By Lambert Strether of Corrente.
As Obama’s second term winds down, he’s been burnishing his legacy. (For a suitably jaundiced take, see Black Agenda Report here, here, here, here, and here.) One such legacy, for good or ill, is Obama’s eponymous ObamaCare, and the Journal of the American Medical Association recently allowed him to burnish that program on its own glossy pages. I touched on Obama’s JAMA write-up briefly here, but I think this is a sufficiently important topic — and the piece so full of falsehood, meretricious reasoning, and erasure — for a full post. Here’s the whole piece: “United States Health Care ReformProgress to Date and Next Steps” (JAMA. 2016;316(5):525-532. doi:10.1001/jama.2016.9797).
In a past life, I used to read style guides for a living (really!). And style guides are especially important for medical journals: Their articles are highly structured so that time-pressed professionals can scan for information quickly; but the structure, the typography, the layout, and especially the lavish footnotes also function as a sort of trade dress, guild vestments, an impervious cloak of credentialed professionalism. So when Obama presents his Abstract in structured form, as the JAMA Style Guide demands, using the headings “Importance”, ” Objectives”, ” Evidence”, ” Findings”, ” and Conclusions and Relevance” he’s speaking as a professional, to professionals, and conforming to a professional’s ethical and technical standards. (But wait: Since when — let’s be frank here — does an opinion piece on political economy have findings? Does Thomas Friedman have findings? Paul Krugman?)
The JAMA editors classified Obama’s article as a “Special Communication” (at top left of page). Here are the requirements the JAMA Style Guide lays on Special Communcations:
Note: JAMA publishes very few of these types of articles: ordinarily, fewer than 6 per year. These manuscripts describe an important issue in clinical medicine, public health, health policy, or medical research in a scholarly, thorough, well-referenced, systematic, and evidence-based manner. Depending on the content, either a structured abstract or unstructured abstract is required. Maximum length: 3000 words of text (not including tables, figures, or references) with no more than a total of 4 tables and/or figures and no more than 50 references.
I contend that Obama’s Special Communication is not scholarly, not thorough, not well-referenced, and not evidence-based., In addition, I believe that Obama’s policy recommendations (“Conclusions and Relevance”) are wrong. Because these points are all so obvious, this will be a very short post!
Obama’s Special Communication is not Scholarly
To me, the essence of scholarship is disinterest, in the old school sense of the word: Not lack of interest, in the sense of indifference, but freedom from interest, in the sense of not being invested in outcomes. (Last week there was a wonderful long-form article in the Times, “The Brain That Couldn’t Remember,” that turns on just this point.) A scholar will follow where the evidence leads; the ideal scholar is ruled by curiosity, not merely by ambition, and certainly not by greed or lust for power. (See, e.g., Shevek in Ursula LeGuin’s The Dispossed, or the protagonists of C.P. Snow’s The Affair, where a miscarriage of justice in a case of scientific fraud is rectified through the discovery of new evidence, followed by the cut and thrust of academic politics.) It must be said that not all academics are scholars, which is why paradigm shifts take so long, and why science proceeds “one funeral at a time”! Of course, these days, when university administrators think of themselves as executives, and have structured teaching and research like a tournament where only a few stars collect winnings in the form of corporate funding, my idea of scholarship may seem old-fashioned, even naive or quaint. But that’s the concept I grew up with and I’m sticking to it.
Assuming, then, this understanding of scholars and scholarship, I don’t see how Obama’s piece can possibly be scholarly. I am not making the argument that Obama is directly or formally conflicted as JAMA editors understand the term. Obama, in common with all JAMA authors, submitted the required ICMJE Conflict of Interest form (PDF), and although the form is kept private, the editors must have approved it. The form focuses heavily on “Relevant financial activities outside the submitted work,” and Obama submitted his financial disclosure form at whitehouse.gov (PDF). However, the form also includes “Relationships not covered above”:
Use this section to report other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work.
So, when a President, who is also the head of his party, writes a piece on statute that bears his name, in an election year, against an opponent he and his party are depicting, rightly or wrongly, as a dangerous lunatic, and against a party that wants to repeal that statute, there are no “relationships or activities” that “give the appearance of potentially influencing” what he wrote. If that’s how it is, fine. Editorial judgement controls. But can Obama possibly be disinterested? No. Exactly as, in a campaign, the candidate’s time is the most valuable asset the campaign possesses, so too with a President’s time, when governing. It’s simply not credible that the White House would invest Obama’s time in this article, in the midst of a campaign, with no political end in view. I grant that Obama’s article is not as gross as a pharmaceutical salesman’s puffery; but despite the trappings of scholarship, this “Special Communication” is not scholarly. As we shall see when we look at what Obama omits.
Obama’s Special Communication not Thorough and not Well-Referenced
Is Obama’s communication “thorough”? Here are Obama’s policy recommendations. From the Abstract:
Findings The Affordable Care Act has made significant progress toward solving long-standing challenges facing the US health care system related to access, affordability, and quality of care. … Despite this progress, major opportunities to improve the health care system remain.
Conclusions and Relevance Policy makers should build on progress made by the Affordable Care Act by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation’s most complex challenges.
Nowhere in the article does Obama discuss single payer programs. It’s as if a simple, rugged, and proven single payer system for provisioning health care did not exist sixty miles north of Burlington, Vermont, and Canada was just a blank space on Obama’s policy map. Besides Canada, Australia, Spain, Taiwan, and the United Kingdom all have health care systems that fall on the single payer, “universal health care” spectrum. And yet Obama, who purports to discuss “review the factors influencing the decision to pursue health reform,” does not mention them. Obama’s meretricious approach is about as “thorough” as that of a phlogiston advocate who omits to discuss oxygen. Fine, advocate away, but let’s be clear that advocacy, and not scholarship, is what’s going on.
Is Obama’s communication “well-referenced”? We apply the same logic; scan the notes, and you will find no references to single payer systems (simple, rugged, proven) in other countries at all. It’s as if Obama was writing a paper on public policy for sepsis, had his own theory, and refused to cite the work of Semmelweis, because Austria was the blank space on that policy map. Could such a paper be said to be “well-referenced”?
Obama’s Special Communication is not Evidence-Based
It’s hard to see how an article that is neither “thorough” nor “well-referenced” could be evidence based, and so this section would be redundant, were it not that Presidential candidate Hillary “Never, Ever” Clinton also claims to take an “evidence-based” approach to health care. However:
“[CLINTON:] It’s important to be guided by evidence about what works and what doesn’t…not ideology or personally held beliefs.
Clinton then proceeds, exactly as Obama does, to entirely erase single payer from the discussion. As I wrote then:
[S]ince the mid-70s, when Canada adopted its single payer system, we’ve conducted the largest controlled experiment in the history of the world. We’ve had two political systems spanning the same continent, both nations of immigrants and once part of the British empire, both mainly English-speaking but multicultural, both with Federal systems, and both with a free market system backed by social insurance. And the results of the experiment? The “evidence”? Canadian-style single payer wins hands-down.
How can any Special Communication that ignores such evidence be evidence-based? Again, tendentious advocacy is fine — that’s what Viewpoints are for — but surely JAMA’s editors could have avoided the deceptive labeling?
Obama’s Proposed “Public Option” is a Terrible Idea
Finally, “the public option” always pops up when single payer gets traction, and liberals always suck all the oxygen away from single payer by pushing it, making single payer “politically infeasible.” For those unfamiliar with this ugly history, the links here and here are must-reads. From the first:
The people who brought us the “public option” began their campaign promising one thing but now promote something entirely different. To make matters worse, they have not told the public they have backpedalled. The campaign for the “public option” resembles the classic bait-and-switch scam: tell your customers you’ve got one thing for sale when in fact you’re selling something very different.
When the “public option” campaign began, its leaders promoted a huge “Medicare-like” program that would enroll about 130 million people. Such a program would dwarf even Medicare, which, with its 45 million enrollees, is the nation’s largest health insurer, public or private. But today “public option” advocates sing the praises of tiny “public options” contained in congressional legislation sponsored by leading Democrats that bear no resemblance to the original model.
According to the Congressional Budget Office, the “public options” described in the Democrats’ legislation might enroll 10 million people and will have virtually no effect on health care costs, which means the “public options” cannot, by themselves, have any effect on the number of uninsured. But the leaders of the “public option” movement haven’t told the public they have abandoned their original vision. It’s high time they did.
And so, again, Obamas is the very reverse of disinterested; in fact, he could be said to be giving certain factions of the political class a set of very familiar marching orders.
My own view is that the “public option” is, in fact, incredibly dangerous. It’s a classic neoliberal approach, that puts government provisioning of services within, and in competition with, “market forces.” Presumably, the “public option” would be one of the services available on the ObamaCare website. Now transpose that implementation to the provision of dignity in retirement, and imagine a “Retirement Marketplace” with Social Security as “the public option” right next to the various heavily marketed 401(k) plans. Can you imagine — even, in your mind’s ear, hear — the drooling from Wall Street at that prospect?
I probably took more time pointing out Obama’s failures as a putative scholar than I should have, but as a child of scholars, I experience the crapification of scholarship keenly, and to see the trappings of scholarship used to cloak a public relations effort that’s part of a political campaign fill me with disgust. Again, advocacy is fine, but label it as such.
But the “public option” is also a sort of policy earworm, impossible to get out of your head once you hear it. It sounds like such a good idea, and I can even imagine that the Clinton administration would propose legislation for in 2017. But it’s no substitute for single payer, and I argue that creates a very dangerous precedent.
 Obama’s Special Communication also has 64 footnotes, not “no more than 50,” but what editor would not eagerly defer to a sitting President on such a trivial matter?
 Therefore, I believe that JAMA’s editors misclassifed Obama’s piece, which should have been a Viewpoint. Here are the requirements for a Viewpoint article, again from the Style Guide:
These papers may address virtually any important topic in medicine, public health, research, ethics, health policy, or health law and generally are not linked to a specific article. Viewpoints should be well focused, scholarly, and clearly presented and must have no more than 3 authors. The text should include the full name, academic degrees, and no more than 2 institutional affiliations for each author. Maximum length: up to 1200 words of text—or 1000 words of text with 1 small table or figure—and no more than 7 references. Viewpoints not meeting these guidelines will not be considered.
You will note that the requirements that Obama’s Special Communication does not meet — thorough, well-referenced, and evidence-based — are not levied on the authors of Viewpoints. Further, since Obama’s article transparently pushes a view — and the political view of one faction of the Democrat party, if it comes to that — it might as well go under the heading for articles that do such things. And for the sake of not degrading the piece to the “Piece of My Mind” content type, I’ll issue a good-for-one-time-only pass on “scholarly.”
 Nor are all scholars are academics; they aren’t.
 Single payer advocates were certainly “factors influencing the decision”; erased then, erased now:
I suggest the real constraints came from three sources, as indicated by their behavior from 2009, when battle for health reform was joined: (1) The Democratic nomenklatura, which censored single payer stories and banned single payer advocates from its sites, and refused even to cover single payer advances in Congress, while simultaneously running a “bait and switch” operation with the so-called “public option,” thereby sucking all the oxygen away from single payer;1 (2) Democratic office holders like Max Baucus, the putative author of ObamaCare — Liz Fowler, a Wellpoint VP, was the actual author — who refused to include single payer advocates in hearings and had protesters arrested and charged; (3) and Obama himself, who set the tone for the entire Democratic food chain by openly mocking single payer advocates (“got the little single payer advocates up here”), and whose White House operation blocked email from single payer advocates, and went so far as to suppress a single payer advocate’s question from the White House live blog of a “Forum on Health Care.” (Granted, the forums were all kayfabe, but even so.) As Jane Hamsher wrote, summing of the debacle: “The problems in the current health care debate became apparent early on, when single payer advocates were excluded [note, again, lack of agency] from participation.”
In short, if single payer was “politically infeasible” — the catchphrase of that time — that’s because Democrats set out to make it so, and succeeded.
I want to thank Roy Poses of Health Care Renewal for correspondence on this matter that helped me clarify m views. It is only fair to say that he disagrees.