On Deliberative Democracy: Citizen Panels and Medicare Reform
Dahl, Robert
By offering three alternative proposals on Social Security, the report of the presidential advisory commission last January performed an unintended service to the country. It did exactly what...
...However, the body I have in mind would differ from that ill-fated task force, and indeed from other similar commissions, in several fundamental respects: • It would be explicitly expert and nonpartisan...
...More ominous for the future is the inadequacy of our political institutions for dealing with highly complex policy questions for which solutions are not only unclear and highly controversial but seem likely to create costs or reduce benefits for important groups of citizens...
...One can make some educated guesses about the number of citizens who might become much better informed and more deeply involved as a result of their deliberations...
...Complexity in public policy is not only here to stay...
...Several years ago, observing members of a Citizen Jury discussing the subject of public education in New Haven, I was impressed once again with the knowledge, relevant experience, SUMMER • 1997 • 57 On Deliberative Democracy good sense, civility, and capacity for learning from one another that ordinary American citizens can display when they are provided an opportunity to do so...
...Let me declare an interest: I served on the Advisory Committee for the National Issues Convention...
...Yet behind the apparent support for these goals lurk two formidable questions: (1) Can the first two goals—a balanced budget and no increase in taxes—be achieved without sacrificing present levels of health care...
...In order to explore one possible answer to this question, I want to use Medicare as an example...
...The future of medical care may be among the most serious long-run problems this country faces, but from the recent electoral contest one would not have learned much about it...
...We need to be more creative in developing alternative ways of responsibly presenting basic information, analysis, and argument...
...Stage II: Shortly after the report appears, a scientifically selected sample of about six hundred adult American citizens would assemble to deliberate on the commission's report for, say, five days...
...Its members would be appointed by the president of NAS and it would operate under the aegis of the NAS...
...Stage V: Finally, then, after the period of public debate and discussion, the president would meet with congressional leaders to negotiate a long-run solution...
...Judging from the trials so far, they would not only develop much more informed judgments about the issue but would also acquire a high level of sustained interest in it...
...Second, although I offer this proposal as a solution, honesty requires that we also think of it as an experiment...
...Second, and related to the first, they would present the best estimates of the long-run costs of each...
...Anyone who hoped that the 1996 campaign and elections would help the country resolve the issue of medical care must have been grievously disappointed...
...For many years the Jefferson Center in Minneapolis has assembled small but randomly selected "Citizen Juries" to deliberate on issues of local, state, and national importance...
...The sole task of a commission on Medicare would be to produce a clear and concise summary of the major alternatives and their projected costs...
...Such an assignment fits precisely with the nature and functions of the NAS...
...Before we come to the pessimistic conclusion that democracy can do no better, or even yield to the tempting but illusory hope that we had better just turn these issues over to experts and politicians to decide for us, surely we should try out some new arrangements for improving public understanding...
...Anything other than a temporary truce in the debate over Medicare will require that a majority of American voters and their elected representatives be able to make an informed choice among the alternatives...
...Inadvertently, the members of the commission revealed some important features of highly complex issues: • All important government policies and decisions result in disadvantages that may or may not be outweighed by their advantages...
...Why the System Doesn't Work Unfortunately, in attempting to deal with such a complex issue we combine nineteenth-century political institutions with late-twentieth-century technologies of mass communication...
...Yet if complex issues should not be decided by expert consensus, how should they be decided...
...Imperfect though these institutions were in some respects, they enabled popular governments to exist on a larger scale and to respond to the wants of more human beings than ever before in human history...
...to latetwentiethcentury technologies of communication no longer work...
...It did exactly what commissions appointed to provide advice on complex policy questions ought to do...
...To do that, however, they will need to acquire a better understanding of the long-run consequences of alternative healthcare solutions...
...My third assumption, therefore, is: let us make sure that even if the experiment fails to accomplish as much as we might hope, it will have done no harm and may have done some good...
...It would come into play after the standard institutions persistently failed to produce a solution to a highly complex problem on which the views of the general public provide no clear or adequate guide...
...Our existing institutions for helping the public to gain informed answers to these questions are not helpful...
...These three trials have demonstrated, I believe, that the deliberative poll is the new kind of political institution that democracies urgently need if they are to deal more successfully with complex issues of public policy...
...On the contrary, it is intended to provide a forum in which a small cross section of American voters can consider and reconsider their opinions after discussion, deliberation, and opportunities to acquire new information and understanding...
...Indeed, the commission should explore ways by which the report could be readily understood by audiences at different levels of proficiency in dealing with intellectually complex matters...
...Consequently, though politicians could choose to ignore these judgments, they would have some explaining to do...
...A great many Americans are baffled by the complexity of the issue and experts are divided on solutions...
...First, they would describe fully and carefully three or four of the major alternative solutions, their advantages, disadvantages, and trade-offs...
...So did most of those running for seats in the House and Senate...
...Most Americans seem to be deeply perplexed about their answers to these questions...
...In presenting options for reducing the deficit in June of 1995, the Congressional Budget Office argued that even though growth in expenditures for Medicare and Medicaid had slowed somewhat, spending on these two programs "is still projected to rise by 10 percent a year through 2005...
...Such a Deliberative Poll has twice taken place in Britain, the first time focusing on the issue of crime, the second time on Britain's relationship with Europe...
...The combination no longer serves us well...
...Is It Worth a Try...
...Experience so far shows that by the end of their meetings many of the participants arrive at judgments significantly different from those they held at the outset...
...Stage III: On the heels of the first Deliberative Poll on Medicare, similar exercises would take place in selected localities throughout the country...
...If at least one fullscale Deliberative Poll were held in every state and several in larger states, somewhere between twenty-five thousand and fifty thousand citizens would be engaged...
...How great the advantages and disadvantages are likely to be is a matter of considerable uncertainty...
...In January 1996, six hundred eligible voters who had been selected as a representative sample of the American electorate met for four days in Austin to deliberate on national issues on the eve of the presidential campaign...
...It was established in 1863 by an act of Congress to advise the federal government without fee on any question of science and technology...
...My concern here, however, is not with the systematic evasion of the problem by the candidates but with a difficulty that transcends campaign strategies...
...it will probably increase...
...Will it be successful...
...After all, our citizens range from those with only elementary education to Ph.D.s and beyond, and they are all equally entitled to know where their interests, and those of the country, lie...
...The 1,600 or so members of NAS are distinguished scholars from all branches of the sciences, engineering, medicine, and the social sciences who have been elected to the Academy by their peers...
...No doubt the first reaction of many readers will be to reject the idea...
...Will it work...
...First, building on our existing institutions and technology for public enlightenment, we need to develop a process that would reduce the influence of political rhetoric and obfuscation and increase the opportunities available to citizens and elected politicians for reflecting, deliberating, and making hard choices about the basic alternatives and their consequences for SUMMER • 1997 • 55 On Deliberative Democracy widely shared goals and values...
...Because the choices registered in a Deliberative Poll are, in effect, those that other Americans would be likely to make if they had the same opportunity to deliberate over the issues, the judgments of the citizens who participate are significant, even legitimate, in a way that no ordinary public opinion survey is...
...It would not be useful for initiating policy proposals or pushing them to the center of political debate, discussion, and public awareness...
...With innovations such as those I have proposed here, we can make them serve us better...
...As I mentioned earlier, President Clinton's advisory commission on Social Security has inadvertently provided a model...
...During the nineteenth century, in the United States as in other countries traveling along the path toward democracy, an adequate level of public understanding of issues and a more or less democratic connection between the great bulk of the people and their government was provided by the historically novel combination of widespread literacy, extensive freedom of speech and press, political campaigns, electoral competition between individual candidates and political parties, free and fair elections, and a broad (though by twentieth-century criteria grossly limited) suffrage...
...The process I propose would not so much replace other political practices as supplement them...
...Our democratic political institutions don't currently serve us well, but they also don't need radical surgery...
...If we add those who had previously been engaged and informed during Stage I, it is not too much to expect that the first three stages would have helped to create a critical mass of informed citizens whose views would be highly influential in all later public discussion of Medicare...
...What distinguishes a deliberative poll from an ordinary public opinion survey is that, as the name suggests, citizens actually deliberate over an issue...
...The difficulty is that a good deal of the conflict is within the individual voters themselves...
...And as I have already said, "the public" would now contain a critical mass of citizens with a better grasp of the alternatives...
...What is more, a deliberative poll would make it considerably more difficult for elected politicians to manufacture a spurious "mandate" that contradicted the conclusions reached in the poll...
...58 • DISSENT...
...The selection and procedures of the 56 • DISSENT On Deliberative Democracy group would follow the design of the Deliberative Poll created by James Fishkin at the University of Texas...
...For organizing these local polls, more expertise is available than one might suppose— for example, in social science departments at nearby colleges and universities...
...Consequently, the staff of the commission should expore the possibilities of employing different media and a variety of technologies for presenting information attuned to the capacities of different citizens...
...Every complex decision therefore rests on assumptions not only about facts but also, though these are usually implicit, about equity, fairness, justice, security, community, freedom, and other values...
...A Proposal The proposal I offer is based on three assumptions...
...Unlike most commissions appointed to inquire into a problem, the Commission on Medicare Alternatives would not recommend a solution...
...Advantages and disadvantages are never distributed equally among citizens...
...On a complex issue like Medicare is it possible to develop a more enlightened public opinion that would provide the ground for political decisions...
...Local polls following upon deliberation are by no means a radically new idea...
...Consequently it is a profound mistake to believe that complex issues can be properly decided by experts relying on technical or "scientific" analysis and judgments.* Though the presidential advisory commission complicates the task of the president and other political leaders, it should serve as a model to emulate, not to avoid...
...Some of the country's best-qualified experts, though in agreement that this projected rate of annual increase . cannot be sustained, contend that satisfactory levels of health care can be assured with annual increases in expenditures of less than 10 percent...
...The president and many congressional Democrats have, in practice, opposed attempts to reduce current levels of Medicare...
...The solutions reported by the Commission on Medicare Alternatives would furnish a ready agenda for debate and discussion by politicians, commentators, ordinary citizens, and others...
...In fact, they function pretty badly...
...But if not, then the prospects for dealing with complex public policy issues by democratic processes are dreary indeed...
...Confronted by the major alternatives, their costs, advantages, and disadvantages, it would be more difficult for politicians to gloss over hard choices...
...Perhaps not...
...but typically they remain evasive about long-run consequences for the budget and taxes...
...And not just with regard to health care...
...but when pressed about the consequences for Medicare, they generally fudged their answers or came up with vague, unexamined solutions...
...For example, they encouraged Republicans to claim that the 1994 elections gave them a mandate to balance the budget and even to cut taxes...
...Complex questions of public policy are not going to go away...
...In fact, its terms should explicitly forbid it to do that...
...The disastrous report of President Clinton's White House task force on health care may appear to argue against yet another commission...
...To achieve this end, the president would invite the National Academy of Sciences (NAS) to form a Commission on Medicare Alternatives...
...54 • DISSENT On Deliberative Democracy Yet in dealing with such a complex issue as health care, the institutions that served well enough in the nineteenth century function less well today...
...The two major presidential candidates skirted the hard questions and shied away from genuine solutions...
...Although Medicare is a part of the broader problem of an inadequate system of medical care in the United States, it is complicated enough in itself to justify separate treatment...
...As a result of divisions of opinion within the commission, its members offered not one but three possible solutions, with a different assessment of the prospective advantages and disadvantages of each...
...Would such a process really make a difference...
...A substantial majority of voters appear to want a balanced budget, no increase in taxes, and levels of health care, particularly Medicare, maintained pretty much as they are...
...If the conflict were only between two presidential candidates, or a Democratic president and a Republican Congress, or a majority and a minority of Americans, campaigns and elections might provide a solution...
...Given the state of political debate and discussion, they have every right to be...
...How can that goal be achieved...
...A process of public enlightenment would consist of five stages: Stage I: A nonpartisan commission of experts would be assigned the task of producing a clear presentation on two highly controversial matters...
...They would probably be about as close to the enlightened judgments of American citizens as a whole as we can possibly obtain—and more enlightened, certainly, than the opinions reflected in a standard opinion survey...
...In short, they actually learn something...
...Although I strongly believe so, it is impossible to know with a high degree of certainty...
...The commission's goal would be to produce a public report with the greatest measure of comprehensibility, clarity, and simplicity attainable within the limits of intellectual honesty and responsibility...
...2) If not, what priorities and trade-offs would a majority of Americans prefer...
...Stage IV: Once the report of the Commission on Medicare Alternatives and the results of national and local deliberative polls were available, a period of more vigorous public debate and discussion could be expected to follow...
...Few people contest the proposition that spending for health care cannot indefinitely increase at its recent rate...
...Because of the way its members are selected the NAS is highly independent of political influences, and throughout its long existence it has produced many important reports...
...In addition to its inherent complexity, what further complicates the problem is the nature of the conflict over possible solutions...
...They break into small discussion groups, meet with experts and politicians, and then form their conclusions...
...For some complex issues at least, the old processes developed in the nineteenth century and adapted (for the worse, perhaps...
...Yet unless and until we try the experiment we will never know...
...These points are nicely demonstrated by Amy Gutmann and Dennis Thompson in Democracy and Disagreement (Princeton University Press, 1996...
...The Deliberative Polls would provide reliable evidence as to how ordinary citizens respond to those choices...
...The purpose of a deliberative poll, then, is not to reflect public opinion more accurately or to duplicate the effects of political campaigns on citizens' information (and misinformation...
...But to do so, they argue, would require radical changes in policies and programs...
Vol. 44 • July 1997 • No. 3
