In the giddy days after the passage of ACA, I was chatting to a PhD student in health economics. He was in love with the ACA. He kept repeating that it would reduce costs, increase quality and increase access. Nothing original. You know the sort of stuff you heard at keynotes of medical meetings; ‘Healthcare post Obamacare’ or ‘Radiology in the new era.’ Talks warning us that we were exiting the Cretaceous period.
He spoke about variation in healthcare, six sigma, fee-for-value and ‘paying doctors to do the right thing.’
‘How?’ I asked.
‘I just told you, we need to pay doctors for value and outcomes.’ He smugly replied.
‘How?’ I asked again.
He did not answer. Instead he gave me the look that one gives an utter imbecile who doesn’t know the difference between a polygon and a triangle.
My thoughts drifted to the great polar explorer William Shackleton, stranded in Elephant Island, Antarctica, with his crew looking at the night sky in negative sixty Fahrenheit.
‘Sir, what are we going to do so not to freeze next to the penguins?’ One of his crew asks.
‘We need to get out of here.’ Shackleton replies, thoughtfully.
‘Well thanks Captain! That’s what I call strategy. Why hadn’t I thought of that?’
Yes, why hadn’t I thought of that? Let’s just pay doctors to do the right thing. So damn obvious, eh! Except Shackleton probably would have said what I had hoped that economist would have acknowledged: ‘I don’t know, you imbecile.’
‘We need this’ is not a strategy. Just because we articulate a problem doesn’t mean the first thing that strikes us is the solution. Neither hope nor desire is either strategy or solution.
Was this economist, a wonk working with complex equation and models, one of the voters Jonathan Gruber was alluding to? Or was he in the ‘know’?
Actually, neither of the above. He was an aspiring technocrat; an emerging type of quantitative scholar who has over intellectualized the social sciences. He thinks he can rationally engineer society, just as an engineer builds a structurally sound bridge. For him the line between data-driven opinion and opinion-driven cherry- picked data is blurred.
He is smart. Very smart. He is not disingenuous or intellectually dishonest. Nor is he brainwashed. He has been commended all his life for post hoc rationalization of his opinions by an audience that listens to the same music. It’s not that the ends justify his means, it’s that the ends define his intellectual means.
Such people do not like arguing. If you question the solution too much they will quote something like ‘people who say it cannot be done should not interrupt those who are doing it.’
They are rarely ever challenged epistemologically. Occasionally, they’ll say ‘now let me play the Devil’s advocate and ask, how our new system can have problems.’ This ends up being a comical affectation of objectivity.
They are rationalists but treat numbers with the same reverence as Galileo’s captors treated god. The gods are different. The certitude in their omniscience is the same.
Technocrats are well meaning, as are people who have boundless faith in them. But being well meaning counts for rabbit droppings when it comes to the objective truth. Reality doesn’t care about our sincerity. Reality is what it is.
What’s the provenance of such optimism in technocracy?
I believe this is a phenotype of rational ignorance. It’s a heuristic. When we want to have our cake and eat it, we say ‘SOS, Technocrat. Get working!’
Few have the time to find out whether the technocrat’s solutions are really solutions or an introduction to another set of problems. More importantly, even fewer have the inclination to do so, particularly if the technocrat is building our perfect world.
There are prescriptions for technocrats. Classes in epistemology, philosophy of science and introduction to Karl Popper. Perhaps an elective with the 30-hour-week French technocrats.
But I doubt much will work. We want them to be fixers, Pulp Fiction’s ‘Wolf’ character. If they honestly told us ‘on the one hand this and on the other hand that,’ if they prefixed every plausible with a wide range of plausibles, if they spoke not about solutions but problems in solutions, they’d be branded as defeatists, as unprincipled waverers and be out of a job.
If our technocrats are falsely certain it is because we cannot bear the burden of uncertainty. It’s because we want solutions, not hear about trade-offs. Even as you are reading this you may be wondering ‘so that’s the solution?’
Every certainty, every point estimate stated without a confidence interval, every solution proposed without projecting its unintended consequences, is misleading. In the swagger of certainty lies not a lie but a truth: we cannot handle the nebulous and the messy. It is nihilistic. We want simple solutions to complex problems.
This is not a right-left issue. This is an issue of democracy, where people with different preferences, want different things, but do not wish to lose anything in the process of getting more. Politicians happily oblige our Disneyland fantasy. And the technocrats start working on the science that pretends to deliver it.
So ladies and gentlemen, the fault lies neither in Gruber nor in our academic stars but in our unresolvable contradictory desires. We want both security and freedom.