What factors make health care socially, dynamically and generatively complex?

When we talk about it, we point to the fact that right now a huge number of Americans are uninsured – which in our system equates to lack of access to health care.  But we fail to define if that is the problem itself or if that is a symptom of a deeper problem.  At first, it seems like a simple problem but there is little agreement about it; for instance some conservatives have asserted that people without health insurance have chosen to go without insurance – they have access but don’t opt to purchase health insurance because they don’t believe they will need it; the contrasting argument holds that a great many workers would opt for health insurance but cannot afford it or don’t have the opportunity.  Equally, a great many employers – especially small employers who are responsible for most job creation – cannot afford to offer health insurance to their employees.  Certainly, a person could go to an insurance company and buy an individual policy (my sister did that at one point); such policies are often cost prohibitive (not just the actual policy but also the deductibles) and offer minimal coverage of treatment and hospitalization.

By connecting health insurance with employment, our system has created a fractured, chaotic landscape in which health care is rationed without any plan or design.  To put it terms that sound like a pun, our system rations health care irrationally.   The fear of rationing health care – something we’ve heard discussed this year – is really about the fear that rationing will work against you – you will denied care you need (which behind the horror stories about Canadians desperately needing some sort of care and having to wait months and months for it).  Our system currently rations care, but does so in a way that is decentralized and disconnected from actual medical need.  By keeping the rationing of health care “hidden” – essentially health care rationing in the US is covert – it prevents us from having a coherent discussion about rationing of health care and prevents us from assessing the effects of that rationing.

The rationing happens in a variety of ways.  People who have health insurance get treatment, but every plan has its own wrinkles – people make treatment decisions based not on actual medical needs but what and how the insurance will pay.  In some plans, even if your doctor says you must have surgery, the plan doesn’t pay if it is not pre-authorized by the insurance company so the patient delays treatment for days or weeks until it is pre-authorized.  With health insurance and employment connected, people make job change decisions based on whether they will have insurance or not.  Or they have to decide if they will take a very high risk gamble; gaps in insurance coverage can also make insurance more difficult to purchase in the future.

Health care costs have increased significantly – faster than inflation and wages and almost every other cost in the economy.  These costs are intimately connected to the other problems but cost increases have multiple causes.  It’s popular to claim that malpractice insurance is a primary cause of increasing costs but experts in the industry don’t generally concur; I’ve read that malpractice insurance accounts for something like 1% of the actual cost of health care. An equally popular claim is that Americans demand “gold-plaited” insurance plans or insist on the most expensive treatments available.  The “story” behind such claims is simple – that when we see our doctors, Americans insist on having every imaginable test because our insurance plans pay for them and we don’t understand the costs and don’t care and we’re technology addicts; or that doctors order lots of extra tests to avoid malpractice suits.  I don’t believe that argument is accurate.  I tend to believe instead that health care costs are driven by a wide array of forces, including the fact that some patients are simply very expensive and the system has to find a way to pay for them as well as patients who are less expensive.  In addition, health care costs are driven by the reality that people without health insurance tend to opt for the most expensive form of care – namely emergency rooms and such.  By setting up a large portion of population to seek such care – rather than the far cheaper preventive care – our system conspires to drive up costs.  Costs are a complex problem – one in which the causes are distant from the effects.

Health care is socially complex – there is no shared perspective, rationale or so on concerning health care.  Disagreements about market solutions versus government based solutions, disagreements about who should have access and who should not, about things as diverse as whether or not abortion should be covered by health insurance plans and whether or not immigrants should be covered.  These are problems whose solutions are not readily agreed upon.  The social complexity around health care isn’t just about specific treatments but also about the appropriate ways to pay for health care, whether government itself can play a role or not.  A favorite conceit of free marketeers is the claim that an unfettered free market will produce the best solution and the ideal response is to remove government regulation and expect consumers to make their own choices.  The contrary view – the liberal model of effective freedom – suggests that through appropriate government action we can guarantee access to health care and thus provide a social safety net that expand people’s ability to achieve their ends.  

An equally challenging aspect of health care is, simply, its generative complexity.  Over the years, the US has attempted various solutions which have results in unfamiliar and unpredictable outcomes.  For instance, HMOs were an attempt to manage costs; the idea was that HMOs would make preventive care more easily accessible and affordable and would reinforce “healthy choices” through a variety of means.  HMOs didn’t work as planned, costs continued to go up.  By its very nature, health care produced unpredictable outcomes.  Problems such as health care present situations in which the past provides a poor predictor for the future.  In recent years, there has been significant debate about the causes of autism; some parents have come to believe that certain vaccines cause autism and so have refused those vaccines; the result has been a rise in previously extremely rare childhood diseases, but not just among the children whose parents refused the vaccines but among other children as well.

Kahane relates his experiences in guiding a variety of groups through tackling highly complex problems.  The solutions for these problems emerge through processes that harness the insights, experiences, hopes, wisdom and skills of a wide variety of people.  One of his central insights into problem solving teaches us that problems requires us to step beyond our individual concerns and perspectives, to put aside our ideological commitments in favor of creating positive social change.

In part three I’ll take a look at a process by which we could have approached health care reform that might have changed the nature of the debate.