Reform

There is a lot of energy around health care and immigration reform these days. At the rate of health care cost escalation, it is reported that the average family will pay about $38,000 a year for insurance just nine years from today. Although our health care system is very complex and involves many organizations at numerous levels, there is very clear evidence that certain players are making choices that contribute to this problem. We have had this information in health care for nearly 20 years since Dr. Jack Wennberg found that the high hysterectomy rate in Lewiston, Maine was the result of the doctors' choices rather than true indications of need.

The usual cast of characters performs here: doctors out to make money by providing care and performing surgeries, HMOs out to make money by reducing the amount of service and surgeries in order to retain capital, prescription companies advertising directly to patients in order to make money, patients out to get what they want (not always what they need), malpractice attorneys out to make money on patient dissatisfaction (not always malpractice), hospitals that offer state-of-the-art facilities at astronomical rates that can drain nearly any person's personal wealth in the last few days of life when other far less costly alternatives exist, etc. The list goes on and on. Each player has some rationale for how and why it plays the game. For some, it seems apparent that they are just trying to make it through life playing by the rules and hoping for the best. But there are clearly those who are exploiting the system and reaping billions in the process.

Getting angry about the situation doesn't seem to make much difference. We drifted into this position over time; and with the help of everyone - the good and the bad. A country doesn't end up #1 in high tech facilities and #49 in infant mortality without some real effort. Cuba has a lower infant mortality rate than the U.S.  These statistics are all over the place and we hear about them on a regular basis, but not much changes as a result.

We can see much the same story unfold around the issue of immigration although some of the players are different. The way the story is generally told, "the villains are poor people who sneak across the border to steal American jobs; there are farmers and growers willing to hire them under the table; there are politicians who are not willing to hold a hard line because they want to get re-elected; and there are people like us who buy the fresh fruits and vegetables at very reasonable prices."

So, the story goes on, "...that even if the migrants are not here to steal jobs (since most Americans would not do that work for such low wages) they are still unfairly burdening our health care system and our schools. The fact that they must bring their children and that they are hundreds of miles, if not thousands, from their communities and possible healthcare is of no concern to us. That is their problem."

Just last evening I was talking with a friend from the San Diego, California area. This is a very good and caring person, and I have no doubt that her intentions were good. Her position was that migrants should come over legally and take their money back to Mexico at the end of the day or week or whatever. She said that she pays migrants to do work for her. She doesn't take out taxes or anything, which she believes is okay since she doesn't expect them to get anything else from the U.S. system (Although that is not legal and is not her choice to make.) She said that the money they make here will allow them to live at a much higher standard in their home country. And, with that, she feels that she is neither participating in the exploitation of migrant workers nor undermining the U.S. system of tax laws. Her argument and behavior are not really irrational, but it is narrow in its focus and illegal in its application. What about those who must travel so far that they cannot return home at the end of the day?

It is not my intention to delve deeply into health care or immigration/migration. Each is far too complex for this blog. I am, however, suggesting that we look in other places for the solutions. Regardless of the final form of the current governmental health care reform efforts, it is doubtful that the pharmaceutical corporations, hospital groups, American Medical Association, American Chiropractic Association, American Osteopathic Organization, individual doctors, and patients will change in a substantive way. They will probably all feel the consequences of the bill and complain about how it affects them negatively. Certain surface features of our health care system might get moved around, but the deep issues will remain. They will remain because they will not be considered. They will remain for the same reasons that we are obese, that we smoke and drink too much alcohol, that we don't exercise enough etc. - because it is too damn hard. For some it will be financially and politically risky as well.

It's not too hard because we can't stop overeating or smoking or drinking. It's not that we can't find time for exercise on an individual basis here and there. There are certainly personal challenges that pose difficulties for us, but another major issue is that we don't know how to make it work as a system. We have become increasingly isolated from a sense of community and, therefore, lose the power and support that used to come from it. Such support is called social capital. Robert Putnam's best-selling book, Bowling Alone, provides a deep exploration of that concept and how we have changed as a nation over the past decades. The Nature of Health by Michael Fine and James Peters, discusses how we might manage and enhance our community health by doing things differently.

In Dirty Rotten Strategies, Mitroff and Silvers discuss how we often fail to identify the real problem, either through ignorance (a Type three error) or intentional misdirection for a narrow, self-interested gain (a Type four error). This failure often comes from not including enough perspectives from various members and groups within the system. Mitroff and Silvers argue that problems only exist within systems. For example, the fact that you have no money is not a problem unless you are part of a social system where money has value, and you need it in order to keep a roof over your head. If you lived alone in the wilderness, having no money would not be a problem - keeping a roof over your head, however, would still be a need. Identifying the real problem is critical. Recognizing that its solution lies within the system is also critical to the long-term solution.

Technology has allowed us to live independently of others in many ways. We can telecommute thousands of miles so that those with whom we work never actually see us outside of an image on an LCD monitor. The Internet provides access to so much information that one can almost diagnose physical problems without medical training, fix a plumbing leak, remodel an entire kitchen, drive from place to place with turn-by-turn instructions via wireless GPS systems.

The list of ways that we can disconnect from others is huge - and growing. We become isolated and yet we work as members of teams. We become deluded into thinking that we can exists as individuals in more ways than is really possible. We forget that we can take money out of a system and live apart from it in large part only as long as the system exists. We have people living in gated communities that keep out the "other people." We can actually forget all about the "other people" when we are at home. And yet, they are necessary for the system to work as it does such that the gated communities can exist in the first place.

We live in denial that the "other people" are necessary for our gated-community lives - or we don't care. As people move toward the top of our social system, they are increasingly protected from the difficulties inherent in the system. In fact, many of those difficulties are created by them as they pursue financial gain. As we sit in our comfort, we can talk about philanthropy and pontificate about how others might live differently. But rarely do we move to a position where we can experience even a moment of those "other peoples'" lives, especially the hopelessness that things will ever get much better.

The solution seems to be dialogue and communication within and between individuals and communities. In addition to providing new ways of seeing things, they build awareness and can create accountability. When I make commitments to others, especially face to face, I am much more likely to follow through. When I am in community on a regular basis, that commitment is there in front of me, and my performance is known to others. Accountability adds energy to my commitments. It keeps me focused. The transparency that allows others to see whether I am being accountable or not adds power to the overall system.

The problem with this, of course, is that a system with this level of openness reduces the opportunities for individuals or companies to take advantage of others as they build their fortunes. Our capitalist system in the U.S. is predicated on the individual and entrepreneurism. It is not a gentle society that strives for peace and harmony for everyone. Our system is fraught with fits and starts when it comes to any meaningful change. Relative to large, systems changes, most of the real change has come through some form of revolution - unions, civil rights, equal rights, women's rights. All of these movements required real sacrifice and risk of life and limb.

I am neither endorsing revolution nor movement away from capitalism. Consolidation of resources, and other forms of wealth, is an historic process that seems to be closer to the natural order of things than the social concepts of distributed wealth, sharing and true concern for others. I am, however, wondering what it will take to see real change occur relative to our current health care system. Occasionally we are reminded of the systems nature of our government as the news reports how concessions were made by one side in order to get something from the other side. Usually, it is framed as a negative event where the one is "held hostage" by the other. In reality, at least in the U.S, it is.  Life, however, is full of compromises as millions of individuals attempt to live and work together in order to experience a "better" existence.

Becoming aware of and openly discussing these complexities and necessary trade-offs might reduce our cynicism about the possibilities for change. Talk may be cheap, but it is not necessarily easy. The zero-sum process of debate is so dominant in our society, that we have little skill with other forms of communication. We don't have much experience sitting with the anxiety and uncertainty the comes with suspending our judgment of what the other person is saying. We usually want to get away from those feelings ASAP by bombing the other side with our facts. Although polarizing people into two big groups with one on each side of the issue, a lot gets lost. We get caught up in arguing about ideas instead of purposes.

Regardless of what happens on the grand national scale, we can begin to talk together in our families, neighborhoods, and communities. The good that is generated there can be a seed for the next level.