• Realists and radicals

    This is a TIE-U post associated with Jonathan Oberlander’s Political Dynamics and Policy Dilemmas (UNC’s HPM 757, Fall 2011). For other posts in this series, see the course intro.

    I’ve argued before, at least once, that political feasibility is a highly relevant characteristic of a health (or any other) reform proposal.

    That’s the strange beauty of our legislative process. It certainly does weed out the political duds doesn’t it? In fact, if anything it has a high false negative rate. Whatever survives is extremely politically robust. It has to satisfy a myriad of special interest concerns and those of hundreds of legislators. It has to survive unbelievable distortions and attacks borne of insanely devious creativity. That’s not a defense of our system. That’s just the way it is.

    I wrote that before I was aware that Jon Oberlander said it all (and more) much better in a 2003 Health Affairs paper “The Politics Of Health Reform: Why Do Bad Things Happen To Good Plans?” In it you’ll find not just a survey of the common pitfalls in feasibility analysis, but also the forces that impose constraints on health reform, defining the feasible space. These are well known to policy wonks, stemming from the nature of our political institutions, politics, culture, and economic system.

    So, there’s enough in Oberlander’s article to fill several posts, though I may not do that. The point I want to focus on here is this:

    [A] major pitfall is to confuse feasibility with desirability and thus not to separate out what is desirable from what is doable. It is, not surprisingly, common to argue that one’s favorite reform option also happens to be the most feasible course of action. No political side has a monopoly on this temptation.

    Is there anyone who does not have a ready answer to “What’s wrong with our health system and how do we fix it?” To me it seems not. Moreover, most people answer this question with such an air of certainty and authority that they seem to wonder what’s wrong with everyone else. “Why can you all not see am I right about this?” they seem to be saying. Few seem to admit the numerous, strong constraints on what we can actually accomplish. Among those who seem oblivious to political feasibility are those at the “radical” extremes of the political spectrum.*

    I’m not one of them (as if you couldn’t tell). I take political feasibility very seriously and devote relatively less time on that which does not appear to have a decent chance of surviving the national political gauntlet. Does that mean I think the radicals are wasting their time? No, I do not. We need them. They offer worthy ideas and push the rest of us to think hard about them. That’s useful, to a point. Some of those ideas may, someday, fall into the politically feasible set since that set is ever shifting. As I said before, it is good to have a lot of arrows in the quiver.

    On the other hand, do I think the radicals are wasting my time? Well, that’s not up to them, it’s up to me. And I don’t permit it. Just as we need some radicals, we need some realists. The realists can’t let themselves be caught up arguing with the radicals all the time. Somebody’s got to mind the store. Though the radicals may be offering solutions for the future (ahead of their time), the realists are busy applying crucial band-aids today and, yes, settling for things that are only marginally better and not radically so.**

    Congress will only do so much so quickly. That’s a fact. As a lover of facts, I act accordingly. But you, of course, are free to dream. It’s not that I don’t like your dreams. I just don’t see how to make them a reality. Not yet.

    PS: By the way, what makes John McDonough’s book about which I’ve been blogging (Inside National Health Reform) so good is that it is extremely attentive to the political constraints under which the ACA passed, with far more insider detail than any other treatment I’ve seen.

    * Here and throughout I am considering  political feasibility at the national, not state level. States are a totally different matter, about which I am not commenting in this post.

    ** In suggesting I won’t spend a lot of time on things I believe are “radical” with respect to national political feasibility, I am not suggesting I won’t spend any time. Nor am I suggesting that others on this blog won’t spend time on them. It’s a question of balancing what’s realistically feasible today vs. what we hope for in the (perhaps distant) future. Each of us as our own discount rate.

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    • I don’t have any magic solutions. As a foreigner, it seems to me that the U.S. has a huge blind spot when it comes to heatlh care. Any other developed country would call for “battle stations” if they had even ONE of the headlines that seem all too common here: infant morality at third world levels, amputations due to diabetes, deaths from infections in hospitals, etc. There seems to be an “I’m alright Jack” attitude to the huge numbers of deaths and disability that result, I assume because it’s the “other” people who are suffering the deficiences of American health care. It must be very demoralizing to be a researcher in the field…

      On a brighter note: “Grey Tsunami: Canada Health System Can Handle Aging Population, According To University Of British Columbia Study ” HuffPost headline this week.
      http://www.huffingtonpost.ca/2011/08/29/grey-tsunami-canada-health-system_n_940938.html
      The difference between B.C. and US, IMO: research leads to B.C. policy adjustments and more problem-solving research. In the U.S., research leads to publication in a journal.