\When Tom Daschle testified on the Hill earlier this month he reassured many by saying that as Health and Human Services Secretary, he would be working for healthcare reform “guided by evidence and effectiveness, not by ideology.” Daschle, like Laszlewski, was suggesting that reform could and should be bi-partisan. But as I suggested in part 1 of this post, Daschle is only half-right. Medical evidence should guide our decisions about what to cover; but when it comes to questions of whom to cover—and how much coverage they should receive– we are going to have to wrestle with “ideology."
For many, the word “ideology” carries negative connotations. This is in large part because, during the Cold War, we used the word to refer to Communism. Capitalism, we argued, was not an “ideology”—it was true. But if you open the American Heritage Dictionary, you’ll find that the word itself is neutral: it simply means: “A set of doctrines or beliefs that form the basis of a political, economic, or other system.” Those beliefs can be true or untrue. “It is one of the minor ironies of modern intellectual history that the term "ideology" has itself become thoroughly ideologized,” observes the anthropologist Clifford Geertz in Ideology as a Cultural System. http://www.gongfa.com/geertz1.htm
Granted, “a set of doctrines” sounds potentially rigid or “doctrinaire.” But there is nothing wrongheaded about having a “set of beliefs” about how a society or an economy should operate. Most of us do have convictions about what constitutes a just or an unjust society. And health care reform is about both those beliefs and science. We can try to sweep that under the rug, but I doubt we will get very far. In the debate over health care reform, differences in the ideas that conservatives and progressives hold dear will continue to crop up.
Conservatives believe that “the market” can solve our healthcare problems. Progressives believe that you cannot count on “the market” to decide in favor of the public good. I would add that “the market” is not moral or immoral; it is “amoral.” If we want a fair health care system, government is going to have to weigh in with laws and regulations that steer the system toward “the common good.”
Obama vs. Barney Frank
\ Like Tom Daschle, President Obama speaks the language of bi-partisanship, and this worries Massachusetts House Representative Barney Frank. “Obama tends to overestimate his ability to get people to change their opinions, and underestimates the importance of confronting ideological differences,” Frank observed in a recent New Yorker profile. Barney is concerned that “Obama’s evenhandedness may prove to be a political liability. On the financial crisis, “Obama said that ‘both sides were asleep at the switch,’ but that’s not true,” Frank observes. “The Republicans were wide awake, and they made choices to oppose regulation. They had bad ideas. [Obama] says ‘I don’t want to fight the fights of the nineties.’” But, Franks tells New Yorker writer Jeffrey Toobin: “I don’t see any alternative to refighting the fights of the nineties if we want to change things.”
Frank is absolutely right. The conservative crusade against government regulation that began with the Reagan administration found its apogee in the lack of rules and oversight of the Bush administration. Keep in mind that the “apogee” of an orbit is that point furthest from earth. Bush took conservative doctrine quite literally over the top–the economic meltdown that followed was inevitable
We Must Believe in Something
This is why we cannot banish “ideology” from the healthcare debate says Yale law professor Frank Pasquale. Values matter. In an essay titled “Is Ideology-Free Health Reform Possible?” posted on Concurring Opinions. http://www.concurringopinions.com/archives/health_law/ Pasquale argues that “the goal is not to be ideology-free, but to recognize and correct for the inevitable biases that ideology can generate.”
On this point, Pasquale quotes Jack Balkin’s groundbreaking work on ideology, Cultural Software: A Theory of Ideology. According to Balkin, ideology is “‘simultaneously empowering, useful, and adaptive on the one hand, and disempowering, distorting, and maladaptive on the other.’ But it is inevitable,” says Pasquale, “and the faster we can get clear on its role in health debates, the more substantive health care reform is likely to be.”
Pasquale notes that his own “convictions” are apparent to anyone who reads his health law archives on Concurring Opinions: “The US health care system wastes huge amounts of money, inflicts financial and physical distress on many vulnerable people, and has been excessively commercialized. Profits are too often put ahead of patients. We can learn from other countries that spend less, and have as good or better health care outcomes. “An ideological framework like that (or its mirror image on the right) is probably necessary to motivate real action on the health reform front” Pasquale adds.
In other words, one must believe in something—and believe quite passionately—if we are going to have the fortitude to overhaul a $2.3 trillion healthcare system.
But we also have to remember that while ideology can be “empowering,” it also can be, as Balkin describes it, “disempowering and maladaptive.” Another way to put this: If you hold too tightly to those biases—if you become too “doctrinaire” or rigid—you may risk letting the perfect become the enemy of the good. Tunnel vision can block the larger picture.
For example, I might believe that all members of our society—illegal immigrants as well as legal immigrants– should have access to healthcare. But if Congressional liberals tried to take a stand on that position, and integrate it into the bill to expand SCHIP, they might well lose the entire bill. Illegal immigrants have, after all, broken the law, and many legislators would argue that while we should provide emergency care for children and pregnant women, we cannot welcome illegal families into a national health care system.
Ideology and Science—We Need Both
Like Tom Daschle, Pasquale contrasts “ideology” and “science.” Unlike Daschle, he believes that the healthcare debate needs both. Quoting Geertz, Pasquale notes that “Both science and ideology are concerned with the definition of a problematic situation . . . “Science names the structure of situations in such a way that the attitude contained toward them is one of disinterestedness. Its style is restrained, spare, resolutely analytic: by shunning the semantic devices that most effectively formulate moral sentiment, it seeks to maximize intellectual clarity. But ideology names the structure of situations in such a way that the attitude contained toward them IS one of commitment. Its style is ornate, vivid, deliberately suggestive: by objectifying moral sentiment through the same devices that science shuns, it seeks to motivate action.”
Ideology is unabashedly subjective. While there are “proofs” for scientific beliefs, there are no objective proofs for our moral convictions. But they are, nonetheless “commitments” that we take very seriously. When we enter the healthcare debate we cannot check our values at the door. (Hat-tip to a HealthBeat reader who made that comment when responding to part 1 of this post.)
But while ideologies are subjective, they are able to “make empirical claims about the condition and direction of society” says Geertz. For evidence, the ideologue point to facts embedded in reality. There is the empirical fact, for instance, that our market-driven health care system is much more expensive than government regulated systems in other countries, and yet outcomes are no better—and often are worse.
Finally, “Before we aspire to do away with the "ornate, vivid, deliberately suggestive" methods of ideology,” Pasquale concludes, “we should remember commitment's place in the world of health care reform. For me, that means universality–a strong commitment to a robust baseline of care for all–should be at the top of reformers' agenda. Cost-containment is important, too, but its achievement needs to hinge as much on values of compassion and equality as on the number-crunching of technocrats.”
I would add that medical research demonstrates that a “commitment to a robust baseline for care for all” is not at odds with “cost containment.” As the Dartmouth research that I have discussed in the past demonstrates, lower-costs and more effective care go hand in hand.
Here Science supports what progressive Ideology preaches: If we create a medical system that focuses on what creates value for patients —and eliminate the ineffective, unproven and wasteful treatments that may create profits for the health care industry, but provide little or no benefit for patients—we can afford to provide one tier of high quality, evidence-based care for all.
Those who argue for bi-partisanship should recognize that we have reached a turning point in American history. The history of the country is a narrative of pendulum swings from conservative to liberal thinking—and back again. Today, as Barney Frank put it, “We are at a moment when liberalism is poised to have its biggest impact on America since Roosevelt because the conservative viewpoint has been so thoroughly repudiated by reality.”
Frank then tells one of his priceless anecdotes: “Someone asked Harold MacMillan what has the most impact on political decisions. He said ‘Events, dear boy, events.’ Events have just totally repudiated [the conservatives]” Frank notes, “and we are now in a position to take advantage of that.”
this alleged tension between ideology (politics) and science grates. the question of how to best treat colon cancer is largely scientific. the question of whether we should spent an extra $10 million on that rather than breast cancer is properly political. more pointed is the question of whether to spend money on kids, who may have many economically productive years ahead of them and declining oldsters, who don’t. And the scientific agenda is set by several political processes (driven partly by ideology), one internal and one public. part of the reason for our frustration today is the shortage of people who are able to function in both environments.
“Here Science supports what progressive Ideology preaches: If we create a medical system that focuses on what creates value for patients —and eliminate the ineffective, unproven and wasteful treatments that may create profits for the health care industry, but provide little or no benefit for patients—”
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I am uncomfortable with this “value for patients” idea because scared and desperate patients generally do not know what medical value IS! Placebos seem to work just as well in patients’ minds many times, and doctors’ manners and appearances often are mistaken for good quality care. So how are patients in this new system going to be schooled as to what real value is?? Will they demand the old snake oils that have made so much money for some with so little evidence of results (value)?
I find it totally disingenuous that the conservatives and GOP operatives now all speak of bi-partisanship or non-partisanship when they are out of power.
When the shoe was on the other foot not only did they ram through the most partisan policies in decades, but they even obstructed the legitimate powers of the president to fill key posts, especially in the judiciary when Clinton was president.
Perhaps Obama doesn’t want to alienate swing voters who have just shifted sides and have really haven’t decided what to believe, but he can play the person above the fray if he wants.
Those in the trenches like Frank shouldn’t give an inch.
I proposed a temporary rule change in the senate because of the need to expedite key legislation over the next few months. According to my plan they would suspend the use of the filibuster for a specified time to allow legislation to be voted on.
When the time elapsed the rules would revert to “normal”. The GOP has been blocking almost ever piece of legislation in the senate that they could since the Dems became the majority two years ago.
I think this demonstrates their real feelings about bi-partisanship and the willingness to cooperate.
Thank you all for your comments. I’m responding to NG now, but will be back to everyone tomorrow–
NG– Thanks for your comment.
When I speak of “value for patients” I an NOT talking about value as defined BY patients.
I am not an advocate of consumer-driven care because I realize that patients are often not in a good postion to know what
would give them the best “value.’
See Eisinger’s “open letter from an oncolgist” on how uncomfortable he feels about leaving it to scared patients –often in great pain–to try to figure out what would be best for them,
When I speak of “value for patients” I am talking about value as definied by medical evidence–better outcomes with less risk and suffering for patients–at a lower cost.
Value” needs to be defined by panels of MDs and medical ethicists who have no financial stake in the outcome, providing guidelines for what would constitute “best practice” for patients who fit a particular profile.
That said, patients need to be included in the decision-making (the “shared decision-making I have talked about in earlier posts) but this is a process that requires that dcotors share full, frank information about risks and benefits of alternative treatments, using decions-making aids (videos and pamphlets) that have to meet international standards,
giving patients time to take these videos and pamphlets home and review them with their families.
Patients then go back to their doctors’ offices or hopsitals where a specially-trained decision-making coach first asks them questions to see if they understands the odds of risk vs. benefit, and then draws patients out to talk about their priorities–their greatests hopes and fears.
This is what patients bring to the table–their knowledge of themselves and their priorites. Medical professionals bring their understanding of risks and benefits. Together, they work to decide on the best treatment for the individual patient.
”
Maggie,
Thanks for your answer to my post, which I totally agree with. It sounds like you are advocating supply-side controls on what is offered to patients, which is exactly what I also agree with for all the reasons you stated. Now that does not mean there aren’t still choices, but the choices are supply-side dictated and ultimately supply-side controlled.
How this differs from consumer directed healthcare may be a nuanced difference, but I still wish consumer directed healthcare advocates would come out and just agree that the choice of offerings are supply-side dictated and supply side limited even in their so-called system. Given that, if supply-side is indeed in control, then why do conservatives believe that patients paying directly for their care would mean much of anything beneficial on the good care outcome side??
NG–
You ask: “if supply-side is indeed in control, then why do conservatives believe that patients paying directly for their care would mean much of anything beneficial on the good care outcome side??”
I think the answer is :First, conservatives just don’t believe that supply controls demand in healthcare.
IN order to believe in the “efficient market” conservatives must believe that consumers are in the driver’s seat in all markets– i.e. that conumer “demand” dictates what providers supply,and at what price. The consumer keeps the market “efficient” by insisting on higher quality at a lower price..
Thus conservatives would argue that we do so many angioplatiest in this coutnry becuase that is what patents demand. And consumers are always right–just as the individual investors who paid so much for AOL in 1999 were right. “The wisdom of crowds.”
Secondly, and perhaps more importantly, conservatives really don’t believe that it is up to them –or socity or goveenment–
to worry about what is “beneficial on the good care outcome side,”
From a conservative’s point of view, trying to engineer the “social good” the “public good” or “better outcomes” smacks of “top-down govt’
planning.”
It is up to individuals to try to find the heatlhcare that will be best for them individually–this is their right and responsibilty.
The larger public good is no one’s responsibilty. To strive for that larger good is, (from a conservative point of view) to invite communism/totalitarianism.
“Secondly, and perhaps more importantly, conservatives really don’t believe that it is up to them –or society or government–
to worry about what is “beneficial on the good care outcome side,”
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Under this assumption, how can pooled payment mechanisms ever be justified and used. Should I have a daily message paid for by pooled mechanisms? Yet surely even conservatives realize that much medical care is unaffordable to most or many individuals, so wouldn’t that fact alone lead one down the path of only paying with pooled money for care PROVEN “beneficial on the good care outcome side,”??
Maggie,
This subject is far from simple or straightforward. Consider the following: A middle class or low income patient has Stage 4 colon or lung cancer and is not expected to live for more than another couple of months at most. A high cost drug, approved by the FDA, exists that could add one or two additional months to the patient’s life expectancy but at a cost of $60K. The patient’s doctor, using shared decision making, informs the patient of the existence of the new drug as well as the cost for a course of treatment. The National Health Board had decided not to cover it because it is not sufficiently cost-effective. The patient wants the drug and wants someone else (society / taxpayers) to pay for it. If the patient were wealthy, he could self-pay, which presents an ethical issue. The patient’s attitude toward end of life care is based largely on core religious beliefs and values – God and only God will decide when it’s my time to die.
In some other countries, the patient would not even be told that he has cancer, let alone informed of the existence of the expensive drug. He would be sent home to die with a supply of morphine. Doctors here might be inclined to just not mention the drug if they weren’t worried about being sued for not fully informing the patient of his options. The ability of the wealthy patient to self-pay makes a life prolonging treatment available to him that is not otherwise available to the rest of the population. This is a lot different from not paying for PSA tests which virtually anyone could pay for themselves if they really wanted it.
For their part, the drug companies will want to sell as much of the drug as possible to maximize their profits. Doctors and hospitals, including non-profit hospitals, will make more money if they can provide more aggressive treatment, assuming the patient wants it. So, they will lobby hard to cover the drug that will, in the end, allow them to be paid more for doing more. Private insurers, for their part, don’t have the moral authority to refuse to cover the treatment if Medicare will. At the end of the day, it has to be the government’s role to say NO and draw the line on what to pay for and not pay for, but there are a lot of vested and entrenched interests beyond drug and device manufacturers who will fight to protect their turf, their profits, and their livelihoods with doctors and hospitals probably fighting harder than anyone.
Finally, the reason many politicians prefer major reforms to be bipartisan is that both sides will have their fingerprints all over the bill. If it’s a failure or if there are significant adverse unintended consequences, there will be enough blame to go around. In short, bipartisanship is protection for politicians against the consequences of being wrong.
Barry:
The problem with your scenario is that it is based upon a condition which needn’t arise in the first place.
The fundamental error comes with the drug approval process. A drug with such limited usefulness should not be approved in the first place. I believe that is what happens in the UK where the approval process takes such factors into consideration along with assessment of comparative efficacy.
Drug companies in the US know that they will get approval for drugs that do “something”, even if it is very little. If they understood that such drugs would be unlikely to be approved they would redirect their research along other lines.
In addition to treatments of marginal utility we also permit herbal compounds and other types of snake oil to be sold, emphasizing the idea that anything goes as long as it doesn’t kill you too quickly (tobacco).
Once you have tilted the playing field the wrong way, it doesn’t matter what shape the ball.
NG, Barry and Robert–
Thanks for hte comments.
NG –
Many conservatives really don’t believe in pooling resources. They believe that we should each be responsible for ourselves and our families.
Those who would acknowledge the need for some pooling to cover medical catastrophes would tend to encouarage either a) only pooling enough money to cover true catastrphes (cancer that leaves you with a $800,000 bill) so that people don’t lose their homes (many conseravtives look at insurance in terms of protecting property rather than protecting health) or
b) poolng a small amount of money to povide the most basic healthcare for everyone–something like Medicaid–but not providing access to the most expensive specialists or the most expensive drugs or treatments.
Barry & Robert:
Robert is right: that very expensive drug that offers marginal benefits should not be on the market–and is not on the market in the UK or many European countries.
By and large they refuse to pour money into ineffective treatments.
And, because their citizens have a much more mature attitude toward death, even wealthy citizens do not insist on (or particularly want) an expensive drug that will give them another few months. (Of course, there are always exceptions, but generally, the cultural attitude toward death is very different.
It’s surprising, we claim to be more religious than other countries, and yet we refuse to accept the fact that we will each die. (One would think that, if you believed in an afterlife, you would embrace death. )
When someone dies, we insist that it is a mistake–that someone did something wrong, that the HMO unfairly denied treatment, that a doctor or nurse or hospital made a mistake, or the patient himself is to blame. “Well of course, he was always fat . .”
Finally, and most importantly, Robert is right: “Drug companies in the US know that they will get approval for drugs that do ‘something’, even if it is very little. If they understood that such drugs would be unlikely to be approved they would redirect their research along other lines.”
Exactly. They spend huge amounts of money producing drugs that are only marginally effective because they know Americans will pay huge sums for them. If we didn’t, they would focus their reserach elsewhere . ..
You’re right: ideology is subjective. But what you go on to say about it shows it is also objective. And its objective elements are the basis for determining whether a given ideological approach is worthy. Obama wants to experiment; test ideological approaches. What we need–and it’s often difficult, if not impossible to provide, is a way of testing those approaches. How to test, e.g., that if left to the market, we could provide healthcare for all? Well, that’s already been shown to be false. Trouble is, the free marketers won’t accept that conclusion from the evidence that for others is so obvious.
Tom–
Good to hear from you.
Yes, you are right: one can bring empirical evidence to bear to argue that a particular ideological approach is more worthy.
And we have a few decades of evidence that when it comes to healthcare, market competition does not raise quality or lower costs.
But, as you say, the free marketeers won’t accept this.
When you try to make an argument using evidence, numbers, charts many conservatives just won’t engage.
They prefer to talk in “slogans” –bumper stickers. They seem to believe that if you repeat something long enough and often enough, it will become true. This can make debate very frustrating.
See Greg Anrig’s book: The Conservatives Have No Clothes.”
“And we have a few decades of evidence that when it comes to healthcare, market competition does not raise quality or lower costs.”
This is a ridiculous statement. When have we ever had anything resembling free market health care??? The government SETS PRICES for over HALF of all care given in this country!!! By definition that’s a hugely distorted market. You can argue that this is good or bad, and I won’t attempt to do either, but please let’s not kid ourselves that we’ve ever had anything close to free market care.
What we have is a market with providers who are forced to take whatever price for their services the government is willing to pay. We have providers who are forbidden from giving care in many markets that would like to have them because the government says there are already too many providers in that market already!!
Healthcare is the most intensely regulated industry in this country, second probably to the banks. This in turn leads to so many ridiculous unintended consequences that I won’t even attempt to flesh them out here.
Maybe free market care is not what we should have in this country – there are pros and cons to both – but let’s please not pretend we’ve ever experienced it.
Furthermore, in the few small instances where the Medicare program has instituted demonstration projects that used quazi-market mechanisms (competitive bidding anyone?) the cost savings were often quite large, with no change in the level of care provided.
PT–
Not all doctors take Medicare.
In NYC we have a great many doctors who do not take medicare or medicaid.
They set their own prices.
(If you have insurance that lets you go out of network, your insurer might pay $160 of a $400 bill for an eye appointment.)
These specialists compete with each other–and their are a great many of them. As more and more join the group that don’t take Medicare and don’t belong to an insurance network, the competition has not caused prices to have gone dowon. They have gone up.
Nor has quality or service improved noticably. One can expect to wait 1 1/2 to 2 hours in the waiting room of a Park Avenue specialist.
In my experience, they are not necessarily better than doctors who take insurance–though as a patient, it’s hard to tell. They have very nice waiting rooms.
Research shows that when new hospitals are built, expanding the number from 4 to 6 in a given town, competition does not cause prices to come down. With competition, pices go up as competing hospitals buy more very expensive equipment and invest in the atriums and other amenities that will draw well-heeled docs and their patients.
The type of free-market competition (with doctors not letting Medicare set their fees) is common not only in N.Y. but in Boston, L.A., the D.C. area, Florida, etc.
“Frank observes. “The Republicans were wide awake, and they made choices to oppose regulation. They had bad ideas.”
What a convenient rewrite of history. Barney Frank blocked regulation while getting a sweetheart mortgage with the help of his sweetheart. What regulation did Republicans oppose, care to share an example? If you want to see opposition to regulation watch this;
http://www.youtube.com/watch?v=_MGT_cSi7Rs
This is why we have Partisan debate, the left is completely dishonest and projects all their failures on the right. Conservatives aren’t opposed to regulation we oppose inefficient, wasteful and counter productive regulation. If you want to have an honest talk about regulation lets discuss Ted Kennedy’s HMO Act of ’73. Lets talk about MA, NY, and CA Small group reform and what it has done to drive up the cost of insurance. When you frame a debate with such dishonesty you don’t deserve the respect of debate.
What price do you beliefs come at? You apparently have no problem lying to the public to trick them into supporting your goals, is that what democracy has come to? Anyone dare dissents just delete their comments like it doesn’t exist.
“There is the empirical fact, for instance, that our market-driven health care system is much more expensive than government regulated systems in other countries, and yet outcomes are no better—and often are worse.”
By what measure are we market-driven? We have books of federal and state laws that govern healthcare and insurance, we haven’t been market-driven in 20 years. We are poorly regulated, we suffer under laws and regulations passed to garner votes not provide efficient and quality care. You can’t even begin to compare our private insurance system to those of other countries. And when you do it is with distorted facts. Every progressive comparison I have seen includes the full US system, which means our private system is dragged down by the woefully wasteful and expensive Medicare system. Further you include in your analysis states like NY and MA which have the highest regulation and the highest expense in the world then project their failure on the entire system. Mid-America private insurance can compete with any other system in the world on cost and outcomes. It’s the progressive failures of government ran plans and over-regulated states that are an embarrassment.