There’s always a story behind the story and sometimes one belies the other. Remote Area Medical (RAM) is a godsend; make no mistake about it. But like any private sector organization, the transparency or accountability we demand from government is not always evident. Today’s “conservatives” would never acknowledge that.
Watching and taking part in the transformation of a rural air terminal into expeditionary specialty clinics, dental and vision, is not an immersion in military precision. It almost can’t be when much of the labor is borrowed. The effort resulting when organization is flattened results in stove-piping. The raw volunteers care about pitching in and recognize the limits of their ability to contribute to technical assembly of the equipment. There are enough seasoned volunteers that as long as the boxes and bags are lined up at their assigned places, they can readily and efficiently assemble and order materials; in their areas. The lack of organization and efficiency among the unguided volunteers is more than compensated for by their numbers and camaraderie. From pitching tents (probably the most organized effort), to setting up tables and chairs, to moving crates and boxes, the unbridled activity ends in mission accomplishment.
This is at the tactical delivery end. Strategically there is always another view that is masked by the appearance if not the reality of good intentions. My father had no time for the American Red Cross. After raging battles on isolated Pacific islands during World War II, the Red Cross sold donuts to the Marines and sailors ashore; the Salvation Army was there handing out goods gratis. Guess which organization he favored. My wife cannot turn down a request for a donation from Saint Jude’s in Memphis despite having no clue who Danny Thomas was; it’s those children. On the other hand, when I see anyone collecting donations to benefit our military service members or veterans, I challenge their credentials on the spot. I wasn’t as discerning with RAM until I saw the DC-47 (a WWII DC-3 configuration) touch down in Lee County. After all, RAM had been endorsed via association by both of Virginia’s United States Senators, our current Governor, and General Assembly members from both sides of the aisle.
About a year ago, the Tennessee Attorney General stepped into an internal quarrel at the highest echelons of RAM about priorities, oversight and accounting. We are not talking about embezzlement here; this isn’t a Bobby Thompson scandal. But it points out an irony in the neo-conservative worldview embodied in Bush I’s “Thousand Points of Light” philosophy: moving public functions to the private sector for “efficiencies” requires continuous public sector vigilance and oversight. Government can set and enforce high ethical standards in the public sector; it is left to investigate and prosecute ethical lapses in the private sector. And, believe it or not after the McDonnell trial revelations, ethical standards in the private sector are much more ambiguous and hard to enforce than in the public sector.
That RAM aircraft is something of a symbol. It probably saved money in the day when used on missions to Guyana. But beyond the public relations value, it is difficult to see how its employment can be rationalized on a mission from Knoxville, Tennessee to Lee County, Virginia. It is quaint, but its cargo could go surface almost as quickly and certainly at less expense and risk. This DC-47 was highlighted in the RAM internal struggle, but may have only been a convenient foil in a personal disagreement over the future direction (aka strategy) of an organization that began with a focus in the third world and has evolved to serve America’s other world.
To be clear, RAM, unlike the Red Cross and many other charities, appears to deliver superior bang for the buck. But no organization should get a free pass just because it is in the private sector. Today’s “conservatives” automatically assume governmental inefficiency and private sector integrity. There is nothing further from the truth.
In a free market, government has no role (other than as a tax authority) in private sector strategic, operational, or tactical decisions, so there is also no way to rationalize efforts to reduce redundancy or leverage cooperation between organizations. Contrary to “conservative” dogma, the free market is an invitation to charitable (or political) waste. We see this in spades when non-governmental organizations respond to disasters or political action committees hype the same hot-button issue. The free market can mean chaos and piling on. Equilibrium is a moving target, not automatic, and the path to it includes regression toward the mean. That is why it is essential for government to stand in the way of any tragedy of the commons. At the macro-level, there is rarely a reason to believe the market will always be rational.
But let’s go back to what “conservatives” claim would be a better way to serve what were some 47,000,000 Americans without healthcare before the Affordable Care Act: the free market and the generosity of others. Right there is the indictment of the philosophy. If the free market worked so well, why were more than 15% of Americans unserved? That doesn’t include the underserved. There are a variety of causes and they won’t be mitigated by such inventions as “health savings accounts” or the generosity of others. Both are opportunities for graft and cons. This is an obvious problem that only the more even hand of government can fight.
And what part of a legitimate growth industry don’t Republicans see? The Republican refusal to cover the Virginia Medicaid gap is all the evidence necessary to show this isn’t about business and market principles. It’s about their hands in our pockets. Closing the Medicaid gap won’t solve the problems of the underserved, but it will go a long way toward creating the kind of demand that might attract the infrastructure capital necessary to mitigate them. When the supply siders (without regard to demand) start opening hospitals instead of closing them, they might have a convincing argument otherwise.