AMA v. Obamacare

Via MKH, I learn that the American Medical Association, "the largest association of physicians and medical students in the United States," opposes Obamacare. To be sure, this is good news, but Obamacare opponents should hesitate to rest too much weight on it. The AMA's opposition, even assuming its intractability, is relevant as a matter of policymaking, useful as a matter of politics, but is not decisive. Here's why.

As a conservative, I'm suspicious of making sweeping public policy reforms based solely on abstract ideas. See, e.g., Arnold Kling, The Conservative, the Progressive, and the Masonomist (6/6/2008) ("Suspicious of radical change, [Burkeians] ... explicitly worried about the selfish, self-seeking nature of humans; believed that abstract theoretical intellectuality --- no doubt would be taken aback by libertarian GMU theoretical skyhooting modeling too --- was thoroughly suspect as a guide to complex societies; favored maintaining traditions where possible, but favored what we would now call incremental change"). I agree with Prof. Althouse, albeit in a different context, that "[b]y professing unconcern for practical reality and a pure, unalloyed love for an idea, one loses control over outcomes and argues unwittingly for bad results ... [and] there is something unprincipled about embracing an abstraction and taking it to its logical limit, without the stabilizing effect of considering policy implications." Ann Althouse, The Humble and the Treasonous: Judge-Made Jurisdiction Law, 40 Case W. Res. L. Rev. 1035, 1039-40 (1990); cf. my comment here (citing, inter alia, the same passage).

The deeper-rooted and more reticulated the thing proposed to to be changed, the more instinctively skeptical I am, and the more I want change to be narrow, targeted, and based on a posteriori experience not a priori theorizing. That's one reason why I'm against Obamacare's vast, far-reaching, and unprecedented reform. (This is another.) It's also a reason why, even if you don't believe federalism is a Constitutional mandate (as some don't, or at least don't take seriously), it has obvious normative value in providing fifty "laboratories of democracy" in which we can test ideas and see what works. See New State Ice v. Leibmann, 285 U.S. 262, 311 (1932) (Brandeis, J., dissenting); Althouse, Vanguard States, Laggard States: Federalism & Constitutional Rights, 152 U. Pa. L. Rev. 1745 (2004). Do legislative term limits help? What kind, consecutive or lifetime, is best? What happens when you have a balanced budget amendment? Does expanding or contracting judges' contact with the electorate improve the quality of judging? Does the quality of legislation suffer from the absence of bicameralism? What happens if we make a constitution easier to amend? What happens when there is a Constitutional right to X? The experience of the states supplies, or can supply, answers to these questions, or at least useful data; see this for an example that's directly on-point.

The upshot of this focus on practical experience in framing reforms is that in most circumstances, I believe that we should give a great deal of deference to the professionals in a given field--the people who are hands-on, the people on the front lines. Doctors, for example. For a fairly extreme example, an issue on which I find it appropriate that my position IS deference to the professionals, my position on "Don't Ask Don't Tell" is essentially "whatever the military wants." If the military want it, § 654 should stay; if they want it gone, it should be repealed. I have no idea if gays serving openly in the military is good, bad, or indifferent to the ability of the military to conduct operations. Congress certainly doesn't. And if you aren't presently serving on active duty in the United States military, neither do you. The best judges of what hurts the operational readiness of the United States military and what helps it--the sole criterion where this issue is concerned--is the United States military themselves. Their word should be decisive.

But that's an extreme if not unique example, and the principle has limits. I counsel deference, in the proportion dictated by specific context, not abdication of judgment. The military is an exceptional context, given their mission and the imminent risk to their lives and limbs; it accordingly gets exceptionally high deference. The same principle applies to other situations, but the level of deference is naturally far lower. Consider tort reform, a vague idea that the GOP has pushed several times in the last decade. The American Bar Association represents the professionals in the field that will be affected. But the ABA's opposition to tort reform does not decide the question. Yes, we would do well to seek the counsel of front-line practitioners in considering such reforms. Yes, it's appropriate to defer to them, to the appropriate extent, on matters where their experience counts. Yes, their opposition is a useful reference point. But other factors must also be weighed, and not only because the ABA's hostility is hardly an admission against interest. There are many reasons why the professionals in a given field may oppose change; some of them are good, but others may boil down to comfort, familiarity, and (at risk of putting it uncharitably) myopia. When your nose is to the grindstone, you get to know the grindstone intimately, and while that has value, you may lose sight of the bigger picture. And, of course, the cost-benefit ratio of rightsizing a company looks very different depending on whether you're someone who will stay, someone who will go, or a stockholder.

The foregoing, then, is the lens through which I read the news of the AMA's apparent opposition to Obamacare. I am glad that the AMA is with us in opposing Obamacare. And I'm not saying that their views shouldn't carry the day, that we shouldn't give all appropriate deference to their views, or even that their opposition isn't reason enough by itself to oppose Obamacare. My reaction to the news is to greet it, but to warn against overselling it. We must acknowledge that just ABA's opposition to tort reform wasn't reason enough to vote against tort reform, the AMA's opposition to Obamacare isn't reason enough to vote against Obamacare. These are useful datapoints, they deserve appropriate deference, but we cannot simply slam the door and declare that "the doctors have spoken, the matter is ended."

Still, what is particularly useful about the AMA's decision is that it provides cover to legislators who want to say no to Obamacare. I think that most Americans instinctively share (even if only in a quite diluted and subconscious sense) the precepts I outlined above, particularly in regard to this issue. If the doctors are against Obamacare, I really believe that will make the man on the street think twice about it. Congress - particularly the blue dogs, see my post here - will be subjected to incredible pressure by the leadership, by liberal pressure groups, and by the administration, to pass Obamacare. The opposition of the AMA is unlikely to convince those legislators who are for it; it may sway those who are on the fence; but its real utility is that it gives those members who really want to say no, but fear the repercussions, something else they can give their constituents with which to resist the pressure.

Post facto:
Don't Ask, Don't Tell, again (2/1/10)