Improving Health Care – A Better Way

The author looks at the recent health care debate and offers some ideas on how to better approach the situation.

Among the greatest threats to personal and financial security is the quality and cost of affordable health care. A catastrophic health condition would likely bankrupt many Americans.    

The Affordable Care Act (ACA) passed by Congress along partisan lines provides an excellent example on the application of traditional problem-solving methods that result in outcomes where “winners celebrate and losers mobilize.”

If the “losers” (those who voted against the ACA) successfully mobilize and become the new majority after the presidential and congressional elections in November 2012, the opportunity will exist to repeal or change the ACA following the same problem-solving process. If the repeal or change is successful, the new winners will celebrate and the new losers will mobilize. Future compromises may minimize the pain among the “losers” and result in equilibrium where people become habituated to the new status quo.

The costs associated with the traditional strategies—e.g., “I’m right and you’re wrong” and “I’m going to get my own way because I have more votes or power than you”—are significant. There are the more tangible costs such as the time, money and other resources used in discussing, passing, defending, changing and/or repealing such legislation. In addition, there’s the opportunity cost of delaying the availability and benefits from new and/or improved policies.

A Better Way

Albert Einstein remarked that “Problems cannot be solved by the same level of thinking that created them.” To reframe this statement a little differently: 

  • “Problems cannot be solved” because variation can never be eliminated. Variation either gets better or it gets worse and can always be reduced.
  • A new “level of thinking” requires a basic knowledge of variation that provides a standard for determining if change results in improvement in the near, mid and long term. 

As I’ve reinforced in previous articles, reducing variation is the “What’s new?” in applying new approaches for resolving problems. 

Variation is a law of nature that states that no two people or things will ever be exactly alike; everything varies. Variation represents the difference between an ideal and actual situation. An ideal is a standard of perfection uniquely defined by the stakeholder(s).

People can agree on the ideal end state as well as on the facts that describe the current situation. People can also agree on one or more causes of the problem and can agree on implementing one or more solutions for reducing variation. In addition, they can agree on the feedback that can be used to determine if the situation got better or worse. But people will always have diverse opinions regarding all the causes and all the possible solutions.

The number of causes and solutions for resolving issues can be numerous because of the natural polarity or variability on any issue. For example, on just about any issue, a few people will be adamantly for or against it and everyone else somewhere in between. However, causes and solutions do tend to fall under the 80/20 rule, where 20% of the best solutions presented will resolve 80% of the problems and/or 80% of the problems can be due to 20% of the causes.

Solutions and approaches that deliberately result in creating opposition where stakeholders perceive a win/lose situation—e.g., “I lose if you win” or “I’m right and you’re wrong”—typically have the least likelihood of long-term success. But like the ACA illustrates, this is the most common approach taken and the most expensive in terms of costs. It can also result in the opposite of what is intended—higher costs and lower quality.

Robert Greenleaf, author of The Servant as Leader, identified questions for leaders to consider when making changes that affect the lives of others:

“Do those being served grow as persons; do they become healthier, wiser, freer, and more autonomous while being served? And, what is the effect on the least privileged in society; will he benefit, or, at least, not be further deprived?”

Building on Past Successes

The U.S. political system was designed with an innate understanding of variability. Our founding fathers accepted the fact that English rule was unacceptable, disagreed on many issues (with slavery being one), and agreed on the ideals expressed in the Declaration of Independence:

“… that all men are created equal, that they are endowed by their Creator with certain inalienable rights, that among these are life, liberty and the pursuit of happiness.” 

Their common cause was to design a system of government—a republic that could be continually improved through new laws and amendments if citizens demanded accountability from their elected representatives.

The American justice system provides another example of the application of the principles of variation. The ideal is justice. Facts are represented by evidence that is allowed to be presented in court. Desired solutions range from innocence, which is a position represented by the defense, to guilt, which is a position represented by the prosecution. The judge ensures compliance to the rules of law, and the jury makes a decision as to guilt or innocence. Appellate courts and ultimately the Supreme Court provide additional safeguards that the system produced a judgment that was fair and impartial. Establishing the standard of determining guilt “beyond a reasonable doubt” is a design attribute that acknowledges imperfection where it is better for the guilty to go free than the innocent to be convicted. 

Regarding health care, the ideal would be adequate and affordable health care for all citizens. The facts in 2010 included the following: 

  • Health care costs (Medicare/Medicaid being the largest budget item) as a percent of the national budget have been increasing, with the assumption being that the increasing costs are unsustainable in the long term. 
  • The majority of Americans are insured by private health insurance.
  • Many Americans aren’t insured by private insurance companies due to the high cost or due to preexisting medical conditions. Those without private insurance have to rely on emergency room care, which is among the most expensive options.  

Rather than rely on traditional “win/lose” strategies, a better way is through competition, with a focus on better quality at less cost. With this desired solution, there needs to be an effective balance between stakeholders, which include consumers, insurance companies, federal and state governments, employers and the health care industry. The stakeholders would need to agree on the evidence to be used to determine whether the changes resulted in improvement. The article “Halftime in America, Part 3” introduces a framework that stakeholders can apply in improving the health care system and/or assessing the results of the changes.

Barriers to Change

Excellent quality is defined as the result of doing the moral or right things. Jonathan Haidt, a moral philosopher and author of the book The Righteous Mind: Why Good People Are Divided by Politics and Religion, posits a theory that may help explain why people and groups choose to purse “win/lose” strategies that achieve less than stellar results as opposed to more effective methods where we all win.

Haidt’s research indicates that moral responses are instinctual—human beings are born preloaded with basic moral values. He believes that political attitudes are an extension of our moral reasoning, which accounts for much of the vitriol that surrounds liberal and conservative ideology.

According to Haidt, an individual’s beliefs and actions are influenced through a filter of values that include caring, fairness, loyalty, authority, sanctity and liberty. These values provide a foundation that is needed for a society to function. He believes that liberals focus more on caring and fairness and undervalue the importance of loyalty, authority, sanctity and liberty. Conservatives also value caring and fairness, but not at the exclusion of loyalty, authority, sanctity and liberty.  

All six values are needed to ensure that balanced social systems are in place to sustain environments that result in caring and fair outcomes. Haidt advocates for a new moral vision borrowed from the Andrew Jackson campaign of 1828: “Equal opportunity for all, special privileges for none.”

Way Ahead

As individuals and citizens, we can demand that elected representatives apply the better approach for managing variability. One way of assessing changes in the health care system is to assess the impact that changes have/will have on your health insurance premiums and the quality of care you are provided through your coverage. 

The costs include not only premiums but also increases in other taxes that may be needed to cover the other aspects of the changes in national health care system. In his article “What Impact Will the Health Care Ruling Have on Federal Employees?” FedSmith columnist Ralph Smith considered the second- and third-order effects that include the impact on the quality of services that are to be provided by Office of Personnel Management (OPM). Under the ACA, OPM is required to set up multi-state plans on “affordable insurance exchanges.”

Without the knowledge needed to manage variation and an awareness of the values that may be influencing decision-making, the debate on changes to health care legislation will continue to be rancorous. There will be no national agreement on the evidence that will be used to determine if the quality and cost of care is getting better or worse. To avoid this situation, we need to demand the application of the better way because, in the words of W. Edwards Deming, “… it all has to do with reducing variation.”

About the Author

Timothy J. Clark retired from the federal government with 35 years of service. He is a former enlisted soldier in the U.S. Army. He retired at the rank of Colonel, with over 30 years of combined service in the U.S. Army, National Guard and Army Reserve. He is a strategic analyst with the American Center for Quality Leadership and is active in economic and community development in a small rural county in Indiana.