Building a Health Commons

One of the critical elements missing from effective health care reform is a context for reframing the large-scale aspects of finance, delivery, public health, information, and other essential elements in comprising a health care system. We have much more experience and success in improving on what we have, particularly in reshaping the micro-systems in which care is delivered and organized. Still, without a larger framework for these changes, we are at times unable to push through necessary systems change when dealing with something as large as the US health care system. Several years ago, I presented the concept of a health commons at the University of New Mexico and I would like to revisit it as one set of ideas that may facilitate a discussion of the essential elements of a reframed health care system.

The idea of a health commons comes of course from the older concept of an economic commons, in which all participate and exist to serve a common good, driven, in part, by individual and corporate self-interest aligned with this common good. In part, it plays a bit of an insurance function, but more importantly it serves as a way for appropriate competition to emerge, choice to be expressed, efficiency and consumer responsiveness to be rewarded, and public accountability to find a voice. Here, in brief, are the six elements that I believe would need to be built to bring a health commons to life. Many of these ideas have been put forward in other plans for reform, so I do not position them as unique, but as essential elements of the idea of a common approach to health care.

We might as well start with the most critical concern: finance. There is much discussion today about the need for a single payer system to reform health care finance. I do not want to engage in that argument here, but perhaps it would be best to take what is most attractive about such proposals, that it offers a simplified, universal financing system, and modify it to the idea of a commons. Perhaps the best approach would be to have regional purchasing cooperatives, which could exist to set standards, maintain universal participation, both by employer mandates and consumer responsibility for catastrophic, adjudicate claims and compliance, and perhaps set an agenda for reform and improvement. These entities might be state-wide for small states, say up to six million in population, and regional in larger states, following population concentration and cultural patterns. Most states already control a critical mass of enrollment to create such a purchasing cooperative. Medicaid, Children's Health, and health insurance for public employees would in most jurisdictions be at least a quarter of the insured population. Add Medicare to this mix and the totals exceed forty percent in most places. Include the uninsured and the total rises to near sixty percent. These numbers are probably enough to begin to create the market defining pressure needed for such a cooperative. As states begin to pay attention to the recent action in Maryland and address issues of employer mandates, perhaps they should consider a more rational next step and create mechanisms that can bring real control to quality, cost, and access. A step such as this would make a real contribution to improving the business climate.

Step two is the rationalization of delivery systems into deeply collaborative delivery enterprises that can integrate care in a way that makes sense clinically, economically, and publicly to consumers. Of course there are current legal restrictions that prevent such cooperation, but it is time we recognized these for what they are, antiquated structures that protect the interests of the incumbents more than the consumer. The power of the aggregated purchasing cooperative could create the needed competition across health systems. In most areas, three to five large integrated collaborative delivery enterprises across medical groups, hospitals, laboratories and other providers would emerge. In some areas, such as isolated rural areas and perhaps some urban settings, the public delivery system might become the sole provider mechanism. Arrangements like these might need special oversight legislation, such as public utility regulation, but it is important that a sole source arrangement still works with the larger purchasing entity and be held accountable for reporting and quality standards. The boards would also be responsible for creating a district plan and goals for health and making annual reports on progress toward the plan using the health information described below.

Public engagement is the third element of a health commons. The absence of such engagement and responsibility contributes significantly to the perverse incentives and lack of understanding by individuals of the health system today. The missing public voice and controlling influence of the consumer leads directly to a health care system that costs too much and underperforms. As the commons idea includes both public and private mechanisms for information and choice, the structure is necessarily complex. Purchasing cooperatives need the governing voices of both aggregated purchasers - governments and businesses - and individual consumers. These could be appointed, but might function most effectively if elected. Collaborative delivery enterprises would be governed by corporate boards in either the private or public sector. Rather than require public membership of these entities, the areas that are served by these delivery enterprises would create boards with broad public oversight responsibilities. Functioning like an expanded health district, these boards might also be given the authority to raise additional funds for health improvement, but such efforts would require the electoral support of the district.

In addition to engaging the public, the health commons must also influence change in the behavior of individuals. The health district board would do some of this work with education, public goals, and reporting of progress. At the end of the day, individuals must have some real investment and incentive for changing behavior. As individuals would be required to contribute to their health insurance costs on a sliding scale, discounts for healthy behaviors and lifestyle choices could be incorporated into the premium structure. These behavior changes must also be supported and encouraged by a more consciously designed community for health. Transportation, housing, recreation, employment, and education practices and policies all contribute to the landscape in which choices about health are realized. As the district board designs a plan or vision for the future it must incorporate these elements in to such a plan.

Health information moves steadily towards a standardization and universality which will improve the quality and safety for individuals. The same quality of information at the district and regional levels will need to be a part of the commons. Performance information of delivery organizations will need to be mandated by the regional purchasing authorities and made available through the district boards. The boards should also aggregate these data across delivery organizations in order to demonstrate progress toward their district-wide goals. This report card could be used as a comparative metric to assess the district against standard measures, as well as report on individual district goals.

Creating the infrastructure for a health commons challenges tradition and creativity in several areas. The ideas presented here move health care into a new public-private space giving it special privileges and obligations. It also changes radically the rights and responsibilities of the individual in relationship to health. Perhaps most importantly it imagines a newly activated and engaged community focusing on health and what it can do to improve its health.