^{Posted on August 18, 2001}

Theodore Marmor responds

Theodore R. Marmor, Professor of Public Policy and Management, Yale University School of Management, responds to Uwe Reinhardt:

This is a very low level of intellectual exchange, hardly worthy of Uwe. First, there is a straw man produced, then a commentary -- based on Uwe's participant observation--about the American citizenry. Not a word about the work on public opinion by, first, V.O.Key, and, more recently, by Ben Page, Larry Jacobs, and Robert Shapiro. In short, this is empirically uninformed generalizations, a subject that Uwe has strong opinions about. This reminds me of the fallacy of post-hoc, propter hoc, one that many economists are guilty of. If an outcome arises, it must have been because someone (group) wanted it and/or did not avoid it strongly enough. Ergo, what emerges must have been what was wanted/ or at least not sufficiently fought. This has little to do with explaining why America has the health care system it has, though the structure of our government--and the institutional advantages it gives to non-governmental interests does.

Theodore R. Marmor

Comment: Post hoc ergo propter hoc? - the great fallacy of logic that temporal relationships establish etiology. Is this or is this not a fault inherent in Professor Reinhardt's discussion? Does "political will" influence government action? Does political will even exist in the presence of an uninformed and unconcerned electorate? Is it a fallacy of logic to propose that a disinterested public fails to create the political will that would be required to enact health care reform? Professor Marmor seems to reject the role of the the lack of public input into the political process, even though that, in turn, does allow for the enactment of private institutional advantages. In my reading of Professor Reinhardt's comments, the concept of this lack of public involvement delivers a strong, implicit message, to which we shall return.

Fundamental to this discussion is understanding just what Americans do believe. Do Americans believe that individuals should be deprived of care simply because they cannot afford to pay for it? Suppose a teenage boy showed up at an emergency room with acute appendicitis, but has no insurance and no funds. Does anyone believe that he should be turned away? Of course not. What about the little girl with a potentially curable cancer, but with no insurance and no money. Everyone would agree that she must somehow be worked into our health care system, even if unable to pay. And what about the widow, who loses her insurance along with her husband, and then develops diabetic ketoacidosis. She too would certainly receive needed care. And the costs for providing care in each of these instances would be shifted to others, with all of us indirectly contributing through our unique, but highly flawed, American approaches to the funding of health care. But in this country, the costs of providing care for these individuals would be met only after they are forced into financial ruin or even bankruptcy. Does our egalitarian spirit that makes us want to assure that these people receive care extend to wanting them to face financial ruin? No, Americans are better than that. But Americans do have to begin to understand that these are the consequences of our highly flawed system of funding care. They have to understand that, with the same resources that we already have, we could provide insurance for these individuals and for everyone else in the nation. If they really did understand this, do you think that they might support that concept? They probably would, except for the hurdle that they believe that they don't want the government involved, or at least they believe that they believe that..

But what do they really believe about government involvement in publicly administered programs of social insurance, specifically Social Security and Medicare? Well, they certainly want their Social Security retirement benefits, although many now want a much larger benefit. They agree that there must be some form of mandatory funding, or tax, but some believe that they can increase the return through private investment accounts. It is not the purpose here to debate the actuarial value of Social Security disability insurance, survivors' annuities, progressive benefits, inflation adjustment of benefits, nor the excessive administrative expenses and risks of individual accounts. The point is that Americans do want government mandated retirement protection, and the majority still prefer public administration, and most of the rest would if they were fully informed on the issues. And Medicare? Focus groups now indicate that the majority do have some understanding of the privatization schemes, and they want a publicly administered Medicare program to always be there for them. In fact, they not only want Medicare to be protected, they want the benefits increased, especially to include pharmaceuticals. They want a bigger and better Medicare program, albeit a government program. Although anti-government elements have been successful in feeding Americans the "we don't want the government involved" rhetoric that they parrot, they have not been successful in convincing them that social insurance is bad. The problem is that we activists have not effectively delivered a message that they can believe and support, the message that universal social insurance for health care would solve essentially all of our problems with the funding of health care. Yet we activists continue to bask in our successes in health care reform.

Our successes? Look at them. Look at all of the legislative proposals that were successfully introduced. Look at all of the initiatives and referendums that made the ballot. Look at the various bills that were passed, lacking only the necessary funding. Look especially at the great numbers of successfully completed studies confirming our suspicions that we have serious problems in health care, in spite of our great resources. Look at the studies that have demonstrated that we can provide comprehensive care for everyone with no increase in expenditures. Look at the great body of literature in health policy that has expanded our understanding. In the past decade, our efforts have intensified, and our successes have escalated. And look at the numbers of the uninsured in the past decade... from approximately 32 million to 40 million!? And the numbers with inadequate coverage... accelerating at a dizzying pace now that we are "empowering" health care consumers. And an administration that has reduced the numbers of uninsured by 3 million... not really, but a manipulation of the numbers that reduces the pressure to do something, even if it didn't really bring one more individual into the ranks of the insured.

Our decade of successes has left us worse off than when we began! And yet we have a nation that believes that they are complacent with the status quo... if only they understood. And that is where we have failed. There will never be reform without political will. And there will never be political will without a clear message from the people. And there will never be a clear message if the people don't understand the real issues. And there will never be reform if we continue to fail in our task of informing the public.

Maybe Professor Marmor was looking for a different message. But Professor Reinhardt's message jumped out at me from the computer screen. The message I saw? HEY! YOU ACTIVISTS. WAKE UP! GET UP OFF OF YOUR DAMN DUFFS. GET OUT THERE AND WAKE UP THE NATION! WAKE THEM UP AND DELIVER THE GREAT NEWS THAT WE CAN PAINLESSLY ACHIEVE EQUITY AND JUSTICE IN HEALTH CARE FOR EVERYONE.

Yes, that is Professor Reinhardt's message. But it is our task.

Don

Uwe Reinhardt responds to Theodore Marmor

Earlier message of Theodore R. Marmor:

This is a very low level of intellectual exchange, hardly worthy of Uwe... (remainder of message deleted)

Uwe Reinhardt responds:

My dear friend Ted:

Although I always welcome your thoughts on matters of social policy, and often profit from them, I am less charmed by your easy habit of dismissing arguments you do not like with adjectives such as "low-level intellectual exchange" or "empirically uninformed," or similar infelicitous phrases. It is not a good habit, Ted, and you ought to disabuse yourself of it. Please stick to the substance of the argument and forget the ad-hominem barbs. You are a smart fellow, we know; but so are others in this debate. You may have noticed that I disagreed with Kip, but I did not call him names nor characterize his arguments with infelicitous labels. The only one I called names may be the lethargic American citizen, but even here the label "teenager" was meant to be seriously descriptive. I do find something juvenile in the idea that one has rights and no civic obligations and, frankly, never did get my mind around the American people until our children had reached teenage years.

A year ago, at one of the Princeton Conferences, Norm Ornstein gave the keynote address. Perhaps you do not think well of Norm. I and many of my colleagues consider him an astute observer of American politics. It is the reason he was invited to give the keynote address at that august conference. One of Norm's propositions that night was that any proposed health reform that might exact any sacrifice whatsoever from any politically potent constituency is dead on arrival. I rose to remark that, in so many words, Norm had characterized the representative American citizen as a selfish lout without any civic vision, without any willingness ever to bear some personal sacrifice for the common good. There was icy silence in the room at first. But in the end everyone, including Norm, agreed that that is basically what he had proposed; and he stuck to it. Implicitly, we all agreed that universal coverage was, therefore, a far-off dream, that we could at most make small, incremental inroads into the problem of the uninsured. Indeed, we agreed that we might be lucky merely to maintain the status quo. What have you, Ted, to say about that? Is Norm Ornstein wrong?

After the 1994 election, I showed my students a graph (it had appeared in the NYT) according to which voter participation in the 1994 election rose sharply with income. As I (vaguely) recall it, over 60 to 65% percent of eligible voters with incomes above $60,000 voted. For the lower income strata the ratio descended to the mid 30s. I remarked to my students that it is small wonder that our economy is being rearranged by the government mainly to suit the tastes of the upper half of the income distribution and, incidentally, that the quest for universal health insurance was more or less derailed for the time being. If the subjects of our compassion don't even bother to vote, and if political activists like Pete Stark and Henry Waxman become imperiled anachronisms, who can help the poor?

Is it really low-level intellectualism to argue that the typical American has a more keenly developed sense of entitlements than of civic duties? Is it really low-level intellectualism to hypothesize that Canadians and Germans, who view their health systems as part of the cement that forges a group of people into a nation, may have a stronger sense of nationhood and the civic contributions that go with it? Are these observation so unworthy that they need to be dismissed with unflattering arguments and the recitation of sundry, allegedly illustrious names, rather than being debated on the substance? What about debating these arguments on the substance, Ted?

Finally, in the realm of politics, is the economist's idea that "if an outcome arises, it must have been because someone (group) wanted it and/or did not avoid it strong enough" or did not fight sufficiently hard for an alternative outcome really so far fetched that it can be easily dismissed simply with an allusion to the "post-hoc, ergo propter hoc" fallacy, without the need to engage the hypothesis directly, Ted? If the economist's line of reasoning is so wrong, what have political scientists to offer in its stead? Do outcomes just happen, without anyone either wanting them or opposing them or not sufficiently fighting for them? How, Ted, DO things happen, then?

I am aware that the structure of our government, in which political influence can be purchased retail, legislator by legislator, chairman by chairman, makes it more difficult to legislate clean health care legislation than does a parliamentary system such as Canada's or Germany's, where there is party discipline and where political influence must be purchased wholesale (i.e., the whole party), if that is legal at all. But to completely dismiss the voter in this picture, as you seem to do, Ted, strikes me as going much too far. Are you telling me, Ted, that the wishes of the electorate do not at all matter in our democracy, that structure is everything?

My perhaps politically naive theory would be that our system of government allows the electorate from time to time to put into power one of several rival elites, who then run the country for the duration of their term, mainly (though not exclusively) at the behest of powerful, moneyed interest groups or powerful ideological allies. The point is that the electorate does have the power to replace the elites at the helm. Surely that power is worth something, and the electorate can properly be held accountable for its exercise or lack thereof. Are you dismissing that power altogether, Ted? Can structure alone explain why a potential elite openly devoted to universal coverage (e.g., Bill Bradley's campaign last year) did not have a chance at all at the ballot box? Did the electorate having nothing at all to do with Bradley's demise? Did it just happen?

Don McCanne does a much finer job than I can in commenting further on your comment, Ted. Let me then leave it at that.

Best regards,

Uwe

Don McCanne commented:

(The message is deleted except for the final comment)

Uwe Reinhardt continues:

That is my message, Don. In my perhaps politically naive but nevertheless firm view, unless the political power of the lower-income strata can be concentrated on the problem of the uninsured, there is unlikely to be much legislative relief in that area (short of President Bush's having another epiphany. Miracles do happen.)

I would assume that I had sent all of you a somewhat angry piece I wrote on this issue two years ago for the US Chamber of Commerce. Ted is likely to dismiss that one, too. But many esteemed colleagues thought I was right on the mark with that piece among them, for example, Peter Budetti. If you don't have it, I'll e-mail it to you.