An Intergal Perspective on healthcare Reform

There are some very valid points here IMO.

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I’ve been asked to blog about my reaction to the healthcare reform package. This could get messy. It’s an extremely complicated topic and there are very few truly thoughtful (or integral perspectives) anywhere that I’ve seen the past 12 months. Even the commentators who claim integral credentials really miss the mark, in my opinion, diving too quickly into their preferred values-framework without giving deep and considered credence to the very strong arguments that exist on both sides (and no, I don’t mean Ds and Rs).

So I’m going to keep my comments shorter than I normally would because this post could be a 100 page issue paper if I wasn’t careful. And in this post I'm not going to focus on my specific critiques of the healthcare system itself (if there's interest I could post on that topic); instead I'll focus on integral observations of the reform debate and on giving you two resources that if you want to be educated on these topics you should read.

First though, two observations need to be made at the outset:

1. Most people are just not informed enough to have a sophisticated opinion on the healthcare issue. (Similar to Kevin Bowman's presentation here on Integral Life of naive conservative and naive liberal economic views.) This is not a criticism, but a characteristic resulting from the complexity of the system itself. Many large-scale issues that have Teal levels of systems complexity are too complex for the average voter or policy maker to understand and navigate. This is a problem everywhere and one of the reasons I continue to argue that integral leadership will be humanity’s most precious resource in the 21st century. And, for the record, I don’t claim to have the full knowledge necessary to dissect the healthcare issue.

2. An integral view requires that we account for the fact that there is not one healthcare system. And there is not one right way to do reform. And there is not one ethical stance towards how to provide healthcare. Or one right view on whether healthcare is a right or a privilege. The integral view demonstrates that every perspective can be situated within the world-space and values-domain giving rise to that perspective. That doesn’t make them all equal – they are vastly different! – but it does mean that 1) all interventions are context-bound by the ethical and pragmatic limitations one chooses to impose and one has to set those boundaries before you can decide what the most effective form of healthcare system would be given that context and 2) an integral reform praxis would look at the psychological, cultural and systemic data at different levels of worldview enactment in deciding what the best way to proceed would be. My criticism of Obama’s approach is that he is an opportunist, not an integralist: he doesn’t care enough about the philosophical divide that will wrack the United States for years to come because of the divisive foundation this reform was laid upon and manner in which it was passed. I’m not angry about this because I understand the limitations of the political culture, but it will produce more social shadow and suffering because of it.

So where to start?

Much of what I could say about healthcare comes down to two fundamental axes of consideration: What is ethical? What is pragmatic? And unlike many commentators I’ve read on this issue, my homework starts with the people who are doing real and sophisticated research in these areas. So here are two gems, both peer-reviewed academic presentations, that present very convincing and well-informed arguments on both sides of the debate, both in ethical and pragmatic social policy terms.

Ethical foundations of a single-payer system and a free-market system

Pragmatic considerations of a single-payer system and a free-market system

The reason I include these is that in my opinion if you’re not seeking this kind of reasoned argument on both sides than you’re missing out. You might also be a partisan. Which is fine as far as it goes, but it also means you’re probably more a part of the problem than you are the solution. Here’s the test, elegantly pointed out by Ken Wilber: when you read a view that differs from your own, does it bother you or inform you? When society reaches the point where a majority of people can honestly claim the latter, we’ll be ready. Until then: there is no chance that an integral political solution to healthcare reform will emerge anytime soon. The world’s not ready. So it goes, as Vonnegut writes.

So the first thing we can observe is that unless policy makers are having a reasoned debate as thorough, considerate and empirically-grounded as what we see in our best scholars, we're going to get deeply fractured outcomes. Which means that the messy war of exclusive worldviews will march on, fighting each other with everything they’ve got, each claiming to have the will of God on their side (though different gods, mind you).

And in their own ways, both are right. We do find ourselves in an evolutionary period where we’re halfway between healthcare as a privilege (200 years ago) and a right (200 years from now). The debate we’re in is a developmental one, an evolutionary one. And don’t think that you can jump the gun on evolution: healthcare has not graduated to the developmental status of food, where we as citizens don’t think twice about providing food stamps for our poorest citizens while also relishing the most expensive items at a fancy restaurant for ourselves. There will be a time when per-capita GDP (i.e., real material wealth per person) will be high enough that we don’t bother thinking about the nominal cost of healthcare, but that’s exactly the sticking point of the current debate: we are a long way off from that point and, if anything, healthcare inflation over the next few decades will keep us stuck where we are today: thinking a lot about healthcare as a drastically-expensive good.

No honest analyst on either side of this debate honestly believes this legislation will bend the cost-curve down: population is going up generally; the aging population is rising; up to 30% of doctors may retire in the face of this legislation (according to some polls); there is no price mechanism to discourage moral hazard (or rational behavior); it doesn’t change medmal; it doesn’t deeply incentivize different behaviors; it will not be deficit-reducing (there is already legislation pending to wipe out about one-third of the savings being used to pay for the bill, savings stemming from a reduction in Medicare payments); the ills of the current system (high administrative burden, reduced innovation and competition etc.) are more embedded by this legislation, not less. And on and on.

So at the heart of this discussion is a disagreement about how we make healthcare a good that works so well we basically take it for granted. Free-market supporters argue that healthcare is not fundamentally different than other life-preserving goods and therefore we should treat it as such: the market after all does have a superior track record of increasing quality and decreasing cost in almost any good it touches (and no, healthcare today is not even close to this kind of market). Single-payer supporters argue that healthcare today is so broken that what we need is to model reform after countries where we can see single-payer systems working effectively so as to increase access. And in case anyone missed the headlines, this legislation doesn’t really do either. It actually perpetuates the problematic hybrid of both a highly regulated quasi-free market with a single-payer system that currently accounts for about half of all healthcare spending in the U.S. It’s sort of the anti-Pangloss, the worst of all possible worlds (again, context is key here though: because this legislation is effectively a form of wealth transfer from the young to the old, for certain people this reform will be great, and for others it will be harmful. Which is right? Both, as far as it goes, and the relative goodness of favoring either side will depend on one’s moral outlook and economic rationale).

This is important, so let me try to state the perspectival-fighting at the heart of this reform in another way: the great contribution of the postmodernists was to show that all views have validity from within their own frame of reference (and some went to the extreme and concluded that therefore there’s no firm truth anywhere). So to prove you’ve digested this postmodern insight (stemming from early vision-logic cognitive complexity) let us suppose that every claim, whether positive or negative, that can be made about the healthcare bill by any person is a truthful claim by them (a subjective validity claim). But what makes statements about healthcare reform more or less true (an objective or interobjective validity claim) or more or less just (an intersubjective validity claim)? That’s where context counts for everything, because integralists came along with their middle vision-logic cognition and said that everything is not completely relative, and while context does shift infinitely (a postmodern insight), we can (and have to!) pin down the context in question to arbitrate the relative truth and justness of various views, particularly given a developmental framework that allows us to see that some views are more adequate than others for a given objective. But defining the specific timeline and terms for that result have to be established before one can have any hope of creating an elegant reform.

So the net result is this: in any healthcare reform that is not integrally-designed – that is, it is designed by an exclusive worldview that wants to hegemonically impose its ethical-pragmatic will on all others, such as the one we just got – will produce outsized delight for some people and outsized suffering for others. What the integral intervention would have sought to do is establish the terms of context by which all the validity claims could be most adequately arbitrated for society: this would require some developmental balance and also a sense of the time frames for success. Not everyone would be happy, but the goal is always to reduce the most amount of suffering.

Which is why…

1. The right integral healthcare reform in my view is to take all the money they’re throwing at the U.S. uninsured problem and spend it instead on clean water and sanitation projects throughout the world, which would easily and far more cost-effectively improve the health and well-being of 20 times more people (about 880 million people) than the uninsured in the United States. And,

2. At the end of the day, I can make a strong argument for the inanity of the current reform approach and for a free market system (with a social safety net) as a more ethical and cost-effective long-term option. But at some level I don’t actually care as a philosophical point: either a free-market or single-payer system would work and do (see Canada on the one hand or Singapore on the other). But the middle-of-the-road approach we're stuck in will be very ugly: a lesson that liberals will ignore, a profit opportunity that capitalists will relish, a battleground that conservatives will agitate, and a fiscal nightmare for my children. And because I can take each of these perspectives and see what’s valid and interesting in each, I am heartened to know that evolution always wins.

In the final analysis, short of the mortality-inducing access restraints of the current system that legitimately need reform, many of the gripes we're setting out to "reform" - whether the pain of higher taxes on the one hand or the pain of a medical bankruptcy on the other - let's get real: these are high-quality problems characteristic of a luxurious first-world society.

Robb

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