The Industry Veteran is back and on fine form, picking up the ball on a piece of crossed out editorial about my least favorite American politician, and running it into the realms of whether the Democrats are right (as Jones the Policy Wonk suspects) to take the milquetoast route, and whether marketing to doctors needs to be different than to other clinicians.

"Theocratic fascist?" I love it. Now those are the terms and the tone I expect to see on a blog. If I wanted neuterizing, backpedalling, vague ambiguity and maudlin sentiment ("hope," "we can do better," "a government as good as its people") I’d watch the Democratic convention.

This leads directly to my opening rant. The Democrats apparently believe that aggressive Bush bashing will repel the "persuadable" 20% of the electorate and, for that reason, most of their carefully orchiectomized speeches have been as energizing as 20mg of Valium. Two reasons make me think they’re making a bad mistake.

Let me start by recalling two, well established facts of voting behavior in this country: (1) voting participation varies directly with socio-economic status and; (2) only half of eligible voters go to the polls. This means that non-voting prevails among the lower two-thirds of the economic ladder that constitutes the Democrats’ social base. Election victories by Democrats, therefore, owe more to mobilizing voting among this base than to persuading the half-assed/undecideds. Democratic non-voters need a reason or reasons to vote. Platitudes about a shining city on a hill, restoring opportunity to America or giving us security with peace don’t cut it. A candidate who lacks personal magnetism, together with the lachrymose sentimentality that Democrats have been shoveling out all week, produce responses ranging from indifference to cynicism and distrust, none of which provides lapsed Democrats with an incentive to vote.

My second argument for sharper, more abusive language contradicts the pollsters’ assertion that negative campaigning and personal attacks merely turn off voters. Pharmaceutical research that I have conducted over many years with physicians and consumers leads me to suspect that the Democrats are receiving some bad advice. When asked how they feel about ads and other promotions that slam a competitor’s product, physicians and consumers typically give the socially correct response by saying that they disdain it. Further probing beneath this response indicates a different, more complicated process at work. Both physicians and laymen disparage negative or critical promotions that lack specificity because the course of action suggested by such communication (i.e., buy our product rather than the competitor’s) does not follow logically. As a result, test audiences believe that promotions full of "empty abuse" insult their intelligence. Physicians, for example, want to see the results of published studies, together with tables, charts and a condensed version of the supporting data. Consumers seek their own forms of corroborating evidence, and this varies according to the product, the market segment and several other factors. Given a rationale that effectively informs their selection process, physicians and consumers actually welcome a sharply stated conclusion: the other guy’s product is less effective and more poorly tolerated than ours. In short, go ahead and call John Ashcroft a theocratic fascist after first discussing the draconian features of the Patriot Act. Call George Bush an arrogant dope, a plutocrat and a lying scumbag after first discussing, well, any of his policies. Hey, if a longtime Republican operative such as David Gergen thinks the Democrats wasted a big opportunity by going soft on Bush, I think he may know something.

Second rant. I mentioned in a previous posting that I completed a study earlier this year involving the policies and practices of Big Pharma companies relative to the OIG/PhRMA guidelines for promoting to healthcare professionals. (OIG is the Office of the Inspector General at the Department of Health and Human Services; PhRMA is the Pharmaceutical Research and Manufacturers Association, Big Pharma’s trade lobby.) In response to exposes over the past few years that featured "dine-n-dash" and paid vacations in Aruba, these two organizations each issued guidelines to specify acceptable and prohibited practices for pharmaceutical companies promoting their products to physicians and other professionals. We first assessed the policies and monitoring processes used by the largest pharmaceutical companies for assuring compliance with these guidelines. Then we analyzed their actual promotional practices out in the field. Suffice it to say that while the overall level of bribery and bribery-in-kind has diminished slightly or has become less overt, the levels of compliance vary among the companies and nearly all reflect major disparities between policy and practice.

More recently a client asked us to make a similar assessment among diagnostic device companies. We found that while compliance differences also exist among these competitors, such differences are smaller than among the pharma companies and, more importantly, the general level of bribery and bribery-in-kind is also far lower. This reduced level of baksheesh became evident early in the study, so we spent a good deal of time and effort trying to account for it. While any complex social behavior usually results from multiple factors, there is a principal reason why fewer payoffs, involving lesser amounts, occur in the diagnostics business. Stripped to its essentials, the promotion of diagnostics involves a far smaller number and proportion of office-based physicians who would demand such gratuities. Very often the decision-makers who select/recommend diagnostic products are clinical chemists, diabetes nurse educators, microbiologists and other non-physicians. Some decision-makers are purchasing agents for hospital and other buying groups. Their product selections must provide strict cost justifications that leave little room for the subjective preferences subject to gratuities. Once again, our princes with stethoscopes, these Mafiosi doctori and purveyors of the Hippocratic myth, have dipped their beaks into the underground economy of healthcare to raise the costs and lower the ethical standards.

Here’s Jones the Policy Wonk in reply to my post on healthcare at the convention where I had written. . . . (and yes I am applauding!)

Maybe if the Democrats repeat their fuzzy message enough times, they’ll seize this issue. My question is, why did they decide this is the big issue? And why are they talking about the cost of health insurance which is somewhat alien to most people and not just focusing on the cost of drugs? I guess it just means that if they talk about it and the Republicans don’t, they own the issue.

The Wonk writes: If I’m interpreting your post correctly, you were asking why Dems are talking about healthcare and why, having decided to talk about it, are they all over the map with it?

You’ll be pleased to know I have an answer for you. Hold your applause until the end.

Short answer is that Democrats have a really clear and simple message on healthcare: "We’re paying attention, we know things are getting worse and remember, we’re the guys you’d rather have fixing this." So, although they’re not coherent from a policy standpoint, the speeches clearly express this political message.

Long answer is that convention speeches are not showcases for policy debate, especially for a challenger. For a challenger, the convention should be a carefully choreographed message event, designed to tell voters who the presidential candidate (and the party) is and why the voters should choose this candidate. Conventions are about winning the presidency and generating long enough coattails to win Congress.

((ASIDE: For a challenger, the convention is especially important because it’s one of the few opportunities he has to speak to the American people and have full control his message. Unlike a sitting president, a challenger can’t demand an hour of prime time for a speech. Most of his media coverage is "earned" media–stories in newspapers and sound bites on TV. The problem is, to get on TV, the challenger has to be "newsworthy." Newsworthyness (if this is, in fact, a word) is determined ex post facto–you get in the papers if, after hearing what you’ve said, the media decides it’s newsworthy. So, it’s a sound bite here, a picture there, and at no point is it a full presentation of the case the challenger is trying to make.   Conventional wisdom in the media is that conventions aren’t newsworthy, because, um, there’s no news (seriously, the logic is that circular)–if conventions didn’t exist in the past and someone had one today, nobody would cover it. This is because conventions are just candidates and party leaders bloviating on what they believe and what they would do if elected to office. I think it’s pretty clear that I disagree on the need for coverage–although it’s not exciting most of the time, it is important for both sides to be able to present their case directly to the American people in the manner of their choosing. Clearly, it’s not going to give the voters the whole story, but it is an important part of the decision-making process–when they can talk about anything in the world, what do they choose to talk about? How do they talk about it? What promises do they make?   Candidates, especially challengers, seldom have the opportunity to present their case directly to the people in a manner of their own choosing. It’s important to see what they say when they do have this change. Personally, I want to at some point see what they say when they know people are going to listen and no one is going to interrupt them. END ASIDE))

So, the reason the convention speakers are talking about healthcare so bizarrely is because though it’s an issue Democrats win on, it’s not an issue they can win with. In my humble opinion, that’s because American voters are still divided ideologically over the appropriate role of government in healthcare, and beyond that they are uncertain that even if this is a problem that government should solve, whether it’s a problem that government intervention can solve.

I’m digressing, but this ties into the comments that Abby made in the blog entry you linked. This threshold of whether this is government’s problem to solve still hasn’t been crossed with voters. I agree with you that the tipping point will probably come soon, as the economic problems brought about by out of control healthcare spending make ideological blindness an unaffordable luxury. But there does have to be an ideological shift or, at the very least, a realization that government=bad, private sector=good isn’t conventional wisdom but is in fact an ideology that serves special interests. There are a lot of reasons this hasn’t happened yet, not the least of which is that one major political party has thrown its full weight behind supporting this privatization ideology. But no small part of the problem is that people in favor of real healthcare reform haven’t gotten a 3 sentence argument together, and haven’t gotten it on the lips of every healthcare expert who favors healthcare reform. There’s a lot of muscle behind the current message, and the alternative has not been coherently articulated.

((FARTHER ASIDE: There’s reason to hope that this is changing. I think Abby is right again, that the key to this is to take a page from Lee Iacocca and point out the competitive burden placed on businesses. And on a personal level, we should talk more about the loss of freedom people suffer when they’re stuck in a job to keep their benefits, and how it crushes the spirit of American enterprise—people are scared of getting sick, so they won’t start a small business and follow their dreams. I think the business argument will go over well. For example, in NY State, 1199 floated a pay to play proposal. I was listening in on a conversation between a leading NY State senator (Republican) and 1199’s head lobbyist, and the Senator commented he was shocked that when he floated this proposal to business interests, they were willing to engage on the issue. Now, the bill still didn’t pass, but the fact that it wasn’t met with scorched earth tactics by business interests is a change whose importance cannot be overstated. Policy wonks need to start asking employers if they want to be in the business of providing healthcare or in the business of selling widgets. Because more and more, they’re in the business of running America’s healthcare system. Hmmm, maybe we can win big business by framing this as: "outsource your employee health costs to the feds!"END FARTHER ASIDE))

In the face of this political reality, Kerry has decided that he can’t win with healthcare, but he can score a few points with it. So his strategy on healthcare is not to go deep into it but to bring it up occasionally to remind voters what they already believe–that the situation is getting worse, that George Bush has no solutions to the healthcare crisis and that voters would rather have a Democrat working on this problem than a Republican.

So they’re bringing up health insurance because it’s a current healthcare problem–it’s tricking down to voters as an explanation their company gives for lower raises this year, as a stumbling block for union negotiations, as increased cost-shifting with higher co-pays, and for the recently unemployed as one of the biggest financial burdens they suddenly faced. They’re bringing up HMOs because it was the last healthcare crisis voters faced, and a crisis that Dems were on the right side of. They’re bringing up drug costs to remind seniors that they believe Bush sold out to pharma interests and pushed through a deceitful Medicare drug benefit.

But fundamentally, healthcare at this convention is an "and also"–as in: "John Kerry is a strong and decisive war hero, leading a party unified by true American values, who will unite the world behind a strong America. Oh, and also, he’s better on healthcare." This is why the speakers sound so bizarre to the wonks. It’s pure politics, and policy is way on the back burner.

Intersting report from Abby Vigenon on Uwe Rheinhardt’s new theory on why we haven’t got universal health insurance. You may notice that I show my colors (while keeping my cool I might add!) in the comments section.