Public Policy and Governance – Page 316

This is Not a Bill

I’ve been following the Sunday series in the New York Times in which Ezekiel Emanuel—vice-provost and Professor of Medical Ethics at the University of Pennsylvania, and former White House advisor—has been explaining high healthcare costs.

I particularly appreciated this week’s discussion, “Billions Wasted on Billing.” My husband and I are at the age when doctor’s visits become more frequent, and I have weekly opportunities to open envelopes to read incomprehensible jumbles of medical and financial jargon under the heading “this is not a bill.” Anyone having experience with mailings of any sort—bills, invoices, reminders—knows that it is impossible to generate and mail anything for less than $5-$7 dollars, once you account for clerical time, stationery and postage. I’ve never understood why the same not-so-informative information can’t be included when the actual bill is sent.

Emanuel’s column was not just about billing, but about all the other repetitive, duplicative paperwork that characterizes our current health care system. How many times do we fill out patient forms with the identical information? How many insurance claims must be completed in different formats by all those white-haired ladies in colorful smocks sitting behind the glass partitions in your doctor’s office?

What does all this cost, and how much of it is really necessary?

According to Harvard economist David Cutler, electronic billing and credentialing could save the system upwards of 32 billion dollars a year. Transitioning to electronic record-keeping would pay other dividends as well: it would allow medical providers to use existing anti-fraud detection methods currently used by credit card companies, and it would minimize the errors that are inevitable when data is manually entered. (No longer getting “this is not a bill” mailings would also have a salutary effect on my blood pressure.)

What Emanuel’s column did not address is the question why medical insurers and providers have been so slow to adapt to the electronic age. I think a part of the answer is the complexity of what passes for a medical system in the U.S.—a complexity that also bedevils efforts to conduct reasonable policy discussions about health care in general.

We’ve all joked about the senior citizen at the Town Hall meeting who shouted “keep government’s hands off my Medicare.” It’s true that most Americans do know Medicare and Medicaid are government programs. We know that taxpayers fund the (much-lauded) Veteran’s Administration. But how many of us understand the extent to which government currently funds pharmaceutical and medical research? Or how much state governments contribute to the cost of medical education? To public health programs? How many of us know what local government units spend for everything from ambulance service to charity care?

I like to think of myself as informed, but I certainly don’t know the answers to those questions. I was astounded a few years ago when, serving on an academic committee dominated by healthcare professionals, I learned that government at all levels currently funds between 60% and 70% of all healthcare costs.

The real question isn’t whether we should have a government system or a private one. We haven’t had a private, market-driven system for decades, and for good reason. Markets require a willing buyer and willing seller, each of whom has the necessary relevant information and the ability to exercise choice. The real question is how to identify the measures that will reduce healthcare costs and improve patient care and access. Right now, we pay 2 ½ times what the next most expensive country pays for a system that ranks 36^th in the world.

That’s a bill we shouldn’t have to pay.

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The Good Old Days

I have officially become one of those cranky old people who bemoan the passage of the “good old days.” Which is sad, since the good old days weren’t all that good.

Most of all, I miss the Republican Party I was a part of–a party that didn’t have an embarrassing slate of kooks for Presidential candidates, a party that had a platform rather than a religiously-held extremist ideology. It was genuinely pro-business, pro-family and pro-good-government.

How times–and definitions–have changed!

In Congress, the GOP has again defeated President Obama’s proposal to create jobs by repairing America’s deteriorating infrastructure. The party I used to belong to would have sponsored such a measure. Indiana’s two Senators participated in the Senate filibuster–something I would have expected of Dan Coats, but that constitutes one more shameful effort by Dick Lugar to ingratiate himself with the crazies who detest him for the sin of previously being thoughtful. But the GOP did offer an alternative to the President’s bill–they reaffirmed that America’s national motto is “In God We Trust.” Not that anyone had suggested otherwise.

A pro-business party understands that economic prosperity depends upon the creation of jobs that allow people to purchase goods from businesses. Whether they trust God or not, most businesses depend upon a well-maintained infrastructure, and a calm social order. Republicans used to understand that.

They also used to understand that responsible economic policies were the best way to be “pro family.” Today, we have the embarrassing spectacle of Rep. Joe Walsh, first-term Tea Partier, getting a “Pro Family” award from the Family Research Council, despite the fact that he owes over 100,000 in back child support for his own children. But he was “pro family” because he voted to repeal healthcare, defund Planned Parenthood and uphold DOMA. Words fail.

Good government? When I was in City Hall, in a Republican Administration, the party put a premium on professionalism and careful analysis. The people I worked with would never have been guilty of the gross incompetence that led to the Litebox blunder. They would never have relinquished control of the city’s parking infrastructure for 50 years, in order to enrich a well-connected vendor at taxpayer expense. (And the Mayor I worked for–who really wasn’t a “politician”- would never have stooped to accusing an opponent of responsibility for an increase in rapes that occurred during the time she served as Deputy Mayor for Economic Development.)

There was plenty wrong when I was politically active. The administration I served was far from perfect, and Republican politicians weren’t saints. But next to what we have today, they sure look good. I miss them–and America desperately needs them back.

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A Step in the Right Direction

The Supreme Court’s decision in Citizens United should have been a wake-up call for those of us who have been concerned over the growing power of corporate America. Corporations have their place–by shielding entrepreneurs from personal liability, they encourage risk-taking and innovation; I have no problem with the corporate form as a useful business mechanism. (Although I do find it ironic that the growth in corporate hegemony tends to be applauded by people who talk a lot about the need for poor people to exercise “personal responsibility.” Corporations were invented to allow people to escape personal responsibility.)

The problem isn’t with the existence of corporate entities, the problem is with confusing these artificial constructs with human beings, and awarding them rights. There’s a reason we call our individual liberties “human rights.” When the Supreme Court essentially ruled that corporations and labor unions could give unlimited amounts to political candidates and causes, and justified that ruling as “free speech,” most observers–certainly this one–considered the decision both ill-considered and extremely dangerous. When the Senate refused to pass a measure requiring disclosure of such contributions, the floodgates seemed permanently open. We are going to see unprecedented sums spent by the 1% to influence the 2012 elections, and distort the electoral process.

The influence of money on our government has been well documented, and the picture isn’t pretty, but I was heartened to see President Obama taking at least a small step toward limiting the wholesale purchase of policy.

It has been reported that the President is drafting an executive order that would require companies pursuing federal contracts to disclose political contributions that have been secret under the Citizen’s United ruling. Despite howls from the usual suspects, this is a modest “good government” measure that does not violate anyone’s free speech rights. If a company wants to do business with government, and receive payment from our tax dollars, we the people have a right to know whether that business has been contributing to lawmakers and/or government officials who will influence those contracting decisions.

It’s not enough–we need to reign in the increasingly common use of obscene amounts of corporate money to gain political advantage. But it’s a start.

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The Free Rider Problem

Yesterday I received my copy of PA Times–a publication that is admittedly unlikely to be on the bookshelves of those who read this blog. It’s issued by the Association for Public Administration, and it has articles that appeal primarily to geeks like me who study how governments work.

The article that caught my attention–and raised my ire–was all about “crowd-funding” government.

Crowd-funding, like crowd-sourcing, is a phenomenon of the internet. People wanting to raise funds for new businesses, or for charitable efforts, use the web to solicit many small investors or donors, rather than attempting to raise capital from banks (many would not be “bankable”) or large amounts from big donors. That’s creative, and I applaud the entrepreneurs and nonprofit organizations that are using that new tool.

But now, according to the article, the same approach is being taken by cash-strapped units of government to raise money for public projects. And I have a big problem with that.

Let me make one thing clear: I do not oppose efforts to trim government spending by revisiting what government does. Although citizens would passionately disagree over the propriety of having this or that task done by government, that is a discussion we should be having. (I would vote to discontinue the drug war in its current form, for example. Others might argue that local government ought not provide golf courses, or other recreational services.)

Once government at any level assumes responsibility for providing a service that benefits all its constituents, however, all of us need to pay our share to support those services. And let’s be honest about what constitutes “benefit.” My children aren’t in the public school system any more, but I benefit in numerous ways from living in a community where people are educated. I also share the disadvantages of a school system that is below par. A good school system adds value to my property, it helps my community attract good jobs, etc.

A government agency that inspects the chicken before my local Kroger can sell it, another that monitors air and water quality and yet another that keeps merchants from peddling unsafe devices all benefit me. I benefit from paved streets and traffic signals, from parks I can walk in, from zoning laws that keep someone from building a strip bar in my neighborhood…Well, you get the picture.

If these government functions are financed by contributions, rather than taxes, we have the classic “free rider” problem. The people who are unwilling to pay their fair share benefit equally with those who do pay. This is the dirty little secret that the rabidly anti-tax folks want to ignore.

In a sane world, citizens would decide by majority vote just what services government ought to provide. Then they would fund those services through a system of fair taxation. We can and should debate just what role government must play in our communities, and we can and should have robust arguments about the sort of tax system that is fair and equitable. We can and should demand efficient and businesslike management of our government agencies.

But when we reorder our common institutions to satisfy the selfish, when we burden those who care about their neighbors and neighborhoods in order that others can enjoy the benefits of government without bearing their fair share of the costs, we’ve truly lost any sense of what it means to build communities.

I don’t know about anyone else, but the last thing I want on my tombstone is the epitaph “free rider.”

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The Deficit That Matters

I know I’ve been beating this horse for awhile now, but I am firmly convinced that the most troubling deficit Americans face is not fiscal.

It’s our deficit of civic literacy.

Only 36 percent of Americans can correctly name the three branches of government. Fewer than half of 12^th grade students can describe the meaning of federalism. Only 35.5% of teenagers can correctly identify “We the People” as the first three words of the Constitution. The National Assessment of Education Progress (NAEP) 2006 report on civics competencies found that barely a quarter of the nation’s 4^th, 8^th and 12^th graders are proficient in civics, with only five percent of seniors able to identify and explain checks on presidential power. Things haven’t improved since then; the 2010 results were released earlier this year, and student performance at the 12^th grade level showed a statistically significant decline since the 2006 test. Average scores for female, White and African American students declined, and the percentage of 12^th grade students who reported studying the Constitution dropped by a statistically significant five percent. A list of all the additional literature documenting the extent of civic ignorance would be too lengthy to include.

The consequences of this ignorance are profound. The most important predictor of active civic engagement is greater civic knowledge–according to the Intercollegiate Studies Institute, greater civic literacy trumps even a college degree, and “no other variable, including age, income, race, gender, religion, or partisanship was found to exceed both the breadth and depth of civic literacy’s positive impact on active political engagement”.

Our research team conducted a survey of state departments of education, as part of an effort to determine the content and extent of civics instruction the various states are requiring. We identified two basic problems: first, there is no generally accepted definition of “civics” or “civic literacy.” Definitions ranged from knowledge of the Declaration, Constitution and Bill of Rights and their historical antecedents (our preferred meaning) to approaches that implicitly conflate community “good works” like planting trees or picking up trash in the parks or by the side of the road, with the production of “good citizens.” Depending upon a state’s particular view of what civics encompasses, civic education requirements might be met by taking a government course, a separate course called “civics,” an American history course, or some combination.

The second problem we found was that, with a few notable exceptions, even in states with very good civics and government standards, like Indiana, those standards are essentially aspirational. The requirements aren’t part of the current high-stakes testing regime, with the result that they are not taken seriously. Public schools’ focus remains firmly fixed upon those subjects being evaluated under No Child Left Behind, and the result is that large numbers of American students graduate from high school profoundly ignorant of the history, philosophy and architecture of their government institutions.

Scholars have identified a number of theorized consequences of our civic deficit: loss of civic identity; loss of public accountability; a paralyzed/polarized politics; a loss of personal agency, and unfortunate effects on the study of religion and science.

Civic identity. America is one of the most diverse countries on earth. Our citizens do not share a political history, a common religion, or a single race or ethnicity. As a consequence of immigration, we frequently do not even speak the same language. In the absence of such cultural ties, we require what Robert Bellah calls a “civil religion” in order to forge a common civic identity. In the United States, that civil religion has centered upon our constituent documents and the governing philosophy they embody, on what I call “The American Idea”. When Americans don’t know the contents of that Idea, when they are ignorant of the history, philosophy and evolution of our constitutional form of government, they may share a common national geography, but they don’t share a civic identity.
Public accountability. We hear a great deal about the obligation of government to be transparent and accountable. We hear less about the obligations of citizens to be sufficiently informed so that they can respond appropriately to information about the way in which government is conducting the people’s business. True accountability requires that those in power report adequately on the laws and regulations they have enacted and the other actions they have taken; it also requires a populace able to measure those laws and activities against the standards prescribed by our Constitution and Bill of Rights. When either half of that process is not functioning, accountability is compromised.
A paralyzed, polarized politics. We can see the consequences of our civic deficit every day, in presidential debates and campaigns for city councils. The loss of civic literacy is a loss of the ability to communicate. We can talk at each other, but no longer with each other, because we are not speaking the same language. American politicians on all points along the political spectrum constantly refer to the Constitution, but you only need to listen a short while to realize that very few of them seem to be talking about the same document. This lack of a common frame of reference makes productive dialogue impossible.
Loss of personal agency. In a country where citizens constantly interact with public organizations—from the Social Security Administration, to the Bureau of Motor Vehicles, to the local zoning administrator—a basic knowledge of one’s rights and duties as a citizen is essential to a sense of personal empowerment and efficacy. This is especially important to people who have limited personal and fiscal resources.
Science and religion. What is rarely noted, but important, is the relationship between students’ civic knowledge and their appreciation of the roots of both the American religious experience and the Establishment Clause. This is equally the case with science; both science and our particular conception of liberty and personal autonomy emerged from the Enlightenment, and some scholars have argued that science cannot flourish in a society in which that relationship is unrecognized.

The question is: what should we do? How do we fix this problem, which is at the root of so many other problems?

First, we need additional research. What are the reasons for our current deficit? Why haven’t we been able to sustain previous efforts to strengthen civic education? What elements of civic literacy lead to civic participation and action? What curricula have demonstrated effectiveness? What do citizens absolutely need to understand in order to be empowered participants in our civic conversations? What do they need to know in order to hold government accountable?

Second, we need a campaign to draw increased public attention to the nature and extent of the problems caused by our deficit of civic literacy. We need to “connect the dots” between our impoverished civic understanding and our political gridlock and polarization, and we need to make the case that citizenship requires more than a birth certificate (short form or long!).

Deficit reduction needs to begin with sound civics education.

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