Speaking Truth to Power — The Need for, and Perils of, Health Policy Expertise in the White House

By Jacob S. Hacker, Ph.D.
The New England Journal of Medicine
September 11, 2008
The adviser is the president’s ally — in the lingo of organizational economics, an “agent” serving the interests of a “principal.” Yet as a bearer of specialized knowledge, the adviser is also responsible to a larger profession, to its values and commitments, and ultimately to the ideal of expertise itself.
The adviser, in short, must both “speak truth to power” and aid in the exercise of power, both offering unbiased intelligence and acting as a very biased assistant. It is fashionable to pretend these two roles are the same, but they are not. An expert adviser has special knowledge, training, and skills — all of which are needed more than ever in the White House. The question is whether these talents can really be used, or be useful, in the bare-knuckles world of American politics — and, more important, whether the values they embody can be upheld when science, advocacy, and democracy collide.
Politics is about power more than truth, about winning more than being right. But expertise is about truth more than power, and being right is the whole point.
Health policy experts can do more sophisticated analyses than ever, and there are more of them than ever, too — in policy schools, departments of economics, schools of public health, think tanks, private foundations, and government. But the progress in quality of expertise has not been matched by progress in thinking about the role of the expert or about how policy advice can and should be adapted to the political realities that those receiving advice inevitably confront. Policy experts are brilliant when it comes to designing proposals but often horrible at thinking through the ways in which their proposals will be refracted through the political prism. Subtle visions of policy are wedded to crude caricatures of politics, and, not surprisingly, those visions all too often either fail to become reality or fail to work.
Worse, the expert’s claim to authority can undercut the more important wellspring of democratic leadership: the demands and wishes of the people. Experts are habitually disdainful of what ordinary citizens believe. People have opinions; experts have facts. When a well-regarded economist complains that democratic policy choice should be restricted because “irrational” voters endorse all sorts of harmful nostrums — whether trade protection or farm price supports (he might have added health insurance with low deductibles, drug price controls, and free choice of doctors) — he may be out on a limb. But the tree is one that many policy experts climb.
We badly need health care experts in the White House who offer advice based on evidence and analysis, not prejudice. But even the best experts need to know when to defer to the political process, to see the purpose of their craft as facilitating democratic debate rather than providing final answers once Americans have decided on the questions.
Winston Churchill once said that “scientists should be on tap, not on top.” That is a good starting point. But sometimes presidential policy experts should also have the good sense to get out of the way.
http://content.nejm.org/cgi/content/full/359/11/1085

“… expertise is about truth more than power, and being right is the whole point.”
In deciding whether policy is right or wrong, it is essential first to decide what goals are to be achieved by the policy decisions. In reforming health care financing, most of us would agree that the goal is to provide everyone with access to all necessary health care without having to be exposed to financial hardship.
We have available a wide range of expertise within the policy community. When you look at the various policy recommendations, some of them, if enacted, would achieve this specific stated goal, but most of them would not. Those that would not are policies that are designed to achieve other less beneficial or even detrimental goals (ownership society: own your own debts). Stated in other terms, those supporting the few policies that would work are right, and those supporting policies that fall short are wrong.
In policy, being right is the whole point.
“Politics is about power more than truth, about winning more than being right.”
Politics is represented by the great legislative battles that we are witnessing wherein one side advocates for policies that are wrong, largely because they’re inadequate, and the other side advocates for policies that are completely wrong because they make matters worse.
Without the continual involvement of members of the policy community who emphatically support that which is right, we’ll continue to witness politics that results in wrong, wronger and wrongest policies.

By Jacob S. Hacker, Ph.D.
The New England Journal of Medicine
September 11, 2008

The adviser is the president’s ally — in the lingo of organizational economics, an “agent” serving the interests of a “principal.” Yet as a bearer of specialized knowledge, the adviser is also responsible to a larger profession, to its values and commitments, and ultimately to the ideal of expertise itself.

The adviser, in short, must both “speak truth to power” and aid in the exercise of power, both offering unbiased intelligence and acting as a very biased assistant. It is fashionable to pretend these two roles are the same, but they are not. An expert adviser has special knowledge, training, and skills — all of which are needed more than ever in the White House. The question is whether these talents can really be used, or be useful, in the bare-knuckles world of American politics — and, more important, whether the values they embody can be upheld when science, advocacy, and democracy collide.

Politics is about power more than truth, about winning more than being right. But expertise is about truth more than power, and being right is the whole point.

Health policy experts can do more sophisticated analyses than ever, and there are more of them than ever, too — in policy schools, departments of economics, schools of public health, think tanks, private foundations, and government. But the progress in quality of expertise has not been matched by progress in thinking about the role of the expert or about how policy advice can and should be adapted to the political realities that those receiving advice inevitably confront. Policy experts are brilliant when it comes to designing proposals but often horrible at thinking through the ways in which their proposals will be refracted through the political prism. Subtle visions of policy are wedded to crude caricatures of politics, and, not surprisingly, those visions all too often either fail to become reality or fail to work.

Worse, the expert’s claim to authority can undercut the more important wellspring of democratic leadership: the demands and wishes of the people. Experts are habitually disdainful of what ordinary citizens believe. People have opinions; experts have facts. When a well-regarded economist complains that democratic policy choice should be restricted because “irrational” voters endorse all sorts of harmful nostrums — whether trade protection or farm price supports (he might have added health insurance with low deductibles, drug price controls, and free choice of doctors) — he may be out on a limb. But the tree is one that many policy experts climb.

We badly need health care experts in the White House who offer advice based on evidence and analysis, not prejudice. But even the best experts need to know when to defer to the political process, to see the purpose of their craft as facilitating democratic debate rather than providing final answers once Americans have decided on the questions.

Winston Churchill once said that “scientists should be on tap, not on top.” That is a good starting point. But sometimes presidential policy experts should also have the good sense to get out of the way.

http://content.nejm.org/cgi/content/full/359/11/1085

Comment:

By Don McCanne, MD

“… expertise is about truth more than power, and being right is the whole point.”

In deciding whether policy is right or wrong, it is essential first to decide what goals are to be achieved by the policy decisions. In reforming health care financing, most of us would agree that the goal is to provide everyone with access to all necessary health care without having to be exposed to financial hardship.

We have available a wide range of expertise within the policy community. When you look at the various policy recommendations, some of them, if enacted, would achieve this specific stated goal, but most of them would not. Those that would not are policies that are designed to achieve other less beneficial or even detrimental goals (ownership society: own your own debts). Stated in other terms, those supporting the few policies that would work are right, and those supporting policies that fall short are wrong.

In policy, being right is the whole point.

“Politics is about power more than truth, about winning more than being right.”

Politics is represented by the great legislative battles that we are witnessing wherein one side advocates for policies that are wrong, largely because they’re inadequate, and the other side advocates for policies that are completely wrong because they make matters worse.

Without the continual involvement of members of the policy community who emphatically support that which is right, we’ll continue to witness politics that results in wrong, wronger and wrongest policies.

Drop in Uninsured Unlikely to Influence Health Care Overhaul, Experts Say

By Neda Semnani
CQ HealthBeat
September 5, 2008
While new government figures show that a greater enrollment in public health programs has helped reduce the number of Americans without health insurance, experts said the data are unlikely to help make the case for expanding those programs as part of broader health care legislation next year.
David S. Johnson, the Census Bureau’s chief of Housing and Household Economics Statistics, which published the new figures, credits public programs like Medicaid and SCHIP for the increase in the insured, a trend experts believe may continue as employer-based coverage falls.
Analysts said the drop in the uninsured rate will have little influence in the broader discussion of health care legislation expected next year when a new president and Congress take office. The economic downturn and other budget priorities make it difficult for health care overhaul–a costly endeavor–to take center stage, they said.
“How much flexibility does the federal government have, given the declining economy and vast array of other problem areas? We have a lot of policy priorities. Health is an important one, but it’s not the only one,” said Joseph Antos, a health care scholar with the American Enterprise Institute, a conservative think tank. “Some kind of reform needs to happen . . . eventually. Gigantic reforms cost money. So ‘eventually’ may not happen in the first year or even in the first ten years of a new administration.”
Mark McClellan, director of the Engelberg Center for Health Care Reform with the non-partisan Brookings Institution, said, “With the fiscal outlook so tight, the challenge will be finding new ways to get costs down and coverage up, while filling gaps in quality.”
Judith Solomon, a senior fellow at the left-leaning Center on Budget and Policy Priorities, said the report examines the period just before the economic downturn and “doesn’t change what is the case for reform, it doesn’t change the case for reauthorizing strong public programs,” said Solomon, who specializes in Medicaid and the State Children’s Health Insurance Program (SCHIP).
The trend of greater enrollment in public health programs may continue in the current economic slowdown, said Karen Davenport, director of health policy with the liberal Center for American Progress. “On the one hand, we’re likely to see a greater insecurity in health coverage; on the other, a further up-tick in public coverage … The report points out just how effective these programs are in catching people when they fall. It shows that the individual market alone doesn’t work.”
http://www.commonwealthfund.org/healthpolicyweek/healthpolicyweek_show.htm?doc_id=704405

All we need to achieve comprehensive health care reform is to elect a new Congress and a new administration, and use the momentum of the first 100 days to push through Congress the voters’ mandate for reform. Right? Hmmm.
If we are going to have new legislation ready by January or February, the specifics of the proposals need to be precisely defined now so that they are ready to be converted into legislative language ASAP.
Is the McCain proposal ready? It would not be too difficult to write legislation that would diminish employer contributions to health plans by eliminating the tax advantages. It also would be fairly easy to allow sale of plans across state borders thereby creating a competitive market of the lowest common denominator of underinsurance plans. Tearing down programs that aren’t working very well and replacing them with programs that are much less effective is certainly not the reform we need.
What about creating a universal market of private plans like the members of Congress have: an FEHBP-like program? To be effective, these plans would have to cover essentially all necessary health care, and include individuals with greater health care needs. Those plans would be very expensive, certainly more than the $12,000 average premium charged for employer-sponsored plans covering healthy employees and their healthy families. Our current business-based private plans would require massive transformation to convert them into private social insurance plans characteristic of some of the European nations. Can you imagine the complexity of the legislation that would be required? Has anyone seen any serious specifics of such an approach that could be converted into legislative language within the first 100 days?
What about allowing the purchase of a Medicare-like option to complement the private insurance market? It wouldn’t be simply a provision to allow a buy-in to the current Medicare program simply because the Medicare risk pool is composed of very high-cost populations (elderly, chronically disabled, and chronic renal disease), and the premiums could never be affordable. Then what would a separate Medicare-like option look like? Good question. How comprehensive would the benefits be? How could cost-sharing be kept at a reasonable level? How much of the premium would the individual be responsible for? Would the balance be paid by the government? Would the private insurers who benefit from favorable selection be required to transfer funds to the public program? Has anyone seen any serious specifics that could be converted into legislative language in the first 100 days?
We do have legislative language for a proposal that actually would work, and it is already in a bill before Congress, with about 90 cosponsors in the House of Representatives: John Conyers’ HR 676. Oh, wait a minute; that’s not feasible, they tell us.
So what do the Democrats have in mind for the first 100 days, should they have control? Easy. They are going to expand the children’s health insurance program – SCHIP – certainly a good thing. They are going to look at the damage done to Medicare by the privatizers, but significant repairs will be too complex to enact right away; they’ll get to that later. Comprehensive reform? Not now; there are too many other important issues. Next year? Well, that’s an election year, so we can’t do it then. But we should be able to get to it possibly before the end of the president’s first term, and certainly by the end of the second.
Window slammed shut!
But don’t anyone start working on these issues now. We have more important decisions to make. Do we support the moral high ground of lipstick on a pit bull, or the moral low ground of lipstick on a pig?
In the face of all of our shameful societal problems, surely someone will come up with this answer to this most pressing problem of the day: the lipstick needs to go on the figurehead of the Swift Boat.

By Neda Semnani
CQ HealthBeat
September 5, 2008

While new government figures show that a greater enrollment in public health programs has helped reduce the number of Americans without health insurance, experts said the data are unlikely to help make the case for expanding those programs as part of broader health care legislation next year.

David S. Johnson, the Census Bureau’s chief of Housing and Household Economics Statistics, which published the new figures, credits public programs like Medicaid and SCHIP for the increase in the insured, a trend experts believe may continue as employer-based coverage falls.

Analysts said the drop in the uninsured rate will have little influence in the broader discussion of health care legislation expected next year when a new president and Congress take office. The economic downturn and other budget priorities make it difficult for health care overhaul–a costly endeavor–to take center stage, they said.

“How much flexibility does the federal government have, given the declining economy and vast array of other problem areas? We have a lot of policy priorities. Health is an important one, but it’s not the only one,” said Joseph Antos, a health care scholar with the American Enterprise Institute, a conservative think tank. “Some kind of reform needs to happen . . . eventually. Gigantic reforms cost money. So ‘eventually’ may not happen in the first year or even in the first ten years of a new administration.”

Mark McClellan, director of the Engelberg Center for Health Care Reform with the non-partisan Brookings Institution, said, “With the fiscal outlook so tight, the challenge will be finding new ways to get costs down and coverage up, while filling gaps in quality.”

Judith Solomon, a senior fellow at the left-leaning Center on Budget and Policy Priorities, said the report examines the period just before the economic downturn and “doesn’t change what is the case for reform, it doesn’t change the case for reauthorizing strong public programs,” said Solomon, who specializes in Medicaid and the State Children’s Health Insurance Program (SCHIP).

The trend of greater enrollment in public health programs may continue in the current economic slowdown, said Karen Davenport, director of health policy with the liberal Center for American Progress. “On the one hand, we’re likely to see a greater insecurity in health coverage; on the other, a further up-tick in public coverage … The report points out just how effective these programs are in catching people when they fall. It shows that the individual market alone doesn’t work.”

http://www.commonwealthfund.org/healthpolicyweek/healthpolicyweek_show.htm?doc_id=704405

Comment:

By Don McCanne, MD

All we need to achieve comprehensive health care reform is to elect a new Congress and a new administration, and use the momentum of the first 100 days to push through Congress the voters’ mandate for reform. Right? Hmmm.

If we are going to have new legislation ready by January or February, the specifics of the proposals need to be precisely defined now so that they are ready to be converted into legislative language ASAP.

Is the McCain proposal ready? It would not be too difficult to write legislation that would diminish employer contributions to health plans by eliminating the tax advantages. It also would be fairly easy to allow sale of plans across state borders thereby creating a competitive market of the lowest common denominator of underinsurance plans. Tearing down programs that aren’t working very well and replacing them with programs that are much less effective is certainly not the reform we need.

What about creating a universal market of private plans like the members of Congress have: an FEHBP-like program? To be effective, these plans would have to cover essentially all necessary health care, and include individuals with greater health care needs. Those plans would be very expensive, certainly more than the $12,000 average premium charged for employer-sponsored plans covering healthy employees and their healthy families. Our current business-based private plans would require massive transformation to convert them into private social insurance plans characteristic of some of the European nations. Can you imagine the complexity of the legislation that would be required? Has anyone seen any serious specifics of such an approach that could be converted into legislative language within the first 100 days?

What about allowing the purchase of a Medicare-like option to complement the private insurance market? It wouldn’t be simply a provision to allow a buy-in to the current Medicare program simply because the Medicare risk pool is composed of very high-cost populations (elderly, chronically disabled, and chronic renal disease), and the premiums could never be affordable. Then what would a separate Medicare-like option look like? Good question. How comprehensive would the benefits be? How could cost-sharing be kept at a reasonable level? How much of the premium would the individual be responsible for? Would the balance be paid by the government? Would the private insurers who benefit from favorable selection be required to transfer funds to the public program? Has anyone seen any serious specifics that could be converted into legislative language in the first 100 days?

We do have legislative language for a proposal that actually would work, and it is already in a bill before Congress, with about 90 cosponsors in the House of Representatives: John Conyers’ HR 676. Oh, wait a minute; that’s not feasible, they tell us.

So what do the Democrats have in mind for the first 100 days, should they have control? Easy. They are going to expand the children’s health insurance program – SCHIP – certainly a good thing. They are going to look at the damage done to Medicare by the privatizers, but significant repairs will be too complex to enact right away; they’ll get to that later. Comprehensive reform? Not now; there are too many other important issues. Next year? Well, that’s an election year, so we can’t do it then. But we should be able to get to it possibly before the end of the president’s first term, and certainly by the end of the second.

Window slammed shut!

But don’t anyone start working on these issues now. We have more important decisions to make. Do we support the moral high ground of lipstick on a pit bull, or the moral low ground of lipstick on a pig?

In the face of all of our shameful societal problems, surely someone will come up with this answer to this most pressing problem of the day: the lipstick needs to go on the figurehead of the Swift Boat.

Survey Reveals that Doctors Feel Pressured by Health Insurers to Alter the Way They Treat Patients

The Medical Society of the State of New York
September 2, 2008
The Medical Society of the State of New York just released survey results, which indicate that health insurer rules often force New York State physicians to alter the way they treat patients — and not necessarily for the benefit of patients. Instead, the rules appear to have been developed to increase insurer profits at the expense of the best health practices and patients’ health.
The survey results indicate: Ninety percent (90%) of the physicians surveyed said that they have had to change the way they treat patients based on restrictions from an insurance company, and 92% said that insurance company incentives and disincentives regarding treatment protocols “may not be in the best interest of the patients.”
Physicians’ most common complaint was that health insurers required them to change prescription medications; 93% of the physicians voiced this complaint. Over three-fourths (78%) said that an insurance carrier has restricted their ability to refer patients to the physicians they believed would best treat their patients’ needs.
A majority (87%) of physicians said that they sometimes feel that they are pressured to prescribe a course of treatment based on cost rather than on what may be best for the patient. Over half (62%) of the physicians surveyed, however, are either somewhat concerned or very concerned that they may be cut out of an insurance network if they do not follow the policies requested by insurance companies.
http://www.mssny.org/mssnyip.cfm?c=i&nm=Insurance_Carrier_Rules
Complete survey results:
http://www.mssny.org/mssnycfm/mssnyeditor/File/2008/In_the_News/Press_Releases/inscarrierrules.pdf

No person disputes the fact that it is wise to use a less expensive generic medication when a newer product on patent is more expensive, has not been shown to be a better therapeutic agent, and has not been in use long enough to identify potential adverse effects that only post-marketing surveys could demonstrate.
A public insurance program would be designed with incentives to provide the best care possible, with secondary incentives to avoid more expensive options that have no advantage over less expensive options. For example, a $100,000 cancer drug that has not been demonstrated to be any more effective than established agents, and which has a 100 percent incidence of toxic side effects, may not be covered by a public program except perhaps as part of an approved research protocol.
This survey once again confirms that private insurers are intrusive in the patient-physician relationship. We know that their interventions are based on business contracts that they have with pharmacy benefit managers and pharmaceutical manufacturers. Their business interests take precedence over the interests of the patients. In some instances, recommended changes may incidentally benefit patients, but they are made only after the insurers first have made a determination that the change will benefit their bottom line.
Moreover, insurers usually dictate which specialists and which hospitals can be used without the patient incurring significant financial penalties. These authorized referrals are based on provider contracts that accrue to the benefit of the insurer without regard to the wishes of the patient and the advice of the physician. In a well designed public program, patients would have choices within the full range of provider options.
Before we adopt reform based on the private insurance model, we should think about what that means. Amongst the great multitude of problems, we would be adopting a system that allows businessmen to intrude between the patient and the physician and take away with them whatever money they can. That doesn’t seem wise when we could have our own public program that is designed to provide the best care for all of us with the resources that we have.

The Medical Society of the State of New York
September 2, 2008

The Medical Society of the State of New York just released survey results, which indicate that health insurer rules often force New York State physicians to alter the way they treat patients — and not necessarily for the benefit of patients. Instead, the rules appear to have been developed to increase insurer profits at the expense of the best health practices and patients’ health.

The survey results indicate: Ninety percent (90%) of the physicians surveyed said that they have had to change the way they treat patients based on restrictions from an insurance company, and 92% said that insurance company incentives and disincentives regarding treatment protocols “may not be in the best interest of the patients.”

Physicians’ most common complaint was that health insurers required them to change prescription medications; 93% of the physicians voiced this complaint. Over three-fourths (78%) said that an insurance carrier has restricted their ability to refer patients to the physicians they believed would best treat their patients’ needs.

A majority (87%) of physicians said that they sometimes feel that they are pressured to prescribe a course of treatment based on cost rather than on what may be best for the patient. Over half (62%) of the physicians surveyed, however, are either somewhat concerned or very concerned that they may be cut out of an insurance network if they do not follow the policies requested by insurance companies.

http://www.mssny.org/mssnyip.cfm?c=i&nm=Insurance_Carrier_Rules

Complete survey results:
http://www.mssny.org/mssnycfm/mssnyeditor/File/2008/In_the_News/Press_Releases/inscarrierrules.pdf

Comment:

By Don McCanne, MD

No person disputes the fact that it is wise to use a less expensive generic medication when a newer product on patent is more expensive, has not been shown to be a better therapeutic agent, and has not been in use long enough to identify potential adverse effects that only post-marketing surveys could demonstrate.

A public insurance program would be designed with incentives to provide the best care possible, with secondary incentives to avoid more expensive options that have no advantage over less expensive options. For example, a $100,000 cancer drug that has not been demonstrated to be any more effective than established agents, and which has a 100 percent incidence of toxic side effects, may not be covered by a public program except perhaps as part of an approved research protocol.

This survey once again confirms that private insurers are intrusive in the patient-physician relationship. We know that their interventions are based on business contracts that they have with pharmacy benefit managers and pharmaceutical manufacturers. Their business interests take precedence over the interests of the patients. In some instances, recommended changes may incidentally benefit patients, but they are made only after the insurers first have made a determination that the change will benefit their bottom line.

Moreover, insurers usually dictate which specialists and which hospitals can be used without the patient incurring significant financial penalties. These authorized referrals are based on provider contracts that accrue to the benefit of the insurer without regard to the wishes of the patient and the advice of the physician. In a well designed public program, patients would have choices within the full range of provider options.

Before we adopt reform based on the private insurance model, we should think about what that means. Amongst the great multitude of problems, we would be adopting a system that allows businessmen to intrude between the patient and the physician and take away with them whatever money they can. That doesn’t seem wise when we could have our own public program that is designed to provide the best care for all of us with the resources that we have.