House of Eratosthenes

The coming battle over President Obama’s nomination of Donald Berwick to the top spot at the Centers for Medicare and Medicaid Services is, like the health care reform debate before it, a struggle between centralizers and decentralizers. Indeed, Berwick is an almost prototypical centralizer. In particular, he has repeatedly expressed fondness for Britain’s NICE, which does cost-benefit analysis for the country’s government-run health care system (ie: rationing).

Reason, as you can see, links to its own archives from about five days previous:

The American health care debate occurs primarily between two factions: On one side are the centralizers. They prize equality of care and access, and believe that, to the extent possible, health risks should be spread proportionally amongst the populace. They argue that health care is sufficiently complex that most individuals cannot make decisions for themselves. And they say that the responsibility for making tough decisions about how to keep health care costs under control ought to be made by enlightened, well-intentioned policy elites.

On the other side are the decentralizers. This faction prizes the subjective preferences of individuals, and takes the line that centralized decision making does not account for individual variations in responses to care, and is a poor substitute for local, personal knowledge. Further, they argue that artificially redistributing risk obscures the true cost of care, and inevitably—and uncontrollably—drives up prices and spending.

Centralizers end up sacrificing everything for this equality. Whether their ego is festooned to the concept and they cling to it until the bitter end, as the centralized capabilities plummet, plummet, and plummet some more; or, if they indulge in some kind of reckoning before any of it gets underway, and consciously acknowledge equality is the supreme virtue — I’ve never been able to figure this out about them.

I can’t find a nurse to fluff my pillow, that’s quite alright. I can’t find a nurse to fluff my pillow and you can — oh dear, some new previously-undiscovered “human right” has just been violated. We have some inequality. Can’t have that!

Looks like Architects and Medicators to me. Medicators are fixated on what other people have, whereas Architects consider such a matter to be almost entirely irrelevant. Architects want to hone a personal skill and then see to it that their personal fortune, for good or ill, is inextricably intertwined with that skill. Their projects are localized and cordoned off by means of some kind of perimeter. They want to tape a 48″ x 36″ vellum to a board, and spend a few weeks concerned only with those few square inches, and nothing outside of that space.

Medicators want security. Not so much a high standard of living, but lots and lots of assurance. They want consistency, none of this “fat times lean times” stuff. And they’re inherently controlling and jealous, so this preference toward centralization ends up being a natural one. They don’t see project perimeters, they don’t see connections between projects and the persons who own them. Everything, even a task as personal as raising a child, “takes a village.”

I submit that the centralizers are simply Medicators who are doing what makes sense in their world. None of us are really specializing in anything, we’re more like a crew on a great big spaceship…a crew without any positions or ranks. And so it just makes sense that all the resources have to be put in a great big pot.

Except someone has to watch the pot. And so their model ultimately defeats itself, because oopsie, now we have to have some superiority, some ranking, some specialty. Someone has to say yea & nay as the resources are distributed from the pot.

And so when an Architect votes, he votes for a clone of himself who has the time to go to City Hall, or the Board of Supes, or the Capitol, that he does not have. Someone who is likely, the likelier the better, to make the very same decisions he would make if only he had the time to be there. And the outcome of these decisions would be positive.

When a Medicator votes, he votes for someone who is not a clone of himself. He looks for someone much, much better; a superhuman; a demigod. And the decisions this demigod would make? They would not necessarily be the decisions the Medicator would make — instead, they would be the decisions found pleasing to nameless, faceless, anonymous strangers. And the outcome? Who cares about that, what is important is that the decisions would be found favorable. To…somebody.

Leave a Reply

You must be logged in to post a comment.

Recent

Items of Interest

Monthly Archives

What They Say

Links

Centralizers and Decentralizers == Architects and Medicators?Thursday, June 3rd, 2010

Centralizers and Decentralizers == Architects and Medicators?
Thursday, June 3rd, 2010