Sunday, September 07, 2008

Aligning the Ought-To’s with the Can-Do’s

If our country is serious about healthcare reform, it behooves us to ask:
  • What OUGHT TO BE done to guarantee everyone has access to affordable, high-quality healthcare?
  • What CAN BE done, realistically, to make that happen?
Wherever there is a misalignment between these Ought To's and the Can Be's (i.e., when we can't do what we ought to be doing), it is wise to ask: WHAT'S PREVENTING US and HOW CAN WE overcome those obstacles?

Unfortunately, when it comes to healthcare, other domestic issues, and even foreign policy, answering these questions isn't easy because it requires that we stop deceiving ourselves, and start critically and objectively evaluating the values, priorities, goals, and underlying beliefs of our culture.
For example, let's say we agree that we ought to have access to high-quality healthcare we all can afford. And let's assume that high quality, highly efficiency universal healthcare isn't possible because of government budget deficiencies. Since this scenario would mean a continuation of our healthcare system's poor quality, high cost, and access inequity, we should be asking questions such as:
  • Why isn't the necessary money available?
  • Is it being spent elsewhere?
  • Are there policies that promote waste and abuse?
  • Would there enough tax dollars if the government's current funds were to be redistributed?
  • Must taxes be increased to raise additional money?
  • Who would be for it and who against redistribution and tax increases?
  • Why would certain people be opposed if it would help so many?
  • How are the winners and losers in the current system, and why?
  • What does it say about the priorities/values of those opposed, and how do they compare with those in favor?
  • What is it about our culture and economic system that promotes belief in such priorities/values?
  • Is the American capitalist model broken; is it pathologically mutated?
  • Would it be wise to make "compassionate capitalism" the norm?
  • How would we deal with the negative aspects of human nature, such as ego, greed, fear, and denial?
  • How can people's minds be enlightened to balance between selflessness and selfishness?
  • Is part of the problem a broken healthcare system driven by a perverse economic model, pervasive ignorance, resistance to (fear of) change, etc.?
While the knowledge we would gain from answering these questions would direct us in developing solutions to the healthcare crisis, many (most?) people would react to all this by saying: "Be realistic! You can't change these things; it's just too difficult. We can't do what we ought to do because there are too many obstacles, so don't waste your time trying!

I disagree! We simply cannot afford such a defeatist view. We can gain a great deal by "looking at ourselves in the mirror." We'd be wise to ask the tough questions and not shy away from the radical transformation of our healthcare system and national priorities. It would be wise to do this with other domestic and international problems, as well.

Consider, for example, the recent interview of Andrew J. Bacevich on the Bill Moyer's Journal. Mr. Bacevich is an author, professor of international relations and history at Boston University, and retired Army colonel. He focused on the relationship between failed U.S. foreign policies and American consumerism. He concluded that our country's biggest problems are internal and the solution requires looking at ourselves in the mirror and asking the tough questions. Here are some quotes:
The pursuit of freedom, as defined in an age of consumerism, has induced a condition of dependence on imported goods, on imported oil, and on credit. The chief desire of the American people…is that nothing should disrupt their access to these goods, that oil, and that credit. The chief aim of the U.S. government is to satisfy that desire…what we want, by and large is, we want this continuing flow of very cheap consumer goods…And we want to be able to do these things without having to think about whether or not the book's balanced at the end of the month, or the end of the fiscal year. And therefore, we want this unending line of credit…[We should] look ourselves in the mirror, to see the direction in which we are headed. And from my point of view, it's a direction towards ever greater debt and dependency.
…[There is a] yawning disparity between what Americans expect, and what they're willing to pay… we don't live within our means. I mean, the nation doesn't, and increasingly, individual Americans don't. Our saving - the individual savings rate in this country is below zero. The personal debt, national debt, however you want to measure it, as individuals and as a government, and as a nation we assume an endless line of credit…[This assumption] is going to be shown to be false. And when that day occurs it's going to be a black day, indeed…[We've moved from] 'an empire of production'…[to] 'an empire of consumption.'… This continuing tendency to borrow and to assume that the bills are never going to come due. I testified before a House committee six weeks ago now, on the future of U.S grand strategy.
…How are we gonna pay the bills? How are we gonna pay for the commitment of entitlements that is going to increase year by year for the next couple of decades, especially as baby boomers retire?" Nobody has answers to those questions…[we] have opted for a false model of freedom. A freedom of materialism, a freedom of self-indulgence, a freedom of collective recklessness
…The big problem, it seems to me, with the current crisis in American foreign policy, is that unless we do change our ways, the likelihood that our children, our grandchildren, the next generation is going to enjoy the opportunities that we've had, is very slight, because we're squandering our power. We are squandering our wealth. In many respects, to the extent that we persist in our imperial delusions, we're also going to squander our freedom because imperial policies, which end up enhancing the authority of the imperial president, also end up providing imperial presidents with an opportunity to compromise freedom even here at home. And we've seen that since 9/11.
…We have created an imperial presidency. The congress no longer is able to articulate a vision of what is the common good. The Congress exists primarily to ensure the reelection of members of Congress…[Our political] system is broken.
…One of the great lies about American politics is that Democrats genuinely subscribe to a set of core convictions that make Democrats different from Republicans. And the same thing, of course, applies to the other party. It's not true. I happen to define myself as a conservative… Parsing every word, every phrase, that either Senator Obama or Senator McCain utters, as if what they say is going to reveal some profound and important change that was going to come about if they happened to be elected. It's not going to happen… because the elements of continuity outweigh the elements of change. And it's not going to happen because, ultimately, we the American people, refuse to look in that mirror. And to see the extent to which the problems that we face really lie within.
…We refuse to live within our means. We continue to think that the problems that beset the country are out there beyond our borders. And that if we deploy sufficient amount of American power we can fix those problems, and therefore things back here will continue as they have for decades.
…How did we come to be a nation in which we really thought that we could transform the greater Middle East with our army? What have been the costs that have been imposed on this country? Hundreds of billions of dollars. Some projections, two to three trillion dollars. Where is that money coming from? How else could it have been spent? For what? Who bears the burden?...It was a fundamental mistake...And that might be the moment when we look ourselves in the mirror. And we see what we have become. And perhaps undertake an effort to make those changes in the American way of life that will enable us to preserve for future generations that which we value most about the American way of life.
So, the U.S. is an empire of consumption relying on credit and military might to feed our materialistic addiction, as we indulge ourselves recklessly and squander our wealth and power with little regard for the common good. Instead of examining ourselves in the mirror and asking the tough questions about what we've become, we foolishly focus beyond our borders to fix the problems that are actually caused by our internal attitudes and systems.
This brings up a few final questions:
  • If we were a wise and virtuous country, what would we say we OUGHT to be doing about healthcare and other domestic and foreign policies?
  • If we were a brave and compassionate country with the will to make fundamental changes for the common good, what would we say we CAN do after peering bravely into the mirror and asking the tough questions about ourselves, our assumptions, and our way of life?
  • If we were such a country, would we then be able realigning our misaligned Ought-To's and Can-Be's by changing values, priorities, goals, and underlying beliefs of our culture?
  • Or are we so deeply enmeshed in our maladaptive ways, and so controlled by our broken/pathological systems and policies, that all we can do is watch hopelessly and helplessly as we "go down the drain" and hand over to future generations a weak and pathetic country in which the American Dream has become the American Nightmare?
The following is an update added on 9/9/08:

Conversations I've been having subsequent to the original post--with with Phil Wray and John Milligan--have offered several useful ideas.

One is to think of aligning the Ought-To’s with the Can-Do’s as a dynamic process, as opposed to a static process, especially when there’s a potential “show stopper” obstacle (i.e., there is no way to achieve our Ought-To goals). This means that when we are prevented from doing everything we Ought-To be doing, the odds are that we can still do some of the things we Ought-To do. Those actions, and the knowledge we gain the process, can, in turn, “open new doors” that enable us to achieve more of the Ought-To’s by, for example, trying different tactics than originally considered, and/or by refining our definition of the original Ought-To’s within reason. In other words, by evolving our vision (goals & objectives) and methods (strategies and tactics) in light of the current realities, but without abandoning our initial intent, we can move ever closer to achieving our mission even when confronted with powerful obstacles.

Another idea is to think of what we should be doing in two levels: Ought-To’s and the Must-Be’s. That is, it is important to clearly rank our goals and objectives in terms of their priorities (primary, secondary, tertiary, etc.). We would have to debate to decide what are our moderate priority Ought-To’s (which need not be essential) and our high priority Must-Do’s (which are absolutely essential). In this way, failure to do what we Ought-To is regarded as undesirable, while failure to do what we MUST is considered totally unacceptable. In either case, the dynamic process above is a way to foster progress even in the face of possible show-stoppers.

So, when faced with major obstacles that prevent us from doing all we should be doing, it is wise to (a) evolve our vision and methods in order to make forward progress and (b) get our priorities straight, so we know what to focus on first. Doing these things, it seems to me, would best be accomplished via a “bottom-up” process in which we look straight “into the mirror” and examine our cultural value and beliefs, while having serious and in-depth debate about who we are as a people, who we want to become, and how to make that societal transformation. This process would work for all the big issues our country now faces, which includes not only healthcare, but entitlements, grand foreign policy strategy, transparency & accountability in government, etc.


Tammi Diaz said...


Dr. Steve Beller said...

HR676 is certainly worth serious consideration!

Our analysis of the healthcare proposals includes a comparison of two universal heathcare proposals: (1) Publically Funded Universal Healthcare Program + Private Insurance and (2) a Single-Payer Program (No private insurance) as proposed by HR676, which only Kucinich supported.

Anonymous said...

Synching up the Ought-to's with the Can-do's can't just be a jump from point A to point B. If we decide that access to health care is a human right, it just won't do to turn capitalism on its head and think we can force health care to fit in an odd sized hole.

As Bacevich mentions, two parallel climates of culture and capitalism are in the way for us to think we can realistically leap to something like HR 767.

How can we know if reaching this event horizon (Ought-To) is realistic until we start opening the doors (Can-Do) one by one so that we can get a better look?

What immediately comes to mind are obvious things that can be accomplished with legislation. Transparency in billing and charges must be the law. Patients need immediate access to itemized charges.

During our approach to this event horizon there seem to be other simple doors that can be opened that may also involve legislation. The mystery has to be removed!

Mandatory posting of price lists is also one good measure.

If Emergency Rooms must accept patients, efforts need to be taken to weed out non-emergency care. Instituting parallel Emergency Room shadow clincs that can handle non-emergency overflow in a timely manner would seem to be another possibility. Instead of register and wait in the Emergency Room, how about a quick triage and referral to the shadow clinc?

Legislate a no state border barrier to health insurance.

We need to open a number of doors to see which way to go to reach our goal.

Dr. Steve Beller said...

Good points, Phil.

I like the “event horizon” concept for the Ought-To’s.

I’d add that quality transparency ought to be tied to price transparency, so patients/consumers can assess the real value of care. While absolutely necessary—even for controlling costs—measuring and improving quality are complex and costly objectives, which requires a major shift in our cultural mind-set and priorities! And, believe it or not, even price transparency is a no easy task, especially for hospitals (e.g., see this link), but things are changing.

I’ve not heard the “shadow clinic” model before, but it makes sense, as does eliminating state barriers to health insurance (if we don’t go with a single payer system).

I also agree that we cannot do it all at once and ought to be "opening many doors" to determine the best way forward, but no matter what we do, we have to combat the think small and don’t rock the boat mentality that is pervasive in our culture, as well as the tendency to “pass the buck” rather than accept responsibility. They would support small changes that don’t matter much, and smoke screens that do nothing substantial. One reason is that some are doing very well financially in the current broken healthcare system and they don’t want to see any meaningful change that might hurt their pocket books. Another is people’s ignorance, or simply fear of the unknowns.

But if the populace put pressure for legislation that brings about radical reform at a steady, doable pace, I believe profound change is possible. After all, many other countries are doing a much better job than we are (see, so why can’t we!?!

John Milligan said...

I agree on Phil's 'Event Horizon' concept. Circumstances do change in the real world and you have to have a strategy that is able to adjust accordingly while still keeping your eye on the end state ball so to speak. Opening the most "doors" possible and maximizing/exploring the options/tradeoffs/costs and offerring the maximum amount of choice (and responsibility)to the individual is something we need to emphasize on the Health Care front

To me there are really no show stopper obstacles perse on total Universal Health Care but we fool ourselves in oft times and lately in policy and strategy formulation and communication that whatever policy/strategy we choose is cost free or sacrifice free. Oft times our eyes are bigger than our stomachs so to speak and we think in terms of cost-free silver bullets. There are no silver bullets in the real world. It's an attitude that pervades much of human consciousness (and politics in DC of late especially) of thinking you can get something for nothing that IMHO is a real killer in this town DC in the last 30 years that has resulted in a demosclerotic and increasingly dysfunctional government.

Once a policy/strategy is in place there are built in constituencies that percolate up on K St and via the internet communications astro-turf media campaign efforts that do not like any changes/adjustments to that set policy and organize against any permutations that may be beneficial. Hillary's failure on Health care will be just a warm up act for what we are to experience in the next Health Care go-around.

Both Repubs and Demos play that K street special interest game and are guilty parties in the current imbroglio we find ourselves today. Once a bad policy/program gets entrenched and embedded, its well nigh impossible to get it out (I call it the reverse toothpaste problem). And we the American people are not guilt free in this whole schema as well and love to be pandered to - in fact now now expect it. To me you cannot get something for nothing and in the real world there are tradeoffs, real costs and new evolving circumstances that must be taken into consideration in any effective strategy/policy that is sustainable. Phil's Event Horizon concept does account for that I think pretty well.

My sense is that on the really biggie mega-issues (Universal Health Care, Entitlements, Grand Foreign Policy Strategy, Transparency/Accountability in Government), a new President whoever it is will have to assign a Bipartisan Commissions with carte blanche to make the the full examination of the extant issues and implementation challenges/costs where eveything is on the table and that can give the politicians some political cover from the K-Street Lobbyists and Special interests (and to astro-turf media campaigns) to make the tough choices and needed adjustments necessary for national sustainability. There are just too many Third Rails out there anymore on these biggie issues and that is especially so with Health care with all the entrenched interest groups on all sides of the debate lined up on K-Street. The next Prez will need to have an intuitive sense on how Washington really works and the oratorical ability to go over Congress and K-Street's heads if needed to go directly to the american public to get Congress/Agencies to legislate/implement the best strategy/policy in place and expunge as much as possible the Special Interest Demosclerotic tendencies of the last 30 years.