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 Offices 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 presidents health czar (a lawyer) were together with 38 members of Congress. There were three M.D.s, all Republican congressmen who opposed the administrations 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 nations 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 countrys 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 nations 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.
An extended version of this essay is available at www.ScientificAmerican.com/may2010