Showing posts with label Healthcare. Show all posts
Showing posts with label Healthcare. Show all posts

03 September 2012

Is the Doctrine of Common Interest Dead?


The concepts of general welfare and collective action are core elements in the Constitution of the United States, which I collectively refer to here as common interest.  Although common interest has been with us since the birth of our nation, and has been a fundamental component of social order since the days of hunter-gatherers, it appears to be in peril today.  The phrase itself draws ire from all political corners: some deride the invocation of common interest as a dangerous slide toward socialism, while others argue it marks the deceitful rhetoric of plutocrats who wish to extract wealth from the middle class.  Yet, our history suggests when our common interest is served – when we work together toward mutually beneficial ends – America is at its best; we are all better off.  President Kennedy’s ambitious objective of “landing a man on the moon and returning him safely to earth” launched one of the most successful programs of political initiative and private enterprise in the history of the United States.[1]  Among other gains, the miniaturization of computing power necessary to accomplish this feat is why we have laptop computers today.  There are many other examples of the benefits of common interest, but the point is this: the security and prosperity of America has never been won by the few, it has been assured by the many with the support of both private and public entities.  So why is common interest being attacked from all sides?  What follows here are some possible contributing factors.

  1. The Ascent of Me-ism.  While doing my doctoral research on the rise of religion in the political sphere by the mid-1970s I came across a monograph on the 1960s by Mark Hamilton Lytle wherein he argued (much to this baby boomer’s chagrin) that “many people in the sixties passed off self-indulgence and arrogance as moral and political commitment.”  In other words, while we traveled in the clothing of righteous liberation, we were actually just enjoying the hell out of ourselves.  Lytle continues, “by listening to Dylan, smoking dope, marching for civil rights, wearing long hair, and protesting the war in Vietnam, anyone could claim to have joined, though what they belonged to was far from clear.”[2]  More recently, Kurt Andersen at The New York Times joined Lytle in boomer bashing when he suggested that the late 1960s marked the beginning of individualism run amok.  Andersen argues, “‘do your own thing’ is not so different than ‘every man for himself.’”[3]  He further finds that the “Me” decade of the 1960s expanded to encompass the entire last half of the century giving rise to a super-selfish culture that has lost its capacity for considering the interests of others.  Recently, this selfish hyper-individualism has been cloaked in a veil of self-deterministic rhetoric most often conveyed by those who identify with the Tea Party.  These are the folks who live in the fantasy of self-sufficiency, while often disproportionately relying on government support programs like Medicare, agricultural subsidies, mortgage interest deductions, federal mortgage guarantees, and Social Security.  They suffer from what philosopher Firmin DeBrabander calls the “delusional autonomy of Freud’s poor ego.”[4]  For Tea Partiers (unless they are thebeneficiaries) all government programs are evidence of toxic socialism.  The questions are, how has this selfish impulse been generalized in American society, and how is it sustained?  Part of the answer lies in three largely exogenous variables: affluence, technology, and the collapse of the Soviet Union.
  1. Affluence, Technology, and Hubris.  Three structural events have occurred since the 1960s to fuel our selfishness and contempt for common interest: we’re rich, we suffer the illusion of ‘connection’ with others, and a force equal to ours no longer threatens us.  Let’s start with affluence.  Don’t get me wrong, I love wealth, but it can produce nefarious effects.  Since Saigon fell and we retreated “with honor” as President Nixon often claimed, the Dow Jones Industrial Average has increased sixteenfold.  By most any measure there is no wealthier nation than the United States, and money (and the debt capacity it supports) has been a significant sustaining force of our selfishness.  If we wanted something, we were a swipe of a credit card, or another issuance of US Treasury bills away from getting it.  Even though the US is fast approaching technical insolvency, the rules of financial prudence do not apply to us since the dollar is (for now) the world’s reserve currency of choice.  Next up: technology.  Again, I love it, but I also recognize it has produced its own deleterious effects.  Humans need to be connected to form a sense of empathy, which is the foundation of many things including our subscriptions to human rights and common interest.  Technology has tricked us into thinking we are connected and that we are bonded by common interest.  We are not. We suffer the illusion of connection and common interest.  Just because someone ‘friended’ you or ‘follows’ you does not mean they know you, or care about you. Just try reaching out to your so-called friends and followers when you are in need.  Absent an established sense of empathy, those cheerful beeps, ringtones, and vibrations that signal friendship quickly fade to silence.  Finally, there has been no other state since the collapse of the Soviet Union to keep the US from imperial overreach; the natural boundaries of power collapsed as well. The result: we, like empires before us, risk decline at our own hand.  Hubris is deadly to both people and states and we Americans have been quite full of ourselves in the last twenty years, as we have sought to remake the world in our own (selfish) image.  Other contributors to the threat to common interest include what I describe here next as the twin delusions.
  2. The Twin Delusions: Free Markets and Big Government.  Both sides of the great political debate of this presidential season – those who hold fast to their belief in free markets and those who believe with equal certitude that more government is better government – are wrong.  Neither thesis alone has any chance of solving the problems we face, yet to even suggest a middle ground that includes elements of both ideological extremes is met with hatred and hostility.  The Affordable Healthcare Act (aka Obamacare) has been one lightening rod of these twin delusions. Healthcare is not a right, nor is it a privilege (as it is most often debated by adversaries); rather, it is a classic example of a public good.  When we are healthy individually, we are also collectively better off.  I often ask: do we really want those who teach our children in school, or prepare our meals in restaurants, to be without healthcare?  Public goods like security, financial stability, and clean air & water are only created out of a subscription to common interest.  As Harvard philosopher Michael Sandel argued persuasively in his new book, What Money Can’t Buy: The Moral Limits of Markets, markets alone are an ineffective tool in the production and sustainability of public goods.  He cites our slide from a “market economy to being a market society” as a dangerous illustration of the moral limits of markets.[5]  Public goods, like landing a man on the moon, or healthcare, or addressing the onset of climate change, are accomplished with a blend of market flexibility and centralized governance. All public goods rely on competitive and innovative markets as well as centralized command and control.  Healthcare should be addressed in the same manner.  The good news is there is more than enough money in the system today to make it work for more people at a level of service unmatched in the world.  However, common interest must be established once again or issues like this will continue to be hijacked by small thinkers and powerful interest groups, which endangers the future of America.  (In the case of climate change there may not be enough interest or resources to address it, but that is another story.[6])  The next factors that threaten common interest include those related to cognitive degeneration.
  3. The Demise of Critical & Integrative Thinking.  The now notorious decline of the American education system – particularly in math and science in our secondary schools – means that other nations will soon (if not already) exceed the United States in developing the critical thinkers who will produce tomorrow’s innovations to address our most urgent needs.  Through a combination of neglect, unintended policy consequences, and disengaged parenting, the education our children receive today is inferior to the education we boomers received that was achieved with fewer resources and analog technologies.  This condition has been further exacerbated by xenophobic attitudes toward immigrants who are educated in our superior universities, but who are then forced to return home when they would prefer to become the next generation of American innovators.  I am not sure whom we believe we are protecting with this backwater thinking, but it is most certainly not the future of America.  The other cognitive victim to the bipolar, zero-sum, us vs. them mind-set that has developed in the United States over the last few decades is integrative thinking.  Complexity, which is the nature of the globalized world we live in, requires multiple disciplines that each provide a piece of a solution that must be combined, or integrated, into an option that had never been thought of before.  This skill, or predilection, is what Roger Martin calls “the opposable mind.”  Martin suggests that, “integrative thinking shows us a way past the binary limits of either-or.  It shows us that there is a way to integrate the advantages of one solution without cancelling out the advantages of an alternative solution.  Integrative thinking affords us, in the words of poet Wallace Stevens, ‘the choice not between, but of.’”[7]  Integrative thinking has, however, fallen victim in part to the hubris mentioned above, and also from the application of cognitive constructs that have their roots in absolutist and universalistic thinking, which emanates from different places; preeminent among them today is religious-based certitude.  In short, the religious righteousness that has ascended unabated since the early 1970s has closed our minds to options that reside in the relativism and complexity of the real world.  Moral certitude has placed absolutism right where we need it least: in addressing complexity.
  4. The Rise of Religious Certitude.  For the last four years I have studied the impact of religious beliefs and convictions on presidential decision making in foreign policy.  I am often asked if religion is a good or bad thing when it comes to policymaking.  For me, the question is moot; it doesn’t matter.  What matters is that religious beliefs and convictions are a factor that we need to understand much better than we do.  Depending on the individual, religious beliefs contribute with varying emphasis on decision making and, of course, the beliefs themselves differ both inter- and intra- faith.  When I construct the cognetic profile of a president each is as individualized as a fingerprint: no two are the same.  What applies more broadly here however, is that the level of religiosity in any given era matters, and in the contemporary era religion matters a great deal.  Since the mid-1970s, religion has been fully ensconced in the private, public, and political spheres in the US.  Throughout history this condition is not unprecedented, but the crescendo that has occurred over the last four decades matches if not exceeds other periods of high religiosity in US history.  During these periods – for better or worse – faith-based religious cognitive constructs find higher expression in all decision making.  While all religions purport a number of common values including tolerance, inclusion and, moreover, an expectation that we would all like to be treated well by our neighbors, the monotheistic religions (Christianity, Judaism, and Islam) – the dominant religions of the Middle East and the West – produce a dangerous irony: they demand of their followers a strict adherence to their particular traditions that (by their monotheistic subscription) does not allow room to consider other religious traditions as theologically valid or worthy.  This sets up a cognitive construct of absolutism and universalism (black and white thinking applied to everyone and everywhere) which compromises the values of tolerance and inclusion that are necessary to form the empathy that is the foundation of common interest.  Absolutism and universalism may arguably be appropriate in establishing moral foundations, but they are ill-suited to deal with the complexity of those issues that effect all people – where common interest must be established and where integrative thinking is required to succeed. In effect, these cognitive constructs get too much playing time in periods of high religiosity that has a chilling effect on common interest.

While James Madison warned us of the danger of factions in his Federalist Papers, and Thomas Jefferson worried about the role of the church in the affairs of state, Tocqueville also observed the curious synthesis of individualism and community that he surmised was fundamental to the success of Americans.  These concerns and observations all point to the importance of common interest and to its preservation at all costs.  Today’s political discourse too often threatens the doctrine of common interest espoused by our Founding Fathers and memorialized in the Constitution.  Selfish hyper-individualism, affluence, technology, the absence of a formidable foe, the twin delusions of free markets and big government, cognitive degeneration, and absolutist thinking that emanates from religious certitude, all contribute to the peril facing the doctrine of common interest today.  It is time for our leaders to find the center again and to set aside notions of absolutism and exclusion in favor of compromise and integrative thinking.  We must once again embrace the concept of ‘the many’ over the idiocentric beliefs and needs of ‘the few’.


[1] John F. Kennedy, “Special Message to Congress on the Nation’s Urgent Needs,” May 25, 1961, www.jfklibrary.org.
[2] Mark Hamilton Lytle, America’s Uncivil Wars: The Sixties Era from Elvis to the Fall of Richard Nixon (New York: Oxford University Press, 2006), p. xiii.
[3] Kurt Andersen, “The Downside of Liberty,” The New York Times, July 3, 2012, www.nytimes.com. See also, Letters to the Editor, “Sunday Dialogue: Are Americans Selfish?” The New York Times, July 14, 2012, www.nytimes.com; and Frank Bruni, “Individualism in Overdrive,” The New York Times, July 16, 2012, www.nytimes.com.
[4] Firmin DeBrabander, “Deluded Individualism,” The New York Times, August 18, 2012, www.nytimes.com.
[5] See Michael Sandel, What Money Can’t Buy: The Moral Limits of Markets (New York: Farrar, Straus and Giroux, 2012), p. 10.
[6] For a (reasoned) skeptic’s view on the climate change debate, see Bjorn Lomborg, “Environmental Alarmism, The and Now,” Foreign Affairs (July/August 2012), pp. 24-40.  For a decidedly unsettling account of climate change, see Bill McKibben, “The Reckoning,” Rolling Stone (August 2, 2012), pp. 52-60.
[7] Roger L. Martin, The Opposable Mind: How Successful Leaders Win Through Integrative Thinking (Boston: Harvard Business School Press, 2007), p. 9.

06 September 2009

Healthcare: What to Read

The healthcare issue is complex (to say the least), which is a significant contributor to its vulnerability to subterfuge.  For those of us interested in understanding it - who want to know what the fuss is all about and maybe even form our own informed opinion - I offer two articles and one study I believe tell you all you need to know.
They are:
1) "The Cost Conundrum" by Atul Gawande in The New Yorker, June 1, 2009, available at www.newyorker.com.
2) "How American Healthcare Killed My Father" by David Goldhill in The Atlantic, September 2009, available at www.theatlantic.com.
3) "Bending the Curve: Effective Steps to Addressing Long-Term Health care Spending Growth" by 9 smart people, available at www.brookings.edu/reports.

Moving on (from healthcare) ... next up ... My Generation's Special Contribution to American Mythology: Spending is Wealth.

04 September 2009

Mr. Brooks 'n Me

My wife has often suggested, after reading David Brooks' column in the New York Times, that there is a synaptic circuit - a telemetric loop that runs between Brooks' mind and mine.  In his column today, 'Let's Get Fundamental' (www.nytimes.com/2009/09/04/opinion/04brooks.html) he argues, citing David Goldhill's piece in The Atlantic (see 'Let the Numbers Speak' post, below) and a research report from the Brookings Institute, that it is time, as I suggested (see 'RIP-Teddy' post, below), to go for it - all out reform - to swing for the fences.

Brooks is more eloquent than I and has just a few million more readers.  I hope he gets his message across before it's too late.  I hope he gets his hour with Obama to offer guidance before next week's address to Congress.  (I'm relatively certain I won't.)  I hope we actually do accomplish reform rather than, as Brooks warns, just "essentially cement the present system in place."  But, maybe I hope too much.  And, maybe Obama is all hoped-out.

As Brooks, I, and the Brookings Institute study agree: the problem is fixable.  The resources are there.  The financial imperative couldn't be more obvious.  The outstanding question: do we have the will?

02 September 2009

Healthcare: Time to Address the Real Question


There’s a great scene in Disclosure, the 1994 movie starring Michael Douglas and Demi Moore. (Okay there’s more than one.) The one I’m referring to is when Douglas’ character, who has been compromised by Demi Moore’s character via a sexual liaison, realizes he’s solving the wrong problem. Douglas is quietly implored by an undisclosed supporter to ‘solve the problem.’ Douglas, of course, thinks he is solving the problem but subsequently realizes it was the wrong problem. When he finally figures this out he prevails. It all reminds me of how the Democrats and the White House are approaching the healthcare debate: they’re addressing the issue by arguing about the wrong things – albeit ably – and allowing a discussion about what is and always has been a public good to be framed in a construct of an individualistic meritocracy.
In today’s Wall Street Journal, Thomas Frank identifies the same strategic error in ‘Why Democrats Are Losing on Health Care.’ Frank argues it’s ‘the big questions that are tripping them up.’ Understanding that the very nature of insurance is a cooperative, subsidized construct; that there’s no such thing as a truly individualistic healthcare choice; that the connection between merit and healthiness ‘is almost as risible’; and that ‘healthcare is not an individual commodity to be bought and enjoyed like other products … that the health of each of us depends on the health of the rest of us.’ (Just wait for H1N1’s return this fall.) In short, the Democrats have fallen into the wrong discussion – a battle they can win and still lose the war.
The larger issue is (see 8/31 blog), who are Americans? Do we believe in public goods, like security, safe water, law enforcement, etc.? Answer: yes. Is healthcare a public good? Answer: yes. When most of us have too much healthcare, some have none, and the providers are rewarded for over-serving those of us who have insurance – bankrupting our future – everyone loses in the long run. And the long run isn’t so far away.
It’s time to put the larger questions on the table and stop playing able technocrats. It’s time to agree on who we are and what we believe in. Then, the question of 'how' gets much easier.

Healthcare: Let the Numbers Speak

If pictures are worth a thousand words, then numbers are worth five hundred. Here are a few numbers to provide perspective on the healthcare debate.
Surely we can do better than this…
From David Goldhill’s article in The Atlantic:
Number of deaths each year from patients infected while in the hospital: 100,000 (more than twice than from motor vehicle accidents).
Number of deaths from blood clots following surgery: 200,000.
Exploding costs…
Also from Goldhill in The Atlantic:
Percentage of Medicare & Medicaid spending to  total government spending in 1966: 1%. Today: 20% (and rising).
‘The federal government spends 8 times more on healthcare as it does education, 12 times what it spends on food aid … 30 times what it spends on law enforcement, 78 times what it spends on land management and conservation, 87 times what it spends on water supply, and 830 times what it spends on energy conservation.’
The cost of power…
From Matt Taibbi’s article in Rolling Stone:
Amount of financial support from the health sector each of the republicans in the senate’s ‘group of six’ – considered the defacto key actors in the senate on healthcare reform – have received.
Grassley - $2,034,000.
Snowe - $756,000.
Enzi - $627,000.

31 August 2009

Healthcare: A Matter of Identity & Destiny

In the midst of cries of socialism and death panels on one side, and predictions of national bankruptcy and moral appeals on the other, lies a tug-of-war of historic proportions to settle a larger issue: who are Americans? American identity has always been a contested issue. Lest we forget there were both ‘Federalists’ and ‘Anti-federalists.’ Occasionally, a seminal issue bubbles to the surface that re-fashions identity. Sometimes they are moral issues like slavery, at other times they are political issues like imperialism (circa 1900), and other times economic – New Deal or no deal? The current debate on healthcare is such an issue – not just because of its underlying moral nature – because it defines our future economic stability.

Ironically, when we ignore the town hall loudmouths and fears of collapse-by-taxes we find a challenge in healthcare that is imminently fixable. It is, quite simply, a big distribution problem: who gets what, when and how ... and, who pays? The good news is there is plenty of money in the system. We know this because we see other countries accomplish more than we do with much less money. We know that what they do is scaleable too – size is not an issue. As actuaries know, size should actually allow us to do better for less. We also know that we have plenty of non-financial resources … hospitals, doctors, technicians, equipment, drugs, etc. And, even though they may be unevenly distributed, remember: there’s plenty of money in the system – we can fix that too.

The fact is many of us have too much healthcare – are ‘over-served’ – while others have none. Many of us have ready access to medical care, albeit with many unnecessary tests and treatments. Others have none and/or are forced into overcrowded emergency rooms, which makes the system even less efficient. Those of us who are over sixty-five, employed by a medium to large company, can afford it on our own anyway, or are a child who qualifies for S-CHIP are covered. Some forty to fifty million others (depending who you believe) have none.

So, all we need to do is hire a bunch of those IBM-ers to sort out a new distribution system, right? But, that’s not really what we are fighting about. If we fail it will be over a larger question: who are Americans? We must decide if we are a nation that believes our government should design basic support systems that address the bottom rung of Maslow’s Hierarchy of Needs, or are we a nation that believes exclusively in self-determination and private enterprise? Is healthcare a utility like power, water, and security; or, is it an industry free to serve its customers for as much money as the market will bear? Most of the world sees Americans as selfish and powerful. Are they right? Or, are we a misunderstood nation of rugged individualists? The reality is messy – as realities are. We are neither. We are somewhere in-between.

Unfortunately, staying the course assures disaster. One thing we cannot continue to afford is the financial reality. We have thirteen trillion dollars in current debt and fifty-three trillion in unfunded liabilities (principally from healthcare and social security). We know we can’t meet those obligations, especially as the states that have been buying our debt are already pursuing other investment strategies away from the dollar (like China). We may not agree to smooth out our distribution system with a team of IBM-ers, but we must deal with at least this: we must get more for our healthcare dollar by restructuring the ‘over-served’ problem. The patient must have a stake so discipline is introduced into the system. Patients must question tests and procedures and maybe even embrace the concept of diet and exercise. Those of us who have healthcare must step back from our sense of entitlement and realize that we do not need all those tests and that maybe there is something fundamentally wrong with all those ‘ask your doctor about _____’ advertisements.

We may not decide to serve those who have none, although I hope we are better than that. (I think the IBM-ers can prove all can be served for less.) But, at the minimum, we must decide we cannot continue to serve ourselves the way we have. If we don’t, our identity may be defined for us – as a one-time superpower that met its demise at its own hand; still selfish, but not so powerful.

30 August 2009

RIP - Teddy Kennedy

The eulogies are over.  The limos are back in their stables.  Now what?  The end of an era, or business as usual?  Was Kennedy a master lawmaker without whom Congress cannot function, or a guy who rode the culture of Camelot and family money for all it was worth?  Does it matter?  Is this, as Matt Taibbi suggested in the latest issue of Rolling Stone, the summer we will point to that marks the moment when our government lost us forever - by blowing healthcare reform - by escorting the elephant of social and financial deficits out of the room in hopes that somehow they enter an arc of self-correction?

Or, is this the moment when we realize we've got to do a work-around; when we come together to excuse our government from its illiberal internment and break a few rules to solve a huge problem.  Is the colossus of insurance providers, drug companies, and their legions of lawyers too big to fail - or face reform?  Is anyone, including President Obama, up to the task?   Will he be, as Paul Krugman asks, the next FDR or Jimmy Carter? As with Kennedy's death, does it matter?

The tipping point (a la Malcolm Gladwell) is staring us right in the face.  Societies progress in a ragged and messy line - through phases of stability, revolution, chaos, and reformation. America is no different - maybe even the poster child due to its openness - its grip on liberty.  Healthcare may be the  fulcrum between order and disorder.  Just take a look at those town hall faces. Time to hang on tight.  It's going to get much uglier before we know where we end up.  One thing is for certain: doing nothing, or too little, is just as dangerous as doing the wrong thing.

I say, it's time to swing for the fences - while there are still fences.