Health Commons: The Courage to Remake

As I write this month’s installment of “As Health Care Turns,” I count six states’ Attorney Generals who are threatening or preparing to sue the federal government on behalf of their citizens over the Health Security Act. This strikes me as more partisan politics than good policy, not because these acts conflict with my political views, they do, but because Ronald Reagan’s Solicitor General, the imminent Harvard Law School faculty member Charles Fried, has called such attempts “frivolous.” This is not to say the law is perfect; it isn’t. But it is a beginning and a framework for us to engage in the serious work of remaking health care in America. If we don’t take this opportunity seriously and roll up our collective sleeves, our children will pay for our shortsightedness throughout their lives.

Rather than create a political brouhaha in the form of silly law suits, the leadership in states could take the opportunity to bring the best health care minds together to consider how to use the polices and regulations in the new law to remake health care in a way that truly benefits everyone in the state. How often do we get a “do over”? We should not miss the chance to reframe questions, reexamine priorities and explore new ways of thinking about health, health care and the role that every citizen plays in producing the well-being of the state. The instinct of health plans, hospitals, professional groups, public agencies, and all of us involved in health care will be to try to master the new legislation so that we secure our position and can be held harmless in the transition. But there is a better way. This legislation offers the states a chance to reconsider what they do, how they do it, who benefits, and who pays. It is a political opportunity of the first order and it should not be squandered.

For fifty years we have lived in a land of health care silos that protected the self interests of the system incumbents and benefited the public only as an afterthought or in ways defined by the residents of the silos. That is precisely why we have such a distinctive approach to health care, one that costs a third more than any other country in the world, and at best matches their performance. Instead of just adjusting the status quo, how about we muscle up the leadership and find the courage to remake things? Here is my idea:

Instead of filing lawsuits, states should convene conversations about how to create Health Commons within their boundaries. Now that everyone will be required to have health insurance, it is in everyone’s interest to have an efficient system for delivery of health services, otherwise we will pay as individuals through premiums or taxes. And if all the tax revenue goes to health care, what will we use to build the schools and pay the teachers?

If we are all paying, it also makes sense for all of us to be concerned about the quality of our air and water, because the costs for treating preventable diseases and accidents will be coming right out of our pockets, every pocket. Obese children, not my concern. Well, it might not have been, but it will be now that everyone has a financial stake in the well-being of the state. Individual behavior that creates a risk burden for everyone – drunk driving, hand gun violence, head injury resulting from not wearing a helmet – becomes less a matter of individual freedom and more a selfish act that costs me money. And I will want some public action to change or at least fix the perpetrator with the the responsibility of these costs. Better we stop fighting each other to protect our individual rights -- and start working together to ensure them. The Commons are an old idea -- public and private action adjusted through policy and private behavior to the benefit of the most people. Think about sheep grazing on an English Green. Too many of our health policies, public and private, have failed to protect individuals (even those who have played by the rules), ultimately socializing costs as the state became the payer-of-last-resort and privatizing the gains of the system for a great host of health care actors. The Commons approach is often dismissed because of the perception of the tragedy that results when a public good is consumed by individual actors. But this past year Elinor Ostrom at Indiana University won the Nobel Prize in economics for her work explaining how collective decision making and action can produce an outcome that materially benefits large numbers of individuals and protects the public resources from being overused. Most of her work is about fisheries and power, but there are some lessons. Here is what we need to create effective Health Commons in every state in the union:

Vision – The first lesson in leadership is that you better know where you want to go or you will never get there. Or as the late Eric Hoffer once put it: “When one does not know what one wants or needs, one can never have enough.” States need to create a vision of what health care in Colorado or California or Oklahoma or Alabama would look like. This will of course take work and the first visions will be abominations, but we have to work at it and the best way to do that is to get started. Some states like California may be too large and we will need visions for the Bay Area, or the Valley or the LA basin. There are a number of public and private venues for this work to begin.

Conversation – Visions are not technical, they are aspirational. To get a vision that works across our varied economic, political and social landscapes, we will need leaders who are courageous enough to engender a wide and deep consideration about what health and heath care means in every state. The closest any state has come to this was Oregon under Governor John Kitzhaber’s leadership more than twenty years ago. The discussion Kitzhaber lead not only shaped policy it also educated individuals about what could be afforded, what choices needed to be made and how personal responsibility was an essential part of the solution. Nothing gets done without this conversation becoming part of every state’s culture.

Concession – We don’t move forward without a willingness to give up some of the perceived gains of the status quo. Every one of us in health care benefits from keeping things as they have been. Even the reformers -- if things change tomorrow, we’re out of a job. Here is the hat trick of the next decade: change the system without too dramatically changing the well-being of the incumbents. This probably means not creating resources that we don’t need – machines, professionals, beds, buildings – and thinking creatively how we can deliver better outcomes with the resources that we have. Of course this will be done far more easily if we have a greater good to work toward. Something like Health Commons.

Translational Efficiency – This is a fancy economist’s principle for how fast we take a good idea and drift it down into the economy. Think about the twenty-year downward drift of personal computers. For translational efficiency, we need four things. Firstly, we need the good ideas about how to change the practice models we use to prevent, diagnosis, treat, and manage disease, disability, and health. The good news here is that we have lots of very good evidence-based research which points to better ways of providing all that we do in health care. Secondly, we need the payment to health services to be better aligned with the outcomes we desire. This will gore some oxen, but it is essential to move forward. Thirdly, we need the skills to make the transition. This is America; we won’t dictate what everyone needs to do to remake the practice models. In fact, what we really need here is to unleash our native entrepreneurship and inventiveness. Finally, we need courageous and insightful leadership. So much better to try leading needed change than to file those pointless law suits.

We need something new to really change American health care. We don’t need anything from England or France or Cuba. What we need is a recovery of those things about our past that both sides of the political aisle value: cooperation, community, inventiveness, accountability, striving, excellence, responsibility and charity.