Meet Me in the Middle

 A lot has happened -- or not happened as the case may be -- in the past month. At the time of writing this it is unclear what, if anything, will be advanced in the health care reform bill. Bets and suggestions run the gamut from pushing ahead with everything, to selecting those parts that are most important and least controversial, to starting over. Any piece of legislation is a balance of policy and politics, and this one has been fully swimming in this soup from its first day of consideration. Undoubtedly something will happen, even if the happening is a deep reconsideration. Regardless, with or without a health care reform, a change is needed simply because it costs too much, produces too little, and leads to too much dissatisfaction among providers and consumers alike.

 Typically in this country we are moved to do things because of the market or the government -- the entrepreneur or the Leviathan -- to use their classical designations. One approach values individual action and responsibility, and the other looks to more of a social or collective effort. Sometimes the market lets us down in frightening times and we run head long to the power of government to right things. Roosevelt’s New Deal and the actions last year by the Obama Administration to save the banking and automotive system and to stimulate the economy, are both examples. At other times we reel away from Big Brother and turn toward individual action and effort assisted by institutions that are favored in a free market because of the service and product they offer at a price we like or can afford. Unfettered shopping and exchange of ideas on the internet or the freeing of pensions for individual action are market liberating examples. Markets are supposed to be efficient ways to allocate resources, correcting themselves when they go too far astray; and they sometimes are. Governments work best when the market fails (and they do), such as when the market has an unlevel playing field and its free play is hampered by lack of information, misinformed or powerless consumers, or manipulation by those that have power and money. In case you have forgotten civics 101, this is why we have free speech, public education, and protection of the press. And in case you have been in a coma for the past nine decades, the two main political parties more or less align with these values for our political economy.

One of the main problems with health care is that it hasn’t been fish or fowl, neither market nor government driven. Instead, it grew from the early 1950s as a “professionally” led arrangement, unfettered by the chastening input from either the give and take that drives markets to be efficient or the heavy hand of sanction for the public good that government can provide. For awhile this was fine, but after everyone got in the act in the 1960s, this form of governance became something akin to having the fox guarding the hen house. The effect of this has been an unfettered access by health care to the public purse and many private payers, without any of the control we would usually impose. Imagine your local school district just passing its annual costs on to the Board of Education who then taxed the district to cover the expense, instead of fitting the budget to the needs. Or a market in which individuals could shop for anything and someone else had to pay the credit card each month. In some ways the way health care evolved, it has incorporated some unfortunate aspects of the market and coupled them to the dysfunctional dimensions of public programs.

What it missed in all of this is the genius of the American middle. Tea baggers and real socialists aside, we are not a very ideologically pure society; and for a large measure that is why we have worked for so long and so well. The middle is where the pragmatists come together to create good polices that leave enough room for individual action and responsibility. We need that kind of clear headed movement right now.

In the middle is where we recognize that Medicare is a government program and that real limitations have to be put on consumption. In the middle is where we see that individual action produces a lot of disease and disability, and that those actions should be paid for by the individuals. In the middle is where we see that there are right and wrong ways to provide health care. Any individual and their doctor can choose to engage in practices that have no proof, just don’t ask me to pay for it. In the middle is where we see the abuse of the supplier whose equipment is marketed up 400% for sales to public programs. In the middle is where we begin to see health care as a right, a responsibility, and an obligation, and where we take the time to figure our how each of these plays out in every day life.

We need to move to the pragmatic middle, recognize that all the stakeholders have a voice, but all need to give up some things for us to move forward. The good news is that while this movement could be assisted by federal legislation, it can also be advanced at the state and sub-state region. We will need a few things however: Firstly, a few leaders to frame the issues and host the beginning discussions. Next, we need participants to see that disadvantaging the other participants is not a way to change. Thirdly, we need to see the region under consideration as a whole, not an insured market, a service area, or our members. It is a population that includes everyone, has defined and knowable needs, scarce resources and distinctive cultures. Finally, we probably need a few new mechanisms for mobilizing the work and turning it into effective action. These drivers might be in the for-profit market, not-for-profit private sector or the public. In fact each of these new health commons should have a rich mix of all three.

As a people we are better than the health care system that has emerged. For evidence of this just think about the heroic actions of individuals and groups who everyday do the right thing, even though the system moves them in the wrong direction. Let’s do what we do best: Jump to the middle, forget our special interests, and solve these problems.