I read a book back in residency that changed my life. I know that's cliched, but there's no other way to put it. People tell me all the time that it's hard to argue with me; that book is why. It's Getting to Yes: Negotiating Agreement Without Giving In.
I think the reason health care reform has disappointed so many is that too few people, on both sides of the aisle, have read this book. Here's a critical passage, right from the beginning:
When negotiators bargain over positions, they tend to lock themselves into those positions. The more you clarify your position and defend it against attack, the more committed you become to it. The more you try to convince the other side of the impossibility of changing your opening position, the more difficult it becomes to do so. Your ego becomes identified with your position. You now have a new interest in "saving face" -- in reconciling future action with past positions -- making it less likely that any agreement will wisely reconcile the parties' original interest.
We live in a world where politicians, and the public, are consumed by positions. We are so concerned with them -- what we are "for" -- that we lose sight of what we are actually trying to achieve.
I used to think that the United States had the best health care system in the world. I'd argue against anyone who wanted to seriously reform it. When I attended a conference on universal health care, a proponent of single payer health care so enraged me that I was consumed with proving her wrong. A colleague and I decided to conduct a large study on physicians' views on National Health Insurance. I was absolutely positive we would find robust opposition. When we found a plurality of physicians actually supported National Health Insurance, I was stunned.
Not only did we publish the results, but I also felt compelled to rethink my position. If I was wrong on this, I might be wrong on many other things. And my review of the research, which I'm willing to wager was about as thorough as anyone else has done, found that there was overwhelming evidence that systems with more socialized financing achieved superior results, covered everyone, and still cost much less per person than our system.
There's no zealot like a convert. Since the evidence was so compelling, I found myself arguing more and more for single payer health insurance. That was a new position, however, and I found it difficult to sway those who believed as I used to.
That's when I went back to Getting to Yes. I stopped arguing my position and started negotiating. I'd get people to agree to the metrics on which a health care system should be judged -- access, quality, and cost. I'd get them to agree on how we should measure them. And then I'd have them apply those measurements to the metrics. It rarely fails.
Unfortunately, that's not the way it seems to work in politics. All people seem to care about is positions.
I've spoken more about health care reform and given more interviews in the last six months than I have in the previous six years. And in each interview, eventually, I am asked what I think about reform. I've dodged the question repeatedly, but it's important you know where I'm coming from. Here is my position:
I think it's ridiculous that single payer health insurance was taken off the table so early in this process. I think that it's laughable that we can't publicly have a discussion about it without losing our collective marbles. I think it's the height of hypocrisy that a single-payer system is American-as-apple-pie if you're 65, but a socialist nightmare if you're 64.
I think it's naive and xenophobic to use scare tactics to cloud the fact that almost any other comparable country in the world provides universal health care to its citizens, achieves similar if not better outcomes, and spends far less than we do. I think it's strange to ignore these facts and proudly proclaim the opposite.
I have felt, and continue to feel, that Medicare-for-all would be a far better solution than pretty much anything else that has been proposed. I've said so from the beginning.
Please hear me, though. None of that matters.
I'm not arguing for a position; I'm negotiating for a goal -- a better health care system. I want more people to be covered. I want to see our quality improve. I want to see costs become more acceptable. That -- not an ideology or a position -- is what I want.
Because of that, even though I think more robust reform would be preferable, I am willing to say that the reform we are likely to get does more good than harm. Many more people will get Medicaid. Many more will get subsidies to help them buy private insurance. Regulations will protect the sick and help prevent medical bankruptcies.
It's not single payer. It's not perfect. And it may not feel like a "win." But it's not supposed to; that wasn't the point. In a principled negotiation no one wins, but no one loses either. In a principled negotiation, you try and get your goals accomplished. You try and get a better health care system than you had before.
I think we will.
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