Two Questions No One Will Ask

America Dissected, a provocative podcast on the politics of healthcare, discusses how and why our healthcare system is so diseased. The host Abdul El-Sayed outlines five causes for this dysfunction:

1. Healthcare is a business. Multiple industries profit off of people only when they get sick, so patients pay for “healthcare” rather than for the “health” that they actually want.
2. Illusion of choice. With fewer and fewer medical providers, particularly in rural areas, patients are stuck with whatever is available.
3. Upselling. The same people who tell us what is wrong with us sell us on the solution to fix it. This inevitably incentivizes prescribing unneeded and expensive tests.
4. After-the-fact reimbursement. Third-party payer systems leave patients asking insurance companies to pay for healthcare costs after the services have been delivered, which runs the risk of leaving the entire burden of cost to the patient.
5. Cost. Costs are out of control, and instead of finding ways to reduce the cost system, payers and healthcare providers find ways to pass on the costs to patients.

El-Sayed then goes one to compare three potential policy solutions offered by the 2020 Democratic candidates to address our failing healthcare: Public Option, Medicare for All, and Medicare for America. In brief, Medicare for All extends the existing government Medicare system to everyone, the Public Option allows people to buy into either Medicare or a private insurance plan, and Medicare for America does something in between. To be clear, all of these are more progressive than the existing Affordable Care Act, and much, much more progressive than any plan the Republicans are offering. El-Sayed suggests that the Public Option would likely be cheaper than private insurance and might eventually out-compete private plans over time. However, he warns that under the Public Option some people would still be priced out of the market and left without any healthcare at all. Furthermore, doctors and hospitals could choose not to accept the Public Option and only see patients with private insurance.

Medicare for All (MFA), he argues convincingly, is the only way to solve our country’s healthcare woes. MFA is a single payer health plan that would extend healthcare to everyone in the country. Doctors, hospitals, and pharmaceutical companies would remain private, while the government becomes our public insurer. The cost of the program would be borne out by some combination of taxes, but if done properly, this system would eliminate copays and deductibles and cover all healthcare expenses. Simply put, MFA would eliminate the problems of healthcare as a business.

Given all of this, why wouldn’t all progressives support Medicare for All? As Senator Warren commented, “I’ve actually never met anyone who likes their health insurance. I've met people who like their doctors. I've met people who like their nurses. I've met people who like their pharmacists. I've met people who like their physical therapists. What they want is access to health care.” Supporters of the far left candidates are not only annoyed at the rest of the electorate for dismissing MFA, but genuinely perplexed by anyone’s hesitation.

Except, well, here’s the thing. Actually two things. Two big things. Two key questions hang over the entire healthcare debate and no Democrat wants to give them voice, at least not directly.

1. Who do people trust, big business or big government?
2. How much are people willing to gamble on getting NOTHING?

For years (and years and years), progressives and conservatives have tackled the first question. Does the solution to our country’s economic woes lie with an uncontrolled free market, a government welfare state, or a corporate welfare state? Conservatives argue that a competitive free market is essential to our democracy. Progressives argue that government support and oversight is necessary to help the poor and control the baser instincts of corporate greed. Oligarchs argue that government should only be used to maintain the power and riches of the already rich and powerful.

MFA requires complete trust in the government. Despite a reliance on government programs such as Medicare and Medicaid, despite worrying about corporations incentivizing profit over public good, despite some beautifully outlined villains in the healthcare debate in the form of Big Pharma and Big Insurance Companies, PEOPLE DON’T TRUST THE GOVERNMENT. A recent Gallop poll reported that 60% of surveyed Americans have “not very much” or “no confidence” in the government to handle domestic issues. Compare this to 29% in 1972 and 33% in 1998. Until Democrats face this deep-seated mistrust head on, MFA is a non-starter, no matter how many poor people lack basic healthcare. Republicans will seize on this doubt and suspicion and kill any attempt to socialize medicine.

This leads to the second key question that no one wants to discuss. Given the immense challenges in passing MFA, how much are voters willing to gamble on destroying what they already have? Assume for the moment that candidate X wins the presidential election and decides to push forward an aggressive progressive healthcare plan that will effectively eliminate the insurance industry, lower pharmaceutical profits, and disincentivize hospital upselling. The Healthcare Industrial Complex would rain down on this president with fire and fury the likes of which even Obama didn’t see with the Affordable Care Act. The disinformation scare campaign would be rapid, intense, and brutal, and legislators would scurry for the hills. Once the dust had fallen, the ACA, if it survived at all, would be on life support, gasping for air.

Or perhaps I am wrong. Perhaps our country would fight the entrenched momentum and rally behind a progressive agenda to deliver a healthcare system that would truly cover all Americans. Perhaps a system could be put in place that would salve all the wounds of the Public Option.

The question is, how much are you willing to gamble? Are you willing to bet it ALL on the BEST plan or bet just a LITTLE on a GOOD plan? Do you have a safety net in place but believe there is a better way forward for our country, or are you afraid to give up what little medical coverage you already have? Like any day at the casino, it all comes down to what is in your pocket as well as what is on the table. And a lot of people with plenty in their pocket are asking a lot from people with very little on the table.

Where does that leave us? Is a cautious measured approach better than a radical restructuring? Not necessarily. Our healthcare system is horribly dysfunctional, and nothing but an economic revolution will save it. But until the Democrats are willing to acknowledge the unspoken risks, the gamble just might be too rich for our blood.

Your Candidate Enters a Castle

A couple of months ago, a Gen X friend who is a staunch Bernie Sanders supporter lamented the centrist Democrats who complain about Sanders yelling all the time. “These complainers,” he commented, “are just outing themselves as people who’ve never known a Jew from Brooklyn.” Now as a Jew from the Midwest with family ties to NYC, I questioned his assertion. But the larger point was that to him, Sanders was channeling a righteous anger at the corrupt state of the world. As podcaster Paul Rieckhoff said, “if you’re not angry, you’re not paying attention.” My friend was right.

Another friend, a Baby Boomer, told me that he was supporting Joe Biden. He commented on Biden’s long history in government, his experience working across the aisle, and his affable personality. “Frankly,” he said, “I’m tired of feeling angry all the time. I feel comfortable with Joe.” He was right too.

No matter what rational or intellectual criteria we voters believe we are using to weigh each candidate's strengths and weaknesses, in truth, we apply our own non-intellectual determinants. Perhaps we lean toward the candidate that makes us feel angry or comfortable or hopeful. Perhaps we tilt toward the candidate we see as most radical or most practical. Perhaps we favor a white male septuagenarian or a female woman of color or a gay veteran millennial because we are convinced that particular person is the most “electable.” And since each determinant carries a different weight, it is near impossible to compare and contrast each candidate’s personality, experience, temperament, and policy on any standard scale.

Until now.

The best paradigm for classifying and codifying candidates comes from a model developed nearly half a century ago. I am speaking, of course, of Dungeons and Dragons.

D&D, the grandfather of fantasy roll-playing games, was created by Gary Gygax and Dave Arneson 45 years ago and is now a billion dollar industry worldwide. Although D&D gained an unfair reputation as an enterprise glorified by socially awkward nerds overloading on junk food in their parent’s basement (as best illustrated by Stranger Things), in fact, the game is played by millions of people worldwide. In fact, the hottest game of D&D in Los Angeles is hosted by actor Joe Mangiello, a man who himself appears to be the result of a particularly lucky roll of the character dice. (“Your barbarian approaches a castle. In front is a beautiful Columbian actress. What do you do?” “I marry her, you losers, and tell you all to SUCK IT!”).

Just like in a presidential election, D&D characters go on “campaigns.” Each character has experience points, a Class (e.g. Wizard, Sorcerer, Druid, Rogue, etc.), an Alignment (Chaotic Good, Neutral Good, Lawful Evil, etc.), and Abilities: Strength (physical power), Dexterity (agility), Constitution (endurance), Intelligence (reasoning and memory), Wisdom (perception and insight), and Charisma (force of personality). The Abilities are determined stochastically, typically by rolling five six-sided dice, removing the highest and lowest roll, and adding the remaining three dice to create a value between three and eighteen.

What a beautiful way to capture a candidate’s strengths, weaknesses, personality quirks, and experience. In fact, I don't know why career advisors haven't switched to D&D attributes instead of Myers-Briggs personality assessments and questionable aptitude tests. Just imagine the conversations at the Department of Workforce Development. "Well, you have high Charisma, Dexterity, and Intelligence, but low Strength. I recommend a career in sales or marketing, or perhaps roguish thievery."

OK, I realize this is all a gross over-simplification, but for now, please just go with it.

In fact, I posit that these abilities could be redefined as “political” abilities, and each ability would comprise three determinants each worth six points. Each determinant stands in for a roll of the six-sided dice. For example:

• Strength is “Political Strength” and comprises 1) political funds raised year to date, 2) name recognition, 3) endorsements, each normalized to a 6-point scale.
• Dexterity comprises 1) political savvy, 2) flexibility, and 3) communication skills.
• Constitution comprises 1) total number of days campaigning in Iowa, New Hampshire, Nevada, and South Carolina, 2) Honesty, 3) and Invulnerability to political attack.
• Intelligence comprises 1) Formal education, 2) Perceived mental acuity, 3) and debate performance.
• Wisdom comprises 1) empathy, 2) executive experience, 3) and overall breadth of elected experience.
• Charisma comprises 1) motivation/manipulation, 2) eloquence, and 3) likeability.

I ran this experiment with the top five polling candidates: Elizabeth Warren, Joe Biden, Bernie Sanders, Pete Buttigieg, and Kamala Harris. Scores were calculated based on external polls, published data, and, only when necessary, my own perceptions of each candidate’s strengths and weaknesses.

The advantage of this model is that candidate characteristics and personalities can be separated from their policies. In fact, policies are no longer endemic to the character of the candidate but are rather viewed as “spells” and given a maximum strength score of nine, just like in D&D. The strength of a spell is the product of the Degree of Change from the status quo (1= not change, 3 = major change) multiplied by the Level of Detail of the plan (1 = broad strokes, 3 = full details for funding). For example, a radical healthcare plan with a high level of detail on how to fund it might be a Level 9 Medicare For All spell, whereas a moderately funded climate change policy with little detail might simply be a Level 4 Clean Energy Revolution spell.

The results are interesting to say the least. Joe Biden, with his ability scores of S(15), D(14), C(12), I(13), W(15), C(13) leads the field in Strength due to his name recognition and endorsements but lags in Constitution due to the least number of days campaigning. Warren, with scores of S(13), D(14), C(17), I(15), W(8), C(15) leads the pack in Constitution but lags in Wisdom due to a lack of executive and general government experience. Buttigieg leads in Intelligence and shares top spots with Harris on Dexterity. Sanders is an overall balanced candidate; he doesn’t lead on any particular attribute but doesn’t lag in any either.

I investigated the healthcare and climate change plans (spells) as well. Not surprisingly, Warren leads the pack with a powerful Medicare for All spell (9) and six distinct climate change spells. Biden lags with a few relatively weak healthcare and climate change spells.

Now some may question my subjective analyses, and if so, they are welcome to recalculate and effectively “re-roll the dice.” However, the important lesson here is that no matter how strong your character, no matter how potent your spell, in the end, it will be the skillful application of ability, experience, circumstance, and occasionally luck that determines a successful campaign. A good supply of chips and soda couldn’t hurt either.