State of Denial

Stanley Feld M.D.,FACP,MACE

I have just finished Bob Woodward’s new book “State of Denial” and feel devastated. State of Denial of describes the facts and information denied by our government about Iraq. I am convinced neither the people running the executive branch or legislative branches of our government are stupid. The dumb part is how information is gathered, reported, scrubbed and then presented to leaders to make decisions. The problem seems to me to be independent free standing information systems that do not communicate with each other. Additionally, everyone presenting the information wants to look good or hide for their mistakes. The longer the mistakes are covered the worse situation gets. The mistakes are the result of the hierarchical structure of a bureaucratic government. Clearly the government needs to be tightly networked.

Bob Woodward has had the ability to survive the Washington bubble for some 40 years without being destroyed by the political machinery. I believe his book may have helped the Democrats win both houses of Congress last week. It may help change the course of the war in Iraq as well as the geopolitics in the Middle East forever. He accomplished his goal, to unseat the Republicans. However, he did not fix anything that is wrong with our government’s decision making process, the defense department, nor the relationship of the administration to congress.

We continually hear criticism of what is wrong. Somehow it seems the government hardly ever does it is right. However, I believe that the intention of all branches of government is to do what is right. The government’s problem is similar to the problem many industries in our country have.

The automotive industry is in almost in a melt down. Why can’t GM or Ford build a better car than Toyota or Honda? I do not think it is because GM and Ford spend $1500 a car for healthcare. I think the smart people running GM and Ford are ossified by the same bureaucratic structure that has ossified our military, intelligence organizations, our energy department, social security administration, the medical care administration, and department of education. The structure of organizations has evolved to inhibit innovation and marginalize creativity.

Michael Mandelbaum, the author of “The Case for Goliath.’ remarked “We’re not just in a ‘state of denial’ about Iraq,” We’re also in a state of denial about the budget deficit, health care, energy and Social Security.”

Thomas Friedman wrote in his column of November 4 “If I had one wish” that he hoped each house of congress was won by the Democrats by one vote. Then the Republicans and Democrats would have to work together in order to get anything done.

The administration is not the only one in a state of denial. Both the House and Senate are in a state of denial. They are all impotent to do anything constructive about the war, the budget, health care, energy and Social Security. It seems pretty to me that if the government really wanted to do something for the people (you and me) it takes more than begging for our vote the last week before elections. They should do sensible, logical and innovative things to fix our problems without protecting the vested interests of those who can afford the best lobbyists. It looks like a football game to me. If one lobbyist is better than the next, the better lobbyist will win. The government ends up doing the wrong thing rather than the right thing for the majority of the people.

Thomas Friedman also said, “The reason that Mr. Bush’s call a year ago to end our oil addiction has been a total flop has to do with a struggle in his administration between foolish market worshipers led by Dick Cheney—who insist markets will take care of everything—and wiser, nuanced policy makers who understand that government’s job is to set broad goals and standards, and then let the market reach them.”

We, the people, are also in a state of denial. About twenty years ago, I had a patient to whom I complained about the state of the world. He had done consultation work for many Presidents. He said to me that we get what we deserve. We have been programmed to have a short attention span, and have been manipulated by the media. The details of our problems and real issues are not compelling enough to command our attention.

I have also recently been impressed by the book Fooled by Randomness. We are information junkies that buy not the best information but the smoothest sounding information. The best Public Relations firms craft the messages that win in our society. We should demand accurate information from our government.

With medical care we should demand free choice to buy the best insurance product on a level playing field under government set broad goals and standards. Then let the consumer driven marketplace decide the winner. We would be surprised how powerful this would be.

Nancy Pelosi’s call for government negotiation of drug prices is another complicated mistake. We need to understand the cost of production of drugs, eliminated waste in the drug companies and let the drug companies compete for our business. Price controls never work.

I spent a lot of time on the DRG fiasco. The final rules have just been published by the government. The point is the hospitals won. The physicians lost. There is no movement to fix the DRG system. Hospital payment was neutral. Physician reimbursement was decreased by 6%. There are no incentives to decrease the complications of chronic diseases. Remember, the complications of chronic disease cost the government 90% of the healthcare dollar. The beneficiary of that money is the hospitals. Guess who has the best lobbyists. Who is in a State of Denial? The government!

Remember the real role of government is to set broad goals and standards for the patient, and let the market reach them. Saying it another way is to set the rules for true price transparency and give patients an opportunity to buy real insurance in the form of the ideal Medical Savings Account. With the incentive to shop for savings and quality, the consumer will force reduced profits. Then we can see if the market place will determine the winner. From past experiences it will work.