Health policy expertise and presidential politics
Speaking Truth to Power — The Need for, and Perils of, Health Policy Expertise in the White House
By Jacob S. Hacker, Ph.D.
The New England Journal of Medicine
September 11, 2008
The adviser is the president’s ally — in the lingo of organizational economics, an “agent” serving the interests of a “principal.” Yet as a bearer of specialized knowledge, the adviser is also responsible to a larger profession, to its values and commitments, and ultimately to the ideal of expertise itself.
The adviser, in short, must both “speak truth to power” and aid in the exercise of power, both offering unbiased intelligence and acting as a very biased assistant. It is fashionable to pretend these two roles are the same, but they are not. An expert adviser has special knowledge, training, and skills — all of which are needed more than ever in the White House. The question is whether these talents can really be used, or be useful, in the bare-knuckles world of American politics — and, more important, whether the values they embody can be upheld when science, advocacy, and democracy collide.
Politics is about power more than truth, about winning more than being right. But expertise is about truth more than power, and being right is the whole point.
Health policy experts can do more sophisticated analyses than ever, and there are more of them than ever, too — in policy schools, departments of economics, schools of public health, think tanks, private foundations, and government. But the progress in quality of expertise has not been matched by progress in thinking about the role of the expert or about how policy advice can and should be adapted to the political realities that those receiving advice inevitably confront. Policy experts are brilliant when it comes to designing proposals but often horrible at thinking through the ways in which their proposals will be refracted through the political prism. Subtle visions of policy are wedded to crude caricatures of politics, and, not surprisingly, those visions all too often either fail to become reality or fail to work.
Worse, the expert’s claim to authority can undercut the more important wellspring of democratic leadership: the demands and wishes of the people. Experts are habitually disdainful of what ordinary citizens believe. People have opinions; experts have facts. When a well-regarded economist complains that democratic policy choice should be restricted because “irrational” voters endorse all sorts of harmful nostrums — whether trade protection or farm price supports (he might have added health insurance with low deductibles, drug price controls, and free choice of doctors) — he may be out on a limb. But the tree is one that many policy experts climb.
We badly need health care experts in the White House who offer advice based on evidence and analysis, not prejudice. But even the best experts need to know when to defer to the political process, to see the purpose of their craft as facilitating democratic debate rather than providing final answers once Americans have decided on the questions.
Winston Churchill once said that “scientists should be on tap, not on top.” That is a good starting point. But sometimes presidential policy experts should also have the good sense to get out of the way.
http://content.nejm.org/cgi/content/full/359/11/1085
Comment:
By Don McCanne, MD
”… expertise is about truth more than power, and being right is the whole point.”
In deciding whether policy is right or wrong, it is essential first to decide what goals are to be achieved by the policy decisions. In reforming health care financing, most of us would agree that the goal is to provide everyone with access to all necessary health care without having to be exposed to financial hardship.
We have available a wide range of expertise within the policy community. When you look at the various policy recommendations, some of them, if enacted, would achieve this specific stated goal, but most of them would not. Those that would not are policies that are designed to achieve other less beneficial or even detrimental goals (ownership society: own your own debts). Stated in other terms, those supporting the few policies that would work are right, and those supporting policies that fall short are wrong.
In policy, being right is the whole point.
“Politics is about power more than truth, about winning more than being right.”
Politics is represented by the great legislative battles that we are witnessing wherein one side advocates for policies that are wrong, largely because they’re inadequate, and the other side advocates for policies that are completely wrong because they make matters worse.
Without the continual involvement of members of the policy community who emphatically support that which is right, we’ll continue to witness politics that results in wrong, wronger and wrongest policies.