Thursday, July 24, 2008

Deliberating about Hard Choices in Massachusetts

All societies must set limits on health care. But how can they do it in a clinically informed, ethically justifiable, and politically acceptable manner?

In “Setting Limits Fairly,” Norman Daniels and I argued that pluralistic societies lack shared principles by which resource allocation and limit setting decisions could be made. We concluded that a fair process is required. Deliberation that considers individual needs, population needs, and medical facts is at the heart of that process.

A deliberative process that considers the relevant reasons for and against policies will not yield answers that everyone likes. But if we know that our positions have been listened to, we are likelier to find decisions acceptable, even if disappointing.

In societies with universal coverage and national or regional budgets (essentially all developed countries except for the U.S.) deliberation typically takes place in government bodies and public commissions. Often the national parliament oversees and signs off on the process.

But how on earth could “deliberation” take place in the fragmented U.S. public/private health system? The Massachusetts health care reform process is struggling with that question right now.

The Massachusetts program is based on a concept of shared responsibility. Individuals who are deemed capable of affording insurance are required to purchase it or pay a penalty on their state taxes. Health plans are asked to offer less costly programs. Employers with 11 or more employees who do not offer insurance pay a penalty into the insurance fund. Government contributes substantially. (Providers, uniquely, have no explicit expectations placed on them.)

Massachusetts is making excellent progress in reducing its uninsured population. But the program is costing more than predicted. That’s where the rubber meets the road in terms of shared responsibility. Who decides how to handle the cost problem? How does it get decided?

Legislatures are imperfect structures, but debating, deliberating, and deciding are their basic function. In Massachusetts, the Connector Board, which I will write more about in the future, is the entity that oversees the reform process. Minutes and the materials for its monthly meetings are posted on its website.

What currently stands out for me in Massachusetts is the way print media and the blogosphere are providing a public space for deliberation. The central meeting ground is the Commonhealth blog, hosted by WBUR, a public radio station. I don’t know how many hits it gets, but the blog is read widely by a broad swath of politically concerned citizens – not just policy wonks.

The Commonhealth blog is a virtual form of the Athenian agora. A wide range of civic, political, industry and policy leaders speak their mind, at enough length to get beyond slogans and sound bites. In recent weeks Reverend Hurmon Hamilton, President, Greater Boston Interfaith Organization, made a powerful moral appeal for shared responsibility, Nancy Turnbull, a former insurance regulator and now a dean at the Harvard School of Public Health, presented a well documented argument that health plans could be doing more, and Richard Lord, CEO of the Associated Industries of Massachusetts, argued in detail that the impact of new funding proposals on employers is unfair.

The Boston Globe has had a comparable range of articles, editorials, and op-ed pieces.

The civility and reflectiveness of the public blog and print dialogue are impressive, and important to understand. There isn’t a referee enforcing constructive debate or a charismatic leader for the process like John Kitzhaber for the formation of the Oregon Health Plan.

My take is that we are seeing disseminated leadership at work. A critical mass of leaders is playing by the rules of constructive political collaboration. This supports the work of the Connector Board, which steers health care reform, conducts its own monthly public discussions, and sets an example for productive public debate.

Massachusetts health care reform is two years old. The honeymoon period is over. The next year, in which the state has to get a grip on the cost of the program, will test the durability and effectiveness of the disseminated leadership and public deliberation that have functioned well in years one and two.


softwareNerd said...

"All societies must set limits on health care..."

I realize that his opening sentence is not the focus of your post, and you probably thinks it is uncontroversial. Laissez-faire is often seen as just another way in which a society sets limits on health care: i.e. by letting individuals decide. The formulation is thus seen as neutral: encompassing all types of systems, from Communism to Capitalism.

However, the formulation reflects a very specific way of looking at political systems.

As illustration, compare the French and American revolutions. Both desired new political systems, based on rights, but they had different perspectives.

The Americans saw rights in the design of man's nature. The key question they asked was: what rights does a man need as protection against tyrants democratic society at large, to make it worth his while to engage in society while pursuing his happiness? Meanwhile, across the pond, the French revolution was conceptualized more as a class-struggle. Perhaps this is understandable, given the historical setting. Their concept of rights came much more from a notion of egalitarianism. The key question here was: how do we design a more egalitarian society?

The French-inspired view is now so prevalent that people (like the professor quoted above) consider it as uncontroversial. They take a system-design perspective, rather than the perspective of what is morally due to an individual person. Finally, this view leads to the type of democracy that the American founders feared.

Jim Sabin said...

Hi Software nerd -

You're right. I do see the comment about limits as uncontroversial, since health care, left to its own, will continue to consume progressively more of a nation's wealth.

You're also right that in principle the sector could be left to individual choice. That's what we do for consumer goods, housing, and more. But I see health care as a societal responsibility. Insofar as we are committed to equality of opportunity, we owe our citizenry an adequate level of health care to address the impediments to equal opportunity created by ill health. For that reason, I don't see the sector as one that can be left to individuals to purchase if they can afford it but to forgo needed care if their wealth is inadequate.

That said, I think there are ways of governing the sector that would not warrant being seen as tyranny.

Thanks for your thoughtful comments!



softwareNerd said...

" care, left to its own, will continue to consume progressively more of a nation's wealth"

If left to individual choice, it would consume more or less of the individual's wealth, rather than more or less of "the nation's" wealth. Some individuals may want to consume more, and other's less.

If an individual is making a decision, I do not see much possibility he will keep spending more on healthcare. And, if he does, and can afford it, the better for him.

I know that the basic difference in my view and yours is that you think people have a right to being made equal to others, while I think equality is merely equality before the law.

However, even from a centrist-socialist viewpoint, I fail to see why healthcare is given so much more importance than housing or food etc. Even from a centrist-socialist viewpoint, wouldn't one be advocating something like a basic "health-stamps" program, rather than equality of health-care.

To get everyone in the U.S. on a level of health care that fairly middle-class people enjoy in (say) India, is easy. While I disagree that the rich should be taxed to provide this, I don't see the centrist-socialists advocating this middle-of-road solution. Instead, of giving everyone an old Ford Fiesta, they want Camrys for all, and the few super-rich can have their Rolls-Royces.

Jim Sabin said...

Hi software nerd -

Thanks for the further reflections!

I agree with you that health care is (a) important but (b) not a supreme good that trumps all others. That's why the rising proportion of GDP that goes to health care is a problem. We could modulate that growth by making individuals financially responsible for all of their health care purchases. If health care were simply another consumer good that would be fine.

But I see it as analogous to equality before the law. Many (but not all) aspects of health care support equal opportunity to pursue our interests. If I have a stroke, without rehabilitation I am disadvantaged just as I would be if the law discriminated against me. I think a good case can be made that societies with the kind of wealth the U.S. has owe their citizens health care that supports equal opportunity in that way.

Because I see health care as supporting the fundamental right of equal opportunity, leaving it to individuals to purchase it if they can and to forgo it if they are too poor is not an acceptable approach. That view, however, isn't a limitless ticket. Just as with other societal obligations, it should be managed, and focused on what is "necessary." Beyond that, some individuals will choose to spend more, and that's fine.