Charles Lindblom published a classic article, "The Science of Muddling Through," in 1959. He compared two approaches to making major public policy decisions: "rational-comprehensive," and "muddling through." Oddly enough, this distinction has important implications for attempts to reform our current medical system.
The "rational-comprehensive" approach requires us to consider all of the possible alternative solutions to a major problem, predict the benefits and costs of each alternative, and implement the best solution. After careful thought and analysis, we choose and implement a big change in one fell swoop.
For practical purposes, though, Lindblom felt that this approach was nearly impossible and overloaded our decision-making circuits. In real life, he suggested, policy makers must usually make a series of decisions about small parts of the larger problem and implement changes gradually.
These small "incremental" modifications of current policy may ultimately add up to a major change, but we are less likely to get unexpected and unpleasant side effects when we muddle through than if we try to solve the major problem once and forever right away. "Final solutions" usually aren't.
Lindblom's analysis has obvious relevance to our medical policy debates. The decision to enact Obamacare was not a perfectly "rational-comprehensive" one, for three reasons. First, it built on the existing Medicaid program and continued to rely on private insurance companies.
Second, it was not based on systematic, careful analysis of alternatives and their probable consequences, but was knocked together by Democrats who did not observe the usual procedural requirements for drafting legislation.
Third, it did not assure that everyone would be insured, implying the need for further, perhaps incremental, policy changes. Still, Obamacare was a major policy change carried out fairly abruptly.
Now that people are becoming used to Obamacare, suddenly overturning it would be a dramatic, major change. It would be "rational-comprehensive" in the full sense of the term, with all of its practical disadvantages.
A federal judge in Texas recently ruled that all of Obamacare must be struck down as unconstitutional. If the higher courts were to uphold this decision, 20-some million people would lose their insurance. Tens of thousands would die prematurely every year due to lack of medical treatment, many more casualties than the lives lost on 9-11.
Unfortunately, the Trump administration is urging the appeals court to uphold the Texas judge's ruling.
If we want to address a problem by making one major change, we need to avoid destroying an existing system without designing and implementing its replacement.
That is why it is so disheartening that President Trump has announced that he wants Congress to wait to enact new insurance legislation until after the 2020 elections.
Trump's promises will require major legislation. He claims that the new insurance will "be much less expensive than Obamacare for the people . . . and we're going to have (protections for) pre-existing conditions and will have a much lower deductible. So, and I've been saying that, the Republicans are going to end up being the party of healthcare."
The problem is that nobody, including Mr. Trump, has any idea how Republicans (or anybody else) can do this. And if the change is going to be a major, "rational-comprehensive" one, it should be subjected to prolonged and intensive discussion in Congress and by the general public.
Only due process of legislation will minimize the danger of making horrible mistakes. It will not do to promise people a wonderful system while waiting to reveal some magic plan — cooked up in Republican back rooms — until after the election.
Republicans are no better at drafting major new laws in secret than Democrats are. And any serious reforms` of the medical system will need bipartisan support to have a decent chance of lasting beyond the next election.
An insurance system that is better than Obamacare would indeed be wonderful, if one can be found. But we need to see what it is first and enact it into law before wiping out the present, admittedly imperfect, system.
To ask voters to take campaign promises on faith invites profound skepticism if not outright derision, especially when they are made by a leader who has been highly selective in the campaign promises he chooses to keep.
"Vaporware" is a new software program that has been announced but does not exist yet and quite possibly never will exist.
Until we see well-thought out details, people need to assume that Trumpcare is the functional equivalent of vaporware.
Paul F. deLespinasse is Professor Emeritus of Political Science and Computer Science at Adrian College. He received his Ph.D. from Johns Hopkins University in 1966, and has been a National Merit Scholar, an NDEA Fellow, a Woodrow Wilson Fellow, and a Fellow in Law and Political Science at the Harvard Law School. His college textbook, "Thinking About Politics: American Government in Associational Perspective," was published in 1981 and his most recent book is "Beyond Capitalism: A Classless Society With (Mostly) Free Markets." His columns have appeared in newspapers in Michigan, Oregon, and a number of other states. To read more of his reports — Click Here Now.