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.[1],[2] 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[3], 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.[4] 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?
Conclusion
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.
NOTES
[1] 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?
[2] 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.”
[3] Nor are all scholars are academics; they aren’t.
[4] 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.
NOTE
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.
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“findings” = “professional opinions” = “what I want you to think”
And caveat emptor.
JAMA BS Delenda Est
Lambert, thank you for your patience in dissecting the matter. You’ve taught quite a lot about the healthcare process and players.
Oddly, Jim Messina isn’t mentioned in the JAMA article.
“I can’t imagine that the president knew about it.”
You forgot the snark tag, Mr. Kirsch.
I remember at the time being incensed at Baucus for the stage-managed hearings, at which dissenting voices were summarily arrested and frog-marched off the scene. But is what you are saying that the corporatist fuckers who run the white house actually manage Baucus so that he doesn;t hear or know about opposition to the stage-managed process he is presiding over? IN case he actually, you know, might be tempted to represent the people?
The depths of the corruption of our federal apparatus are sick-making – including the JAMA insulting its own standards, and the intelligence of its readers, in favor of blatant political advocacy. And ass-kissing. Fuck the greedy corrupt fuckety fuckers to hell.
“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.”
“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.”
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We start nowadays with the premise that the market is the best answer to each and every problem. Despite innumerable essays on the difficulties – nay, impossibility of using the market to apportion health care efficiently or effectively.
But so it goes – the rachet always goes in one direction at the direction of our differently branded parties, but de facto synonymous red and blue teams. More money from patients to go to more corporations…
And our fact free “political” debates, in which examples of single payer systems up and running successfully in numerous countries are given as much credence as bigfoot.
Currently true, but stress builds in the system (rachet) and then is released in a chaotic event (unpredictable when and what), and a new system (different, not necessarily better) emerges.
Climate change. There is no escaping loss of coastal land and loss of food. A plan which relocates 50% to 75% of the human race appears inconceivable.
I considered I would pass before the effects of climate change became extant. I’m now not so sanguine.
“introducing a public plan option in areas lacking individual market competition”
Looks like letting the gov provide the difficult destitute rural areas and leave the pro class and high deductible working class to the grifters. SOP. We’ve crossed the rubicon, though, and the beatings will continue until morale improves…
Don’t worry about the grifters being left out of any “public plan option.” Can anyone name a State which has not subcontracted Medicaid administration to the grifters? Yes more beatings. Thank you Lambert.
excellent post. the crapification will continue till morale improves.
Of course he does, every cab ride is a fact-finding mission for him…
From a tactical point of political reform, going for a “public option” or almost any other large scale, extensive reform, will find legislators in a fight to the death living hell. Since relative to Universal Medicare, going that route directly or allowing the mixed economy of private health insurers to coexist next to government funded health care plans with some more ridiculous add on here and there, e.g., the “public option”, it is better to engage directly in battle to turn the entire health care system into a single payer universal Medicare system.
The political fight will not be much less than for a clear beginning to make universal health care a reality. Any reform which is not part of a comprehensive movement to place the entire health care sector into a single payer universal Medicare format will just be a bloody battle for another random piecemeal add on. The lives saved by the final battle for complete conversion will exceed whatever a partial dead end reform could win in the end. If we are going to fight like hell anyway for something as inadequate as a “public option” we might as fight like hell for the whole enchilada.
I have a couple of anecdotes that highlight the lousy ACA. Both my children were covered by employer health insurance until the beginning of August when they left to transition back to graduate school. Each lost their insurance near the beginning of the month and must wait until September 1st to get new insurance.
There is no way to cover the Gap because new insurance cannot be bought until the old Insurance expires and since it expired after the first of the month the new policy would not go into effect until the first day of September. And since you have to buy insurance in a particular state, my son was left out in the cold as he traveled around the United States. It was senseless for him to get a policy in Massachusetts that would only cover him in network in Massachusetts when he will never be here.
But they will not be dinged on their tax forms because all you have to have is insurance for one day in a month, so they have obviously thought of this terrible issue. I wonder how many people get caught with huge medical bills waiting for new insurance to go into effect? You hear the phrase often that a person serves at the pleasure of the president. In the United States, we live at the pleasure of the health insurers, big pharma and the medical industrial complex.
My wife and I are uninsured. Recently, we received the wonderful news that she is pregnant with twins. We also learned that pregnancy is not defined as a “life event” that allows for picking up an Obamacare plan outside of the open enrollment period. Child birth – yes. Pregnancy – no. Upon further research, I learned that the “pregnancy as a life event” issue had been aired by some advocates, but the insurance lobby deemed that allowing it would incentivize women to hold off on getting their crappy Obamacare plans until pregnant.
That is, a health policy and public policy problem was decided by accountants, on actuarial principles.
And now I’m being brow beaten into voting for the next shitty Democrat – one appreciably worse than the last one – because the alternative is so much worse.
Congratulations.
If you haven’t already, look to see if you have any community health centers near you. If you are lucky enough to have one they may be able to help bridge the gap, providing low or even no cost health care depending on income.
Excellent breakdown as usual Lambert.
For me the big story here is JAMA, because let’s flip the tables a bit, and throw out most of the salient points about Obama selling a fraudulent product. Let’s say for argument’s sake that Sanders had won, and had implemented Berniecare for All in 2018. Then let’s say in 2023 Sanders publishes a piece in JAMA extolling Berniecare for having “made significant progress toward solving long-standing challenges facing the US health care system related to access, affordability, and quality of care”. In this case the claims could very well be true, Sanders’ article could meet perfectly all the requirements for a “Jama Special Communication”. Even then, it would still be utterly unethical for Jama to provide Sanders a pullpit to burnish his legacy, and even worse, it would be an utter abuse of power for Sanders to use his position of power to cheapen a scholastic publication (use of public resources for personal gain=def. of corruption).
This makes what Obama has done all the more despicable.
Yes, it would. If a President wants to deliver a political message, they have an enormous number of options. So, naturally, Obama seeks to pollute a seemingly apolitical medium because the optics are better. Just vile.
I don’t often attribute long term thinking to Obama and his advisors, but I’m going to do so here. It is NOT just that the optics are better, it is that by doing this and getting them to do it despite its obvious shortcomings within their own standards, it provides a pretty decent weapon in the ever increasing battle to hide that ACA is rapidly falling apart. Not only can they point to the fact that JAMA published this and use it to refute contrary information, it will probably make JAMA reluctant to publish more accurate and better researched pieces that prove it got taken by the President of the United States until it can no longer be avoided. Win Win. And one more example of the crapification of Health Care, health care information and yes oversight that has been a long term neoliberal project of making sure America is third world country on every level.
In some ways, the bigger question is why JAMA chose to harm themselves in this manner. Delusion, collusion, take over or just stupidity.
what the Mob does–get you dirty. yes, why did JAMA choose to be initiated?
Just as the Canadian Medical Association opposed utterly the introduction of single-payer Medicare for all in Saskatchewan in the fifties, so also does the AMA.
No mystery here why the dirty deal was done.
Didn’t you see Obama’s speech at the convention? And Michelle’s? These are wonderful, wonderful people. And such great parents. How could anyone say anything bad about them?
Goodbye Obamas. Don’t let the door hit you on your way out.
Great piece, Lambert, thank you. Can’t come here as often any more, but always get great value.
It’s not affordable now (premiums have skyrocketed). And it will cost much more money than anticipated in the longer-run. The reason is simple. The doc’s can’t make money under Obamacare (esp. with a surfeit of new regulations to account for).
Private practice physicians are going to go out of business, quit, retire, or join a gov’t funded institution. With socialization, docs will work 40 hours a week (instead of 60 + hours). And if you know anything at all about medicine, you know this will produce shortages (access problems), and cost over-runs (gov’t sponsored projects are not efficient and have limited accountability), and quality care will be history (there’ll be less training and fewer specialist and more malpractice lawsuits), all as a result. It will benefit the legal profession (as surreptitiously intended), more than the medical profession.
WTF are you smoking?
I live in Canada. We have ‘free’ (govt-paid) health insurance, administered by regular-type physicians, clinics, hospitals which may or may not be private, community-owned, religious, for-profit or non-profit. A woman who is my age (ahem) is the daughter of a rural doctor. When Tommy Douglas introduced Medicare here, her father was so happy. “It means we’ll *get paid*!”
We have lovely hospitals and clinics here. Good access, good equipment, good staff, nice, smart and well-trained techs, yada. As your Pres Bush said, if we have a problem, we just go to emerg. There is no bill, ever. No deductible, no limit, no means test, nada. We get health *care*. I think it should include prescriptions, dental, chiropractic and some other stuff it doesn’t, but your Medicare was only ever expanded once, to kidney transplants. And there was a limit on that, too. Moment of silence for my friend LB who lived in Oregon, who died when his replacement kidney didn’t take for longer than Medicare would cover.
Talk about death panels. Feh.
A longtime friend used to be the managing editor of a medical journal. Believe me, the style guide was taken VERY seriously.
Yes!
Breaking the 50 footnote rule seems trivial until you realize that they’ve set up a two-tier dystem where the most powerful get to break the rules and the rest don’t..Like everything, eh?
Because I love Lambert’s work, here is a summary definition of Public Option:
Progressive Health Care Dictionary: “Public Option”
n. Ruse to divert progressive attention from the fact that the Affordable Care Act would not provide universal coverage, would not control costs, and would not diminish the power of the insurance, hospital and pharmaceutical industries. Shields same from single payer. Beset by internal contradictions – was supposed to be simultaneously vehicle for destroying private health insurance with public competition and “passable” alternative to single payer. Whittled to meaninglessness 2009-2010 Congressional debate. Jettisoned, replaced by health insurance co-ops.
Provenance: Invented whole cloth by Jacob Hacker (2008). Eagerly adopted by mainstream enforcers of center-left legitimacy.
Evidence of Efficacy: Zero. Never been tried. Purely theoretical.
Status: Surrendered without fight by Democrats 2010. Currently zombie plank in 2016 Democratic platform..
See Also: “Obamacare co-ops;” “Handjob for liberals” “Bad US health policy ideas never die”
The JAMA Article coming from Obama the Constitutional Attorney ???
I would be interested in knowing what Roy Poses’ disagreements are…
I really don’t want to speak for Poses, but I’ll quote this one sentence, hoping I don’t misrepresent his views:
In part, I designed the post to respond to this; that’s why I focused on the Style Guide so closely.
JAMA and AMA have sold us out. The AMA represents only 10-15% of MDs. Obama and Obamacare have about eliminated the solo practitioner. Good luck America with protocol medicine. We have and will continue to have a two tiered system. One for the “haves” and one for the “have nots”.