Posts Tagged ‘IMAC’

Shame on You, Mr. Hentoff

Monday, August 24th, 2009

Mr. Hentoff,

I have been following you for years – ever since my father suggested I read your column because you were honest and independent-minded and liberal. I have admired your steadfast positions, including on abortion and right to life issues. But your last column was truly shameful.

Given your career and the reputation you have built and maintained, you should be embarrassed to have such poorly sourced journalism attributed to your name. It reads like something an overeager Cato intern might have thrown together – with the sloppy reference to Pelosi condemning the “furor” as “un-American” and the casual defamation of Ezekial Emanuel. It’s hard to tell if you made these points out of laziness – not taking the time to investigate the standard right wing talking points on health care – or if you chose to use your stature to lie.

If you had chosen to read the op-ed published by Speaker Pelosi and Representative Steny Hoyer (conveniently linked to here) you would have noticed that they never called the protestors or the furor “un-American” as many right wingers have claimed. Instead, they made a statement which you doubtless agree with:

Drowning out opposing views is simply un-American.

Which means your statement – misidentifying the co-author of the piece as Senate Majority Leader Harry Reid – calling them “blind to truly participatory democracy” began with a faulty premise.

Regarding your next point: If you had chosen to read the article you quote by Dr. Ezekial Emanuel (among others) instead of simply quoting the Washington Times editorial quoting the article – or if you had even done some sort of search beyond that single right wing editorial – you would have found that Dr. Emanual was not describing how he believes medical resources should be allocated – but considering what should be done in times or situations of extreme scarcity, such as during a pandemic or with extremely scarce resources such as organs to be donated. The article describes 8 systems for distributing extremely scare resources/services – and recommends 6 of them be incorporated into any decision-making process. The quote you push here is cribbed from the description of one system. It is a blatant falsehood to claim it represents Dr. Emanuel’s overall thought on the subject. And I know you are an old man, but would you seriously put forward the moral proposition that if your kidney is failing – and so is a 12-year old girl’s – you should get priority to that kidney?

To state that this quote means that Dr. Emanuel is in favor of medical rationing is a lie. To state that it means Dr. Emanuel is in favor of euthanasia is a lie. (In fact, one of the articles you link to clearly states that Dr. Emanual is and has been opposed to euthanasia.). To  insinuate that the plans currently under consideration are pushing such rationing or euthanasia or death panels is finally a lie too far.

You clearly know little about the bills under consideration – as you conflate the subsidies for voluntary end of life counseling and the Independent Medicare Advisory Board – as Sarah Palin in her ignorance did – into a “life-decider” panel that decides whether you merit “government-controlled funds to keep you alive.” You also make this ominous point:

The members of that ultimate federal board will themselves not have examined or seen the patient in question.

Of course, it is unclear what panel it is you are trying to describe here. As mentioned above, it seems a conflation of one panel in the proposed legislation – and a provision to subsidize end of life counseling – with both fearfully conflated and confused into one panel that has a quite different purpose. The closest thing to what you’re describing in the bill would be the Independent Medicare Advisory Board – which is an amended version of the current MedPAC which sets Medicare reimbursement rates. It would be checked by Congress and the President – either of whom would be able to reject any untoward recommendations by the board. In addition, either the IMAC or another advisory board would collect and distribute research on “best practices” in medicine – comparing the comparative effectiveness of different treatments for the same or similar diseases.

Of course, none of these boards would be making decision about individual patients – as you claim. But clearly, you didn’t take the time to look into any of this.

Shame on you, Nat Hentoff. This was a poor piece of journalism that only succeeds in spreading lies about health reform even further.

If you value your journalistic integrity, you should issue a retraction and apologize to Dr. Emanuel – or double down and explain what primary sources you have for your rather frightening conclusions. Until then, your opinion must clearly be dismissed as the shoddy piece of right wing talking points that it has become.

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Obama and the Technocrats

Monday, August 3rd, 2009

Last week I wrote about Obama’s focus on using technocratic institutions to tackle the nation’s most intractable problems. I attributed to Obama a particular attitude towards our current media-political system – one consistent with many reformists – and then explained how Obama was seeking to push the change he had campaigned on, the difficult choices, onto these technocratic institutions, thus solving his political and policy problems at once. But by outsourcing significant authority to these bureaucratic and independent (and thus not quite accountable) organizations – from IMAC to the Federal Reserve to the National Infrastructure Bank – Obama was bleeding authority from elected institutions. At the same time, I tend to agree with the reformist critiques that recount the massive failures of our current media-political system to tackle most (if not all) long-term structural problems.

But since I’ve written this, I have come across a number of pieces challenging this idea from various perspectives on the left.

Mark Schmitt, an editor for the progressive The American Prospect, saw Obama’s approach as the opposite of what I did – though he focused on national security and justice issues. Schmitt agrees with the reformist attitude I attribute to Obama, writing:

[T]he idea that America’s “existing democratic institutions are strong enough to deliver accountability” flies in the face of all observed reality. For at least eight years, those institutions consistently failed to deliver accountability, and the Department of Justice and courts likewise failed to punish some of the greatest abuses of power in our history.

But he is himself frustrated that Obama does not share it. He concludes:

It takes some discipline to understand that organizational culture, not organizational structure, determines success or failure. And it takes a lot of patience to wait for an organizational culture to turn around and resist the temptation to add a commission here, a new agency there. Obama’s organizational discipline was the hallmark of his campaign, and we can only hope that his unyielding insistence that “our existing democratic institutions are strong enough” will eventually make them so.

Benjamin Wallace-Wells writing in The New Republic strongly disputes any attempts to link Obama’s technocrats with Kennedy’s technocrats (as I did) – writing that the Kennedy men weren’t brought down by their knowledge and rationality, but instead:

Their error was an excess of ideology; they were not empirical enough.

He concludes that the brilliant men of the Kennedy administration are different from the brilliant individuals of Obama’s:

Kennedy chose as his defense secretary the president of a car company. Obama chose the sitting secretary of defense. Obama’s brainiacs–people like Larry Summers and Tim Geithner and Peter Orszag–come from a different meritocracy than Kennedy’s did. They are not brilliant generalists. For better or for worse, they are experts.

It is clear that Obama’s technocrats are of a different sort than Kennedy’s – and I made that point as well. It also seems that many of them are students of history and have attempted to learn the lessons of their predecessors – from John Kennedy’s and Lyndon Johnson’s “best and brightest” to Clinton’s New Democrats. But I’m eager to see some commentary dealing with the fact that Obama has found an elegant solution to many of these intractable and politically fraught problems – from global warming to health care to financial regulation to infrastructure spending – an independent, technocratic institution that removes political considerations from these decisions and thus receives relatively broad bipartisan support. (I believe the independent agency proposed to tackle each of these problems has some bipartisan history.) And then to tease out what the potential implications and pitfalls of this are.

Because while Schmitt and Wallace-Wells make good points in disagreement with my thesis – their supporting facts do not undermine my point, just their broader generalizations from these facts.  Clearly – Obama respects existing institutions more than I gave him credit for – especially in the areas of national security and justice (and even financial regulation you could argue.) But it’s also clear that Obama’s solutions to many difficult domestic policy questions are to outsource the hardest decisions to incrementalist, technocratic, independent institutions.

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Is Obama Leading Us To A Technocratic Dystopia?

Thursday, July 30th, 2009

Implicit in many of Obama’s policy proposals and programs is an assumption shared by many reformers (from here to here to here): that America’s political system is broken and that our traditional democratic institutions just aren’t up to the job of managing serious and difficult areas and making rational, long-term decisions when the payoff only comes after policy-makers are out of office. I’m not sure that they’re wrong – but I’m wary of the decision made by the Obama administration to focus on creating a technocracy to manage these areas.

In many of Obama’s programs and proposals, there is a bureaucratic independent or quasi-independent agency that is designed to manage whatever process is relevant to the program and that receives from the Congress authority to make decisions on its own. To the technocrats’ credit, in most cases, although the decision-making is outsourced to these agencies, Congress has some sort of limited veto over them. The appeal of outsourcing authority to these institutions comes from the fact that they are theoretically insulated from politics and are capable of making minor decisions over a long period of time which – if managed properly – can effect significant changes. The idea is that – rather than forcing through a controversial and wholesale change – you set up an independent agency that will gradually manage things in order to achieve the changes needed. This makes a great deal of sense politically – as the agency can be tasked with some anodyne goal that everyone can agree on – and as it makes controversial decisions,  politicians can distance themselves from each individual decision while still supporting the independence of the organization (as you often see with the Federal Reserve). They can say they didn’t vote for this or that specific proposal – and that they oppose it – but that given the authority of this independent agency, there’s little they can do. On a policy level, this also makes sense – as any attempt to push through wholesale reform is limited by one’s knowledge at the time the legislation is drafted. Better to experiment and try various small steps and set up different incentives to accomplish the same thing than to attempt to impose some pre-made solution. It’s also worth noting that these technocratic institutions are often supported on a bipartisan basis – while specific reforms are generally opposed by one side or the other. The appeal is obvious – yet the anti-democratic impulse is disturbing.

One example of these organizations is the IMAC (or Independent Medical Advisory Committee) which would be a technocratic institution that would set the pay rates for reimbursement of various Medicare programs and eventually perhaps for all government-sponsored insurance (as MedPAC does now) and also compare and evaluate what treatments work best to treat different conditions and make recommendations. Unlike MedPAC which simply advises Congress, IMAC would make annual recommendations which would take effect if accepted by the president and not vetoed by the Congress. The White House has been selling this plan as a way to take the politics out of Medicare reimbursements and restrain costs. A similar approach helps explain why Obama is pushing for the Federal Reserve (the organization to which the IMAC is most often compared) to be the regulator of those institutions that are “too big to fail” as well as tracking and regulating various other systematic risks – despite their role in the collapse that just occurred. What the Federal Reserve is known for is its independence from political pressure and its technocratic bent, thus making it the perfect vehicle for Obama’s efforts to reform the financial industry even though it clearly failed so recently. There is the proposal for a National Infrastructure Bank which would direct federal transportation money – again, independent of political concerns. The cap-and-trade program would likewise gradually institute dramatic reforms by giving authority over to a technocratic institution that would manage carbon emissions – distancing these actions from politically accountable leaders.

On each individual proposal, the solution seems compelling, but as an overall trend, it is disturbing. When Obama was elected, many claimed that there was a similar feeling of hope and progress to when John F. Kennedy was elected – and as then, when Kennedy gathered “the best and the brightest,” Obama has reinvigorated the idea of public service. But the downfall of these Kennedy men was their belief that they could “control events, in an intelligent, rational way.” Obama’s technocrats do not seem to have this same hubris. Their hubris is of a different variety: they believe that they can best manage complex areas and achieve needed reforms not through political action but by creating bureaucracies onto which they put the difficult political decisions.

But what kind of system do we end up with then? As rules and regulations are created by technocrats and then merely accepted or rejected by the elected officials. This system seems to resemble an oligarchy with democratic checks. With the Federal Reserve along with other less independent agencies already deputized to take care of most government responsibilities, we have already started down this road – but it doesn’t seem wise to double down on this approach. Unfortunately, I do not offer a solution – only a concern.

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