Friday, February 14, 2020

On The Bloomberg Candidacy

I started out being for Amy. Then I switched to Elizabeth Warren. Then I did a full 180° away from her, favored Amy again and Mike Bloomberg (tentatively), and that's where I stand today. I doubt that my course is aberrant; many people are searching.

But as I'm searching, hoping for the magic bullet that will displace the affliction named Trump and install a high-quality new President, as I listen to what other people think, I worry that Bloomberg's entry into the race is too much of a deus ex machina solution, and maybe I'm overlooking the effect of a billionaire parachuting in. Is it unfair, and is it destructive, just in the way it is being done? Forget his policies for the moment, just look at the method.

That's what I did, and here's what I came up with.

Money and politics have never been strangers to each other – “money is the mother's milk of politics” – and the Michael Bloomberg candidacy has illuminated the connection anew. Rich people have run before, big money has been behind many candidates for a very long time, there have been “kingmakers” with access to money, and even George Washington is reported to have been one of the richest men in the country. But the Bloomberg candidacy is unique. His money is not hidden but in full view, and his bankroll is so immense that he can finance not only his own campaign but the campaigns of many others with no help from others. One man, one bankroll.

I want to examine the criticisms of Bloomberg's campaign, but first, let me briefly mention what some of his proponents say about this kind of campaign. Trump actually made a mendacious defense of his own campaign that could fairly be applied to Bloomberg's – funding ones own campaign avoids entanglements with other funders who will often expect favors in return, if only for access. A second defense is that a very large campaign chest will be necessary to meet Trump's huge cash advantage. Third, proponents rightly declare that Bloomberg's candidacy is not a vanity project, that he is a known political actor who has used his wealth in the past for many worthy causes: gun control, coal factory abatement, public health and hospitals, and many others. Fourth, many welcome his entry to the field as an anyone-but-Trump effort by someone who can arguably win. And finally, many welcome him simply for his qualifications – no candidate rivals him for his combination of private and governmental executive experience, reminding us that New York City has a larger population than 38 of the states.

But those points having been made, others are not so sanguine. Besides criticism on the issues, which I will not take up here, the very fact of a billionaire self-funded candidacy seems to have two basic critiques. One centers simply on his being a member of the billionaire class, who are not to be trusted. The other centers on how the process of running for office is unfairly easier for a billionaire than for someone with more ordinary means. Each observation deserves scrutiny.

Billionaires Are Suspect

Some say that billionaires are objectionable, obnoxious, selfish, exploitative possessors of ill-gotten gain, and probably a lot more. Some say a billionaire will inevitably protect their own interests and the interests of other billionaires, will lower taxes on themselves, maintain their deductions, protect the banks and instruments of capitalistic concentration. Some say they have no feeling for the situation of ordinary people, especially those of color, and will therefore inevitably shortchange them.

I don't know any billionaires personally, but I have no doubt that many billionaires would fit these descriptions. (I love one scientific study that posted observers at a difficult intersection and found that the more expensive cars were more likely than the less expensive cars to disobey the law.) We know that the wealthy and large corporations have lobbied their way to unfair governmental favoritism. To put it the issue more generously, we know that every person has perceptual limitations, and that each person is especially cognizant of conditions of their own background, which is why Sonia Sotomayor and before her, Thurgood Marshall, have been so very valuable on the Supreme Court. Billionaires would be no exception to this rule of thumb.

But while we can be suspicious of how a billionaire might act, we also know how unfair it is to assign attributes of any group to a member of that group – be it gender group, sexual orientation group, religious group, national group, income group, professional group, regional group, political group, racial group. Makimg this assumption is, in fact, the very definition of prejudice. Calling Bloomberg “just another billionaire” is a lazy attribution. For one thing, just look at how different are the billionaires who have been running this last year – Howard Schultz, Tom Steyer, Bloomberg, and (possibly) Trump.
Maybe the most inspirational way to make this point is to cite example of President Franklin Roosevelt. No one could have a more patrician background than FDR, yet no one could have been a better friend to the poor and the working and middle classes than he was. Perhaps triggered by his being afflicted by polio and making friends with the poor white people near Warm Springs, Georgia, whom he befriended when he established his therapeutic community there, certainly reinforced by his equally patrician wife Eleanor, FDR's mission as President was to be a protector of the common person, so much so that he was called “a traitor to his class.”

Would Bloomberg qualify as a neo-FDR? Probably not; who would? But the point is, it's possible, and dismissing Bloomberg as simply “another billionaire” is foolish.

Self-funders Have An Unfair Advantage In Running

It is undoubtedly true that billionaires who self-fund face markedly fewer obstacles to their candidacies in comparison to the usual candidate. The American system of financing political campaigns is in itself unfair and inefficient. Fundraising diverts the time of candidates and congresspeople away from their actual work in policy and politics. The built-in conflicts are obvious, not only for those who take the traditional route of cultivating wealthy donors, but even for those taking only small donations. The poor cannot contribute, and a decision to take only small donations contributes to social conflict – witness the fury against the rich manifested by Sanders and Warren, both of whom refuse large contributions and eschew super-PACs.

(In fact, if you think about it, it's amazing that so much about a campaign is focused on money. How to raise it, who is raising it, who gains favor by it, how people vote with their pocketbooks as to who gets to be on the debate stage, that it is to some extent a microcosm of how much our whole society concentrates on money. It's really quite an indictment of our society, from an anthropological point of view.)

Clearly, a self-funded campaign avoids the pitfalls of raising money that others face. I can well understand the fury of those candidates who have had to scrape and beg for money and been hamstrung by its lack, and who now face the disadvantage of not being able to match, despite their efforts, the huge Bloomberg resources for advertising and campaigning.

Nonetheless, can one really say that he is “buying the nomination?” I think not. If so, Schultz and Steyer would be more relevant. Yes, you can buy access and attention, but the voters still have to like what is presented to them, and the media will give free rein to those who would criticize.

Moreover, if one could buy the nomination, why didn't Bloomberg come in early and sweep the field preemptively? He did quite the opposite, waiting until is was almost too late. When his early analysis led him to conclude that he was an unlikely winner – despite his resources – he let the game play out without him. It was only when Biden showed weakness and Sanders showed strength that Bloomberg concluded that he was needed, and that he had a chance.

Moreover, it's not only billionaires who have enhanced access to running. What about movie actors? Their fame provides access, which can be viewed as unfair – what does fame have to do with governing? But they have not been able to sweep into office any more than Bloomberg can, although if they perform well they can be elected. Generals have also had access to nominations that others don't enjoy, and some have measured up while others haven't. Bloomberg is not just some random billionaire who thought to himself, hey, it would be nice to be President. He is arguably one of the best prepared people in our history to take on the job.

Conclusion and Suggestion

So, in sum, I think it's hard to say that Bloomberg has no business using his money to leverage himself into the race. He will still have to sell himself to the people, and it might be an uphill battle. In the end, he will have to prove himself acceptable as a prospective President, and as someone who would have the total capacity to beat Donald Trump. If he can prove himself worthy, we shouldn't deny him the nomination just because he is a billionaire. We shouldn't cut off our nose to spite our face.

Finally, presumptuously, let me offer a couple of suggestions.

I have always been taken by the brave way JFK chose to address the Catholic issue in 1960, when he gave his famous Houston speech to the Protestant ministers, asserting that a Catholic could be a good President, and how he received a standing ovation. I don't think Bloomberg has Kennedy's oratorical gift, but it might make sense for him to give a speech “Why I Am Not A Bad Billionaire.” He could take on the issues directly – Will I try to protect my billions and those of my rich friends? Why are my taxes better than Warren's wealth tax? What objectives of Bernie and Elizabeth and the other candidates do I share? (I would go for anti-trust and universal health care with lower copays and deductibles)?

Then I would take Amy Klobuchar's example of FDR's poor mourner, “I didn't know him, but he knew me.” I would praise Amy for citing that. I would say, we should all aspire to that. Then I'd say, none of us can be everything, so we all need to work together to give the country leadership. I see huge strengths in this party and in the other candidates. My hope would be to assemble us all as a team, to overcome the depredations of the last four years, to return to lawfulness, to return to decency, to return to humanity, to correct the course of this country, to raise the level of our prosperity for everyone, to become an ever fairer country, to be good global citizens, and to establish an order of dealing with the environment in a way that will last beyond our years.

I have no idea what kind of a President Bloomberg would make, or if any of the suggestions I make here will turn out to make sense for him. I'm hopeful. I'd love to see a good President come in. And it's vital, of course, to beat Trump and to foil his ongoing coup.

But we shall see.

Budd Shenkin

Sunday, February 9, 2020

Adding Insult To Injury - Discoordinated Care In Large Medical Centers

How Hospitals Abuse The Fathers Of Physician-Daughters

Discoordinated inpatient care for acute conditions is a chronic disease in Academic Medical Centers, and other large medical centers as well. No one is in charge! No one person takes responsibility! Too many of the “team members” - what a misnomer that is! – partake of “it's off my plate” disresponsibility. I'm using the prefix “dis” rather then “un” because it seems to me there is a sense of active neglect, not just passive. J'accuse!

With any task, two basic factors affect your performance – incentive and ability. Is there something that makes you want to do it? It can be internal ideals – I want to be a good doctor, I want to help these patients. Or it can be external influences – it makes me money, or it helps my prestige.

The second factor is ability. Do you have to tools to bring to the task? Has the necessary procedure been invented, and all you have to do is apply it? Or, if the procedure isn't at hand, can you invent it? Are you smart enough to apply the tools, or invent them?

So, why is it that we hear so repeatedly about the discoordinated care, the poor quality care for an individual patient so often? I've blogged about this before, referring to a Health Affairs article where a doctor-daughter was unable to intercede in her father's acute cardiac care at a big medical center to forestall obviously poor actions by the doctors and nurses.

Now comes a similar article in the current New England Journal of Medicine

Here, a geriatrician-daughter finds her 72 year old father grievously mistreated after a high intensity cardiac event that brings him to an academic medical center, where team after team prescribes drugs discoordinating with the other teams, and where her father becomes severely delirious. Ironically, it is the daughter herself who in the past invented exactly the procedures to use in an inpatient setting to prevent delirium – the large medical center has not implemented these procedures, and or course she is unable to intervene in the rigid procedures of the discoordinated team to help her father. Luckily, he recovers and even goes back to his medical practice for a number of years, as did the father of the Health Affairs patient. Both cases have successful outcomes, thanks to advanced medical science, despite the severe errors and thus over-extended medical stays because of complications due to discoordination.

Why does this continue to happen? Why isn't a single person held responsible for each patient? Why isn't this obvious, repetitive problem solved? Why are not proved administrative procedures instituted universally?

Is there sufficient incentive? I guess there isn't. No doubt there are many doctors and others within the system who see the problem and wish it could be solved, but most don't understand the problems and see possible solutions, and those who do are in no position to effect the changes they would like to see.. In large bureaucratic operations, the power at the top is separated by many layers from the problems down below – and indeed, insulated from the human relations that impel any decent human being to want to solve the problem. Are they blissful in their ignorance? Maybe. Administrators are a different lot from doctors, and even doctors who become administrators can be sucked into the administrative maelstrom of ignorance and focus on goals other than patient care. If you have been a doctor, you know what problems beset the ill, you know what procedures militate against good integrative quality. If you are an administrator, you lack that experience. The best ball teams have former players at the top, some of whom are brilliant and can build great teams based on their knowledge and ability. Where are the Jerry Wests of medicine?

So, those in power might not have the knowledge necessary to detect the problem, and those with the knowledge might not have the power. So, the power of ideals is blunted by bureaucratic structure. What about external incentives, like money and prestige? Would they accrue from overcoming the iron structure of poor bureaucratic medicine? Would quality measures detect the better care afforded by coordinated care? Probably not; maybe a little. Certainly not enough so as to be palpable proof that “we are a superior medical center!” Local areas tend to be monopolistic, so in the end there are no local comparisons, and even nationally, they are hard to detect and not well publicized. Yes, there are awards and there are groups of hospitals that sign up for progressive high-quality agendas, but it takes a lot of effort to do this, and it's not clear that one receives any competitive advantage for aspiring to these higher ideals. If you are a high ideals leader of a medical center, you can do it, you can lead a medical center to high quality, just don't expect anything other than internal satisfaction and team celebration from having done it. Once again, as we are seeing in national politics, “high character” is essential.

But say the incentives are in place -- are there tools available? In a word, yes. Here in the NEJM article the anti-delirium protocols are poignantly present in the very person of the patient's daughter. I don't know the field well enough – I was an outpatient doctor – to know all the coordination tools available for high intensity inpatient care, but I'm sure they are there. They could be picked up and used, if there were a structure amenable to their use.

But in the end, of course, money rules. The medical centers are doing just fine, making lots of money, protected by their deep roots in the campaign financing lobbying system that we currently enjoy. If there were big bucks available for coordinating care, the resources of medical centers would be employed to drill those wells. ACO's might possibly supply some incentive, but it's minor in extent, and the fight over who gains what part of the extra bucks can be exhausting and disincentivizing – it's just not worth it, much of the time.

To coin a phrase, if we are to improve medical care, we need “deep structural change.” Until we have that, we will continue to read rueful articles where parents of doctors are enfolded in the arms of large systems of care where poor care is administered and the doctor-daughters find themselves unable to affect the machine they see abusing their parents and they issue a cri du coeur and the medical journal regretfully publishes it and we read of the horror and say to ourselves, maybe we'll go quickly, and we won't have to endure the insult medical centers add to injury.

Budd Shenkin

Sunday, February 2, 2020

On Pete Buttigieg

Pete Buttigieg is, basically, a great example of chutzpah, trying to vault ahead of the pack with one great step. He must figure, nothing ventured, nothing gained. But accommodating to his audacity of hope by nominating him would be a vast mistake.

Let me explain.

Pete Buttigieg is an eloquent, fast-thinking, intelligent and stately young man. Some have said that he's an old person's idea of a young man, but let's just say he seems to have a wonderful temperament. He is well educated, Harvard and Oxford, has management advisory experience from working at corporate consultant firm McKinsey, has military experience at a low level in a combat venue, and has been a mayor without spectacular achievement and with some notable weaknesses, of a small city. Nice resumé for a promising young man.

But is it enough? My analogy: “I just met a really nice guy! He really seems to understand surgery, from what he says. I was so impressed! He has worked in many different settings, progressing from an aide to a medic to a physician's assistant. He is critical of many of the surgeons he has seen work. I'm thinking of asking him to do my hip replacement.”

Picture this instead: his name is placed before a corporate board. He is interviewed and his work history is reviewed. Discussion ensues; everyone has been impressed. His chief advocate to the board says, “This guy is so terrific, I think he should be our CEO!” The board members look at each other; one smiles, another smiles, and the board then erupts in laughter, understanding that it must be a joke. The laughter dies down, no one knows what to say, and then they turn expectantly to the most respected senior member of the board. She says, “Yes, you're right, he's a wonderful find for us, and the mark of a superior organization is to be able to identify quality, attract quality, nurture quality, promote quality, and utilize quality. Let's not miss our chance with this wonderful candidate. Let's jump over a couple initial steps. What division could we offer him to be the head of? Let's make sure he's on track! Let's see if he can fulfill his promise.”

He'd make a wonderful cabinet officer, wouldn't he?

Budd Shenkin