Monday, March 22, 2010

Thoughts on healthcare reform, systems and transformation

Last night, the U.S. House of Representatives passed the Senate version of a healthcare reform bill and a set of “fixes” that will go back to Senate for approval.

Here are two questions that this long national exercise raises for me:
1.  In what ways is healthcare in the United States a system?
2.  What kind of change are we getting? Is it transformation?

U.S. healthcare as a system?
Healthcare in the U.S. is and is not a system. (Duality, paradox, ambiguity--you can’t avoid it.) The way healthcare is delivered in this country is so fragmented that virtually no one would call it a coherent or sustainable system. Yet everything is connected to everything else, so in that sense it is a system.

All of the fragments work to optimize conditions, outcomes and benefits for themselves. Sometimes this is in competition with other fragments, often it is in isolation from other fragments, only rarely in cooperation or collaboration.

So what we have is a many-headed monster that we have had difficulty even perceiving, let alone taming.

If you accept the axiom that all systems are perfectly designed to achieve the results they get, then the facts that we pay far more for healthcare in this country and get less than best in the world results should come as no surprise.

What kind of change are we getting?
There was a lot of rhetoric last night about this. The voices against the plan that passed said this change is too much, too fast. I ask is it big enough and fast enough?

Changes can be viewed as incremental, transitional, or transformational.

Those who were against the plan that passed said they favored an incremental approach: fix a few of the fragments, slowly over time. Although this approach may be problematic for a number of reasons, let’s look at the systems ramifications.

The best way to get unintended consequences is in trying to address in isolation small fragments of a complex systems. Since everything is so interconnected and incoherent, it is almost impossible to see how actions in one part will eventually have consequences later. In fact, many current problems are the unintended and unanticipated effects of the last fragmented fix.

A really transformational approach that would completely change the system, viewing it as an interconnected whole, making it coherent was not on the table. One  transformational approach to healthcare is the single payer approach called Medicare for All in H. R. 676.

This plan, in bill form, is under 30 pages long. It completely transforms the whole healthcare system. And because it is addressing the whole system, it gets to the simplicity and elegance that lies beyond the complications trying to bring coherence to a collection of disjointed fragments. It is really worth reading if you are interested in a transformational, systems approach to a wicked social problem.

Find H.R. 676 at

What we are getting in the healthcare legislation that is now moving through Congress is a transitional change. It tries to bring the fragments into a more coherent alignment without really transforming the system. It seems to be based on a sincere effort to comprehend the whole system, rather than look at fragments in isolation, but it does not rise above the complications of maintaining a system that is inherently fragmented.

A commentator on the BBC last night characterized the healthcare bill as just a piece of consumer legislation.

Let’s hope it is at least that.

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