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In the interest of “showing my work,” and showing the process that got me to here, it occurred to me after writing my post about Political Sustainability of the US Healthcare System that I should share this. In 2014 I reached out to Don Berwick, Uwe Reinhardt, and a few others and had an interesting back and forth, particularly salient are Prof. Reinhardt’s remarks. Here’s a summary.

In 1997, Uwe Reinhardt asked a question of Americans and leaders of American health care in particular, “As a matter of national policy, and to the extent that a nation’s health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?”  While every other modern nation has answered this question affirmatively decades ago, the US remains stubbornly divided on the answer. Our debate in 2009-2010 over the Affordable Care Act and the resultant ongoing reverberations continues to punctuate this point.

Wanted: A Clearly Articulated Social Ethic for American Health Care

Uwe E. Reinhardt, PhD

JAMA. 1997;278(17):1446-1447. doi:10.1001/jama.1997.03550170076036

In 2014, Don Berwick published an editorial in JAMA pointing out that American factionalization, dating back to the Founding Fathers, has limited our ability to act, quoting Madison, “to the permanent and aggregate interests of the community,” insofar as health care is concerned.

He argued that the “antidotes to health care’s confiscation must include something bigger, more forceful. This is the time for mobilization—not just the intellectual mobilization of clever community projects but also the political mobilization that ended the Vietnam war, began to deliver on civil rights, birthed modern feminism, and started down the long road toward equal rights for the LGBT community.”

He continued, “Who can mobilize? It will not be the health care behemoth; it is not evil, but it is too big to change itself. Instead, change will require the collective political will of those who are losing ground every day to health care’s unbridled confiscation of the future: laborers who want to protect their families, business leaders who want to survive in a competitive economy, a better-informed citizenry who want health, not procedures, and health care professionals who want not the hassles of complexity but work that adds meaning to their lives. Quite frankly, it will require leaders with the courage to take on the factional control that Madison rightly feared.”

After reading this, I was moved to write Dr. Berwick, Prof. Reinhardt and some others. I will largely confine the rest of this to the insights of the late, great Professor Reinhardt.

I noted that nearly every physicians’ professional organization in the country have already endorsed the ABIM Charter on Medical Professionalism, including its call for social justice in healthcare:

I would venture that every medical school and every health professional school would love to participate in such a discussion. I could envision this as a building and sharing collective effort starting in one city with all of the above professional stakeholders, plus the faculty of schools of population health and other academics, experts in international systems such as yourself and Dr. Reinhardt, business leaders (Paul O’Neill comes to mind), citizens and advocates, and many more, presenting work and having conversations, passing those conversations in summary form to the next group, and eventually building to a point of consensus among an important and broad coalition.

Prof. Reinhardt responded to my initial email as well:

My wife Tsung-Mei Cheng and I were part of the creation of the Taiwan health system, especially in the initial global survey of which Dr. Hughes speaks. Tsung-Mei’s classic paper on the genesis of that system is attached. It explains in detail how that country exploited a unique window of opportunity to get universal health insurance coverage virtually overnight. She may want to chime in.

But the governance system in Taiwan at that time was rather different from ours (or from theirs today). The country then was run by a highly educated and highly motivated elite that appears to have reached early on a consensus on the social ethic that was to dive Taiwan’s NHI, namely, an egalitarian ethic. The elite structured the NHI according to that ethic. Among other things, it made that elite rule out the US approach as a model from the get-go. There wasn’t a plebiscite or referendum on the issue in Taiwan, although politicians appear to have sensed that the public craved protection from the financial inroads of ill health.  

As I once put it in a fairly angry essay that borders on Gruberism (after the failure of the Clinton plan; attached as well), the problem in the US is not that the plebs is confused. I believe in general that the plebs eats what it is served by a unified ruling elite it respects, here as elsewhere in the world. Recall how easy it was for a unified elite that had reached a consensus on invading Iraq, Hillary Clinton included, to make the public go along with that momentous decision even though, as country singer Alan Jackson so forthrightly puts it in one of his songs, many of the public probably did not know the difference between Iran and Iraq or what Iraq had to do with 9-11.

No, the problem in America is that the elite does not share a consensus on what the social ethic governing American health care should be. I am not sure it ever will reach such a consensus. So, in my view, any meeting of the sort you have in mind, Dr. Hughes, will end up as a Tower of Babel among the elite on the issue of social ethics. I made that point a while ago in debating Michael Cannon of the Cato Institute.

In my less cynical moments I have always found touching the solicitude with which America’s political elite professes to admire and consult the wisdom of the people whom, alas, that same elite spends so much time judiciously misinforming, to manipulate the public’s mind. In more somber moments I am reminded of de Tocqueville’s DEMOCRACY IN AMERICA (especially Chapter XV), in which he openly mocks that false solicitude when he writes that “the sycophants of Louis XIV could not flatter more dexterously” than does America’s political elite when it heaps praise upon the peoples’ wisdom. In fact, however, that political elite seeks “wisdom” and guidance mainly from the moneyed interest groups that are their financial patrons. What opulent operators of gambling dens think about in the shower in the morning, for example, surely counts for more in the way our country is run than does the wisdom of millions of the people.

True, the plebs is granted the right to change the actually ruling elite from time to time though general elections, but once in office that elite dances to the tunes of the moneyed special interests – often the same special interests, leading to the same dance by the elite in power. Was there really any significant difference in the way the Bush and Obama administrations dealt with the opulent miscreants of Wall Street? It all can explain, for example, why so many Americans simply have tuned out of the electoral system altogether and gone fishing. Therein, I admit, does lie a certain grassroot wisdom.

As it happens, I just got back from Taiwan where I delivered a lecture on The Political Economy of Health Care in the U.S. I made roughly the same points there.

Best regards,

Uwe

My response:

Uwe, would it be cheeky of me to say, “I feel your pain?”

I think it safe to say that the “liberal consensus” that resulted in LBJ’s Great Society and continued even far into Nixon’s presidency have taken on serious water in the past few decades, but I do think it is still there, in spite of, as Uwe points out, the misinformation being delivered to so many on a regular (and lucrative) basis.

Having said, that, I do believe there is much more consensus on what those of us in health care professions believe about social justice in health care than perhaps among the general public or the policy making elite. The public and elite hear what those with the most time and money in the system want them to hear, after all, and do not generally hear from the rest of us. I think voicing and amplifying that consensus and articulating it so that it can break through into regular public consciousness would not be a waste of time nor effort.

I do not expect to ever win over my uncle, a die-hard O’Reilly fan, but I could definitely work on my aunt…

Cheers,

Chris

In my post Friday, the discussion turned to conservatives’ views on universal healthcare, specifically about the deserving/undeserving paradigm. I have written about this before a great length, including in a piece called We’re Not Ready for Universal Healthcare (because we disagree on basic morality). I wrote about the voluminous evidence that conservatives puritanical mindset makes them suspicious of others and unwilling to consider social welfare benefits, including healthcare, because they might go to people that they consider “undeserving.” I presumed that the great majority of conservatives felt this way.

However, I have been working with a group called USA Healthcare, a group dedicated to getting past the usual left-right construction of arguments about universal healthcare. We decided that rather than presupposing what conservatives think, we would actually ask them. So, we did a survey of about 250 self-identified Republicans and asked them about our principles, namely universality, simplicity, and affordability. The results surprised me and I posted about them here in an article entitled, Maybe We Are Ready for Universal Healthcare?

The most salient points to our discussion are these:

• Is healthcare a right? 32% of our cohort thought so! 42% agreed it was a necessity and 17% think of it as a public service good. Less than 10% thought of it as a consumer good!
• Only 3% thought healthcare is deserved by only those who can afford it.
• However, when asked straight up if healthcare should be universal 28% disagreed. 

I’ve documented my thoughts about this and the rest of the survey results, so I won’t repeat them here. But the reason I’m writing this is because I recently had a conversation with a friend from Utah who is part of a universal healthcare advocacy group in that state. He said one of the stumbling blocks they encountered was resistance to the word universal and the idea of universality. He attributed it to the same puritanical mindset of believing that there were truly people undeserving of our help and support.

It reminded me of something we had explored in our USA healthcare group previously, “Who exactly would you leave out of universal healthcare?” And, taken further for evangelicals and Mormons, “Who would Jesus leave out?”

I reminded my friend of our survey results showing that relatively few of our respondents seem to hold this “undeserving” position. He pointed out that in his experience, every Republican politician held this view. And I think he’s right.

But I think this is where our opportunity lies. As we discovered in our polling, with regards to all the elements of our USA triad, the ordinary Republicans who responded were not all that different in their assessments of the problems and solutions to the American healthcare mass as we had presupposed. I’ll let you review all of this for yourselves, but this could be a wedge issue, not Democrats v. GOP, but rather ordinary GOP identifying voters and their leadership. Ordinary citizens do not get the benefits of being in the pocket of the Medical Industrial Complex. No campaign or PAC donations, no lobbyists flattering them, etc.

Uwe Reinhardt called this Political Sustainability. I did a YouTube video about this, but basically it is the idea that even though healthcare is financially unsustainable for people who get sick and have to pay for premiums out of their wages, and even though it is economically unsustainable for us as a nation to keep paying these prices and having these bad outcomes, it remains sustainable politically. The money and influence of the Medical Industrial Complex makes it so!

Since I now realize I haven’t yet made the Political Sustainability  video into a blog post yet, I will do that this week for further discussion!

That’s all for now!

So I watched this video, How Writing Online Made me a Millionaire, because I like the YouTuber and have been looking for tips on how to grow my YouTube Presence and blog more and better. It is largely about the concepts in the book Show Your Work, by Austin Kleon. I watched Austin talk about his work as well at his South by SouthWest talk from 2014. (Also, I am not sure if this is legal or why it is still up, but you can listen to the audiobook via YouTube here.)

The insights I have received have changed the way I think about blogging, YouTubing and moving forward on Healthcare Reform and Universal Healthcare.

Here are the first two things that were revelations to me: “Scenius” and “Process.”

Scenius is the concept that puts the lie to the “Great Man” theory of history. Alex Gentry at Medium has a nice exploration of this, but I will give mine, because I recently watched the movie CBGB, because we love Alan Rickman. David Byrne is a brilliant musician, but he was living across the street from CBGB’s in its heyday, interacting with the most innovative musicians in the world on a routine basis. Is he a genius? Maybe, but he’s also a “Scenius,” the term coined by musician Brian Eno to describe this effect. Read the Medium piece for the details.

Process, as in “trust the process.” For me, anyway. I think the author means more than this, but for me it is about letting go of trying to create fully formed projects, be they YouTube videos or developing a Healthcare in America Commission, or deconstructing Healthcare.

But what it also means is trusting that putting stuff out there, like this piece here, and generating interest and collaborators, and giving props to the people who inspire us, will create a community. The community will find its members. How many times have you searched the internet for something and couldn’t find anyone asking the same question as you? More often you can find someone asking that question, and that is the beauty of the internet.

I started a journey a few years ago trying to figure out a way to change peoples’ minds about Universal healthcare and I have found that there really isn’t anybody applying cognitive science to this problem. So here I am, a couple years later, much more knowledgeable, but without a large collaborative community to help it happen.

Chapter 3 is Share Something Small Every Day. After I read it I may commit to that, but for now, I will put this out there and try to share something most days, at least and see what happens!

This is my something for today. I am cross posting on my blog and my DailyKos diary.

Here is a link to the OECD country summaries for healthcare systems.

Four P.E.I. doctors paid more than $1 million in 2017 | Local | News | The Guardian:

‘via Blog this’

Why conservatives are so obsessed with guns.:

“A more workable psychological explanation begins by noting that psychologists have found consistent differences between conservatives and liberals in personality traits, attitudes, and moral stances. To summarize some of the research findings, conservatives tend to be more likely than liberals to accept or even embrace authority that is perceived to be legitimate. Conservatives tend to be more moralistic and more conventional than liberals. They tend to have a stronger need for order and control and stability and a greater dislike of change.

“Conservatives also tend to value equality less than liberals. They have less empathy and are more likely to see human nature as bad. Compared with liberals, their moral sense is less centered on fairness and kindness and more on loyalty, deference to authority, and moral and sexual purity. Conservatives also show a greater tendency than liberals toward dichotomous thinking and have a stronger need for certainty and cognitive consistency. (“I don’t do nuance,” George W. Bush famously told Joe Biden. )

“The differences are not universal, of course, and there is nothing intrinsically bad or intrinsically good in the characteristics typical of either camp. But conservatives tend to lean one way, liberals the other.

” And some of these differences appear to be directly expressed in divergent beliefs relevant to the gun control debate. For example…

“…But it is hard for conservatives to accept these arguments. The interaction between characteristic conservative personality patterns and universally shared patterns of cognitionleads to conservatives being disproportionately skeptical of evidence provided by “experts” and scholarly studies. So conservatives turn to other means to soothe their anxiety. Some project their own anger onto others, fantasizing that people of color, immigrants, and feminists are the cause of their own inner torments. Anger, if nothing else, makes them feel bigger and more powerful.”

‘via Blog this’

Health Care’s Price Conundrum | The New Yorker:

‘via Blog this’

Some Americans spend billions to get teeth whiter. Some wait in line to get them pulled. | The Washington Post:

‘via Blog this’

Uwe E. Reinhardt: U.S. Health Care Prices Are the Elephant in the Room – The New York Times: