Wicked problem #2: health care in the United States

Initial assessment

• Clarity about stakeholders –
  • Size includes everyone living in the United States directly, but considering secondary effects (related to bargaining power of providers, critical mass in research, etc.) hundreds of millions of people outside the US as well.
  • Stakeholder diversity is enormous and complex. Although everyone is a patient from time to time, many also have differing stakes both in the status quo and in possible changes.
• Consensus around the need for change is unclear. Some point to the strengths in the current system and worry that reform will diminish the advantages and create new problems, but even among those who favor change, there are vastly different views on the root problem, where leverage exists, and even what the target benefits should be.
• Similarly, the type of solution is subject to considerable debate and dispute. Some favor a public health payor and provider system, others for a more regulated private, system, and several hybrids can be imagined.
• Boundary conditions and constraints are not fully defined. Is this supposed to be a universal solution that discourages private enterprise? Are “alternative” providers included? To what extent should public policy on other matters (e.g., abortion, euthanasia) be implemented through a health system?
• Understanding of secondary effects is unknown. The United States is the largest, most complex market for health care in the world and covers everything from basic research to the most basic outpatient care. In addition, health and economics cover virtually every political issue today directly or indirectly.
• Diversity of factors is similarly enormous, simply because health issues can not readily be measured and are subject to enormous emotional considerations.
• Urgency is high, in the sense that it is hard to experiment further with these kinds of reforms. If the reforms fail, there is no going back to the current status quo. Rather, a whole new set of realities will become apparent.
• The solution set is divergent and largely unknown – in spite of all good intentions and ingenuity, there will be lots of bumps on the road and unforeseen complications. Consequently, the end state is essentially unknowable.

Reflections on taming this beast

• Finding leverage – as Dan Roam points out, this issue is really about insurance. Who absorbs the cost and risk of health problems, and who has the incentive to reduce risk and reduce costs? Healthcare reform should seek to realign incentives to create more virtuous behavior.
• Eliminating trouble-makers – in many wicked problems, there are stakeholders who are a) heavily invested in the status quo, and b) have means of hindering change. There needs to be a separate strategy for neutralizing them, either by buying them out from their investment, or reducing the power they have to stop change. The focus in this debate appears to be the health insurance companies, which is why there is talk of regulating them in a different way. I am not convinced it’s that simple, so I’d advise deeper analysis (or reading the analyses that have been performed).
• Instituting feedback loops and learning – early warning systems are needed to identify potential problems and bottlenecks in the changes that are underway.
• Keeping the engine running – question here is, how do we make sure that people get coverage, are in fact covered, and receive health services while the change is underway?
• Where to be brutal – nobody likes to use brute force, but sometimes it’s a bit like a band aid that needs to come off. Better to rip it off, wince at the pain, and move on.