Saturday, October 3, 2009

Give the people what they want -- if you can figure it out

During the course of the heated health care debate, as during all matters of excited public discussion, there's been a lot of talk about "what the people want." Do people want single-payer care? Public option? Market-provided medicine? Everybody peddling a scheme for overhauling doctors' offices and chastising insurance companies seems very concerned about what the people want -- and claims to know the public's true desires. But, as most of the chatterers know, or should know, "the people" don't really exist, and they don't want any one thing.

The problem was illustrated in a recent Politico article, which fretted:

Legislators hoping to learn what their constituents think about the issue — and how to vote to keep them happy — face a dizzying deluge of hard-to-reconcile data, some of which suggests that voters are more than a little confused, as well.

What to make of it, for example, when one poll finds that 63 percent think “death panels” are a “distortion” or “scare tactic,” and only 30 percent think the issue is “legitimate,” while another finds that 41 percent believe that people would die because “government panels” would prevent them from getting the treatment they needed?

Or when one survey finds that 55 percent of Americans support the public option, while another says 79 percent favor one — but also notes that only 37 percent people surveyed actually knew what “public option” meant?

Part of the problem is, as Drew Altman and Mollyann Brodie wrote in a 2002 paper on the limitation of health care polling, "you always have to worry that you are polling about things that the average person may not be following closely enough to understand, and that the result you get is as much a response to key words and phrases such as 'federal government,' or 'Medicare,' or 'HMO,' as it is a response to the merits of the policy options being asked about. Policy-option polling pushes the limits of what polling can do, particularly if the policy options are complex."

Beyond that, though, is the problem raised by the French sociologist, Pierre Bourdieu: "Putting the same question to everyone assumes that there is a consensus on what the problems are, in other words that there is agreement on the questions that are worth asking."

Another way of putting it, as presented by political scientist Sidney Verba, is that the “agenda reflects the interest of the poll taker” and “the set of issues covered may be very different from that which is on the mind of the respondents.”

And indeed, we've seen that dilemma at work in spades in recent months. The question that many D.C. insiders want to ask has to do with what the federal government can do to expand access to health care and control costs. The answers that they're getting back, in the streets and at town hall meetings, indicate that many Americans are more concerned with questions about other issues, including government overreach, immigration and federal spending. Plenty of respondents charge that the government caused the problems it now claims to address, and that letting it have any role in the solution will make matters worse. The range of the discussion has only been expanded by the complexity of the health care debate, with hot-button terminology and endless details.

In fact, there is no "the people" to have an opinion about health care (or many other issues). There are many peoples -- ultimately, hundreds of millions of individuals -- who have not just different answers, but different questions in mind. That is, when they even understand what everybody else is so exercised about.

Policy makers sometimes seem to want to frame public discussion as if we're all a group of friends deciding on where to grab a bite to eat. But how do you get 300 million people to agree on Chinese instead of pizza -- or even that it's supper time at all? Some of them just don't want to be bothered with questions or obligated to follow the discussion -- which isn't the same thing as saying that they don't care if you drag them along to a dinner theater.

Because of the fractious nature of any society and the suspect nature of an apparent majority opinion on any issue, democratically asking everybody's opinion is less an ideal way of deciding each and every matter than it is a least-bad means of determining what policy will tick-off the fewest people on those very few matters that require some sort of collective response.

Do you really want to come to a policy conclusion that will please a nation of 300 million people? Then get ready to craft 300 million separate solutions.

Or else concede that, no matter how much polling you do, no matter how much effort you make to discern what "the people" want, any effort to make top-down policy for an entire nation is ultimately authoritarian, with the solution crammed down the throats of dissenters.

Then again, we could just get rid of the top-down policy-making and let people run their own lives and come to agreement with one another on voluntary, non-coerced solutions.

Hmmm ... Perhaps we could come up with a poll to ask what people prefer ...



Anonymous Anonymous said...

I'm all for letting everyone pick insurance based on their needs, just like car insurance. Everyone should have a minimum policy to cover catastrophic events, but outside of that let people pay for what they want. Once people understand that it costs money to go to the doctor for every ache, maybe there is chance that costs can be reigned in, until then. No chance.

October 3, 2009 4:03 PM  
Blogger Johnny said...

See also Arrow's Impossibility Theorem.

October 4, 2009 11:32 AM  

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