Public Policy and Governance – Page 324

So One Hologram Says to the Other….

My son Stephen is home for the Thanksgiving weekend, and last night the three of us watched one of the shows in Nova’s “Fabric of the Cosmos” series. This one explored the nature of space–which is not “nothingness” as we might imagine.

These Nova productions do a great job of simplifying complex science, drawing analogies to things we understand. That said, by the time the show concluded, my head hurt.

I had no idea that black holes–in addition to squashing everything that has the misfortune to get swept up within their immense density–keep copies of what they crush on their “outside.” (Whatever the outside of a black hole is.) Nor had I encountered the theory that our world might consist of holographic images of those images.

Does your head hurt yet?

I may not have learned much about physics from this particular explanation, but it did illustrate, once again, the immense gulf between what I know and what science has discovered. And that makes me wonder–again–about the processes we use to make policy in this country.

If I were a lawmaker, and I was being asked to vote upon a measure to fund a particular scientific inquiry, how would I evaluate the merits of the project? What if I was being asked to ban a certain line of experimentation? And even if I had access to excellent advice, how would I justify my vote–whatever it was–to those who elected me?

When Texas was a potential site for the Hadron Collider, there was a frenzy of fear that it would create a black hole that would swallow the Earth. It was subsequently built in Switzerland, began operations recently, and thus far, at least, we’re still here. Or at least our holographic images…

I really don’t want to turn policymaking over to the technocrats and nerds, but I also don’t think Joe and Jane Sixpack and I are equipped to make a lot of the decisions that we collectively need to make.

As the world gets more and more complicated, we need to think carefully about the level of knowledge we need to make good policy, and how we might keep decision-making both democratic and informed.

Unfortunately, this hologram has no idea how to do that.

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Too Complicated for Democracy?

A breakfast discussion this morning about the Indiana Legislature and “Right to Work” reinforced a concern I’ve harbored.

For years, when I heard discussions about “Right to Work,” it seemed obvious to me that everyone should have the right to work without being forced to join a union. That, after all, was the way the issue was framed, and I was totally unaware that the reality was more complicated. Once I understood the issue more fully, I changed my policy preference.

The problem is, more and more issues are like Right to Work. No matter how simple the framing, the policies themselves require more in-depth knowledge in order to genuinely understand what is at stake. Formulations that compare decisions about the national budget to those you make for your own household, “Dirty Harry” approaches to criminal justice, “we just need to deport illegal immigrants” simplifications and numerous other “everyone knows” “it’s just common sense” approaches to government decision-making are simple, deceptively appealing, and usually (but not always) wrong.

The question is: how well can democracy work when even the most diligent voter (and how many of those are there?) is unlikely to be informed about the complexities of the policies being proposed by candidates? How can we citizens make good decisions in an increasingly complex world?

I don’t have the answer to that question. But in a complicated world, a measure of humility would seem to be in order. At the very least, voters should cultivate a healthy suspicion of candidates displaying too much certitude–candidates who tell us the problems are simple. And we should run like hell from the ones who profess to have all the answers.

Democracy Vouchers

It’s hard to find anyone other than Karl Rove who disagrees with the proposition that there is way too much money in politics.

It doesn’t take a rocket scientist to recognize that–in the words of the Supreme Court–money equals speech. Unfortunately, what the Court meant and what reality looks like are different; the sense in which money is really speech is that people with lots of money have a much louder voice in policymaking than people who have less. Most of us understand that while robust debate is healthy, buying politicians doesn’t exactly advance the political process.

What it may take a rocket scientist to figure out, however, is how to fix our broken system.

He may not be that rocket scientist, but Lawrence Lessig is a Harvard professor with an intriguing idea: “Democracy Vouchers.” In his plan, each citizen would be given a $50 tax rebate, in the form of a voucher that he or she can assign to any political candidate who has agreed to accept only donations of $100 or less from individuals–not from PACs, not from Corporations, just $100 or less from real citizens.

Could this work? Probably not–for one thing, it doesn’t address so-called “Independent Expenditures,” which currently pose the most significant threat to our democratic system. As I understand Lessig’s proposal, it wouldn’t touch SuperPacs and the like.

If polls are to be believed, American citizens have finally, reluctantly, come to consensus on the diagnosis of what ails our body politic: we’ve allowed money and special interests to corrupt the system in favor of the “haves.” If it turns out that “Democracy Vouchers,” won’t cure us, we need to figure out what will.

And we need to figure it out before the patient is too far gone to be resuscitated.

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Masson’s Home Run

I always read Masson’s Blog, and always find him insightful, but this morning’s post on the mis-named “Right to Work” proposal is an absolute home run.

In an era that elevates spin over accuracy, naming/framing all too often substitutes for describing. “Right to Work” is a wonderful example–who could be opposed to people’s right to work? It is phrasing that feeds into the American belief in individual rights. And as Doug Masson explains, it is a phrase that has very little relationship to the reality of the legislation.

As Masson writes,

The perniciously named “right to work” is a misnomer. What the law really does is use government authority to prohibit a certain kind of contract. As it stands now, employers and employees have the freedom to enter into a contract whereby one of the conditions of employment is that employees join a union or, at least, pay some equivalent of union dues so they are not tempted to be free riders, receiving union benefits without paying for them. So, it’s a contractual provision that is currently permitted but not required. “Right to work” is a limitation on this freedom to contract. The General Assembly tells employers that they are not permitted to make union membership a condition of employment.

This is typically dressed up as championing the rights of future employees who might not want to join a union as a condition of employment; but the oddity is that typically the advocates of this restriction on contracts are, in other contexts, champions of absolute freedom to contract and could rarely care less what a potential employee thinks about the conditions of employment set by an employer. (Don’t like that condition of employment? Fine, go work somewhere else.) But, when union membership comes up, horrors! Conditions that are pro-union or anti-gun are off the table, but pretty much anything else goes.”

Home run!

This post should be distributed far and wide.

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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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