Category: Health Policy

Out of Control Health Costs or a Broken Society

Oct 9, 2023

Flawed Accounting for the US Health Spending Problem

By Jeff Goldsmith

Source: OECD, Our World in Data

Late last year, I saw this chart which made my heart sink. It compared US life expectancy to its health spending since 1970 vs. other countries. As you can see, the US began peeling off from the rest of the civilized world in the mid-1980’s. Then US life expectancy began falling around 2015, even as health spending continued to rise. We lost two more full years of life expectancy to COVID. By the end of 2022, the US had given up 26 years-worth of progress in life expectancy gains. Adding four more years to the chart below will make us look even worse.

Of course, this chart had a political/policy agenda: look what a terrible social investment US health spending has been! Look how much more we are spending than other countries vs. how long we live and you can almost taste the ashes of diminishing returns. This chart posits a model where you input health spending into the large black box that is the US economy and you get health out the other side.

The problem is that is not how things work. Consider another possible interpretation of this chart: look how much it costs to clean up the wreckage from a society that is killing off its citizens earlier and more aggressively than any other developed society. It is true that we lead the world in health spending. However, we also lead the world in a lot of other things health-related.

Exceptional Levels of Gun Violence

Americans are ten times more likely than citizens of most other comparable countries to die of gun violence. This is hardly surprising, since the US has the highest rate of gun ownership per capita in the world, far exceeding the ownership rates in failed states such as Yemen, Iraq and Afghanistan. The US has over 400 million guns in circulation, including 20 million military style semi-automatic weapons. Firearms are the leading cause of deaths of American young people under the age of 24. According to the Economist, in 2021, 38,307 Americans aged between 15 and 24 died vs. just 2185 in Britain and Wales. Of course, lots of young lives lost tilt societal life expectancies sharply downward.

A Worsening Mental Health Crisis

Of the 48 thousand deaths from firearms every year in the US, over 60% are suicides (overwhelmingly by handguns), a second area of dubious US leadership. The US has the highest suicide rate among major western nations. There is no question that the easy access to handguns has facilitated this high suicide rate.

About a quarter of US citizens self-report signs of mental distress, a rate second only to Sweden. We shut down most of our public mental hospitals a generation ago in a spasm of “de-institutionalization” driven by the arrival of new psychoactive drugs which have grossly disappointed patients and their families. As a result, the US has defaulted to its prison system and its acute care hospitals as “treatment sites”; costs to US society of managing mental health problems are, not surprisingly, much higher than other countries. Mental health status dramatically worsened during the COVID pandemic and has only partially recovered.

Drug Overdoses: The Parallel Pandemic

On top of these problems, the US has also experienced an explosive increase in drug overdoses, 110 thousand dead in 2022, attributable to a flood of deadly synthetic opiates like fentanyl. This casualty count is double that of the next highest group of countries, the Nordic countries, and is again the highest among the wealthy nations. If you add the number of suicides, drug overdoses and homicides together, we lost 178 thousand fellow Americans in 2021, in addition to the 500 thousand person COVID death toll. The hospital emergency department is the departure portal for most of these deaths.

Maternal Mortality Risks

The US also has the highest maternal mortality rate of any comparable nation, almost 33 maternal deaths per hundred thousand live births in 2021. This death rate is more than triple that of Britain, eight times that of Germany and almost ten times that of Japan. Black American women have a maternal mortality rate almost triple that of white American women, and 15X the rate of German women. Sketchy health insurance coverage certainly plays a role here, as does inconsistent prenatal care, systemic racial inequities, and a baseline level of poor health for many soon-to-be moms.

Obesity Accelerates

Then you have the obesity epidemic. Obesity rates began rising in the US in the late 1980’s right around when the US peeled away from the rest of the countries on the chart above. Some 42% of US adults are obese, a number that seemed to be levelling off in the late 2010’s, but then took another upward lurch in the past couple of years. Only the Pacific Island nations have higher obesity rates than the US does. And with obesity, conditions like diabetes flourish. Nearly 11% of US citizens suffer from diabetes, a sizable fraction of whom are undiagnosed (and therefore untreated). US diabetes prevalence is nearly double that of France, with its famously rich diets.

We’re All In The Hot Seat Now.

Oct 4, 2023

BY MIKE MAGEE

It’s not that easy living in the “Big Easy” these days and co-existing with a world dominated by water concerns. When Times-Picayune gossip columnist Betty Guillaud (as the folklore goes) “coined New Orleans’ undisputed nickname” in the 1960’s, it was a lifestyle eponym meant to favorably contrast life in “The Big Easy” with hard living in “The Big Apple.”

That was well before August 23, 2004, when the levies failed to hold back the Gulf waters, and 1,392 souls perished leaving two names to last in infamy – Katrina and Brownie, of “Brownie, you’re doing a heck of a job” fame.

Now it’s not as if it’s been all smooth sailing for New York City and water. I mean, look at the history. When the British overran the Dutch in 1667, one of the first priorities was to dig the first public well and include a marvelous technologic attachment – a hand pump. That was in front of an old fort at Bowling Green, near Battery Park.

But by the early 1700s, the absence of a sewage system and saltwater intrusion from the Hudson and East Rivers, plus a crushing population explosion, had foiled the clean water supply. The solution – temporary at best – haul in fresh groundwater, in limited quantities, from Brooklyn.

Poor Kids. Pitiful Us

Sep 18, 2023

By KIM BELLARD

Well, congratulations, America. The child poverty rate more than doubled from 2021 to 2022, jumping from 5.2% to 12.4%, according to new figures from the Census Bureau. Once again, we prove we sure have a funny way of showing that we love our kids.

The poverty rate is actually the Supplemental Poverty Measure (SPM), which takes into account government programs aimed at low income families but which are not counted in the official poverty rate. The official poverty rate stayed the same, at 11.5% while the overall SPM increased 4.6% (to 12.4%), the first time the SPM has increased since 2010. It’s bad enough that over 10% of our population lives in poverty, but that so many children live in poverty, and that their rate doubled from 2021 to 2022 — well, how does one think about that?

The increase was expected. In fact, the outlier number was the “low” 2021 rate. Poverty dropped due to COVID relief programs; in particular, the child tax credit (CTC). It had the remarkable (and intended) impact of lowering child poverty, but was allowed to expire at the end of 2021, which accounts for the large increase. We’re basically back to where we were pre-pandemic.

President Biden was quick to call out Congressional Republicans (although he might have chided Senator Joe Manchin just as well):

Today’s Census report shows the dire consequences of congressional Republicans’ refusal to extend the enhanced Child Tax Credit, even as they advance costly corporate tax cuts…The rise reported today in child poverty is no accident—it is the result of a deliberate policy choice congressional Republicans made to block help for families with children while advancing massive tax cuts for the wealthiest and largest corporations.

Many experts agree: child poverty, and poverty more generally, is a choice, a policy choice.

Has Sensemaking Collapsed When It Comes To U.S. Healthcare?

Sep 5, 2023

By MIKE MAGEE

This past week my wife and I were at a family event to celebrate my brother-in-law’s 70th birthday. Our extended family has more than a few doctors. A physician nephew who had read CODE BLUE and had a strong interest in health policy asked if I felt I (and others) were too hard on doctors. My response was yes, but that it was intentional and came with the territory. Combining scientific, sometimes life and death expertise, with high-touch compassion, understanding and partnership has always been a “big ask” but that was what we and others had signed up for as “health professionals.”

But can a health professional be “professional” in a fundamentally misaligned health system? And, if not, does a health professional have a responsibility to engage in an effort to reform and transform the system to behave professionally?

Professionals are generally members of a vocation with special training, highly educated, enjoy special trust and work autonomy, abide by strict moral and ethical obligations, and in return are generally self-regulating. Their academic training is expected to reliably provide those they serve with special skills, judgement, and services. When they deliver, society responds with confidence and trust and durable long-term relationships.

My nephew and many of his contemporaries have come to believe that this is neigh impossible under the current heavily corporatized, profit driven, inequitable, under-insured, and widely inaccessible system. They have begun to voice that being an ethical and competent professional in an unprofessional system is not possible, and not their fault.

System redesign guru, W. Edward Deming, the father of Quality Control Management, and the man credited with assisting the Japanese in transforming their auto industry, had this to say about transformation in 1993: “The prevailing style of management must undergo transformation. A system cannot understand itself. The transformation requires a view from outside…The individual, once transformed, will: set an example; be a good listener, but will not compromise; continually teach other people; and help people to pull away from their current practices and beliefs and move into the new philosophy without a feeling of guilt about the past.”

Six years later Don Berwick MD, Emeritus President of the Institute For Healthcare Improvement and now Harvard Health Policy professor, delivered a classic speech, “Escape Fire: Lessons for the Future of Health Care”, sponsored by the Commonwealth Foundation. In it Don recounted the events surrounding the tragic fire at Mann Gulch, Montana which claimed the lives of 13 “smokejumpers” on August 5, 1949. He reviewed the lessons learned in a system analysis by Professor Karl E. Weick of the University of Michigan, in his paper titled,“The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster.”

Berwick explained, “Sensemaking is the process through which the fluid, multilayered world is given order, within which people can orient themselves, find purpose, and take effective action. Weick is a postmodern thinker. He believes that there is little or no preexisting sense of organization in the world—that is, no order that comes before the definition of order. Organizations don’t discover sense, they create it…In groups of interdependent people, organizations create sense out of possible chaos. Organizations unravel when sensemaking collapses, when they can no longer supply meaning, when they cling to interpretations that no longer work.”

Now roughly a quarter century ago, Berwick concluded, “I love medicine. I love the purpose of our work. But we are unraveling, I think…Sense is collapsing… We need to face reality…Why did it take the Mann Gulch crew so long to realize they were in trouble? The soundest explanation is not that the threat was too small to see; it is that it was too big. Some problems are too overwhelming to name. I now think that that is where we have come in health care; I have been radicalized.”

Clearly the visions we have been using are under-powered, and we seem to be heading in the wrong direction with information technology and AI fully prepared to make permanent a system that is moving patients to despair and doctors to early retirement. What are the questions my nephew and his health policy colleagues should be asking now?

1. How do we make America and all Americans healthy?

2. What is our national health care plan, and who is in charge?

3. How do we balance national and state responsibilities?

4. How do we maintain balanced humanistic and scientific care, and preserve patient and health professional autonomy over complex life and death decision making?

5. How do we advance healthy behaviors while providing high touch access to health professionals for acute and moderate issues?

6. How do we use information technology and AI to expand human and social, rather than just financial, capital?

7. How do we prioritize investment in human contact between patients and health professionals over wealth enhancement and brick and mortar expansions?

8. How do we put a smile (independent of money) back on the faces of doctors, nurses and patients?

9. How do we separate hospital and physician profit driven research from direct patient care?

10. How do we move to geographic annual budgeting of comprehensive care and eliminate individual billing/reimbursement operations?

Mike Magee M.D. is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside the Medical-Industrial Complex (Grove/2020).

20th Birthday Classic: “Healthcare” vs. “Health Care”: The Definitive Word(s)

Aug 25, 2023

This is the last of the classics that THCB will run to celebrate our 20th birthday. And we are finally tackling the most important of questions. Is what we call this thing one word or two? Back in 2012 Michael Millenson had the definitive answer–Matthew Holt

By MICHAEL L. MILLENSON

A recent contributor to this blog wondered about the correctness of “health care” versus “healthcare.” I’d like to answer that question by channeling my inner William Safire (the late, great New York Times language maven). If you’ll stick with me, I’ll also disclose why the Centers for Medicare & Medicaid Services is not abbreviated as CMMS and reveal something you may not have known about God – linguistically, if not theologically.

The two-word rule for “health care” is followed by major news organizations (New York Times, Washington Post, Wall Street Journal) and medical journals (New England Journal of Medicine, JAMA, Annals of Internal Medicine). Their decision seems consistent with the way most references to the word “care” are handled.

Even the editorial writers of Modern Healthcare magazine do not inveigh against errors in medical care driving up costs in acutecare hospitals and nursinghomes. They write about “medical care,” “acute care” and “nursing homes,” separating the adjectives from the nouns they modify. Some in the general media go even farther, applying the traditional rule of hyphenating adjectival phrases; hence, “health-care reform,” just as you’d write “general-interest magazine” or “old-fashioned editor.”

Most importantly of all, the Associated Press decrees that the correct usage is, “health care.” That decision is not substantive – there is absolutely no definitional difference between “health care” and “healthcare,” despite what you might read elsewhere — but stylistic. As in The Associated Press Stylebook.

The AP is a cooperative formed back in 1846 by newspapers to share reporting via a wire service. Today, the AP calls itself the backbone of global news information, serving “thousands of daily newspaper, radio, television, and online customers….On any given day, more than half the world’s population sees news from the AP.” When that news arrives in text format, its spelling is determined by the AP stylebook. Which means a few billion people see the spelling, “health care.”

A stylebook? Isn’t spelling determined by dictionaries? Perhaps, but when you’re sharing content on deadline across the world, it helps if everyone agrees to refer to, say, the Midwest, not the Mid-West, and to use other common linguistic conventions.

Stylebooks differ. The AP would say that health care is two words; the Chicago Manual of Style, popular in academia, would write that as 2 words, but agree with the premise.

So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. A successful lobbying campaign on behalf of the lower-case form helped persuade the AP to adopt the new spelling in its 2010 stylebook update.

When Modern Hospitals changed its name to become Modern Healthcare back in 1976, it did so in part to seem, well, modern. It hadn’t been that many years, after all, since airplanes were flown by air lines, not airlines. Then, in the business-oriented 1980s, “healthcare system” became a convenient linguistic upgrade of the dowdy “hospital” that had gobbled up ownership of doctors’ offices providing outpatient (not out-patient) care.

At the same time, a growing number of companies decided to make this expansive new word part of their proper name or, at the very least, their style sheet. For instance, HCA, founded in 1968 as Hospital Corporation of America, today describes itself as “the nation’s leading provider of healthcare services.” The Reuters news service, heavily involved in business news, now uses “healthcare” in its stories.

The 2001 Institute of Medicine report Crossing the Quality Chasm provides a snapshot of the term’s transition. The report declares, “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.” The author of that ringing statement is the Committee on the Quality of Health Care in America.

However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999. AHRQ was a renamed and refocused version of the old Agency for Health Care Policy and Research, created in 1989. AHCPR, in turn, had almost been named the Agency for Health Care Research and Policy until an alert Senate staffer realized that the abbreviation would be pronounced, “ah, crap.”

Speaking of abbreviations, Tom Scully, the first administrator of the Center for Medicare & Medicaid Services, once explained to me why it is known as CMS, not CMMS. It seems that Health and Human Services Secretary Tommy Thompson wanted an agency name with a catchy three-letter abbreviation, like FTC or CIA, to replace the old HCFA (Health Care Financing Administration). So a legal opinion was obtained from the HHS counsel that employing an ampersand to separate the words “Medicare” and “Medicaid” permitted the use of the CMS designation. Some might suspect this Solomonic ruling of caving in to a bit of pressure from above.

Which brings us to God. Some years back, the AP decided that while “God” would remain capitalized (the pope was not similarly blessed), the second reference would be “his,” not “His.” As influential as the AP might be in this world, those concerned with a Higher Authority still write about God as if He were something more than an ordinary man.

I keep waiting for the AP editor who made that decision to be struck down with lightning by the Deity. But, on the other hand, She may have a sense of humor.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.

The Next Pandemic May Be an AI one

Aug 23, 2023

By KIM BELLARD

Since the early days of the pandemic, conspiracy theorists have charged that COVID was a manufactured bioweapon, either deliberately leaked or the result of an inadvertent lab leak. There’s been no evidence to support these speculations, but, alas, that is not to say that such bioweapons aren’t truly an existential threat. And artificial intelligence (AI) may make the threat even worse.

Last week the Department of Defense issued its first ever Biodefense Posture Review. It “recognizes that expanding biological threats, enabled by advances in life sciences and biotechnology, are among the many growing threats to national security that the U.S. military must address. It goes on to note: “it is a vital interest of the United States to manage the risk of biological incidents, whether naturally occurring, accidental, or deliberate.”

“We face an unprecedented number of complex biological threats,” said Deborah Rosenblum, Assistant Secretary of Defense for Nuclear, Chemical, and Biological Defense Programs. “This review outlines significant reforms and lays the foundation for a resilient total force that deters the use of bioweapons, rapidly responds to natural outbreaks, and minimizes the global risk of laboratory accidents.”

And you were worried we had to depend on the CDC and the NIH, especially now that Dr. Fauci is gone. Never fear: the DoD is on the case.

A key recommendation is establishment of – big surprise – a new coordinating body, the Biodefense Council. “The Biodefense Posture Review and the Biodefense Council will further enable the Department to deter biological weapons threats and, if needed, to operate in contaminated environments,” said John Plumb, Assistant Secretary of Defense for Space Policy. He adds, “As biological threats become more common and more consequential, the BPR’s reforms will advance our efforts not only to support the Joint Force, but also to strengthen collaboration with allies and partners.”

Which is scarier: that DoD is planning to operate in “contaminated environments,” or that it expects these threats will become “more common and more consequential.” Welcome to the 21^st century.

THCB 20th Birthday classics: A Brief History of Price Controls by Annoyed Republican Administrations

Aug 18, 2023

By UWE REINHARDT

One of the greatest pleasures of running THCB has been to get to know and host the writings of some of my health policy heroes. This week I have already published work from Jeff Goldsmith, and Ian Morrison & Michael Millenson among others will be featured next week (as the party won’t quite stop). Perhaps one of the most amazing things was that the doyen of health economists, Uwe Reinhardt, offered to write some original pieces for THCB…prodded by former editor John Irvine. This is one of my favorites, riffing on a talk I heard him give in (I think) 1993 about how HCFA was like the Kremlin and how free market Reaganite Republicans had made it so. This piece is from Jan 2017 and Uwe sadly died that November.–Matthew Holt

Although, unlike most other nations, the U.S. has only two parties worth the name, their professed doctrines compared with their actions strikes me as more confusing than the well-known Slutsky Decomposition which, as everyone knows, can be derived simply from a straightforward application of Kramer’s rule to a matrix of second partial derivatives of a multivariable demand function.

The leaders of the drug industry, for example, probably are now breaking out the champagne in the soothing belief that their aggressive pricing policies for even old drugs are safe for at least the next eight years from the allegedly fearsome, regulation-prone, price-controlling Democrats. My advice to them is: Cool it! Follow me through a brief history of Republican health policy, to learn what Republicans will do to the health-care sector when it ticks them off.

Republicans like to tar Democrats over allegedly socialist policy instruments such as price controls, global budgets and deficit-financed government spending. Democrats usually roll over to take that abuse, almost like hanging onto their posteriors signs that says “Kick me.” I say “abuse,” because Republicans have never shied away from using the Democrats’ allegedly left-wing tactics when health care chews up their budgets or turns voters against them.

Academics Weigh In On How To Bring Down Trump

Aug 17, 2023

By MIKE MAGEE

This week, as a fourth indictment came due, a tragic Donald Trump headed back to social media, digging himself into a hole that will eventually lead to some personal hell. But before Donald Trump, there was William Frederick Kohler.

He made his appearance on the American stage on February 28, 1995, an historian who had just completed his “Great Work” – The Guilt and Innocence of Hitler’s Germany. He was odd and dark and duplicitous. His life’s work was ready to go. All that was left was to write the introduction to his book. Instead his attention was diverted, as he followed his impulse to memorialize his own story dedicated to the “concealment of history beneath my exposition of it.”

Secretive and opaque, he was focused on a very special audience he labeled the “Party of the Disappointed People”, a group with whom he shared the affinity “that the loss has been caused in great part by others.” He hid the pages of the new and very personal (but incomplete) story from wife Marta inside the pages of the near completed Nazi history. And for some reason, he inexplicably headed to his basement and began to dig a tunnel to escape (or uncover) evil.

Kohler, like Trump, was not normal. Those who have analyzed his character describe him this way: “Preoccupied with evil, the nature of truth, and the effects of an individual’s relationship with others, he recalls his bookish childhood with a mother who drank to remember the ‘good old days’ and a bigoted father; graduate work in prewar Germany, where he hurled a brick on Kristallnacht; his unhappy marriage; and the lost love of his life, Lou, a former student. Kohler’s story exhibits the same inconsistencies and deceits he finds in history: Kohler, the personal memoirist … is as unreliable as Kohler, the eminent historian. A virtuoso performance without a grand finale.”

Kohler is the fictional creation of philosopher and novelist William H. Gass, author of the award winning novel, “The Tunnel.” The author is described in the opening line of his 2017 New York Times obituary as “a proudly postmodern author who valued form and language more than literary conventions like plot and character.” He died on December 7 of that year, at age 93, in St. Louis, where he had taught philosophy and linguistics for 30 years. Born in Fargo, North Dakota, he was translocated to Warren, Ohio at 6 months, and raised according to his own account by “an abusive, racist father and a passive, alcoholic mother.” These revealing personal details trace back to a writing style he developed and labeled, “metafiction,” or stories in which the author inserts himself.

Of more relevance to America’s current political dilemma is that Gass received his PhD from Cornell in 1954, in return for his dissertation “A Philosophical Investigation of Metaphor.” A metaphor, as we know, is “a figure of speech in which a word or phrase literally denoting one kind of object or idea is used in place of another to suggest a likeness or analogy between them (as in drowning in money).”

Gass’s love of metaphor is on full display in “The Tunnel”. You can almost hear the beloved high school advanced placement English teacher pleadingly asking her sleepy students “What do you think the tunnel represents?” Of the novel, one critic wrote, “As the novel progresses we see the lies, half-truths, violent emotions, and relative chaos of Kohler’s life laid bare, and while he continues to dig away at the memories of his past he also begins digging a tunnel out from the basement where he works, a reflection of his tunneling through himself.”

Beyond Gass’s own story line, and that of William Frederick Kohler, one can easily catch glimpses of Donald Trump. As he entered the strange world of politics, he embraced the use of metaphor with memorable 3 and 4 world phrases like “drain the swamp”, “the system is rigged,” and “take our country back.”

THCB 20th Birthday Classic: As I’ve always suspected, Health Care = Communism + Frappuccinos

Aug 15, 2023• 1

By MATTHEW HOLT

Our 20th birthday continues with a few classics coming out. Back in 2005 I was really cutting a lyrical rug, and would never miss a chance to get that Cambridge training in Marxism into use. This essay about whether health care should be a public or private good has always been one of my favorites, even if I’m not sure Starbucks is still making Frappuccinos. And 18 years later the basic point of this essay remains true, even if many of you will not have a clue who Vioxx or Haliburton were or why they mattered back then!

Those of you who think I’m an unreconstructed commie will correctly suspect that I’ve always discussed Marxism in my health care talks. You’d be amazed at how many audiences of hospital administrators in the mid-west know nothing about the integral essentials of Marx’s theory of history. And I really enjoy bring the light to them, especially when I manage to reference Mongolia 1919, managed care and Communism in the same bullet point.

While I’ve always been very proud of that one (err.. maybe you have to be there, but you could always hire me to come tell it!), even if I am jesting, there’s a really loose use of the concept of Marxism in this 2005 piece (reprinted in 2009) called A Prescription for Marxism in Foreign Policy from (apparently) libertarian-leaning Harvard professor Kenneth Rogoff. He opens with this little nugget:

“Karl Marx may have suffered a second death at the end of the last century, but look for a spirited comeback in this one. The next great battle between socialism and capitalism will be waged over human health and life expectancy. As rich countries grow richer, and as healthcare technology continues to improve, people will spend ever growing shares of their income on living longer and healthier lives.”

Actually he’s right that there will be a backlash against the (allegedly) market-based capitalism — which has actually been closer to all-out mercantilist booty capitalism — that we’re seen over the last couple of decades. History tends to be reactive and societies go through long periods of reaction to what’s been seen before. In fact the 1980-20?? (10-15?) period of “conservatism” is a reaction to the 1930-1980 period of social corporatism seen in most of the western world. And any period in which the inequality of wealth and income in one society continues to grow at the current rate will eventually invite a reaction–you can ask Louis XVI of France about that.

But when Rogoff is talking about Marxism in health care what he really means is that, because health care by definition will consume more and more of our societal resources, the arguments about the creation and distribution of health care products and services will look more like the arguments seen in the debates about how the government used to allocate resources for “guns versus butter” in the 1950s. These days we are supposed to believe that government blindly accepts letting “the market” rule, even if for vast sways of the economy the government clearly rules the market, which in turn means that those corporations with political influence set the rules and the budgets (quick now, it begins with an H…).

Naive Realism and the Legal Profession

Aug 9, 2023

By MIKE MAGEE

In 2002, psychologist Emily Pronin and her co-authors, in an article titled, You Don’t Know Me, But I Know You: The Illusion of Asymmetric Insight, laid out the concept of “Naive Realism.”

As she explained, “We insist that our ‘outsider perspective’ affords us insights about our peers that they are denied by their defensiveness, egocentricity, or other sources of bias. By contrast, we rarely entertain the notion that others are seeing us more clearly and objectively than we see ourselves. (We) talk when we would do well to listen…” Point well taken, but these (most would agree) are trying times.

The problem of our divisions is certainly worse now, two decades later, than when it was first labeled. 2023 headlines speak to “political polarization,” “division,” “factual inaccuracy,” and “loss of civility.” And yet, we hold tight to the “rightness”of justice under the law, and set out to demonstrate with extreme confidence that our democratic institutions, under assault, have mostly held.

Madison was well aware of extreme labeling of opponents as “unreasonable, biased, or ill-motivated.” He warned on February 8, 1788 in Federalist 51 that “If men were angels, no government would be necessary. If angels were to govern men, neither external nor internal controls on government would be necessary. In forming a government which is to be administered by men over men, the great difficulty lies in this: you must first enable government to control the governed; and in the next place oblige it to control itself.” His solution? Our legal system, and checks and balances.

Hamilton, in the first paragraph of Federalist 1, tees up the same issue, in the form of an unsettling warning. He writes, “It has been frequently remarked that it seems to have been reserved to the people of this country, by their conduct and example, to decide the important question, whether societies of men are really capable or not of establishing good government from reflection and choice, or whether they are forever destined to depend for their political constitutions on accident and force.”

The “force” on January 6 was no accident. Hours before the armed insurrection of Congressthat morning, USA Today published “By the numbers: President Trump’s failed efforts to overturn the election.” The article led with, “Trump and allies filed scores of lawsuits, tried to convince state legislatures to take action, organized protests and held hearings. None of it worked…Out of the 62 lawsuits filed challenging the presidential election (in state and federal courts), 61 have failed…Some cases were dismissed for lack of standing and others based on the merits of the voter fraud allegations. The decisions have came from both Democratic-appointed and Republican-appointed judges – including federal judges appointed by Trump.”

By all accounts, our nation and her citizens, owe our Judicial branch (its judges, lawyers, and legal guideposts) a debt of gratitude.