Words matter: healthy and unhealthy politics

Abstract

Politics, especially health-care politics, often seems like a black box to health professionals. In the presidential race in the USA, for example, virtually all national health politics have been focused on the one segment of American medicine that is only marginally touched by our new Affordable Care Act: Medicare. The central charge, repeated by Mitt Romney and his Republican party backers (who want to replace Medicare with a voucher system), is that the Affordable Care Act (aka “Obamacare”) will “cut US$716 billion from Medicare”, reducing benefits by this amount. Although the assertion is inaccurate, it is politically effective. The Democrats have seemed impotent to respond, even though Obamacare actually increases benefits (including drugs and preventive care) to Medicare recipients. Are we all destined to remain passive spectators, or are there analytical tools we could apply to understand what is going on, and maybe even help shape the dialogue? A collection of essays by renowned political policy experts Ted Marmor and Rudolf Klein on health-care politics suggests “yes we can”. The book aims to explore and explain the big ideas (and big problems) in health-care politics, mostly, but not exclusively, as fought out in the USA and the UK. They define public policy concisely as “what governments do and neglect to do”, and the function of politics as: “resolving (or at least attenuating) conflicts about resources, rights, and values”. Marmor and Klein's approach to political analysis is based on their own “trinity of conceptual building blocks”: ideas (including how the problem is framed), institutions (the constitutional arrangements within which the government operates), and interests (including money, of course, but also moral convictions about right and wrong and about appropriate and inappropriate action). It is also essential to recognise that all politicians must operate under the “double imperative”: doing what is necessary to first get elected, and second to stay in office. Most of the essays in this volume apply the trinity approach to analyse specific public policy problems and disputes in health care, including resources and rationing; the state and the medical profession; patients, consumers, and citizens; and the politics of health crusades. There are many insights in these essays—I especially liked the discussion of the transformation of the UK's National Health Service from a “church model” to a service “garage model”, and the quotation from Enoch Powell who noted, almost a half century ago, that in medicine, as in eating, appetite for more comes with the first taste of medical care. The absence of any limits on our appetite for medical care has been a central challenge for the USA, whose citizens accept no limits on care, and disdain even attempts to discuss end-of-life care as an endorsement of “death panels”. The fear that medical care will be limited by the government helps explain the political power of even a false assertion that under Obamacare seniors will see their Medicare benefits reduced. In their concluding Coda, Marmor and Klein assure readers that their trinity framework is a “do-it-yourself conceptual tool kit” that anyone can use to analyse issues not covered in the book, and new issues that will come up in the future. Let me test this assertion by applying their trinity approach (ideas, institutions, and interests) to abortion in the USA. The constant “double imperative” background has led many American politicians to take extreme positions on abortion, because some citizens will vote for or against a politician on this single issue. In terms of “ideas”, the capture of the “right to life” language by the antiabortion forces, later supplemented with “partial-birth abortion”, helps explain much of the movement's broad and continuing appeal—one in which life contrasts with death, and “partial birth” should always end with a live baby. Under “institutions”, the US Supreme Court can be seen as initiating the political dispute with its 1973 Roe v. Wade decision. And the consistent political objective has been to change the US Supreme Court itself by trying to get presidents to appoint, and the US Senate to approve, Justices who would vote to overturn Roe v. Wade. “Interests” helps us appreciate how societal views of “right and wrong” (of abortion itself, and even of “appropriate” exceptions to any proposed ban—even the use of bizarre adjectives, such as “legitimate” and “forcible” to limit the rape exception) affect both sides of the debate and determine whether compromise is possible. The trinity approach really can enhance political understanding. The concluding words of the Coda are worth underlining: “conceptual precision and verbal clarity are the essential foundations of any [political] analysis: words matter and jargon is the enemy.” Put another way, you cannot “win” a political battle over partial birth abortion by insisting that it be called by its medical name, intact dilation and extraction.