The Obama transition team has a website up at change.gov, as many of you may know. Specifically, they have a section where you can share your thoughts with the transition team. I don't know if they are actually reading these submissions, but I wrote one up anyway. I'm sharing it here…
I'm going to set aside my inner cynic that someone will actually read this, and talk about what has been worrying me as a concerned US citizen. I know that there is only so much an administration can do to solve the myriad problems we face, and that trying to tackle too much at once is a recipe for universal failure. Therefore prioritization is obviously key.
My primary overarching concern over this country has been any lack of a long-term strategy. I don't mean for one specific area like the economy or healthcare, but I mean *any* kind of long-term strategy for *anything.* Thus far, it seems as though we've been shifting aimlessly from one priority to the next, dictated to us often by market prices of various commodities and shifting popular wants.
That's no way to run a country.
This list is not in any kind of prioritized order because I think all are equally important at the end of the day:
1) Education: The US has been falling behind in the ability of our high school graduates to afford and go to college. This is happening even as the entry-level requirement for many jobs is having a college degree (even though the particular job may not actually warrant it).
Almost universally, my college professors have publicly lamented the fact that high school graduates are not prepared for the intensity of the material that they face as freshmen in college. As a smart, in-touch individual, I know for a fact that my math was not up to par, and I went to an excellent public high school and graduated in the top 10% of my class. Our state colleges and institutions do a spectacular job, and we should continue to invest in them, but if a student is incapable of succeeding there thanks to a poor secondary education, something is wrong. Accountability in secondary schools is very important. Maybe we need better ways to measure student performance, I do not know. Something must be done, however, because we are falling behind countries like India whose high school students are better prepared for college than ours.
The gap between boys and girls continues to widen. While we've done very well by our girls in the last 20 years, our boys have languished. Education should not be a zero-sum game wherein one sex succeeds at the expense of the other. We have neglected boys and focused all of our efforts on girls, and this is neither fair nor desirable. Both sexes can succeed together, and our educators need to remember this, and not just recommend a visit to a pediatrician or psychiatrist for our boys because stimulant ADHD medication isn't the universal diagnosis and answer.
2) Healthcare: The US lacks any kind of long-term healthcare strategy or vision. While I believe that some form of universal healthcare coverage is both necessary and desirable, President-Elect Obama should stop saying that every person will be able to get health coverage like members of Congress have because this is not possible, nor is it desirable. When and if universal coverage happens, there will still be two tiers of healthcare. A basic, public tier, and a second private tier that citizens may opt to use if they desire to pay more. Please keep in mind that I say this with no malice toward the currently uninsured. My dad had a heart attack this past spring and waited 36 hours before going to the ER — because he knew that he would end up $50-80K in debt. (And he did.)
Secondly, politicians need to stop conflating the idea of universal health coverage with universal health access. The two are not the same. Just because you are covered doesn't mean you can see a doctor. We don't have enough doctors and physician extenders (Nurse Practitioners, Physician Assistants) in this country to see everyone, and going to the ER is not the answer either: they're already overcrowded.
Massachusetts is experiencing this now. While we are often looked to as some kind of model for the rest of the country, the reality is that our system is far from perfect. It's costing the taxpayers boatloads of money because healthy people that can afford to pay are NOT signing up at nearly the rates that the unhealthy poor are. After all, if you're healthy, you don't need preventative care, the colloquial thinking goes, and even if you do, it's cheaper to pay out-of-pocket to see a doc than it is to pay a high monthly premium. In Massachusetts, the accounting math isn't working out as expected because of this particular adverse selection catch-22. Complicating the financial problem, there are not enough primary care physicians in this state to see the massive influx of new patients which highlights the second point I made: coverage does not guarantee access. That means they go to the ER, which is inherently more expensive than an ambulatory office visit.
To reform healthcare meaningfully, you need to do it in a multi-phase manner:
- Attract the best and brightest back into medicine. That means making the idea of practice attractive which means real, honest-to-God tort reform, not lipservice. When a physician is paying more to medmal companies than s/he is taking home, there is a very serious problem. Talk about a disincentive to practice.
- Along those lines, we need more primary care physicians. That means paying them more. Right now, the RVRBS is stacked in favor of specialists, and members of the committee are appointed for life (stupid idea). PCPs do more patient visits than specialists on the order of 8:1, but they are not represented in anywhere near this ratio in the RVRBS committee. That means that procedures are over-valued and cognitive specialties (primary care, rheumatology, endocrinology, etc., etc.) are undervalued because it is difficult to measure the relative value of a cognitive visit. As a result, medical students are gravitating towards specialties which pay more, and the free market is not allowed to compensate for the relative lack of PCPs because the way reimbursement is calculated is fundamentally flawed. In the long-run, this means more expensive healthcare because patients will be seeing specialists instead of PCPs, simply due to lack of PCP supply.
Senator Obama has advocated investing in technology, which is very necessary, but electronic medical records and other efficiency concerns are not a panacea, either. The entire system is broken from top to bottom and improving efficiency in a superficial fashion will NOT solve the huge, underlying problems. A study recently published estimated that only 50 cents of every dollar spent in the name of healthcare is spent on patient care. That's a bigger problem than mere technological inefficiency.
3) Energy independence: Senator Obama has promised energy independence, and his message has not changed since his 2004 DNC keynote speech. Right now, our government is listing from priority to priority. Gas prices go up, and all of a sudden the public is clamoring for the government to "do something." Prices go down, and people stop caring, but we know that petroleum supplies are fixed and demand is effectively infinite. That means that eventually prices will go back up, and we need a long-term solution. Keeping the country's eye on the ball is the government's job, because it's clear that most private citizens cannot or will not.
Command and control government regulation is sexy and it makes it look as though government is "doing something" about our dependence on foreign oil, but a more progressive Pigovian tax is probably a better way to accomplish the goal of getting our automakers on-board with the next generation of propulsion than is mandating fuel efficiency and carbon emissions standards. Even if the money is returned in the form of an income subsidy, modifying demand is more effective than trying to legislate supply.
We need government intervention because energy independence and a healthy environment cannot be achieved by individuals acting by themselves — bless their hearts. It needs to be broad and bold in scale and impact. Replacing the light bulbs in your house and planting a few trees might be part of A solution, but it's obvious that it's not the ENTIRE solution.
4) Iraq: Iraq is the only US priority that seems to have a strategy under the Bush administration. While I believe firmly that the Iraq war was "dumb," like Senator Obama, we cannot simply leave and end up with a power vacuum in that nation. We messed it up, and now we should be on the hook to fix it. I am reminded of the lessons from the 70s in Afghanistan which allowed us to defeat the Soviets covertly, but ultimately paved the way for the Taliban because the US "wasn't in the business of nation-building". Money for war, but not for education and infrastructure-building. We can see the disastrous long-term consequences of these policy choices that we are dealing with even today.
5) Outsourcing and Globalization: O&G will continue under any administration, and we should not try to stop it. In the long run, it is good for our economy anyway. However we cannot forget the workers that have lost their jobs. Suggestions run the gamut for re-training builders and makers for the healthcare and technology sectors, but we cannot ignore the fact that people are not cattle to be herded in one direction or another. Many of these individuals don't want these jobs because building and making things is part of who their identity. They don't want to be nurses, phlebotomists and IT technicians. And they shouldn't have to be.
Instead we should gently nudge them in the direction of infrastructure repair (which needs to be a priority in the new administration) and the new renewable energy economy. With a focus on renewables and infrastructure repair, President-Elect Obama can employ the tens of thousands who have been laid off in fields that are not dissimilar to where they came from, which will keep them happier and more productive.
(Of course, if these people want to change careers completely, they should have these educational opportunities available as well, which ties into my thoughts about education.)
6) Public Service: The best and the brightest need to see government as a worthwhile place to spend their energies. The politics of the last decade has been toxic for self-actualized smart people, and they haven't wanted to go into public service. I know Senator Obama knows this, and simply by being open-minded and obviously intellectual, he has done a lot to change the stereotype of politicians and public service. For that, I am grateful, and I can honestly say that I am considering public service as a long-term career whereas under the Bush administration, such an idea would have been laughable. I know that there are many other smart people in my generation who feel the same way. For that, I am thankful.
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