This article is by Donald M. Berwick, MD, published in JAMA (November 2014).
In this issue of JAMA, 3 Viewpoint s, by Powers et al, Fuchs, and Fisher and Corrigan, address problems, possibilities, and mechanisms for reshaping the US health care enterprise to better meet community needs at an affordable cost.
In their Viewpoint , Powers et al grapple with a question as old as democracy: How can productive collective action, which is required for a state to succeed, emerge from the factional divisions for which protection is required for democratic principles to succeed?
The founding fathers of the United States debated this vigorously. In the most famous Federalist Paper, Madison favored a large republic in the hands of a meritocracy to counterbalance the passions of a majority “faction” that might overwhelm legitimate minority interests. Others wanted to protect states’ powers, arguing that smaller political units could be more responsive to local groups.
Madison defined a faction as “a number of citizens, whether amounting to a minority or majority of the whole, who are united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community.”
Health care is ground zero for this problem, and the stakes are immense. Health care is a behemoth “faction” that controls one-sixth of the US economy and distorts the nation’s economic and political future. I recently ran as a candidate for governor of Massachusetts, and, in the course of an 18-month campaign, I saw vividly the effect of this dominating industry on the opportunities for the total well-being of a population of nearly 7 million people.
The Massachusetts state budget offers one example of the window on this problem. Between 2001 and 2014, government support for almost every category in that budget declined substantially in real terms. Public higher education: down 26%. Early childhood education and care: down 28%. Local aid: down 44%. Parks and recreation: down 43%. Meanwhile, state health care expenditures increased 63%. The patterns are similar on the private side. For businesses, the state’s medical costs, which are the highest in the nation, are one of the most substantial barriers to growth; and laborers’ take-home pay has at best stayed level, whereas their out-of-pocket medical costs and payroll deductions for health insurance have soared.
This amounts to nothing less than confiscation by health care of opportunities for growth and success in other sectors. The only plausible defense is that health is crucial and this level of funding is needed to ensure it. However, as Fuchs illustrates in his Viewpoint in this issue of JAMA, the evidence just is not there. No relationship exists between health care expenditures and health outcomes, either internationally among developed nations or nationally among the states with higher income levels. Health care in the United States is just taking the money, not because it needs it to advance the nation’s interests, but simply because it can take the money. It would be difficult to find a better modern example of a Madisonian faction.
Powers et al warn that distress over health care’s hegemony leads to simplistic “stories” to explain why it costs too much and delivers too little. Critics pick their favorite potential culprit and create, repeat, and believe their own claim that “if only…” insurers would behave, or patients would take more responsibility, or hospitals would be more communitarian, etc, all would be well. Those simplistic, unitary arguments, Powers et al claim, do damage to achieving deeper understanding and more productive action on health care as a complex system. The authors urge open, multistakeholder discussions that avoid reliance on simplistic causal stories and that aim for productive compromise.
Fisher and Corrigan agree, and in their Viewpoint they propose two supports for such compromise: a local or regional governance structure (a multistakeholder backbone organization to coordinate action) and a reliable funding stream for such coordinated action. They cite the Nobel prize–winning work of Ostrom, who studied how some local communities manage to avoid the “tragedy of the commons” with respect to stewardship of some limited, common-pool resource (like a fishery or forest).
As far as they go, these authors are correct. Simplistic stories do indeed dominate health care debates. However, many of the stories are true, as review of the first half of the View point by Powers et al makes clear. The problem is not that the stories are wrong; it is that each, taken separately, is severely incomplete. Yet tolerance is low in the sound-byte era for explorations of the complex causal interactions among finance, training, habits, physical structures, cultural norms, regulation, and organizational history and design. Moreover, the opacity of health care—the persistent lack of good information about cost, quality, and outcomes—continues to confound conversation. It would be such a relief, but quite wrong, to blame and try to defeat one single, key culprit.
As Fisher and Corrigan emphasize, it is difficult to imagine systemic remedies without a platform for systemic leadership and coordination, which would, of course, require resources. Pure market advocates would likely prefer to set the invisible hand to work, but markets are no more likely on their own to sort out the health care mess than they are to clean the air or produce a literate citizenry. Some combination of public and private action is required.
As sound as they are diagnostically, the Viewpoints by Powers et al and by Fisher and Corrigan go nowhere near far enough as frameworks for real solution. Both strongly encourage cooperation, but, to paraphrase Frost, “something there is” in the US health care world that does not embrace cooperation. Time and again, the nation has witnessed not the growth of cooperative solutions to health, but their stalling and, too often, their demise. Promising collaborative projects have come and gone, but none has produced yet the durable, extensive improvements in cost and health that the United States needs. Current examples offer continuing hope, such as the Washington Health Alliance, the Common Table Health Alliance in Greater Memphis, Tennessee, and 14 other communities also engaged in the Aligning Forces for Quality program of the Robert Wood Johnson Foundation. However, to be frank, and keeping in mind the enormous gaps in performance that Fuchs reiterates, not a single community in the nation has yet come close to the scale of improvement in health, health care, and per-capita cost that ought, in theory, to be achievable.
So, what to do next? Probably, as the Viewpoints by Powers et al and by Fisher and Corrigan imply, this is a time for local and regional action, rather than national. The political atmosphere in Washington, DC, is too unfavorable for the needed bold goals, systemic dialogue, and cooperative problem solving. Recently, Martin et al have tried to make a case for health care leaders’ moving consciously from strategies of leverage (maximizing influence) to strategies of cooperation. That requires establishing shared goals for the system as a whole, building trust among stakeholders, developing new business models, and combining competition and cooperation, rather than relying on one or the other, solely.
But even that is not enough. The conditions for success fully managing the commons that Ostrom discovered are very difficult to achieve among health care leaders with decades of investment in preserving institutional self-interest. The sheer scale of the health care enterprise, even at the level of a single region or city, makes the barriers high.
The antidotes to health care’s confiscation must include something bigger, more forceful. This is the time for mobilization—not just the intellectual mobilization of clever community projects but also the political mobilization that ended the Vietnam war, began to deliver on civil rights, birthed modern feminism, and started down the long road toward equal rights for the LGBT community.
Who can mobilize? It will not be the health care behemoth; it is not evil, but it is too big to change itself. Instead, change will require the collective political will of those who are losing ground every day to health care’s unbridled confiscation of the future: laborers who want to protect their families, business leaders who want to survive in a competitive economy, a better-informed citizenry who want health, not procedures, and health care professionals who want not the hassles of complexity but work that adds meaning to their lives. Quite frankly, it will require leaders with the courage to take on the factional control that Madison rightly feared.