10 January 2020
Dear Interested Readers,
Do We Need To Better Understanding How Our Values Vary Before We Can Reform Healthcare?
I am always excited when I see an interesting article in the “Perspective Section” of the New England Journal of Medicine. This week was one of those weeks. The lead article was “Costs, Benefits, and Sacred Values — Why Health Care Reform Is So Fraught” by Lisa Rosenbaum, M.D. There is a companion “goodie,” a recorded interview with David Cutler, the Harvard healthcare economist, who was a major participant in the drafting of the ACA, and is the author of many articles and books including The Quality Cure: How Focusing on Health Care Quality Can Save Your Life and Lower Spending Too (2014).
For anyone whose brain feels like a tangle of spaghetti whenever they think about the complexity of the healthcare issues that face us, I highly recommend both the article and the interview. As you might expect, what follows will be a review of the article.
As the article’s title suggests, the items discussed lie on a spectrum from the mundane to the spiritual. Even before reading the article, after thinking about its title, my mind went to the reality of the deep divisions between red and blue mindsets that complicate everything from immigration issues to equal rights for women with gun control, healthcare, LGBTQ+ concerns, global warming, and the living wage issue in between. All of these issues are amped up in feeling by personal values. What is politics other than the people of like minded values and concerns coming together in an attempt to steer the outcome of any issue toward harmony with their own “values?” The cynical among us often imagine that other people’s “sacred values” have evolved as a rationalization of their concept of “rightness” for the policies that are aligned with their best interests.
It’s interesting that the Constitution was not written with political parties in mind. Parties began to evolve during the ratification process. George Washington had hoped that we would have a government free of political parties and warned of the trouble they could cause in his farewell address. Surveying where we are now may suggest to you that we should have followed his advice.
It appears that one of the outputs of the party structure that did evolve was the difficulty of passing legislation that can last through changes of administration from one party to the next. It is also true that the supermajority requirements for the passage of controversial pieces of legislation in the Senate were not written into the Constitution but have evolved over time as an extension of the two party system, and are an encumbrance to the initial passage of significant social legislation. The final barrier to legislation that fosters social change is the ability of those with a minority opinion to take the question to the Supreme Court, which in turn has become increasingly political as judges are essentially political appointees for life as confirmed by the last two successful nominations following the denial of a confirmation by senate Majority Leader Mitch McConnell of nomination hearings to Merrick Garland, nominated by Barack Obama in the last year of his presidency.
As some say Churchill said, “Democracy is the worst form of government except for all those other forms that have been tried.” As Bill Belichick might say, “It is what it is..” Those famous men may be right, but it is also worthwhile for us to try understand how our basic differences that create different political opinions arise. This is particularly true if we ever hope to overcome them. If our red v. blue divide is our “national disease” we need to understand it better, if we are to have any chance of living better with it, even if we can’t overcome the tendency to sort ourselves into two opposed mindsets. To remain in a partisan mode, it is good to know your enemy.
In previous posts I have referenced Jonathan Haidt’s 2012 remarkable book, The Righteous Mind: Why Good People Are Divided By Politics and Religion. In a Sunday New York Times review from 2012 that you can read if you click on the last link, William Saletan wrote:
The problem isn’t that people don’t reason. They do reason. But their arguments aim to support their conclusions, not yours. Reason doesn’t work like a judge or teacher, impartially weighing evidence or guiding us to wisdom. It works more like a lawyer or press secretary, justifying our acts and judgments to others. Haidt shows, for example, how subjects relentlessly marshal arguments for the incest taboo, no matter how thoroughly an interrogator demolishes these arguments.
To explain this persistence, Haidt invokes an evolutionary hypothesis: We compete for social status, and the key advantage in this struggle is the ability to influence others. Reason, in this view, evolved to help us spin, not to help us learn. So if you want to change people’s minds, Haidt concludes, don’t appeal to their reason. Appeal to reason’s boss: the underlying moral intuitions whose conclusions reason defends.
In a chapter entitled “The Moral Foundations of Politics” Haidt shows how the five “foundations” of morality that his research and the efforts of other experimental psychologists have demonstrated can sort out to be good fits that explain the origin of the red and blue mindsets. We all fall along a spectrum of responses to the issues and concerns of these foundations, but they do show a significant variation in “expression” when we compare conservatives to liberals. The first benefit of such an analysis is to remove a sense of “more moral” or “less moral” from the discussion. Both sides consider their position to be “right.” Everything else is a rationalization supported by the underlying reality of “what is.” It occurs to me that if in our enlightenment we can accept a broad expression of sexuality that goes far beyond male and female, we should also be able to realize the possibility that there is an equally diverse sense of what is “right” in other spheres. The ultimate challenge is to move forward together despite our inherently different points of view.
Haidt is a good teacher and summarizes his thoughts at the end of each chapter. At the end of the chapter on the Moral Foundations of Politics, he made the following points:
- … [I] defined innateness as “organized in advance of experience,” like the first draft of a book that gets revised as individuals grow up within diverse cultures. This definition allowed me to propose that the moral foundations are innate.
- …if you look for links between evolutionary theory and anthropological observations, you can take some educated guesses about what was in the universal first draft of human nature…
I like the concept of the basic instincts being like a first draft. That suggests they are some form of inheritance, or that they arise from early influences in our development. The benefit of the “first draft” concept also leaves room for growth and change as we process our experiences in life. I know that my viewpoint or understanding on many issues has changed over the years. That people can learn and change is a hopeful concept. Ronald Reagan may be a good example of someone who changed his views as life progressed. Over his life he migrated from what was a liberal worldview to being the godfather of American conservatives. Those foundational “guesses” that Haidt suggests are:
- The Care/ harm foundation evolved in response to the adaptive challenge of caring for vulnerable children. It makes us sensitive to signs of suffering and need; it makes us despise cruelty and want to care for those who are suffering.
- The Fairness/ cheating foundation evolved in response to the adaptive challenge of reaping the rewards of cooperation without getting exploited. It makes us sensitive to indications that another person is likely to be a good (or bad) partner for collaboration and reciprocal altruism. It makes us want to shun or punish cheaters.
- The Loyalty/ betrayal foundation evolved in response to the adaptive challenge of forming and maintaining coalitions. It makes us sensitive to signs that another person is (or is not) a team player. It makes us trust and reward such people, and it makes us want to hurt, ostracize, or even kill those who betray us or our group.
- The Authority/ subversion foundation evolved in response to the adaptive challenge of forging relationships that will benefit us within social hierarchies. It makes us sensitive to signs of rank or status, and to signs that other people are (or are not) behaving properly, given their position.
- The Sanctity/ degradation foundation evolved initially in response to the adaptive challenge of the omnivore’s dilemma, and then to the broader challenge of living in a world of pathogens and parasites. It includes the behavioral immune system, which can make us wary of a diverse array of symbolic objects and threats. It makes it possible for people to invest objects with irrational and extreme values—both positive and negative—which are important for binding groups together.
Haidt’s foundations attempt to show how “the two ends of the political spectrum rely upon each foundation in different ways, or to different degrees.”
Haidt postulates that the left relies primarily on the first foundation that is built on care and fairness, and that the other four foundations are much less important to liberals. Number 5 is a good example of a foundation that the left minimizes. Concepts of sanctity and degradation lead to the attitude in conservatives that causes them to oppose abortion, and to oppose extending equal rights of the LGBTQ+ community since they consider any manifestation of sexuality other than heterosexual relationships to be repugnant. The surprise in Haidt’s analysis is that those in our country who lean rightward have a high affinity for all five positions. They are “compassionate conservatives.”They resist getting something for nothing, or not being a “team player.” They like authority. They like being in a group. They can’t stand “freeloaders.” Haidt postulates that there may be an inherent political advantage to conservative positions since more Americans demonstrate an affinity for the full range of moral foundations he describes when they are tested by questions. It is good to be reminded that this work was published in 2012, long before the election of Donald Trump, but at a time when Trump was already expressing positions that Haidt would predict to be favorably viewed by conservatives.
Now let’s look at “Costs, Benefits, and Sacred Values — Why Health Care Reform Is So Fraught.” Dr. Rosenbaum begins her article with reference to a town hall meeting in South Carolina in 2010 when the conservative politician conducting the meeting was confronted by an angry member of the audience who warned that the government should keep its hands off “his Medicare.” Something like this has happened on more than one occasion and the first reaction is to laugh at the ignorance and inconsistency of thought expressed by the speaker, but there are other explanations as will emerge in her discussion.
She takes a shot at describing the “current state:”
As debate about U.S. health care begins anew, with particular focus on a “Medicare for All” type insurance design, it’s worth considering why weighing the complex but real trade-offs involved in health policy remains so politically challenging. Unlike, say, action to address climate change, whose advocates must often appeal to people’s interest in future events, health care is already a universal concern: everyone has been ill or loved someone who has been. And with more than 27 million Americans uninsured and a health care system that costs more than any other country’s while often delivering lesser quality, few people would dispute the need for something better. Yet consensus around reform remains elusive.
She paints a picture of fear and frustration. The ninety plus percent of Americans who are covered would like something better, but would like to have it with proof or guarantee that it will be better than what they have. They are not willing to give up what they have until their fears are resolved. It’s hard for them to believe that something won’t go wrong in the transition that will result in a loss either in the form of care that has a lower quality, care that will cost more, or both of those things plus other disasters yet to be experienced. Most Americans want something better and a majority of Americans feel that healthcare should be “a right,” but they are afraid to “go for it” for fear that in the transition much will be lost.
The Democrats have to present their proposals in ways that take these fears into consideration. “Mayor Pete” emphasizes personal control and choice when he offers Medicare For All Who Want It, and Elizabeth Warren has modified her Medicare For All proposal to have a three year “phase in” which is a tip of the hat to the public’s fears. Almost lost in the discussion is the reality that straight Medicare is still associated with large out of pocket costs and does not cover many needed items. Medicare Advantage also has some distinct disadvantages like a restricted network. Bernie Sanders’ Medicare For All is very different from either of the current forms of Medicare and is a much richer offering than anything we have now. The problem with all of the “improved” programs is predicting the costs since there is much uncertainty about how much providers and hospitals will be paid and variation within what would be covered and the portion of cost to be covered by individuals. On top of those concerns there is the question of what will happen when government control changes party hands the next time. Will we see an attempt at dismantling all that has been accomplished, as we have seen Republicans try to do with the ACA? Dr. Rosenbaum continues:
The complexity doesn’t end with predicting costs. Even an outcome that seems purely beneficial, such as more generous coverage for more people, gets complicated when critical details are considered, such as what exactly will be covered and who will decide. As professor of health policy Ashish Jha emphasizes, “Liberals would love Medicare run by Obama. But we don’t always elect Obama. Sometimes we elect Trump.” Giving the government a bigger role could mean relitigating benefits like basic reproductive health coverage every 4 years. “How deeply ingrained into the political process do we want coverage to be?” Jha asks.
That is a clear expression of the fact that with our two party system no law or social program is guaranteed when the government’s administration moves to the opposing party. The continuing attacks on the ACA, first in Congress, then by administrative abuse, and now in the courts, underlines Dr. Jha’s point. That’s not all:
Other trade-offs, such as the possibility that a single-payer system would compromise innovation, are also uncertain. Government programs, health economist Amitabh Chandra points out, are slow to embrace change; for example, Medicare added prescription-drug coverage in 2006, decades after commercial insurers did. Pharmaceutical manufacturers argue that their own ability to innovate could be thwarted if we vest too much health care power in the federal government. Allowing Medicare to set drug prices, for instance, might rescue people who can’t afford their medications today — but potentially at the expense of those who will die of diseases for which treatments are lacking.
Don’t you hate it when somebody licks the red off your candy? If you can’t relate to that metaphor, it’s a bummer when your dreams become shaky under closer scrutiny. Part of the problem is that “It is what it is,” and “We are who we are.”
In the face of complex trade-offs, it’s tempting to reach for simple solutions. Jha, who is often asked why the United States can’t have a single-payer system like those in some other high-income countries, explains that “there is almost no health care system that can be transplanted without the host rejecting it.” He paraphrases the late health economist Uwe Reinhardt who, when asked about praise for the Danish health care system, would say something like, “Denmark has a great health care system. But if you want me to adopt the Danish health care system, you must also give me the Danish political system, and it would surely help if you also gave me the Danish people.” …Opponents of what’s broadly considered “socialized medicine” object to the creation or expansion of federal programs, even though once they’re receiving government health care benefits, most Americans…wouldn’t tolerate having them rescinded. Such loss aversion is nondiscriminating, of course: a central reason for wariness of Medicare for All is the desire of the privately insured to be allowed to stick with what they know.
Dr. Jha’s analysis is the equivalent of looking in the mirror and being honest about what you see. The paper then moves on to issue of values. The paragraph below can be understood in the context of Jonathan Haidt’s five foundations. It is a pretty good example of conflicts within and between The Care/ harm foundation, and The Fairness/ cheating foundation:
If complex uncertainties, powerful ideologies, and human idiosyncrasies compromise rational debate, the moral conflict at the core of health care reform makes reasoned analysis harder still: Is health care a right that should be guaranteed by our government? Or is it a privilege, a commodity, or merely a lifestyle choice? Inglis [the conservative politician who was confronted in the town meeting] mentioned someone he knows who told him how to “solve health care: You let people die on the steps of the hospital. That will teach them. They will get insurance then.” Trying to explain to someone with this worldview that millions of Americans who work nevertheless either can’t afford insurance or end up with bare-bones coverage or crippling medical debt seems futile…Moral psychology clarifies that when “sacred values” are at stake — and for many people, health care is one of them — the mere suggestion that we should analyze costs and benefits can be offensive….
Toward the end of the paper, and in the follow up interview with David Cutler, the same thought comes through. What most “covered” Americans want is a reduction in the cost of their portion of their care. Many, but not as many who want their costs lowered, believe that every American should have access to quality care. What is so difficult is figuring out how to make those desires become policy and reality in an environment of conflicting values that are an honest expressions of who we are. I believe that in time we will get there. The path to permanent solutions will need to include time taken to become clearer about our shared values.
The View From The Ice
Since I live just a few feet from a lake, there is probably nothing that I look at more than the lake. It’s the first thing I see when I look out of the window to see what the day might be like. The lake is visible from almost every room that I use in our house. On days like last night, when the moon is full and there are no clouds, it’s the last thing I look at as I lower the blinds and turn out the lights. In the summer I am out on the water most days until sunset, and my perspective is toward the shore. In the winter I am not out on the lake until I am sure it is safe.
Over the holidays, one of my sons and his wife were eager to walk on the lake. I was a little apprehensive until we observed some ice fishing activity. On one of my walks I saw a rowdy group out on the ice near the road about two miles from my house. They were about a hundred feet off shore in a cove near where I turn around on my usual walk. They were pretending to be fishing, but they had circled lawn chairs around a fire pit and had a large cooler of local IPAs. They were enjoying the winter equivalent of a day at the beach. When I shouted out to ask whether they had caught any fish one of the troupe made a zero sign with his left thumb and first finger while he held up a beer can with his right hand. He gave me a big smile and a shrug of his shoulders that gave me the clear answer that fishing was not his priority. Fishing was only an excuse for the day he was enjoying. About a mile closer to home there were some college aged men playing a vigorous hockey game. Some of their female “spectators” had skated out toward the middle of the lake, and were paying no attention at all to their hockey heroes
After I reported that I thought the ice was fine to the crowd at my house, based on what I had observed, my son and his wife decided that it was time to take their own walk on the ice. I asked them to bring back a picture for me to share with you. It was late in the day so things are a little on the darkside, but it seemed that after using so many shots out from the shore, it was time for me to give you the view from the ice.
I am planning on spending more time on the ice this winter. I am not much of a skater since I grew up where the only place you saw ice was in your tea. I still have a pair of no wax cross country skis that I bought in the seventies, and I have relatively new snowshoes. I think I will start with the snowshoes. I also have “inherited” quite a bit of ice fishing gear from my old fishing buddy “Bob” who passed away two years ago, so I am all set for my own ice fishing adventures. In other years I have frequently seen people fishing just off my shore in what would be the foreground of the picture. Bob and I did some ice fishing a few years ago, but without much luck, but we did enjoy our beverages. My five year old grandson and I did hook a three inch perch through the ice when he was here during Christmas 2018.
That was my last try. It is time to cut some holes in the ice again. I tried out my auger yesterday, and the ice in my cove, near the tracks in the picture, is now sixteen inches thick, plus about six inches of fresh snow. According to the Farmer’s Almanac, twelve inches will support an eight ton truck. Fifteen inches will support ten tons. I have seen the ice be over twenty inches thick. If things go really well, I may try “Nordic skating” before the winter is over.
The prediction for this weekend is for the weather to be warmer than usual. I won’t worry about the ice melting. That won’t happen until mid April. Wherever you are, and whatever the temp, I hope that you have a great weekend outdoors. Just be sure that if you are out on the ice it’s at least four inches thick.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
