CENTER FOR
POLICY STUDIES

My Health Care Policy Nightmare

A Commentary by Joseph White Ph.D.

Prepared for the CWRU School of Medicine Health Policy Symposium

October 3, 2008

You’ve heard a lot of policy analysis, so I thought it might be better to change the tone. I don’t have powerpoints, I do have a story.

You know how it is. When you’re tired and working hard and a bunch of things are going on at once, sometimes you reprocess it all in your dreams, and things get jumbled together in strange ways. This happened to me a few weeks ago.

It was curriculum night for my daughter’s sixth grade, and all the usual parental anxieties were high. Some of our friends have switched their children to private schools, even though Shaker Heights has a decades-old reputation for superb education, as evidenced by the college destinations of High School graduates. Partly it’s because our system does not score so well on the Ohio Achievement Tests; and partly it’s because, in a desperate effort to improve those scores, our school administrators clearly have begun teaching to the tests, designing the curriculum around the tests.

At the same time, as a good member of the health policy community, I had been assiduously keeping up with the literature, catching up in my reading of the journals late at night. And I had to prepare some talks about the election and health care reform. I fell into a fitful sleep sometime after midnight, and the strands weaved together in a dream.

I dreamed we did not have universal public education in the United States. Instead, our education was financed like healthcare.

There were many schools, some better and some worse. Over the years, employers had concluded that employees cared greatly about education for their children, and so most provided educational benefits for their employees’ children. So most students’ education was paid for by those benefits; but they varied in generosity and, of course, with employment. Large employers were sometimes able to get discounted contracts with networks of schools, but employers varied in both their networks and how much of the tuition they paid. Many small employers paid nothing. I was lucky: our university had a good plan, and my Abby was going to a good school, but there was talk of cutting the benefit.

Other people were not so lucky. Our friends the Greens were only intermittently employed. Gina mainly did substitute teaching (ironically) for one school corporation, and Jack could only find steady work doing tax accounting from January through April. So their daughter Sarah wasn’t able to go to school. She was being home schooled, as best her mother and father could manage. Sharon Black, a single mother we knew, was able to send Charles and Justin to school because Ohio had created a special program for poor people, called Educaid. But it only paid a limited amount, so Sharon had to drive her sons out of her neighborhood, to the nearest remotely decent school that would accept them, and in this case that meant 32 students per class and not enough textbooks. When Sharon was sick, she would try to find a neighbor to drive; and if she couldn’t they had to stay home too.

Educaid was limited because most voters were able to take care of education, most of the time, through their employment. A few could even pay directly out of pocket. So the voters and their legislators were only willing to spend tax dollars for the “truly needy” – and that didn’t include the Greens. Whenever there were proposals to guarantee education to all school children, they were beaten back by a series of arguments. Parents whose children were getting pretty good education funded by their employers worried that government education would be as poor as the Educaid system, so their sons and daughters would be much worse off. Others worried about paying more taxes. Even owners and managers of companies that might benefit by having education taking off their books worried about making government stronger.

Naturally there were reform efforts. Surveys projected that, at any given time, perhaps 20 percent of the school-age population was not in school. A large body of research showed that children who were not in school learned less; that as a result they had worse job prospects and life chances. Liberals pointed out that every other advanced industrial democracy had universal public education, and they also had better trained workforces, more equal incomes, and even spent less on education. Nobody was in charge of the U.S. system, cost was viewed as a sign of quality, entrepreneurs started all sorts of schools with fancy equipment to try to attract the parents who had good education benefits from their employers, and there were extensive marketing and advertising wars to get those customers.

There was some evidence that when parents who had been without education benefits for a while found new jobs with benefits, and were able to enroll their children in school again, those children required extensive and expensive remedial help. Some advocates for universal education therefore argued that it wouldn’t be quite so expensive as it sounded, because of the savings from reduced emergency remedial teaching.

Far more than twenty percent of students, of course, would be out of school for some period during the traditional 13 years of schooling. But some people were used to that. It was the norm. Besides, a lot of voters had secure enough lives that it didn’t happen to their children: even if there was a short spell of unemployment, they could pay the tuition, temporarily, out of pocket. As for the students who missed a year or two – well, their parents probably didn’t expect their children to go to a good college anyway. Besides, there were so many of those students that the colleges had to provide some remedial education, too.

I was so scared for Abby, in my dream. My job was safe – I’m a tenured full professor at one of the top universities in the country. But what if I died? What then? And what about Sarah Green, and Charlie and Justin Black? What about them, and what kind of nightmares might their parents have?

But, in my dream, the forces for universal public education had rallied again. It wasn’t clear that their candidate would win, or even exactly what their candidate was proposing. But their party platform declared that, “if one thing came through in the platform hearings, it was that our party is united around a commitment to provide universal, affordable, K-12 education.”

The conservative forces were opposed, as they had always been, and talked about “big government” and “Washington bureaucrats,” and “freedom.” They said students in the countries with universal public education often couldn’t get into good colleges, or had to wait for textbooks; that some even came to private schools in the U.S.. Their main proposals were to eliminate the employer subsidies for tuition, replace them with a modest tax credit from the federal government, and provide special Home Schooling Accounts (HSAs) so parents could buy private tutoring and computer learning programs. But it was easy to predict that if the Republicans won the presidency little would change, because they were highly unlikely to win control of Congress. What I had to figure out was what I would predict if the Democrats won the presidency.

I had to figure that at least 80 percent of Congress would be committed one way or the other: 40% Republicans who would vote against almost anything that approached being a major expansion of public support for K-12 education, and about 40% Democrats who would (after a lot of grumbling) vote for something resembling what their president and party leaders and committee leaders agreed on. That left a bunch of cross-pressured legislators in the middle. Some cared about education and unequal opportunities but worried about the federal budget at least as much. Some would be Republicans who didn’t like expanding government, but thought the situation might be getting too bad to bear any longer, and had districts that could go either way in the next election. Some would be Democrats who had large education companies in their districts, so had constituents in the private education industry who gave them many reasons to hesitate. The people who would benefit were not as organized as the people who could lose income.

In my dream, and I don’t think only in dreams, legislators want to do good but also want to limit political risks. They will take risks, but they have to be sure that the policy is worth the risks. So they look to consultants and trusted advisors to inform them about the political risks, and they look to expert communities to inform them about the policy consequences.

That’s where the dream, already fitful and frightful, turned into a real nightmare. For I dreamed that a moderate legislator – say, a conservative Democrat from North Carolina – knew the vote in 2009 or 2010 might be the most important vote of her career in Congress, and she wanted to get it right. A large group of “education service researchers” had grown up around universities and think tanks. Education service researchers argued that education would be more affordable if it were organized differently, or if teachers had better guidelines about how to teach, and had convinced some legislators to create a federal Agency for Education Research and Quality. They had journals, like Education Affairs, that published their research, and there was further research from other government agencies, like the Education Payment Advisory Commission (EdPAC). So she asked her staff to review the journals and set up meetings with experts, so she could figure out if reform was worth the political risks. And this is the impression she got from the world of health policy “expertise.”

She learned that there was quite good evidence of the damage done by intermittent education. The conservatives were wrong when they said that most children learned even if they did not get to school, or the remedial programs made up any difference. She was less sure about the data about other countries. On the whole, the research literature about universal K-12 education said it would be a good idea.

Yet a lot of other education policy literature made her worry if it was worth the risks. Professors in Schools of “Public Knowledge” believed that what mattered was not simply what schools did but, logically enough, what students learned. Many argued that too much attention was paid to the “education” model; even to the “education-industrial complex.” They argued that many factors other than education had big effects on knowledge. For example, students who started out poor knew they had lesser prospects than richer kids, so were less likely to see value in applying themselves to their studies, and the stress of their impoverished lives made it harder to concentrate on schooling anyway. And then corporate America was trying to dumb them down through television. Then there was a more conservative version, which said that students’ learning depended on the values they learned from parents and churches; that all the money in the world spent on public education would do little good if the students didn’t have better values from their homes; that the schools couldn’t teach the behaviors that led to learning and that, if children learned those behaviors from their parents, they could study at home and advance even if they had to miss a year or two of formal schooling. These public knowledge arguments, from both left and right, left our congresswoman worrying that she might vote for a big, expensive public program; get lots of constituents mad at her, and not improve peoples’ life chances so much after all.

Her staff also learned about a whole lot of education services research that revealed immense variations in educational practices. Some schools paid teachers more and some less; some had many more hours of class and some less; some emphasized math and some science and some English. The only evident explanations of these variations involved factors such as how many trained science teachers were in an area (areas with more science teachers offered more specialized science classes). Or pure local custom. Relatively similar cities in New England, for example, had very different education practices and costs but little difference in outcomes as measured by tests. Education Affairs had recently anointed the most eminent of the researchers in this line of work as the most influential “education policy researcher of the past 25 years.”

Thousands of articles argued that education was not “evidence-based,” and there had been little change for decades. Hundreds more argued that even if better evidence of education effectiveness could be found, that was the wrong question. What ought to matter was cost-effectiveness of education practices, and there again were hundreds or thousands of articles in the journals, but little evidence of more cost-effective practice.

All those articles could be interpreted as meaning that to spend more money to create universal public education would just be like tossing money into the ocean. Our Congresswoman had to wonder that it might be much more fiscally responsible to get education working better before spending lots of scarce federal dollars, dollars that might require raising taxes on her constituents, to finance such an inefficient, irrational system.

But maybe, she thought, her aides were looking in the wrong places. Or bringing her the wrong experts. She was worried about the budget, so maybe she should focus on what economists had to say.

She and her aides learned that economists were quite divided on many issues. Yet there seemed wide agreement, even among many economists she thought of as “liberals,” on a surprising premise. Almost all seemed to agree that one of the major causes of inefficiency was the fact that employers were able to provide tuition benefits and nobody paid taxes on those benefits. It seemed to her that the employment tuition benefits were the main thing that made the education system functional at all for most of her constituents. They would be terrified of having it taken away. Yet some of the most eminent education economists in the country insisted that this linchpin of the existing system was fundamentally irrational, unfair, and excessively expensive. They seemed to agree with the Republicans that the whole system should be blown up, and that her own candidate’s proposal was fundamentally misguided.

If they were right, she had two choices. She could follow their advice, and vote for a plan that included their kind of recommendations. But that would scare many of her constituents to death, and it seemed exceedingly risky as policy, too. Or, she could ignore their advice, and vote for something like her new president was proposing, which actually mandated that more employers contribute towards the cost of tuition. Yet how could she, a moderate Democrat who worried about fiscal responsibility, vote for a program that so many economists, including many associated with her party, thought was bad economics?

Then I woke up.

So I don’t know how the legislator of my dreams would have voted. But I think it’s pretty clear what my subconscious, or the God of Political Analysis, or some force was trying to tell me, Joseph, in my dream.
Ask yourself this question: if all the kinds of research I found in my dream existed when universal public education was established, what are the odds it would have been established?

I think the odds would have been quite low. The kind of research I dreamed about does exist (and similar arguments are made) for education now. These arguments surely make it more difficult to increase funding for public education. They do not prevent it from existing because it already exists.
But we do have the health services research community, and public health community, and health policy journals, and lots of economists. And it would be real easy for people who read that literature to conclude that so much is wrong with the health care system that maybe (just maybe) investing taxpayers money in it to expand access before all those other problems have been fixed is not worth the costs.

I personally would not draw that conclusion. But the kinds of arguments and implications I encountered about education in my nightmare are in fact drawn by opponents of universal health insurance.

The 2008 Republican platform poses public health measures as a superior alternative to a “government-run universal health care system takeover.” It declares that, “we can reduce demand for medical care by fostering personal responsibility within a culture of wellness, while increasing access to preventive services, including nutrition and breakthrough medications that keep people healthy and out of the hospital,” while calling for a “national grassroots campaign against obesity” (2008 Republican Platform: 37, 39). Liberal public health advocates may see public health and national health insurance initiatives as complementary, but that is not obvious at all to conservatives, and need not be obvious to anyone else. The conservative call for “consumer-directed” health care plays off much of the Health Services Research community’s argument that patients should be “empowered” with more choices about their care.

Many of the same analysts who make the arguments about quality and other problems would, if asked, say that extending insurance to everyone is important, vital, is PART of quality. Not having access to care at all is very low quality of care, and they don’t REALLY mean that physicians have no idea what they’re doing. But the overall effect of John Wennberg and the variations literature, all the talk about weak evidence, all the public health literature about medical care being less important than other things, and all the economics that focuses on the evils of the tax subsidies above all other concerns has to make it difficult for those swing members of Congress to vote to spend good taxpayer money on such a supposedly flawed system. What matters is not a careful balancing of factors. What matters is doubt, reasons to decide the policy gains aren’t worth the political risk. And so much of the smart, sophisticated, health policy analysis that I see can only create doubt for politicians trying to make that tough call.

So my dream had two meanings. The first is that we have become too accustomed to the horrible inequities of our health care system, inequities that, with all of the problems of our public education, sound shocking when we imagine them for education.

The second is that the health policy community of which I am a part, its research and its discourse, whatever the intent of its participants, is itself an obstacle to passing national health insurance.

Both of which mean I wasn’t having a nightmare. To my mind, given MY values, I’m living in one.