Capital Commentary is the weekly current-affairs publication of CPJ, written to encourage the pursuit of public justice.

The Impractical Pragmatism of Healthcare Reform

James Skillen


October 23, 2009

President Obama and congressional leaders ventured into healthcare reform in a way they thought would make it most likely to succeed. At the start the president hoped to draw in those with big stakes in the system—like the insurance companies. The details could then be negotiated. He let Congress write the first drafts in public view to avoid the Clintons’ mistake of drafting their proposal behind closed doors. And since most Americans recognize that the present healthcare system is broken, they wouldn’t have to be sold on the need for reform.

But what if the healthcare crisis can’t be resolved by pragmatic punches inside a box that is part of the problem? What if the interests of the insurance and drug companies will not let reform go far enough to succeed? What if the aims of Republicans and Democrats can’t be melded?

Today in Washington we are witnessing a political process so weighed down by decades of bits-and-pieces pragmatism (Medicare and drug benefits for seniors; Medicaid for the poor; state-governed insurance companies; tax-free health benefits for employees in some companies; free-market this and government-run that) that continuing along the line of pragmatic incrementalism is no longer practical.

This is not to say that Congress and the president cannot pass a new law. They may do it. But what they finally come up with will almost certainly not constitute a coherent, long-term answer. And most of those who vote No have had nothing better to offer.

Part of the tragedy of the effort is that the current complex mess has not been held up in its entirety for close comparison with alternative systems. Public debate by those with legislative and executive responsibility has been purposely confined to bargaining within narrow limits in order to achieve something, however incomplete.

Sadly, our American healthcare system does not compare very favorably with the systems of other developed countries. Whether you consider life expectancy, access to care, the costs, or treatment success rates, we don’t measure up. And the five bills that senators and representatives are now trying to weave together will not, in a new synthesis, significantly change the situation. Many citizens will remain uninsured; costs will not be adequately controlled; the lobbying power of those now spending hundreds of millions of dollars to get Congress to do their bidding will not be restrained.

If you think I’m a cynic trying to give you a headache or push you into depression, you are mistaken. I’m simply arguing that the so-called pragmatic (“do what will work”) approach to reform is not working because the box in which reform is being pursued is part of the problem. There are ways to get out of that box, but those ways require significant change of political outlook and aims.

If you have time to read only one book, get hold of T.R. Reid’s The Healing of America (2009), which sets our system in precisely the kind of international comparative light that our impractical pragmatists are unable or unwilling to do.

Or look up the big-picture writings of Arnold S. Relman, M.D., former editor-in-chief of the New England Journal of Medicine. Then there is Harvard economics professor Martin Feldstein who has managed to outline an alternative, comprehensive plan in the space of a single op-ed column (The Washington Post, 10/8/09). Daniel Callahan explains why Americans have difficulty envisioning an alternate system (“America’s Blind Spot,” Commonweal Magazine, 10/9/09), and Regina Herzlinger’s Who Killed Health Care? (2007) is eye opening.

These insightful experts do not all think alike. Their experience differs widely. But they open windows on reality and show why the most practical thing we could do would be to break with the impractical pragmatism of politics as usual.
— James W. Skillen, Senior Fellow
     Center for Public Justice

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Capital Commentary is a weekly current-affairs publication of the Center for Public Justice. Published since 1996, it is written to encourage the pursuit of justice. Commentaries do not necessarily represent an official position of the Center for Public Justice but are intended to help advance discussion. Articles, with attribution, may be republished according to our publishing guidelines.”