Health Reform's Hearing Problem
Both Sides Are Deaf to the Real Debate About Consequences
In his debates with Hillary Clinton in the winter of 2008, Barack Obama flatly denied that his approach to reforming health care would require an individual mandate requiring everyone to buy health insurance. Events have proved him wrong.
His administration now agrees with the analysts who argue that only by ensuring that no one games the system can reform be made to work. The mandate serves to ensure that individuals do not buy insurance only when they are ill. Other elements of the reform similarly serve to ensure that neither insurance companies nor employers will game the system. As Paul Krugman has argued in the New York Times, each of these strategies to prevent gaming is necessary to make the whole thing work. The point, though, is that the push for implementation has turned Obama's policies into something other than what he promised.
This change in Obama's position goes a long way toward explaining the objections to the new reforms that are being raised vociferously through grass-roots action by citizens on the right. The issue here is not that these citizens consider Obama untrustworthy -- though they do. The issue, rather, is that they recognize that the stated goals and structure of a policy may not fully capture its full range of outcomes in practice. This is why these citizens, including professionally briefed participants such as Sarah Palin, can continue to maintain, in the face of a barrage of insistences to the contrary, that the reforms will (1) result in rationing and (2) establish "death panels."
These activists do not claim that the proposed reforms include policies whose explicit purpose is to ration, nor do the more careful among them claim that the policies will establish panels to help people decide when to die. They are not arguing about the semantic content of the policies; that is, they are not arguing about the meaning of the words that are actually in the relevant drafts of bills. Instead, they are considering, as the pragmatist philosopher William James put it, "what conceivable effects of a practical kind the [policy] may involve -- what sensations we are to expect from it, and what reactions we must prepare."
Their claim is that, whatever the stated goals of policymakers, the concrete outcomes that will flow from the policies on the table will include experiences that feel like rationing and conversations that sound like "death panels."
In asking lawmakers to consider not merely the goals of their policies but also the experiential meaning of concrete realities that those policies may bring, they have a point. One can't answer them by saying: "These policies won't ration; there will be no death panels." If these reforms do either of these things, they will do so as a matter of unintended consequences. The appropriate answer, therefore, is to explain the institutional checks that will prevent the emergence of such unintended consequences.
Can we say that under the new regime one will always be able to pay out of pocket for any procedure one desires, subject only to the limitations of triage practices that have always established priorities for who receives care when and that have, therefore, always provided an ethic for how to ration a limited good in the face of unlimited desire?
And perhaps the counseling sessions meant to help us all think about end-of-life issues should be conducted when each of us is in the prime of life. To demystify such counseling sessions, the president held up as examples himself and his wife, who have living wills. But they have set these up when the natural end of their life seems remote. In the context of such counseling sessions, this distance surely provides a certain psychological protection. Perhaps if we developed a practice of expecting these counseling sessions to occur in our 40s and 50s, we would view them, like financial counseling, simply as a necessary step toward being able to enter retirement with peace of mind.
There is a real debate going on in what appear to be crazy town hall meetings. If only both sides had ears to hear. Would somebody please call the otologist?
The writer is the UPS Foundation Professor of social science at the Institute for Advanced Study in Princeton, N.J.