Last week I took the position that honest intellectual debate is overrated. To my disappointment, I didn’t notice any substantial pushback,* so I’ll have to provide it myself.
First of all, what I was getting at was that honest intellectual debate over health policy isn’t necessary or sufficient for political compromise. It’s not necessary because compromise could be reached without honestly engaging with the evidence and underlying facts. You want something. I want something. Who cares how we engage the evidence? Let’s gain from trade! (Related: I never thought any of my landlords were honest, but I traded money for shelter with them anyway. I needn’t care how intellectually honest the fishmonger is to buy his fish.)
Honest intellectual debate also isn’t sufficient for political compromise because, well, they’re different things. Two people can engage honestly on the facts and research and disagree on the policy implications. Two people can agree, for example, that some Medicaid patients have poor access to some providers without agreeing on whether the program should be privatized or not. Compromise is an additional step that doesn’t itself follow from honest intellectual debate, not that it would hurt. If you’re a candidate and your election prospects depend on not compromising, you won’t, even if you’re intellectually honest. We need compromise. Honest intellectual debate is a sideshow.
I’ll agree with myself on all that. But does it therefore follow that honest intellectual debate is overrated? Here, I’ll disagree with myself. And I’ll point myself to my very own post, coauthored by Sarah Jane Reed and Sarah Emond, on the work of the New England Comparative Effectiveness Public Advisory Council (CEPAC).
At CEPAC meetings, council members and other participants have honest intellectual debates about test and treatment options in various clinical areas. After our engagement with the evidence, we take votes on what it means. From those votes, and their interpretation as provided by council members in discussion, we produce reports that inform payers, providers, and patients about the comparative and cost effectiveness of test and treatments. Those reports have served as bases for changes in coverage policy by private and public payers in New England.
So, honest intellectual debate can do quite a lot of work! And CEPAC is not alone in this regard. MedPAC, the Institute of Medicine, and other advisory institutions can and have also engaged in honest intellectual debate for useful purposes. If anything, the work of groups like these is underrated, not overrated. I was wrong!
How can honest intellectual debate be useful in the context of CEPAC, MedPAC, the IOM, and elsewhere but neither necessary nor sufficient for compromise on broad health policy issues like whether and how to expand coverage? I think the answer is that these organizations select members to participate in a specific, technocratic, deliberative process in service to an advisory role with no policy-making authority. All of these elements–careful selection, technocratic, advisory/no authority–are important, but most of all the “advisory/no authority” part. Being only advisory, such organizations don’t attract or generate the kind of heat or, frankly, interest a congressional debate does.
The moment an organization has authority to actually do something, it’s a juicy, almost necessary, target for forces that turn light into heat and profit from them, corrupting honest intellectual debate. (Related, see this very interesting report by Public Agenda about how ordinary citizens–with no authority–engage health policy-relevant evidence and proposals and come to some fairly clear conclusions about what is and is not likely to be an acceptable path forward.)
There is just no way the ambition for power and money that drives politics and commerce can rationally disregard the utility of hijacking an authority-possessing body. How could it do so and still be true to the imperative to win or maximize return? No, such an organization will be besieged and, in time, the ability for honest, intellectual debate will be largely driven out. Of course, Congress has authority! Throw in the way members of Congress are selected–not to deliberately serve a technocratic end, that’s for sure–and honest intellectual debate in that body is near impossible to fathom. Nothing like what happens at CEPAC is likely to happen among congressional committee members from opposing parties, least of all when the cameras are rolling.
Now, things aren’t quiet as absolute and clean as all this. Politics and stakeholder interests exert some influence on advisory bodies too, to varying degrees. But there is at least a chance of protecting a space for some honest intellectual debate. Meanwhile, it’s of course true that organizations with authority can also harbor pockets of intellectual honesty. You just don’t often see or hear it, not in real time anyway. By necessity, it’s off mic and in the kleig light’s shadow.
Therefore, honest intellectual, where possible, is not overrated. Nevertheless, in general, we should not expect honest intellectual debate about the big health policy issues among members of bodies with authority to make policy, like Congress. The most we should hope for is compromise. That is ambitious enough.
* A few tweets hardly count.
