That could be us again

There is a certain irony to the current torrent of discoveries and advances in genomics, imaging, biological drug development, and minimally invasive surgery. Paradoxically, all these extraordinary developments are occurring at a time of great uncertainty about how to finance basic healthcare, never mind novel, high-tech, personalized medicine. But perhaps the even greater irony is that while we are finally beginning to reap benefits of the human genome project and innovative biomedical technology, unprecedented political polarization is paralyzing federal and state government at precisely the moment when decisive action is needed. 

Among our festering national problems are prolonged economic stagnation; unsustainable federal, state, and municipal debt; failing public schools; and deteriorating physical infrastructure. And then there are our failures to maintain an efficient electrical grid, develop a coherent alternative energy policy, and act on climate change, despite manifest evidence of its untoward effects. From this perspective, healthcare delivery reform looks like a relatively trivial challenge.

That Used to Be Us, by Thomas Friedman and Michael Mandelbaum,¹ addresses each of these challenges in a cogent and practical manner. The basic theme of the book is that for the past 2 decades, starting with the end of the Cold War, America has forgotten its tried-and-true formula for success. They argue that November 9, 1989 (the day the Berlin Wall fell) was of far greater consequence to the future of the United States than was September 11, 2001. 

Friedman and Mandelbaum contend that the end of the Cold War freed former communist countries to join China, India, and the other emerging Pacific Rim nations in embracing information technology (IT) and creating vibrant, modern, market-oriented economies with highly disciplined and effective education systems. They contend that we failed to grasp the immense implications of either the IT revolution or economic globalization and thus failed to make necessary adjustments. Conversely, the authors argue that we overreacted to the long-term threat posed by radical Islam by spending extraordinary sums for military actions-paid for by foreign debt, the source of which, incidentally, was US consumer spending on imported products! 

The pillars of our past success

The authors posit that the country faces 4 major questions: how to adapt to economic globalization, how to adjusto the IT revolution, how to cope with soaring budget deficits, and how to resolve the conundrum posed by rising energy demands and imminent climatic threats.² They argue that rather than trying to copy the formula for success used by China or Singapore, we simply need to update our nation’s traditional formula for prosperity, which rests on 5 “pillars.”³

The first pillar is providing far more rigorous, high-quality public education to meet global economic and technological challenges, as we did at the dawn of the industrial revolution and again in the 1950s. 

To compete in the global hyperconnected economy, we need a workforce capable of continuous innovation. To create such a workforce, we need teachers who are masters of their subject areas (not just education theory), principals who are accountable for their schools’ performance, parents who are actively involved in their children’s education, and students who read books, not just their friends’ text messages. 

The second pillar is modernizing our infrastructure,³ from bridges to fiber-optic cables and wireless networks, as we did when we built the Erie Canal, railroads, and the national highway system. Much of our most vital physical infrastructure, including fresh water and sewage drainage systems, dates back to Depression-era public works projects. As the recent Super Bowl so vividly displayed, our electric grid is also aging and increasingly inadequate.⁴

Friedman and Mandelbaum’s third pillar is immigration.³ While politicians debate stronger border fences, the immigration of highly skilled engineers and scientists has slowed dramatically and in some cases, as with China and India, begun to reverse. The authors note that while immigrants represent 12% of the US population, they have started 52% of Silicon Valley companies and hold 25% of US patents.⁵ While we wait the 20 years it will take to repair our math and science education pipelines, we should be welcoming highly skilled immigrants with open arms.

The authors’ fourth pillar is government support for basic research and development.³ Total US government funding for research has dropped from 5.5% of the federal budget in the mid-1960s to 0.4% today.⁶ Biomedical research requires 15 to 25 years to mature to clinical applications. Thus, it is ironic that we are just now realizing the benefit of the doubling of the National Institutes of Health (NIH) budget that occurred under President Clinton. What price will we pay for the nearly decade-long decline in the NIH budget in inflation-adjusted dollars? 

The fifth pillar of US economic success is the implementation of economic regulations³ that protect consumers but do not prevent prudent, long-term investment risk-taking. Michael Lewis’ book The Big Short: Inside the Doomsday Machine succinctly describes how deregulation and “dysregulation” over the past 2 decades led to excess risk and a failure to protect consumers while impeding truly productive investments.⁷ It was the unraveling of President Franklin Delano Roosevelt’s banking and Securities and Exchange Commission regulations over the past 20 years that triggered the greatest liquidity crisis since 1929-what a coincidence. 

Why government can’t act

Most of the challenges facing this nation have obvious solutions. For example, it is obvious that the federal and state deficits must be reduced by both raising taxes broadly and modifying entitlement programs to ensure their long-term sustainability. Public employee pension reform is needed at the state and municipal levels of government. It is also clear we need to scale back our foreign military interventions while (re)building at home. It is patently obvious that we need a Cold War-style focus on science and math education and educational accountability. Immigration reform, enhanced federal research and development funding, and a complete overhaul of government regulations are also matters that must be addressed now.

So why doesn’t government act to update our traditional formula for economic success? As physicians we should ask why a Republican president and Senate were unable to enact tort reform and why healthcare reform just squeaked by under a Democratic president and Congress. The answer is that American politics has become hyperpolarized. Both major parties have lost their centrist leaders.

According to Friedman and Mandelbaum, there are multiple reasons for this polarization. They include aggressive gerrymandering by state legislatures of congressional districts to create highly partisan constituencies, “rotten boroughs” dominated by one party.⁸ This, in turn, leads to victory by the most ideologically “pure” and uncompromising primary candidates who are then assured victory in general elections. Add to the mix the loss of centrist broadcast news networks (Where is Walter Cronkite when you need him?) in favor of highly segmented, ideologically focused cable news outlets like MSNBC and Fox, and hyperpartisan talk radio.

Massive increases in special-interest political action committee money and campaign expenses have also contributed to paralysis. To make matters worse, Senate rules now require supermajorities to pass most legislation. Thus, both sides now focus on divisive social issues to reassure their base while listening to special-interest groups whose funding they have become addicted to-all while avoiding the fundamental structural issues that threaten the nation’s long-term economic health. The result, in my opinion, is the least effective government processes since the antebellum period. 

Take-home message

Friedman and Mandelbaum’s solution to this political imbroglio is to radicalize the center of America’s political spectrum. They urge a third-party candidate for president who would modernize our 5 pillars, tackle the deficit, and implement a sane energy policy. However, they don’t think that a third-party candidate would actually win! They point out that viable but unsuccessful third-party candidates are often far more successful at implementing their agendas than is the actual winning candidate, since the latter must appeal to alienated voters to govern.

For example, Teddy Roosevelt’s Bull Moose candidacy in 1912 led to Wilson’s adopting the Progressives’ platform. On the right, George Wallace’s unsuccessful 1968 third-party candidacy led to Nixon’s “Southern Strategy,” which fundamentally realigned state party allegiances in both the North and South. It was Ross Perot’s 1992 quixotic and fundamentally centrist campaign that led President Clinton to focus on deficit reduction-and our last federal surplus. 

It is an interesting strategy, and a certain New York City mayor might have the resources to implement it. However, apportioning congressional districts in fair and consistent ways and reforming campaign financing would likely have similar effects-albeit over a longer time period. Stronger leadership by centrist politicians would also help. Finally, perhaps voters will simply become fed up and start electing candidates who espouse compromise and rational, centrist solutions while eschewing fringe candidates who focus on polarizing social issues.

As physicians, we cannot expect rational healthcare policies from Washington-whether they are tort reform, permanent fixes to the sustainable growth rate, adequate Medicaid funding, NIH budget increases, or the elimination of nonsensical regulation-without fixing the political system itself. We are in a unique position to educate our patients and leaders alike. So to answer Friedman and Mandelbaum’s unspoken question, I think that could be us again. 

Dr. Lockwood, editor in chief, is Dean of the College of Medicine and Vice President for Health Sciences at The Ohio State University, Columbus, Ohio.

References

1. Friedman TL, Mandelbaum M. That Used to Be Us: How America Fell Behind in the World It Invented and How We Can Come Back. New York: Farrar, Straus and Giroux; 2011.

2. Friedman TL, Mandelbaum M. Ignoring our problems. In: That Used to Be Us: How America Fell Behind in the World It Invented and How We Can Come Back. New York: Farrar, Straus and Giroux; 2011:14-33.

3. Friedman TL, Mandelbaum M. Ignoring our history. In: That Used to Be Us: How America Fell Behind in the World It Invented and How We Can Come Back. New York: Farrar, Straus and Giroux; 2011:34-53.

4. NPR. Visualizing the U.S. Electric Grid. http://www.npr.org/templates/story/story.php?storyId=110997398. Published April 24, 2009. Accessed February 10, 2013.

5. Friedman TL, Mandelbaum M. The war on physics and other good things. In: That Used to Be Us: How America Fell Behind in the World It Invented and How We Can Come Back. New York: Farrar, Straus and Giroux; 2011:197-227.

6. Moses H 3rd, Dorsey ER. Biomedical research in an age of austerity. JAMA. 2012;308(22):2341-2342.

7. Lewis MM. The Big Short: Inside the Doomsday Machine. New York: W W Norton & Co; 2010.

8. Friedman TL, Mandelbaum M. The terrible twos. In: That Used to Be Us: How America Fell Behind in the World It Invented and How We Can Come Back. New York: Farrar, Straus and Giroux; 2011:229-257.