President Harry Truman once famously wished for a one-handed economist, because the ones advising him were forever saying, "On the one hand . . . but on the other hand. . . ."

President George W. Bush went one appendage further: "If [these economists] had three hands they'd say, on the one hand, on the other hand, and then on the third hand."¹

Yet presidents keep coming back to economists and other policy experts, especially in the fiendishly complex field of health care. Democratic presidential candidate Barack Obama leans on Harvard economist David Cutler; his larger stable of health advisers includes Austin Goolsbee and Jason Furman, both economists.

Republican John McCain relies on economics Ph.D. Gail Wilensky, as well as on the former director of the Congressional Budget Office, Douglas Holtz-Eakin, another economist.

Economists are not, of course, the only experts to which presidents and presidential aspirants turn. On health care, Obama and McCain are advised by lawyers, doctors, holders of public-policy degrees, and the occasional noneconomist social scientist. What remains constant is the role these advisers occupy, a role awash in ambiguity, opportunity, and risk. The adviser is the president's ally — in the lingo of organizational economics, an "agent" serving the interests of a "principal."

Yet as a bearer of specialized knowledge, the adviser is also responsible to a larger profession, to its values and commitments, and ultimately to the ideal of expertise itself.

The adviser, in short, must both "speak truth to power" and aid in the exercise of power, both offering unbiased intelligence and acting as a very biased assistant. It is fashionable to pretend these two roles are the same, but they are not. An expert adviser has special knowledge, training, and skills — all of which are needed more than ever in the White House. The question is whether these talents can really be used, or be useful, in the bare-knuckles world of American politics — and, more important, whether the values they embody can be upheld when science, advocacy, and democracy collide.

Consider the travails of noted health policy expert Len Nichols. As Hillary Clinton battled for the Democratic nomination, Nichols joined a conference call for reporters set up by her campaign. The topic was an Obama advertisement charging that Clinton would force people to buy insurance "even if they can't afford it." On the call, Nichols likened the ad to "having Nazis march through Skokie" — a depiction the Clinton campaign immediately disavowed. Shortly thereafter, Nichols apologized for letting his "passions" overwhelm him. The head of the New America Foundation, where Nichols works, declared his comments "regrettable," not least because the foundation "does not endorse or advise any campaign in an official capacity."²

Nichols's sin — besides the obvious rhetorical offense — was to cross the line between expert and partisan. Politics is about power more than truth, about winning more than being right. But expertise is about truth more than power, and being right is the whole point. The authority of the expert cannot survive long when expert judgment is seen to hinge on grudges or biases. The abiding concern of the expert adviser is how to maintain independence while acting as a faithful ally and advocate — how to make power serve truth while still serving the principal.

Yet the greater, and more vexing, problem is far less recognized: the limits of expertise itself. When the Clinton administration's health plan died in 1994, many dismissed its health policy advisers as naive. And yet the closest of these advisers were not just highly regarded health policy experts, they were some of the most knowledgeable the White House has ever seen. Paul Starr, who had masterfully dissected the past failure of national health insurance, left Princeton to help write the plan. Scores of other experienced policy gurus — including Len Nichols — lent their wisdom. Even Ira Magaziner, the much-maligned policy wonk who oversaw the president's gargantuan health care task force, had more than a passing familiarity with health and economic policy. All of them had studied the lessons of history — and ended up repeating them anyway.

The modern presidency demands expertise. The rise of a massive, interconnected executive branch, the ever-increasing complexity of public policy, the "permanent campaigns" of contemporary elections, with their endless issues, talking points, and proposals — all make the president's job as much about fostering and managing competing information streams and creating communities of allied expertise as about fulfilling the authoritative role President Bush evocatively termed "the decider." Contemplating Dwight Eisenhower's arrival, Harry Truman foresaw the challenge for the former general as presidential impotence: "He'll sit here, and he'll say, `Do this! Do that!' And nothing will happen."³ But the more basic challenge may be to decide what to do on issues as varied and complex as global warming and stem-cell research, health care financing and financial-market regulation. Here expertise is invaluable, unavoidable — and sometimes, as the failure of the Clinton plan reminds us, perilous.

Health policy experts can do more sophisticated analyses than ever, and there are more of them than ever, too — in policy schools, departments of economics, schools of public health, think tanks, private foundations, and government. But the progress in quality of expertise has not been matched by progress in thinking about the role of the expert or about how policy advice can and should be adapted to the political realities that those receiving advice inevitably confront. Policy experts are brilliant when it comes to designing proposals but often horrible at thinking through the ways in which their proposals will be refracted through the political prism. Subtle visions of policy are wedded to crude caricatures of politics, and, not surprisingly, those visions all too often either fail to become reality or fail to work.

Worse, the expert's claim to authority can undercut the more important wellspring of democratic leadership: the demands and wishes of the people. Experts are habitually disdainful of what ordinary citizens believe. People have opinions; experts have facts. When a well-regarded economist complains that democratic policy choice should be restricted because "irrational" voters endorse all sorts of harmful nostrums — whether trade protection or farm price supports (he might have added health insurance with low deductibles, drug price controls, and free choice of doctors) — he may be out on a limb.⁴ But the tree is one that many policy experts climb.

Ironically, then, the failure of the Clinton administration's plan was made more, not less, likely by the amount of policy expertise poured into its design. The Clinton advisers sought the ideal policy synthesis. Though aware of political realities, they treated them as problems of policy design, to be managed within the confines of the president's blueprint rather than incorporated into a political strategy that would make the president's goals and ideals, not a 1342-page bill, the guiding light of congressional debate. And the advisers designed the proposal knowing full well that many of its elements, such as greater emphasis on tightly managed health plans, were at odds with what most of the public professed to want. That was a problem for the political consultants, who would try to figure out how to "sell" Americans on what was good for them. The result was a fiasco — and a cautionary tale about the limits of expert presidential advice in an age that demands it.

This time around, health policy advisers — whatever their formal background, and whether two-handed or more Vishnu-like — would do well to take a different tack. We badly need health care experts in the White House who offer advice based on evidence and analysis, not prejudice. But even the best experts need to know when to defer to the political process, to see the purpose of their craft as facilitating democratic debate rather than providing final answers once Americans have decided on the questions.

Winston Churchill once said that "scientists should be on tap, not on top."⁵ That is a good starting point. But sometimes presidential policy experts should also have the good sense to get out of the way.

Dr. Hacker reports receiving advisory board fees from Pfizer and speaking fees from America's Health Insurance Plans, both of which he reports donating to charity. No other potential conflict of interest relevant to this article was reported.

Source Information

Dr. Hacker is a professor of political science at the University of California at Berkeley, codirector of Berkeley Law School's Center on Health, Economic, and Family Security, Berkeley, CA, and a fellow at the New America Foundation, Washington, DC.

References

1. President Bush discusses economy, trade. Washington, DC: The White House, May 2, 2008. (Accessed August 22, 2008, at ^{http://www.whitehouse.gov/news/releases/2008/05/20080502-8.html.)}
2. Melber A. Clinton surrogate compares Obama ad to Nazi march [updated]. The Nation. February 1, 2008. (Available at http://www.thenation.com/blogs/campaignmatters?bid=45&pid=278988.)
3. Neustadt RE. Presidential power: the politics of leadership. New York: Wiley, 1960.
4. Caplan B. The myth of the rational voter: why democracies choose bad policies. New Haven, CT: Yale University Press, 2007.
5. Rose N. Churchill: an unruly life. New York: Simon & Schuster, 1994.

NEJM

Volume 359:1085-1087     September 11, 2008     Number 11