. In retrospect the administration should have read Hofstadter's essay and conducted a series of political "war games" in which they tried to anticipate and innoculate against the full range of fears that could be triggered by the health reform debate.

Demonizing the paranoid style only makes things worse. Sometimes the rustling in the forest was just the wind, but sometimes it was a tiger. Too much trust is just as dangerous as too much vigilance. I, like many others, was inspired by the President's wish for a "different kind of politics," but that aim should not lead to the delusion that the entire political spectrum can be drawn into deliberative discussion!

(If you want to see Hofstadter's full essay, it's here.)