Bush, Fallibilism and Health Care

I am writing this in response to recent comments about Bush’s arrogance and the insinuation that he sees himself as infallible, that he does not listen to his advisors, that he believes that his personal intuition is the will of God, and that he has a messiah complex. I was especially dismayed by John Piper’s recent Fresh Words in which he contrasts Lincoln’s humility with the absence of confession of personal fallibility by both Bush and Kerry.

It is absolutely true that Bush is not the orator Lincoln was. He often seems uncomfortable except in extremely partisan settings where he is guaranteed a sympathetic audience. He speaks in sound bites, pausing awkwardly in the midst of sentences, indicating that the teleprompter controls his delivery more than the meaning of his statements does. It is also true that he is often his own worst advocate and is too defensive to freely admit to errors and miscalculations. (I happen to believe his defensiveness is justifiable given his treatment by the mainstream media.) However, it is clear that Bush’s policies and decision-making assume human fallibility where Kerry’s do not.

Decision-making

Bush is a satisficer; Kerry an optimizer. Satisficing is a model of rational decision-making first described by Herb Simon, I believe, in his Administrative Behavior. It assumes that human reason is both limited and bound. Perfect information is impossible; even if perfect information were available, the human mind is limited in its capacity to process it. Therefore, decision-makers and problem solvers ought to search for solutions that are good enough -- that is, satisfactory -- not necessarily optimal. Once we know that we have identified a good course of action – that is, doing something is substantially better than doing nothing -- the additional cost we incur to find the optimal course, even if it were possible to find it, would eat up all the benefit of that better solution. The additional costs may take many forms: delays, costs of information gathering, human costs, etc.

What does a satisficer look like in the real world? Often it will look like he makes decisions prematurely. Optimizers, especially, will accuse him of making decisions without enough information. He is free to take bold action. Knowing that he can never know exhaustively the consequences of his decisions, he will act with principle as his guide. He can make a best guess as to the outcomes of his decisions, but, ultimately, he will base his decisions on what is right on philosophical or moral grounds. Because he knows every decision he makes is wrong to some extent -- it is after all non-optimal – he sees no point in dwelling on errors and mistakes. Second-guessing decisions after the fact is as useless and costly as seeking the optimal solution before-hand. It is more useful to consolidate the gains achieved by actually doing something.

An optimizer, on the other hand, rarely acts. He assumes that perfect solutions are possible and that the cost to attain the optimal solution is irrelevant. Can there be any question that Kerry is constantly in the process of gathering information and refining his positions? His constant criticism of Bush only makes sense if he assumes perfect decisions are possible a priori. Is it at all surprising that Kerry made his name in the Senate only as an investigator, not as a legislator? At least in the arena of decision-making, it is Bush who humbly embraces human fallibility and Kerry who arrogates to himself the possibility of exhaustive knowledge. Bush is a leader; Kerry a legal engineer.

Health Care

Bush’s domestic policies assume human fallibility as well, exemplified by his health care plan.

Both candidates seem to recognize that financing American health care is messy. Normal market models do not apply; not because health care decisions are somehow not economic decisions -- they are. Economics simply deals with the allocation of scarce resources that have alternative uses. As much as people wish the opposite were true, health care is a scarce resource. Rationing does, and must, occur. There are also alternative uses for health care. Any elective surgery provides a good example for this, especially cosmetic surgery. We must admire the knowledge and skill demonstrated by plastic surgeons in these extreme makeover shows on TV; but we also recognize that there is an unlimited demand for their services and a variety of alternative uses of their skill.

The mechanism for allocating resources in a market economy is price set by supply and demand. Prices serve the very useful function of impersonally enabling millions of transactions between consumers and suppliers. Prices are, in essence, ambassadors conveying messages about the desires of consumers and suppliers and negotiating a compromise agreement between them. However, the fundamental laws of supply and demand, assuming a transaction between consumer and supplier, don’t really apply in health care; the consumer, purchaser and payer are all different parties. Generally, the employer is the purchaser. Benefits managers within our large corporations evaluate the prices and quality of services of different health plans. The employee is the one who actually then uses the service. The insurance company, or the government, pays for the service. So, market forces are muted and confused in our health care system.

Once we recognize that our health care system is an economic hybrid, we can devise a couple different strategies to fix it, to purify it, if you will. The first, Bush’s, is to introduce more elements of a standard market economy into health care financing, to reunite consumer and purchaser. The intent of health savings accounts, and cost sharing mechanisms, is to involve the consumer of the health care service in the purchasing decision so that standard laws of supply and demand can work, and so that price can play its normal very useful role in allocating health care resources.

Kerry’s strategy, on the other hand, remains a hybrid but moves away from a market model for health care toward centralized control. It reunites payer and purchaser, but not consumer. The consumer is even more insulated from the purchase decision than before. Kerry would deny that. He argues that his is an entirely voluntary plan. However, everyone who has worked in health care knows that the 80/20 rule applies: 20% of the cases generate 80% of the cost. (Actually in the studies I’ve been involved in a much smaller percentage of cases generated a greater percentage of the cost.) Kerry’s plan is to reduce employer-based health insurance premiums by making the 20% of cases and 80% of cost the responsibility of the government. There is absolutely no question health insurance premiums will go down, and no employer would continue to offer private insurance plans for catastrophic health care. However, the actual aggregate cost will not go away but will probably increase because of administrative inefficiencies.

Under Bush’s proposal, the market guides millions of individual health care decisions. Otherwise the health care system is too complicated, and unintended consequences of policies too varied and unpredictable, for the limited human mind to fully comprehend. Under Kerry’s plan technocrats will deliberately steer health care decisions through the creation of “self-executing rules” similar to those already in play in the Medicare system. Bush’s plan assumes limitations of human understanding; Kerry assumes an intelligentsia can overcome these limitations.

Isn’t the summary of Kerry’s befuddled campaign simply this, “I’m smarter, more competent and can second-guess anything!” Bush, in spite of a swagger and cocky smirks, assumes human fallibility and reveals humility where it counts.

The Period of the Judges

The Bible summarizes the period of the judges, after the death of Joshua, with an indictment of lawlessness, “every man did what was right in his own eyes.” (Judges 17:6 and 21:25) God, in His mercy, raised up judges both to deliver the nation from oppressors and to remind them of the covenant—to call the people back to the rule of law.

I generally dislike parallels drawn between the US and OT Israel. However, I am shocked by the contrast between our period of judges and the biblical one. Our Supreme Court judges seem intent on undermining the rule of law in favor of an absolute right of autonomous liberty.

The most shocking thing about the majority opinion in Lawrence v. Texas is not that it overturned Texas’s anti-sodomy laws but its basis for doing so. The court based its decision on the due process clause of the 14^th amendment, “nor shall any State deprive any person of life, liberty, or property, without due process of law.” But its reasoning is absurd. Under “substantive due process” any law that abridges fundamental rights violates the due process clause. It is not a question of legal procedure or fair application of law; it is a question of the content of the law. A law that abridges a fundamental human right violates “due process” and is inherently unconstitutional. (Liberty consists in the free exercise of fundamental rights. The right to privacy -- read “abortion” -- is such a constituent element of liberty.) But with Lawrence v. Texas, the court introduced absurd tautological thinking: one of the constituent rights of liberty, they say, is the right to liberty. We have an absolute right to liberty that cannot be abridged, limited, or constrained. No law can restrict my freedom – even as I choose to define it for myself. Since the purpose of law is to constrain behavior in some way, and constraint is unconstitutional, there is no longer any role for law in human society.

Note Justice Stevens’ statement from Planned Parenthood v. Casey, quoted by Justice Kennedy in the majority opinion of Lawrence v. Texas.

“These matters, involving the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy, are central to the liberty protected by the Fourteenth Amendment. At the heart of liberty is the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life. Beliefs about these matters could not define the attributes of personhood were they formed under compulsion of the State.” Ibid.

Justice Stevens (quoted by Kennedy in majority opinion)

Although our first impression is that this is a judge getting carried away with his own poetic language once we realize it is meant to ground the findings of the Supreme Court we have to become intensely concerned. Either it means nothing and shows the vacuity of the court’s reasoning, or there is no longer any place for law. Antonin Scalia gets it (Thank God for Antonin Scalia.)

“And if the Court is referring not to the holding of Casey, but to the dictum of its famed sweet-mystery-of-life passage, ante, at 13 (“‘At the heart of liberty is the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life’”): That “casts some doubt” upon either the totality of our jurisprudence or else (presumably the right answer) nothing at all. I have never heard of a law that attempted to restrict one’s “right to define” certain concepts; and if the passage calls into question the government’s power to regulate actions based on one’s self-defined “concept of existence, etc.,” it is the passage that ate the rule of law. “

Antonin Scalia (dissenting opinion)

Obviously, Supreme Court justices would not explicitly dismiss the rule of law; however, Lawrence v. Texas proves that this Supreme Court is much too comfortable with an extreme subjectivism under the guise of the defense of private human rights. They ultimately substitute their own opinions about morality for law. Ironically, no one saw this more clearly than Alexander Hamilton in his defense of the Constitution in the Federalist Papers, “a dangerous ambition more often lurks behind the specious mask of zeal for the rights of people than under the forbidding appearance of zeal for the firmness and efficiency of government. History will teach us that the former has been found a much more certain road to the introduction of despotism than the latter, and that of those men who have overturned the liberties of republics, the greatest number have begun their career by paying an obsequious court to the people, commencing demagogues and ending tyrants.” (Federalist No. 1)

The biblical judges recalled law and liberated the people; our judges assert autonomous liberty and will ultimately substitute their own will for law.

Messianic Complex

I am in the middle of trying to rebuild my computer after a terrible crash. However, I can't resist commenting on Chris Matthews' show, today, in which he showed excerpts from the third presidential debate where Bush talked about how often he prays and how he derives comfort from prayer. Rather than admiring Bush's faith and humility, he used these excerpts to lead a discussion as to whether Bush saw himself as a messianic figure. Matthews simply doesn't understand the religious impulse. He has lost it. I once enjoyed watching Hardball, but in the last couple months he has engaged in such absurd partisanship that I can't bear to watch him any longer.