I recently took part in a “civil discourse,” an unusual occurrence in this era of media pundit-orchestrated shouting matches.
Unlike a debate with winners and losers, a civil discourse begins with the premise that, when there are different points of view on a topic, it is better to understand those with whom we disagree than to turn off the sound.
By listening and asking probing questions, we come to understand how such a smart person could possibly disagree with us.
Set in an architectural masterpiece – Frank Lloyd Wright’s Beth Sholom synagogue in Elkins Park, Pa. — this conversation on “The Role of Government in Health Care” was moderated by well-respected public television commentator Chris Satullo.
No surprise to anyone who knows me, I represented the liberal perspective — i.e., supportive of the Affordable Care Act (ACA) and convinced that its goals are achievable — and Stuart M. Butler, PhD, of the Center for Policy Innovation at the venerable Heritage Foundation in Washington represented the conservative viewpoint.
Although the topic is emotionally charged and politically polarizing, the most striking thing was how many things we agreed on!
Irrespective of our political persuasions, we agreed that healthcare should be affordable, adequate, and equitable.
My conservative counterpart and I also agreed that the healthcare system needs treatment for multiple “diagnoses” – waste (e.g., overtreatment, failure to coordinate care, complex billing processes), misaligned incentives, and an appalling lack of transparency.
Perhaps the most compelling point of agreement was around helping people make more rational decisions around end-of-life care.
The laser-like focus of our disagreement was how the healthcare system should be organized to achieve our mutual objectives.
Dr. Butler views entitlements — Medicare and Medicaid — and other aspects of government involvement as the root of the problem and looks to the marketplace for solutions (e.g., individual government-issued vouchers for healthcare purchases).
The theory is that empowered patients and households with more skin in the game will choose more responsibly and seek value in the dollars they spend on healthcare.
The difficulties are those of getting the market to be adequately transparently organized and transparent, and of helping patients navigate such a system through good information, and well trained and compensated intermediaries, for example.
In my view, the business of healthcare is what has run amok — only the government has the clout to compel the healthcare industry to give patients more accessible, equitable, high quality, transparent care.
Although we still have a long way to go in reducing waste and addressing a medical error rate that, in any other industry, would not be tolerated, positive change is happening as a direct result of the payment reforms (e.g., bundled payments) and new models of care (e.g., medical homes) that are integral to the ACA.
The difficulty I see with my position is that the government makes assumptions and acts on them without benefit of evidence.
So, what did I take away from this “respectful disagreement”?
My views haven’t changed – nor, I imagine, were the views of the over 500 people who attended the program – but that was never the intent.
I did come away with an understanding of how much common ground Dr. Butler and I shared on this hot topic and a healthy respect for civil discourse.
David B. Nash is founding dean, Jefferson School of Population Health, Thomas Jefferson University and blogs at Nash on Health Policy and Focus on Health Policy.
