The long and divisive fight over U.S. health care reform exposed basic weaknesses in the processes of governance. As is so often true in American politics these days, politicians and lobbyists kept complex subjects to themselves, pushing expert discussion and systematic public debate to the sidelines. Although the final legislation expands coverage, and I favor it for that reason, it falls far short of the changes we need to lower costs and improve health outcomes.
During 14 months of debate over health care, the administration did not put forward a clear, analytical policy white paper on the aims, methods and expected results of the proposed reforms. Only the Congressional Budget Office’s budget scoring of legislative proposals was even partly systematic; no comparable independent analysis exists on other substantive issues. The actual health consequences of the legislation were never reviewed or debated coherently.
The one-day Health Care Summit in February epitomized the problem. The president, the vice president, the secretary of Health and Human Services and the president’s health czar (a lawyer) were together with 38 members of Congress. There were three M.D.s, all Republican congressmen who opposed the administration’s plans, but no public health specialists, health economists, speakers for civil society, leaders of health maintenance organizations or representatives of other health care organizations. The debate was all about who would pay for what, not about how to organize health delivery to achieve better, lower-cost outcomes.
One might think that the real action had all happened earlier, in congressional hearings, in brainstorming sessions and in the bargaining sessions with key stakeholders. Yet the earlier process was relentlessly driven by political and lobbying calculations and without the informed participation of the American people, who were left to vent at Tea Parties and on blog sites. The mammoth legislation is impenetrable, a widely noted fact. Experts were never invited systematically to comment or debate about it so as to help the public and politicians understand the issues. The lack of clear policy documents from the administration meant that the public had little basis for reaction other than gut instincts and fearful sentiments fanned by talk-show hosts.
In general, our political system regularly puts around the table people who are not the best equipped to find deep solutions to our problems. Certainly it has also done so on climate change, with the nation’s expert community kept at arms length from the legislative drafting process. As with health care, the outcome has been House and Senate draft legislation that lacks public support. The same has been true on Afghanistan: the “war cabinet” has lacked real expertise on that country’s culture, economy and development challenges, and the U.S. public has remained uninformed of true options.
As a start toward better policy making, the administration should put forward a detailed analysis justifying each major proposed policy change. That white paper could form the basis for coherent public debate and reflection, along with Web sites where outside experts would be invited to share opinions accessible to the public. The public, too, would be invited to blog about that position paper. A version of the draft legislation understandable to lay readers would also be posted (alongside the more technical and inevitable legalese) and opened to online commentaries by experts and the public. The administration and Congress would rely more heavily on external advisory panels to tap into the nation’s wealth of expertise and to draw on the views of business, academia and other sectors of society.
In our governance systems today, the intrinsic complexity of the challenges easily outpaces the gut instincts and amateurism of the existing government machinery. I would not presume or recommend that decisions be left to the purported experts, who often represent special interests or have their own biases or narrow views. Still, a systematic vetting of policy options, with recognized experts and the public commenting and debating, will vastly improve on our current policy performance, in which we often fly blind or hand the controls over to narrow interests and viewpoints.
This article was originally published with the title Flying Blind in Policy Reforms.
Already a Digital subscriber? Sign-in Now
If your institution has site license access, enter here.
See what we're tweeting about
14 Comments
Add CommentProfessor Sachs has stated in seven paragraphs what I've been struggling to formulate for the past year. And he didn't use even one swear word!
Reply | Report Abuse | Link to thisHis column makes me glad I subscribed to Scientific American magazine after a several year hiatus.
High minded ideas! But down here on Planet Earth the only way we can hope to get to Prof. Sach's goal is to pass a Constitutional Amendement that (A) makes "comprehensive" legislation illegal and (B) requires that each bill be limited to language in 12 point type that fits on one 8" x 5" index card.
Reply | Report Abuse | Link to thisVery high minded goals! But down here on Planet Earth Prof Sachs' goals can be reached only by Constitutional amendment which (A) outlaws "comprehensive " legislation, and (B) reqires all bills to be printed in 12 point type and limited to one side of an 8" x 5.5" index card:
Reply | Report Abuse | Link to thisOR
by rolling back Government's role and keeping it simple - e.g., print money, build roads and defend us from the bad guys.
Mr. Sachs derides the process by which health care legislation was adopted, laments its short comings, yet spontaneously concludes, "Although the final legislation expands coverage, and I favor it for that reason, it falls short . . . [by not lowering costs]."
Reply | Report Abuse | Link to thisHis conclusion that the legislation is worthy of support in spite of its shortcomings belies the sincerity of his criticism of the process by which it was adopted. He adopts the same thinking process of the legislators and Obama -- we don't care that it won't reduce costs, will reduce medical innovation, reduce health care quality, will dilute services to people who pay for them, will ration healthcare -- because more people get covered. He concludes without any of the required analysis that the legislation is good. If that is so, then why would we need all of the analysis? Just pass it.
Mr. Sachs fits neatly into the category of left-wing socialist. That should not be seen as an insult -- it is merely a description. He thinks that the few should pay for the many.
What of the parents who have a disable daughter and is trying to save enough money so she can be cared for privately after their death? They know of the horrible treatment the mentally disabled receive institions and group homes. There is rampant abuse, laziness, and poor practices in these facilities, even today. Yet, these parents will have to spend their money to pay for today's medical care for someone who is not disabled -- but simply does not produce enough to buy premium medical care. The savings of these parents will be squandered and the government will ultimately conclude that it will care for their daughter, too, because it has impoverished these parents.
What right does Mr. Sachs have to say that the product of one person's sweat should go to pay the medical care of another person when the first person is not even able to provide the needed life care for his disabled daughter? Truly, he has no right to do so, he has only the power to do so.
Power is a slippery commodity Mr. Sachs.
Jeffery Sachs call for more systematic approach to policy making that allows for both public input and serious analysis by experts is laudable. Intriguingly, and probably unconsciously, the Obama Administration has been conducting an experiment of this approach. Sadly the results so far are disappointing.
Reply | Report Abuse | Link to thisKnowing that there were difficulties in Americas Human space efforts the then new President recruited a distinguished panel of outside experts representing diverse perspectives. This Augustine Committee conducted numerous public hearings and looked hard at a plethora of alternatives. After much effort they published a report that outlines a variety of possible approaches along with methodologies for analyzing each one systematically and posted it online where any interested person could download it. Those of us who took the time to study the report found a wealth of information, insight and creative thinking about Human Spaceflight Plans in the United States.
Sadly, few bothered to do more than look at the pictures or watch the brief press conference. Congress didnt even wait for publication. Responding to hints that some white collar welfare jobs may be threatened by rational analysis Committee Chairman Norm Augustine was thanked for his efforts by being summoned to Capitol Hill to be lectured on his misguided ways.
When the report did come out contractors dependent on the status quo were spinning away and journalists on short deadlines were lapping it up. More detailed discussion was reserved for bloggers with relatively small audiences and dense academic papers.
One person who apparently did take the time to look hard at the Committee report was President Obama who proposed a new NASA budget that is clearly informed by its findings. This resulted in an immediate and well funded campaign of misinformation and sophistry which continues.
By the time Congress adopts a budget I have little doubt that the pork will all be saved and the rationality and pragmatism of the Augustine Committee report will be long forgotten. I was taught in school that there is no such thing as a failed experiment. Even so, it seems to me that the country I love has developed a political system where failure is the only option. Heres hoping Congress proves me wrong.
This article is genious. If it makes perfect sense to me and plenty of other subscribers, why don't the politicians think of it. For any plan to be effective, it needs a good foundation. That foundation is based on the cultural characteristics of the nation proposing the idea and the one that it is being made for. Besides that, American citizens need to be kept at least somewhat informed. It's best to have the information in layman's terms because so many of us never even graduate highschool. Bravo, Mr.Sachs, for coming up with a socio-political formula that makes sense.
Reply | Report Abuse | Link to thisThis is a good analysis. It happens in businesses too. The scientists and people who make the products and know about them are sidelined while the marketing experts take over. I have had situations where I have been chastised for offering up too much information and getting in the way of the image of the product instead of the reality. Too many elected officials think that the business model is the way to go. I do not see president Obama as being one of these people but he is fighting a raging tide of ignorance.
Reply | Report Abuse | Link to thisThis is a good illustration of the problems in government. A thoughtful analysis followed by dramatic charges of left wing socialism followed up with a smug psudo-personal one liner with a dash of arrogance. There is no place for this kind of rhetoric here in a scientific discussion and there should be no place for this in politics either. I think this should be flagged as hate speech.
Reply | Report Abuse | Link to thisIn a situation where you are running for election every 2 years as a US rep., where a 2012 straw poll for president is done every 3 months or so (the first one the day after the 2008 election) and where the lunatic fringes have completely taken over the policy discussion, no expert participation is going to work. Well thought out formulated views and informed policy decisions have no place in the real world of hard nosed "death panel" type garbage politics where pleasing the fringe and keeping your seat are the only driving goals.
Reply | Report Abuse | Link to thisJeffrey D. Sachs, your political article sounds like spewed hate mail from a loosing Republican who miserably lost in two major elections and does not have the sense to realize it. Where were you, and these Teabagers, when Bush was plunging the environment, the health care system, the housing market, the banking system, and the economy into bankruptcy, poverty, and despair? It is too late to start spraying the water after the horses got burnt up in the fire the Bush administration started.
Reply | Report Abuse | Link to thisPresident Obama tried for a year to bring the Republicans on board with this health care, the environment, and the economy and all he got from them was the poison spewing from their ugly faces. The Republicans wanted us to wait, wait, wait. We have already waited 50 years for health care reform...how much longer do you want us to wait?
There are 36 million people in this country who cannot afford the standing health care. The health care reform is not perfect, and the Democrats do not claim that it is, but it is a start and it can be made more perfect to where it can provide health care to all American citizens. The same can be done to the Environment Policy making.
How much say did the people have in the Bush administration? I can tell you...ZERO!
You want the Obama administration to be more open and upfront with the people but you do not want the government to expand to give the people this right. If you do not want the "cake", how can you expect to eat it?
It is relevant to note that Independent_Agent's 'rebuttal' contains no substantive thoughts on the article itself, and is therefore a perfect example of Sachs's argument. Independent_Agent stopped after the abstract, made an assumption about the content, and proceeded to expound on a topic with little knowledge of the subject.
Reply | Report Abuse | Link to thisHow very Republican. That's not an insult, it is merely an observation.
Of course, the original republicans were enlightened, and so would have rejected ad hominim and derivative arguments in favour of rigorous debate. But don't let that stop us. Ideologies are much more interesting than rationality, that's why the Enlightenment died after a brief struggle with life.
@IndependentAgent
Reply | Report Abuse | Link to thismJust being a devils advocate but when I hear anecdotes that centre around "parents who have a disabled daughter" my mind is immediately on alert - is this a ploy in the debate, an appeal to emotion to distract us from the key issue? Coming from a country that has universal health care, I take great interest in the American perspective. It is easy for us non-Americans to think that your insurance companies have much more say than the regular person, but this is simply because our systems are different. Perhaps your system, where insurance companies compete to provide the best coverage at the lowest cost, and don't unduly influence the legislation of laws to abrogate their responsibility, works well indeed.
My country however does not feel overly "socialist" (not in the commie-pinko way that I gather Americans are encultured to respond to that word). Neither do we feel extremely "socialist" when we use public roads. We certainly don't feel that the capitalist class, the few, pays for a service for the whole, since both classes and their health and well-being are inextricably linked. There is no discernible resentment that all classes have roads and health care available to them, because anyone, rich or poor, has the option of using expensive but faster toll roads or additional private health care. So it is not black and white, we are not through and through socialists after all.
The article states that the bill falls short in reducing costs, not that it fails in every way. The article calls for more transparency and the break up of the control of interest groups over congress. It's your country, but I would guess that informed Americans, the people, would rather be in control of a transparent and public-access decision-making process instead of relinquishing it to an iron triangle of interest groups, bureaucracy and congress. At least Eisenhower wanted that.
On that level, at the least - and here I am side-stepping emotive anecdotes about hard-working parents trying to support a handicapped daughter and not making it because they have to pay for rehab for gang members - you would have to agree - and let's also forget the emotive word 'socialist', since transparency and public involvement are not mutually exclusive with capitalism - this article does have some merits.
The root of this problem is two fold and simple. You the consumer have been removed from the determination of price in the medical setting. Consequently the most powerful control on prices can not be exerted; your sense of value for what you are getting. This issue is made more complicated by the fact that we as a culture have been trained that we do not pay for health care. You complain about a co-pay for an office visit but do not blink at laying down a grand for a new TV. These two issues have been manipulated by both insurance companies and the fed to keep you isolated from health care cost decisions.
Reply | Report Abuse | Link to thisThe quickest method to bring HC costs down is to put the consumer back in the decision process. At a federal where I worked we found that 87% of our daily walk-in patients would not have come had they had to pay a dollar to get their chart pulled. You might consider that harsh treatment of patients but remember, that 87% did not need to be there in the first place. They had issues that were self resolving; we could do little if anything for them, nor should we have. The issue is that 87% runs up the costs and prevents us from getting to the 13% who really do need to be seen. If there is something seriously wrong are you going to let a dollar stand in the way; I doubt it.
The people who do not want you in the decision process are the administrative class. Without the current system they will not be building multimillion dollar buildings every year or paying for multimedia add campaigns with your insurance dollars. Instead we can get back to what we need to be doing; seeing the people who need intervention and trying to get the rest of you to take responsibility for the poor life choices you make that put you in need of us Disease Care Providers in the first place.
Sachs article on flying blind in policy reform in health care is correct.when Clinton tried to do the same thing he failed for the same reason.In feb 09 I sent Valarie Jarrett in the White House suggesting setting up a series of regional conferences under written by including everyone involved in health care i.e. all areas health professions,lawyers,economists- ethicists,lay people,insurance.reps, hospiital assoc.medical schools,no responce
Reply | Report Abuse | Link to this