health care

A strong and slow boring of hard boards

All the arguing I’ve been doing over the health care proposal on the table, including with some of my closest friends, reminds me of this great Max Weber essay, “Politics as a Vocation”:

We must be clear about the fact that all ethically oriented conduct may be guided by one of two fundamentally differing and irreconcilably opposed maxims: conduct can be oriented to an ‘ethic of ultimate ends’ or to an ‘ethic of responsibility.’ This is not to say that an ethic of ultimate ends is identical with irresponsibility, or that an ethic of responsibility is identical with unprincipled opportunism. Naturally nobody says that.However, there is an abysmal contrast between conduct that follows the maxim of an ethic of ultimate ends–that is, in religious terms, ‘The Christian does rightly and leaves the results with the Lord’–and conduct that follows the maxim of an ethic of responsibility, in which case one has to give an account of the foreseeable results of one’s action.

You may demonstrate to a convinced syndicalist, believing in an ethic of ultimate ends, that his action will result in increasing the opportunities of reaction, in increasing the oppression of his class, and obstructing its ascent–and you will not make the slightest impression upon him. If an action of good intent leads to bad results, then, in the actor’s eyes, not he but the world, or the stupidity of other men, or God’s will who made them thus, is responsible for the evil. However a man who believes in an ethic of responsibility takes account of precisely the average deficiencies of people; as Fichte has correctly said,he does not even have the right to presuppose their goodness and perfection. He does not feel in a position to burden others with the results of his own actions so far as he was able to foresee them; he will say: these results are ascribed to my action. The believer in an ethic of ultimate ends feels ‘responsible’ only for seeing to it that the flame of pure intentions is not quelched: for example, the flame of protesting against the injustice of the social order. To rekindle the flame ever anew is the purpose of his quite irrational deeds, judged in view of their possible success. They are acts that can and shall have only exemplary value.

But even herewith the problem is not yet exhausted. No ethics in the world can dodge the fact that in numerous instances the attainment of ‘good’ ends is bound to the fact that one must be willing to pay the price of using morally dubious means or at least dangerous ones –and facing the possibility or even the probability of evil ramifications. From no ethics in the world can it be concluded when and to what extent the ethically good purpose ‘justifies’ the ethically dangerous means and ramifications. 

There are all sorts of ways that you can pervert this idea of “responsibility,” from the assumption that responsible politicians are always hawkish (and non-hawks are correspondingly irresponsible) to the proposition that the stance of responsibility implies an excess of caution (the accusation of which has dogged both Obama and John Kerry before him). 

The proper sense, though, I think, is to recognize that politics, especially national politics, has a unique relationship to life and death of citizens (both of one’s own state and of others) — and that an ethic of responsibility demands that one account for the consequences of policy on these terms. To that end, a policy-maker will frequently have to compromise themselves ethically and politically (in the narrow sense of electoral politics). Here’s Weber again:

Politics is a strong and slow boring of hard boards. It takes both passion and perspective. Certainly all historical experience confirms the truth–that man would not have attained the possible unless time and again he had reached out for the impossible. But to do that a man must be a leader, and not only a leader but a hero as well, in a very sober sense of the word. And even those who are neither leaders nor heroes must arm themselves with that steadfastness of heart which can brave even the crumbling of all hopes. This is necessary right now, or else men will not be able to attain even that which is possible today. Only he has the calling for politics who is sure that he shall not crumble when the world from his point of view is too stupid or too base for what he wants to offer. Only he who in the face of all this can say ‘In spite of all!’ has the calling for politics.

 

Moving the goalposts

As much as I’m disappointed by the outcome, I have to love Nate Silver’s analogy/analysis of the failed push for a public option. Essentially, Silver’s take is that the core group of conservative Democrats were never going to accept a public option, said so early, repeated it whenever they were asked, and so, a bill containing a public option was never going to beat a filibuster. 

Suppose the following scenario plays out when you’re trying to buy a used car:

Dealer: The price of the car is $2,000.
You: For that beat-up Honda Accord? I’ll give you $1,200.
Dealer: Nope, it’s $2,000.
You: How about $1,500?
Dealer: I’m going to stick with $2,000.
You: Will $1,700 get it done?
Dealer: My best and final offer is $2,000.
You: Give a guy a break! $1,875?
Dealer: $2,000.
You: $1,995 and a free Slurpee coupon?
Dealer: Now we’re talking — step into my office.

Is that a negotiation in bad faith? Is the dealer moving the goalposts? No. He’s being very stubborn and very firm — but he’s also being very explicit about what he wants. It’s possible that you were an incompetent negotiator and that maybe if your first offer had come in a little lower, or a little higher, you could have gotten a better price. But more likely the dealer simply had more of the leverage and ultimately $2,000 is an acceptable price to you, even if it’s more than you were hoping to pay.

Progressives did just about everything in their power to try to get a decent public option into the bill. They threatened. They bargained. They complained. They organized. They persuaded. They begged. There was the opt-in, the opt-out, the trigger, the Medicare buy-in. There was no lack of initiative or creativity. And they actually had quite a bit of success: from 43 votes in August, they got up to perhaps as many as 48–52 for a strong-ish public option, and 57–59 for a weak-ish one. People like Kay Hagan, Tom Carper and Kent Conrad, to varying degrees, came on board.

But just because you perceive yourself as being in a negotiation with another party doesn’t entitle you to win that negotiation, or even to split things halfway. Sometimes your adversary doesn’t think there’s anything to negotiate at all. Sometimes they would in theory be willing to negotiate if you could find the right leverage point, but there’s nothing that fits the bill, for all your best efforts. Sometimes their first offer is pretty much as good as it’s going to get, and not merely a negotiating ploy.

What’s that? Oh, yes. Silver explicitly excludes Sen. Joe Lieberman (Prick — CT) from this analysis. Lieberman’s about-face on the Medicare buy-in proposal, motivated seemingly only by a desire to get payback from progressives who didn’t support him against Ned LaMont, would be comic if it didn’t play with people’s lives.

 

The strangely low entropy of the universe

Ezra Klein (!) links to a weird and wonderful meditation on the strangely low entropy of the universe:

Why do we find ourselves so close to the aftermath of this very strange event, this Big Bang, that has such low entropy? The answer is, we just don’t know.

Then there’s an analogy with chickens and eggs.

(Thanks Dan!)

 

The Useless Iconoclast

A couple of months ago, I started typing up a long post bashing David Goldhill’s Atlantic Monthly cover story on health care that everybody was lauding (especially David Brooks). The article had appeared in the midst of August, when health care reform was on the ropes, and it seemed like just another antagonist helping to push the process to defeat. But by September, when I was drafting the post, the prospects for reform had brightened dramatically. It was revived! With a public option! In the Senate, even! So I put my post away.

Another article, in the New Yorker this time, is getting my dander up again. (OK, it’s a blog post, but for any other publication it would have been an article.)

These articles perpetuate the belief rampant in journalism that systemic change happens in sweeping gestures. And very, very occasionally, it does. But over the past 90 years, almost every sweeping change proposed to overhaul the health care system has gone down to crushing defeat. The real changes have been step by step, bit by bit. Even Medicare when enacted was a mere condolence for the death of the comprehensive insurance system Truman had envisioned 20 years before.

But the worst thing about these articles is that they’re not content to just paint a grander vision than is practical or possible. They also spit at the seeds of change reformers have fought hard to embed within the legislation that’s proceeding.

At the heart of both Cassidy and Goldhill’s arguments is a familiar contention and one I agree with — that one of the biggest problems with the US health care system is the way it distorts costs by shuffling most payments for health care through a gruesome patchwork of employers and private insurers. Goldhill would reboot the current system in favor of a more libertarian solution, establishing affordable options for catastrophic coverage and handing out vouchers for individuals to purchase more routine care. Cassidy suggests he’d like a more progressive solution, perhaps straight-up single-payer insurance.

If their arguments stopped there, I’d appreciate them. Either of these proposals could be part of a good conversation about what health reform might look like in an ideal world. And I think it’s tremendously important that folks continue to paint these alternative visions of what health care can become.

What I find most maddening about these articles, though, is the pose of the lonely iconoclast. The way the authors pretend their ideas are so novel and transgressive that no one’s pointed them out until now. The way they ignore the past 90 years of attempts at health care reform. And worst, worst of all — the way they off-handedly dismiss the real reforms that try to incorporate those ideas into actual legislation as pragmatically as politics allows.

Both men frame their arguments as though they’re the hard-headed realists pointing out the truths no one else will acknowledge. But both are ignoring (or dismissing) reality themselves, not even really engaging with politics as it exists in the real world.

If you don’t mind a bit of wonkiness, read on. Read the rest of this entry »

 

Catastrophic Thinking

I remember years ago, when I was dating a girl, getting into a conversation with her cantankerous grandfather about health care. He was a remarkable man — had been a principal in Detroit public high schools for years, and had seen a lot. 

Anyways, to Mr Anderson, it was simple. All you had to do was take care of people when something really terrible happened to them. He would tell a story about watching someone fall down and crack his head open on the sidewalk. He and a few other strangers picked the man up and carried him to the hospital a block away. “Nobody asked or worried if he could pay,” he said. “They just saved his life and sent him home.”

That’s some people’s idea of health care — the nurses and doctors in the ER patching you up, so you don’t bleed to death in the street. This is usually because they’ve never gone for a prenatal visit or vaccinations, and they think routine screenings are a waste of time. They don’t ask their doctos about suspicious moles, or what they should be eating, or if they’ve started to have some trouble making it all the way to the bathroom. 

This was me, too, not long ago. I once had to go to the emergency room for a terrible nosebleed that wouldn’t stop on its own. I later joked to friends, “I only go to see the doctor exactly when I’m bleeding from an important part of my body for more than a few hours.”

This kind of thinking comes particularly naturally to young men, where they’ve stupidly been told to hide their pain (emotion, too) and to valorize athletes and movie characters who play through pain. The only time you’re allowed to cry is when you’re watching the end of The Natural — not because the main character is slowly bleeding to death, but because he hit a home run anyways. 

We’re dumbasses, really. But there are a lot of us.

Anyways, the resident young guy at the NYT op-ed page, Ross Douthat, floats an idea — universal catastrophic health care coverage — that could be kind of a good one, or a totally dumbass one, depending on how it breaks. I’m suspicious, however, that Douthat’s preferred implementation probably leans dumbass.

See, it’s all in the details. If “catastrophe” is defined as health care costs exceeding a defined percentage of one’s income in a calendar year, it plays one way. I’m actually kinda sympathetic to this, although I see problems.

If, however, it’s defined as coverage for really bad things that happen to you, as opposed to “routine” care, that’s actually really problematic. Because — and I think, as someone who’s recently had a catastrophic health care condition, I can say this — catastrophic care and routine care are completely interdependent.

Here’s how it works, in both directions.

Routine care prevents catastrophes from happening. Or, it catches them before they become hard and expensive to treat. I think this is relatively well-understood, so I’m not going to say as much about it.

Catastrophic care demands routine follow-ups. After you’re diagnosed with AIDS, or cancer, you need to meet with your doctor regularly and take steps to stave off infections. After you break your arm and leg, you need extensive physical therapy before you can work (or walk) again. After a C-section delivery, both mom and baby need regular check-ups. That’s most of what your health care is after something major — just people checking up on you, to make sure that whatever they did to put you back together again took, and that you’re not going to get swooped up by something else while you’re vulnerable.

That, and you take a lot of pills. Which usually counts as “routine care” even if your pills are keeping your skin from turning inside out.

I forgot to finish my almost-grandpa-in-law’s story. Later, he asked about the guy with the cracked skull that he’d brought to the hospital. About a week after he was released, he caught pneumonia and died. “After all that, he couldn’t take care of himself,” Mr Anderson sniffed, sad and disgusted, wise and blind, all the same time.

Now, go read Malcolm Gladwell’s “Million Dollar Murray,” and then tell me whether Douthat makes any sense, for anyone other than himself and guys like him.

 

Gawande, D-MA

Faiz Shakir at Think Progress has a pretty stunning proposal: appointing Harvard-based surgeon/author/hero Atul Gawande to Ted Kennedy’s vacated senate seat in Massachusetts.

On the day he would step foot in the Senate, Dr. Gawande would be the most knowledgeable health policy expert in the chamber, an incredible resource for his fellow Senate colleagues, and a champion for reform.

Matthew Yglesias writes:

Someone holding a Senate seat during a critical period but with no future political ambitions would have a pretty unique opportunity to play a kind of bold leadership role if the Senator in question were someone with the knowledge and credibility to really contribute to the debate.

I like Ezra Klein’s take best:

I’d worry that Atul himself would find it a bit of a disappointing experience, as knowing stuff is not likely to matter much at this stage in the process… But it would be a bulletproof choice, and would certainly lead to a great New Yorker article.

This jibes with my sense that the timing is off, unless the health care bill is going to take a lot longer than most people think it will. But, jeez…

It’s almost like the Senate should have a handful of at-large, two-year members who are experts on particular policy issues. They’d rotate in like non-permanent members of the UN Security Council.

(This is probably why I should not be allowed to design a system of government. It’d have epicycles all over the place. Even more than the current U.S. Senate.)