Highly recommended article by Dr. Atul Gawande on the political fight over PACA.

[Mayberry Machiavelli]

Dr. Gawande describes the nature of the health care problem and why it is easier to demagogue against solutions than to provide simple solutions that are easy to sell. He also describes the main types of arguments used against PACA in a broader historical context of how similar lines of argument have been employed to resist other social changes in the past:

http://www.newyorker.com/online/blogs/comment/2012/06/something-wicked-this-way-comes.html

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Two decades ago, the economist Albert O. Hirschman published a historical study of the opposition to basic social advances; “the rhetoric of intransigence,” as he put it. He examined the structure of arguments—in the eighteenth century, against expansions of basic rights, such as freedom of speech, thought, and religion; in the nineteenth century, against widening the range of citizens who could vote and participate in power; and, in the twentieth century, against government-assured minimal levels of education, economic well-being, and security. In each instance, the reforms aimed to address deep, pressing, and complex societal problems—wicked problems, as we might call them. The reforms pursued straightforward goals but required inherently complicated, difficult-to-explain means of implementation. And, in each instance, Hirschman observed, reactionary argument took three basic forms: perversity, futility, and jeopardy.

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The rhetoric of intransigence favors extreme predictions, which are seldom borne out. Troubles do arise, but the reforms evolve, as they must. Adjustments are made. And when people are determined to succeed, progress generally happens. The reality of trying to solve a wicked problem is that action of any kind presents risks and uncertainties. Yet so does inaction. All that leaders can do is weigh the possibilities as best they can and find a way forward.

They must want to make the effort, however. That’s a key factor. The major social advances of the past three centuries have required widening our sphere of moral inclusion. During the nineteenth century, for instance, most American leaders believed in a right to vote—but not in extending it to women and black people. Likewise, most American leaders, regardless of their politics, believe people’s health-care needs should be met; they’ve sought to insure that soldiers, the elderly, the disabled, and children, not to mention themselves, have access to good care. But many draw their circle of concern narrowly; they continue to resist the idea that people without adequate insurance are anything like these deserving others.

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(more at link)

The article is short, basically a blog post, but very concise. I personally think Gawande is the best writer on social, ethical and political issues surrounding medicine right now. If you are unfamiliar with him, I'd recommend you check you his books and articles. He is a gifted writer and his style is not dry at all, it's informative but also entertaining reading.

Many of his articles are compiled online at the New Yorker's website, and a lot of these have been incorporated as chapters in his books:

http://www.newyorker.com/magazine/bios/atul_gawande/search?contributorName=Atul%20Gawande

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1. K&R

Interesting analysis.

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