The Congressional struggle over healthcare has been like a heavyweight championship that has gone the distance, with both fighters still standing but bloodied. As of this writing, it is not clear which side has prevailed or even whether both have been knocked silly. Whatever the outcome, however, the battle will not end because the state capitals will join Washington, D.C. as a place where legislation will determine the shape of the healthcare system in the future.
Wherever there is legislation, there are lobbyists, and where there are lobbyists, there is money. Lobbying about healthcare is big business. The spigots of money turned on during the past year will continue to gush as a network of pipelines channel money into capitals from Dover to Des Moines. In view of the myriad issues to resolve by votes, the floodwaters of lobbying money are far from cresting.
The Cost of Political Speech
While I am great supporter of democracy, with its attendant competition for ideas and dollars, I worry about the future because it turns out that free political speech is not free. In fact, free speech is very, very expensive. The great likelihood is that the price is going to increase. If each state witnesses a legislative struggle of the kind that occurred in Washington, D.C., in 2009, the amount of money expended will total in the tens or even hundreds of millions of dollars. In California, for example, $80 million was recently spent in industry lobbying on an initiative on drug pricing.
Not surprisingly, the playing field is not level and the amount of money available for advocacy efforts and political contributions varies enormously in a way that can distort the process. The big players, such as the insurers and pharmaceutical industry, have resources that dwarf those of the organizations of physicians or nurses, for example. When it comes to advocacy groups for patients, the problem is even more severe. Fundraising in the current economy is very tough and these organizations, financially clobbered by the recession, do not have access to enough money to mount state advocacy efforts, especially if future political struggles require a presence in 50 different capitals.
For a democracy to thrive, it vitally needs participation from its citizens, whether that comes in the form of votes, money, or ideas. If the past debate on healthcare is an indication, ideas are at a premium, just as dollars are. This situation is especially true because the field of ideas is crowded, shifting, or chaotic. Indeed, any group engaging in the political process needs a treasure chest of good ideas, including fall-back positions, because the necessity for compromise can knock down positions like duck pins bashed by a careening bowling ball.
Providers are busy people and their minds are elsewhere—mainly on caring for patients. Few have been able to think through political options to establish a full menu of positions beyond the more clear-cut issues such as Medicare reimbursement. In politics, the half-life of an idea can be very short and the rush of the legislative process can demand almost instant reformulation and recalculation. If no single payer, then what? If no public option, then what? The scenario can be switched according to political viewpoint and the ups and downs of deal making and horse trading.
Not surprisingly, the playing field is not level and the amount of money available for advocacy efforts and political contributions varies enormously in a way that can distort the process.
The value of ideas in Washington explains the number and prominence of think tanks. The members of think tanks are often top scholars; in other circumstances, these people would be professors at places like Princeton or Berkeley. While think tankers do important work, their scholarship is not directed to new knowledge but flows from the impetus to justify a position. It should be no surprise that the intellectual output of think tanks has an uncanny relationship to the input in terms of money or the values of the benefactors.
Ideas for Rheumatology
As René Descartes said, “I think, therefore I am.” Therefore, for rheumatology to exist and—better—to thrive as a political being, it has to think. This thought must be deep and wide and concern the full gamut of issues that confront our specialty. A think tank for rheumatology would be a great, but we live in the real world not a political utopia. Our thinking will be a bootstrap, grassroots effort and require as many people and diverse opinions as possible to forge a common vision about healthcare delivery that can transcend the more limited realm of practice and reimbursement.
To me, thinking and writing are powerfully conjoined. I suggest that The Rheumatologist would be a great place for members of the ACR and ARHP to do their collective political thinking, sending up ideas and relaying their research and experience on healthcare issues in their communities. I am putting out the welcome mat for articles—whether they are opinion pieces, broadsides, or manifestos on healthcare—so that these pages can resonate with a lively and constructive dialogue for years to come.
For those of you who may be reluctant to submit an article, let me assure you that seeing your ideas in print is both an important public service and a great thrill. You can even send a copy of The Rheumatologist with your article as a memento to your parents or children. They will beam. You will also relish the feedback from readers. Whether they tell that your ideas are brilliance or nonsense, the fact that your ideas engaged someone enough to write to you is an accomplishment that should give great pride.
The struggle for healthcare goes on. Be a player. Send an article to The Rheumatologist.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.