The Power of Promises

Before I begin: Am I the only one who is put off by this picture? I bear no ill-will towards the President, at least not in a personal sense, but there is something about this that just doesn't sit right with me. I feel like I should be looking at it from a dingy bridge underpass in a George Orwell novel. Maybe it's just me.

In any case, the mantra "Yes We Can!" remains in full force. However, I believe the administration is finding out that it is a lot easier to talk about change than it is to actually accomplish it in any positive sense. At least when it comes to health care.

To be fair, the President has put forward certain ideas that would slow the growth of Medicare and Medicaid, but they fall far short of what will be ultimately necessary if these programs are to maintain some semblance of solvency. These proposals, however, have been coupled with calls for increased spending on such things as preventative care, a politically popular item yet one which, time and again, has been shown to possess no real long-term savings potential. Even in the face of data pointing to the contrary, and the reticence of Congress' own Congressional Budget Office to back the claim, proponents maintain that if you spend the money now to keep people healthy you will save more down the road by not having to pay for expensive chronic illnesses.

Sounds good, right? The problem, besides the fact that prevention itself costs a great deal of money (take universal screening, for example: most tests will be carried out on individuals who are entirely healthy, representing a welfare loss to the whole community), is that old age and dying are expensive propositions, and is where we exercise more than three-quarters of our health care spending as a nation. What's more, they are unavoidable byproducts of the human condition. In fact, a recent New England Journal of Medicine article even demonstrated that, over the course of a lifetime, healthy individuals who live to a ripe old age incur greater costs than unhealthy individuals. No amount of prevention can stop Father Time and the ravages he brings. Simply put: if you spend more money on health care, you spend more money on health care, no matter how good it may sound politically.

Then there was the "plan" unveiled last week by the President, flanked by industry representatives, to reduce $2 trillion in health spending over the next ten years. I place "plan" in quotation marks here because I heard no plan. I did hear half-hearted promises, which these days seem to be just as good.

Irrespective of the great fanfare surrounding the meeting of lobbyists, hospital, insurance, physician and patient associations, I did not hear anything even resembling a plan that might somehow accomplish the feat set out by the President. The "plan" appeared to be more of a lukewarm agreement that, yes, it would be nice to lower health care costs. Once the discussion turns to who will bear the brunt of that $2 trillion cut, I foresee a lot less handshaking and photo-ops and a lot more fist shaking and jockeying for favor. Still, to hear some members of the press describe the event, it was an occasion of great moment, a historic milestone. This may be so, as the groups involved do not, traditionally, see eye to eye on what any kind of health reform should look like, but apparently it was Mr. Obama who finally brought the foes together.

Keith Hennessey, former Director of the White House's National Economic Council, provides a superb analogy of the reality of this situation at his MUST READ BLOG. I shall paraphrase:

Imagine Mayor Bloomberg of New York City were to hold a press conference with the General Manager of the Yankees, announcing that, working with the players and coaches, he will develop plans to win 40 more games this season than they otherwise would have won (Lord knows we need it). Those plans will improve the team's hitting, pitching, and fielding. Fans will then applaud and go home happy.

Later that night, while fans are watching Johnny Damon miss a play at third that a fielder with a stronger arm would have made, some questions might arise. Among them:

How will you improve hitting, pitching, and fielding? How will you make Damon a better fielder?

What did he mean when he said he "will develop plans"? Doesn't he have any already? Why didn't he talk about those?

How are we supposed to verify that the team won 40 more games than they otherwise would have, since we will never know how many games they would have won?

Other than having picked the number 40, what is Bloomberg even doing at this press conference?

If this is such a good idea, what has changed to make it happen now? Is the Mayor claiming that his persuasive powers alone are worth 40 more wins?

These questions are fundamental to our efforts to reform the health care system. How can we make treatment more efficient and accessible? How can we align incentives so that providers are encouraged to accomplish those things we deem systemically desirable yet have somehow not materialized? In the end, it is private industry that must take the steps to improve performance and quality, and somehow remain financially viable while doing it. The government can help by creating an environment conducive to investment and reform, but a President cannot "persuade" an industry to undertake actions that it otherwise would never have taken. Presidents are not clairvoyants who can see the inefficiencies in management that lifelong medical professionals have somehow missed.

In Mr. Hennessey's words:

The President is attempting to claim credit for savings that (a) do not yet exist, (b) are not backed up by any specific changes in industry practices or government policies, and (c) are related to him only in that the groups announced they were adopting his quantitative goal. For all of these reasons, the President's claim that these savings will materialize is wildly unrealistic ... This is like the Mayor claiming credit for the 40 additional wins now, and telling fans that he will be responsible for the team winning the pennant.

I only wish it were that easy. The Yanks need a pennant.

*I believe I should close with this - Please do not take this as a partisan jab, nothing would disappoint me more than if my analysis came across as mere demagoguery. Take it for what it is: an assessment of an individual who's political raison d'etre is cemented in his ambitious drive towards "change," which has still never been clearly identified. I merely wish to point out how promises have somehow replaced policies when it comes to the behavior of our elected officials. Inconsequential on the surface, this new course can spell serious peril, as one candidate can always out-promise another. Let us not find ourselve mired in the prophetic words of the 18th century Scottish historian Alexander Tytler:

A democracy cannot exist as a permanent form of government. It can only exist until the voters discover that they can vote themselves largesse from the public treasury. From that moment on, the majority always votes for the candidates promising the most benefits from the public treasury with the result that a democracy always collapses over loose fiscal policy, always followed by a dictatorship. The average age of the world's greatest civilizations has been 200 years.

Great nations rise and fall. The people go from bondage to spiritual truth, to great courage, from courage to liberty, from liberty to abundance, from abundance to selfishness, from selfishness to complacency, from complacency to apathy, from apathy to dependence, from dependence back again to bondage.