The Self-Reflecting Mirror of Good Intentions

“The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn’t pretend to have the answers. Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down—or not.”Atul Gawande, The New Yorker (via Real Clear Politics)

Or not? Or not? Or not?

Wait a minute. Proponents of Health Care Reform insisted that a crisis existed in American medicine – a crisis of steadily increasing costs and the uninsured. Forget for a moment the pages and pages and pages of regulation: the essential steel-frame structure at the heart of the bill consists – it seems to me! – of committees that have yet to write the myriad of rules that will govern the future of health care in this country. Isn’t that the case? Am I getting it wrong? And if I am, it’s not like the authors of the legislation took care to write something a layperson like me could understand. Do even the authors know what is in it?

I respect the good Dr. Gawande very much, but I cannot understand how any physician or scientist – who ought to pride him or herself on evidence-based medicine – would sign off on something like this? It’s all supposition. It’s all promises. It’s all the self-reflecting mirror of good intentions.* There’s no there there. Not really. Not if you look beyond the gimmicks.

Hey, if I’m being unfair, or misunderstanding, drop a line in the comments box, okay?

* I used the above phrase in this comment at zenpundit on an entirely different subject. I’m pretty sure I made it up on the spot, but somehow, I always have a subterranean fear that I am plagiarizing someone a lot more clever than I am. Not sure what that is about, but now, thanks to my penchant for TMI, you all know that about me!

Update: I am not saying the uninsured or costs are not a serious problem. What I am arguing is that the very legislation intended to solve the problem of cost is a roll of the dice in that regard. Why do we need an oxymoronic government “department of innovation” anyway? Why not break down government-set barriers and allow the experimentation to take place in the absence of said barriers? Honestly, I couldn’t understand a bit of the logic behind that article.

Another Update: “Two Views On Health Care From The New Yorker,” Peter Suderman (Reason – Hit and Run)

9 thoughts on “The Self-Reflecting Mirror of Good Intentions”

  1. The legislation ignores the cost problem and attacks a series of strawmen, including the uninsured. Until people pay for routine care out of pocket, as they did in 1950, there will be no solution for cost. The other day, I saw a figure that the amount of health care cost that is paid for by individuals has dropped from something like 67% in 1950 to 12% today. The bill will do nothing to change this except, possible, to make it worse. Second, it is hideously expensive and will increase the risk of fiscal collapse. Over on Megan McArdle’s blog the other day, I commented on the possibility that, one day soon, the Treasury auction will fail. People will not buy our bonds and default will become a possibility. Another commenter posted the reassuring information that such a failure could never happen as the fed will buy the rest of the t-bills.

    With what ?

    Oh well. Somebody must know how to solve this.

  2. You are befuddled because you are trying to find the means by which this legislation will actually initiate economies in the delivery of quality health care for the general public.

    This bill, along with innumerable others, only offers that goal as a rationale to justify its enactment. Its real, and only, true objective is to gain control of a significant and fundamental area of social and economic life in this country.

    The purpose of this legislation is the acquisition of power, and enormous amounts of money.

    Your confusion will be relieved when you stop looking to see how the programs will achieve their stated goals, their good intentions, and look at the many ways they accomplish their true purpose—the enhancement of state power.

  3. Yes, it’s mostly about grabbing power rather than improving medicine.

    Gawande’s comments make perfect sense if you assume that his goal is to promote Obama’s scheme rather than provide a neutral evaluation of it. I think that’s a reasonable assumption.

  4. The vast majority of people who support health care “reform” don’t have any detailed understanding of the issue. This includes people in the medical field itself who are often shockingly ill informed about basic economic principles.

    Instead they operate from a very simple model in which private actors are bad and state actors are good. They believe that all problems are caused by “greedy” business people and that the solution to all problems is to get the wise, noble and benevolent state to control the greedy business people.

    That’s it. That’s all it is. Everything else is just slapdash post hoc rationalizations.

    It doesn’t matter what the issue is, if it touches on money, then that the greedy-merchant versus the benevolent noble is the model they use.

    These people really believe that they can solve all our medical woes by simply transferring medical decisions to from those motivated by money to those motivated by power. Starting with that massive unspoken assumption, they spend very little time examining the nuts and bolts the specific implementation because they believe that any power-motivated system will work better than any money-motivated system.

    If you talk to a diverse group of these people (or sometimes the same person at different times,) they will offer a range of contradictory models and predictions about the programs outcome. The only constant is that at any given time, they adopt the argument they believe best justifies the rule of the power-motivated.

    You can tell this is functionally a religious belief because they won’t be able to tell you any of the tradeoffs or dangers of their plan. It’s all good with nothing bad. We will get cheap medical care with expensive quality. We will all get standardized, cheap medical care with no loss of flexibility or innovation. We will expand coverage to tens of millions while paying less. We will stop “wasteful” and “needless” test while guaranteeing that everyone gets every conceivable test they need.

  5. Mr. Love,

    An amazing, incisive, and insightful comment. May I add the following?

    1. Business people are “greedy” by definition. That will never change. If it were to change, those business people would rapidly go out of business.

    2. But (so they say) ‘THIS time’, the power-motivated system really will be wise, noble and benevolent.

    So no matter how much evidence one might advance against the ultimate wisdom, nobility, and benevolence of power-motivated systems, ‘THIS time’ remains a (theoretical) possibility.

    Greed is bad; benevolence is good. That’s all the Q.E.D. many people I know need. Hurray for the government!

    Analyst John D. Mueller (look him up at has some marvelous (new) things to say about economics, among them that ‘modern’ economics has ignored the economics of family life, which is properly distinct from the exchanges of public life.

    If (culturally, educationally) most people had a clear idea of the IMPORTANCE of honoring both ‘family sphere’ economic activity and ‘public sphere’, and the importance of keeping these two spheres DISTINCT, then, and perhaps only then, ‘benevolence’ would not always automatically win against ‘greed’ when people think about public matters.

    For now though, people conflate what is proper to family life with public life, to all our subsequent woe. And the conflation of economic thinking into a mushy ‘one realm’, rather than making a proper distinction between economic exchange and virtue within a family and economic exchange and, yes, virtue, within the public sphere is only one part of this.

    And of course, we now have people arguing, or even simply declaring as self-evident, that ‘since there is no difference’ between public and private, then the public sphere — defined as the realm of people motivated by power — is all there is.

  6. Great comments everyone, especially Shannon Love, who got closest to what I was trying to say.

    I see that I did not express myself well in this post. To clarify:

    Intentions are not the same as results. It seems, at times, as if we are a culture in love with the idea of good intentions, in process over substance, and without much regard for accountability or results.

    People believe what they believe. The physician proponents of this bill believe a government-run system is more just and that the results shall be as intended, perhaps because of this “justness.”

    What bothers me is the veneer of empiricism that some attempt to throw over the issue. I mean, I don’t read every Health Care op-ed or “Perspectives” in the New England Journal of Medicine, but most that I’ve read are generally supportive of reform. Unfortunately, in my opinion, most are not as skeptical of claims as they ought to be in such a forum.

    The medical profession likes to tout its rigor, but I’ve not seen it in approaching this debate, at least, not in the corners of academia that I’ve inhabited.

    It is important to push back on the veneer of empiricism. The impression that proponents are trying to give the general public is that reform follows good science, and that anyone following the peer-reviewed literature would agree with reform. But it’s not good science, it’s nothing more than wishful thinking.

    – Madhu

  7. Remember that advocate physicians, like Gawande and Himmelstein and Woolhandler, have never been in private practice. They have lived their lives as a salaried employee, and a pampered one at that, of a large institution. They have never met a payroll or negotiated rent. The largest transaction they have ever done is buy a house and many of them haven’t done that.

    I’m not saying the private practice doctor is an industrialist but we, the few that are left, have opened an office and wondered if anyone would come. We have figured out how to market ourselves without violating ethical principles(much less important now than it was 50 years ago). My partner and I were general surgeons. We started out with one small office in a new suburb. We figured out some new twists on marketing. Some were simple like always being available. One of us would always hang around the x-ray department until about 9 o’clock because that’s when GPs and internists would come in to look at their x-rays and, maybe, ask advice. We treated the ER as a referring physician, always being grateful for the case they referred even when it was an uninsured Spanish speaker. We were always nice to OR nurses because, at least in our middle class suburb, they were neighbors and their neighbors would often ask who the good surgeons were.

    We told our office girls (sorry to be sexist) that we would pay for them to go to lunch somewhere nice once a week on condition that they took an office girl (or all of them) from a referring doctor’s office. When somebody needs to have surgery, it’s the office girl who makes the appointment. Eventually, as our practice grew to five surgeons, our office manager became the medical community employment bureau. She would keep resumes of girls who had applied for jobs and hadn’t been hired. She would always ask if it was OK, which took the sting out of not getting the job. Other doctors found out about it and would call her to ask if she had somebody good for such and such a job. Over time, every medical office in the community was staffed with women who had gotten their jobs through our office. Guess who they called when there was a patient who needed surgery ?

    There’s more but that is a sample of “how to build a practice from scratch.” Does anyone think that Gawande knows that ? The only practicing physicians who support Obama are just out of training. I checked on a lot of them when he had that first “white coat ceremony.” Many were hired by hospitals. It’s a different world. Ours was more fun.

  8. I quite liked hearing about how you built up your practice, MK. You make a good point. Salaried hospital physicians experience a different reality than someone who starts his or her own practice. And certainly physicians just out of training often know nothing about basic economic principles. We don’t teach them in medical schools. Does anyone know of such a course?

    And the following article seems to support some of the above comments!:

    – Madhu

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