The above links will take you to the Center for the Health Professions site.

Centering on...A National Imperative

We quite easily divide our lives into private and public halves. Privately, we glorify individuals and their actions in the market as consumers, making rational decisions and voting with their feet. It is a world of responsiveness and efficiency, but the buyer needs to be aware because there will be winners and losers. On the public side, we advance communal or community action with its imprecise expression of values and ideals, which is nothing but messy in the pluralistic and diverse culture in which we live today. At its worst, the public side comes to be represented by unresponsive bureaucrats who are protected from the punishing withdrawal our business because they inhabit a monopoly. But at times the public side works well and we find institutions and their individual agents acting with resolve to serve the commonwealth and produce profoundly different outcomes, including some that simply are not available to us from profit-seeking institutions. Nonetheless, we divide much of our lives into public education or private schools, private houses or public housing, the police or private security, public transportation or our cars, each option having a different pay off of communal and individual reward.

The economist A. O. Hirschman points out that the emphasis we place on the public-private continuum tends to be cyclical with one age favoring the actions of the individual and others aspiring for the community. As a young man I remember a newly elected President challenging a generation to not ask what it can do for itself, but what it might do for others. Such choices are never binary, and our daily lives will always be infused with minor acts of selfless and selfish behaviors, but it is probably safe to say that, as with any vital tension, we are always moving toward one pole or the other, seeking the right balance in our lives and society.

Today health care in the US is much taken with the private side. We pay for performance, make transactions transparent to the individual, create competitive options for consumers to move toward, and seek the reorganization of systems of care to make them act more effectively for our individual interests. These days, politicians are famous for displaying horrific expressions as they accuse their opponents of wanting to have the creaking hand of government more involved with the delivery of health care services. This last specter is the most disingenuous of the lot as it is the very same politicians who ramp up the unregulated public subsidy of health care and dare not question how the public purse is spent for fear of being accused of being a "Granny Killer" by some upstart opponent in the next round of elections.

But this movement toward market mechanisms in health care is perfectly understandable. The health care system has claimed to serve a broadly public interest with private efficiency, yet for the better part of the past six decades it has built a very unresponsive private bureaucracy which serves its own interests first and those of the consumer second. It has accomplished this by insulating itself from competition using public laws and regulations which serve its interests rather than those of the public. In this process it has done many things that have accrued to the needs of the American people, but it is becoming painfully obvious that it has done many more things that now appear to threaten the wellbeing of the public. The system's bloated costs, less than stellar outcomes, and wretched level of consumer service make it seemingly easy prey for rabid discipline by the junk yard dog actions of an unleashed market.

Before we buy all of our care on our credit card at Wal-Mart, it is important to recall that health care has lost its way not because it became too responsive to the market or to the public sector, but because its mixture of public and private actions were poorly drawn and executed. Hiding behind the veneer of disinterested professional actions, the incumbents in the health care system advanced interests which seemed to reflect the public's needs, but in fact advanced the interests of their particular professions. Unregulated by market or public oversight, such isolation will soon make any individual or institution subject to the self-deception that it makes the best possible choices. There simply is no other explanation as to why the US health care system's costs are more than a third greater than any other nation's costs, yet we have no better outcomes and fail to cover everyone. The simple truth is that time was never taken to articulate the ideals that we would want to achieve for our health care system, to design the public regulatory structure to measure progress towards our ideals, or to implement mechanisms, market like in their genius, that would define the terms of competition and the common context in which organizations would compete for the favor of an individual's business for staying well, healing illness and making the important transitions of life. Or more bluntly, what makes us believe that the Big Box stores will serve the public interest anymore than do the Big Box hospitals?

What the health care system needs to go forward is a new framework that allows the virtues of the public and private worlds to come together in ways which promote efficient provision of care, but does so in a manner which recognizes that the needs of individuals vary and that health care is the most personal of all services, often provided in the most trying of circumstances. The creation of such a health commons will of necessity be somewhat local in nature. In some areas the locality may be an entire state, in others the density of population and provider resources will mean that it should operate at a much smaller geographic scale such as a county or even smaller units. These smaller scale units will allow for a process which is missing from health care today: a vision of what our system of care can and should be. To move toward such a vision, the commons will of necessity create new ways for providers to integrate prevention and treatment services, and ambulatory and in-patient care, in the interests of the publics they serve. It will also mean that consumers, both individuals and corporations, will have active roles in making decisions about their preferences, but also in meeting their responsibility to help create healthy environments. This new framework will require rich public reporting on system performance and consumer-orientated data. To improve, the US health care system needs a different framework through which valuable public, professional, and institutional resources can be fully deployed to the task of bringing the health care vision to life.

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