Sunday, December 7, 2008

Case Study: How to solve USA healthcare system

Case Study: How to reform and solve the problems of the USA’s healthcare system.

Today we’ll use the problem of healthcare in the USA as a case study to observe and study the only way to successfully solve the problems and provide a “universal” and high quality service. Without following this methodology the healthcare problem just will not get fixed. To explain the methodology, I have to use an analogy. The reason I am using an analogy is to teach how to problem solve and use a specific methodology that is needed for this category and type of problem. Here it is.

Suppose that you are the head of a large family, and you have quite a range of people that you are responsible for: adults, children, and the elderly, working people, a homemaker, a person with disabilities and a veteran, students, etc, all living with you and looking to you to provide for them. You don’t have a place to live until one day you find that your great uncle, who is very wealthy, has died and left to you his house, which is widely known to be “the best” house in the region. Excited to finally have a roof over the head of your large family, and having no options but to live in the house, you move in and this is what you find. While obviously much money has been spent, and parts of the house are very magnificent, it has been designed in an incredibly strange way that makes it almost unlivable. It is a three story house and on the first floor are the bedrooms, just the bedrooms. You go to the second story of the house and find that it is designed to be an “attic,” that is unheated, no plumbing and only used for storage, and there are elaborate storage structures built throughout the floor. Amazed, puzzled and disconcerted, you go to the third floor, which is tucked into the roof, and there you find the one and only bathroom, and the kitchen. They are marvelously tiled and decorated, and have great appliances, but they are in the most unusable and inaccessible part of the house! Further, when you look at the blueprints, you find that all the plumbing and electrical wiring, gas service and so forth were all installed with only this configuration in mind. What in the world do you do? By the way, you found the blueprints in the “home office,” which is in the garage, while the car is parked on the front lawn. I won’t even tell you what you found in the basement.

Here is what the typical politician or “planner” does. He or she views the existing configuration of the house as “constraints” that they must work within, while doing some “remodeling” over a long period of time. For example, they know that a bathroom has to be installed on the first floor, so that they can be accessed, so they start thinking about how to reroute plumbing there, etc. Stop! What is the problem with that approach? You are de facto buying into the assumption that you need to leave the bedrooms on the first floor. Maybe you should and maybe you shouldn’t. You scratch your head and look at the disabled family member, the elderly, and the children and know they can’t climb the stairs to get to the one and only bathroom. So now you argue with the other decision makers in the family whether you should install an elevator or chair lift on the stairs while you study how to build or move the bathroom to the first floor. Whenever someone has a new idea what to do, you run to the garage where your home office is located. Every time you come up with an idea to fix one problem, either short term or long term, a bunch of other related problems and implications spring up. What do you do?

The proper thing to do is to ignore everything about the current configuration, except of course the lot size that the house and outbuildings occupy, and with a blank sheet of paper design within the skin of that lot acreage and the main structure of house roof and supporting walls “the perfect configuration.” Do not try to “solve each problem” one at a time, even though that is the continual call of being “practical” and “working within the existing constraints.” Taking the needs of each member of your family into consideration, you sit down and design the “perfect” interior configuration for your house.

How do you do this? You do it by listing a set of principles first. These principles state the core basic needs of each member of the family. You do not jump ahead to list the “how to” or the “answers” yet. See, if you do that, you do things like “move the bathroom downstairs where it belongs,” without realizing that you actually need a bathroom on every floor. So first you list, using that example, the number of people who need bathroom facilities, their ability to access them, and implications of the various potential locations. For example, you might want one near the front door if you have frequent visitors and also for the children to quickly go into when they come home from school to wash up, or after playing. So you list the principles based on 1) how you and your family live as a whole and 2) what specific needs must be met. An example of a principle would be:

1) Because we have several elderly, disabled and otherwise high sanitation need individuals, we need to have enough bathrooms so that one is always available even in heavy use times of the day.

See? You have not yet determined the number or placement of bathrooms; you have stated a principle that is a criterion for all subsequent tactics of planning and configuration.

This is how the new “Health Care mavens,” whoever they may be, need to address the healthcare system of the USA from the start. Absolutely start with a clean and fresh piece of paper and list the principles first, and ignore all the voices who shout suggestions and demands. Especially ignore those who say that “we have to take into account this or that existing situation.” Take nothing for granted, because if you do, you will without knowing it eliminate a slew of potential proactive opportunities for real change, instead of ad hoc bandages. Even those who suggest radical changes are much more self constrained than they realize, since they are both consciously and unconsciously working within the dictates of the existing system, just as if the new homeowner in our example thought that a bathroom can only go where the plumbing leads, or where, accepting the bedroom configuration, those who need the bathroom sleep and keep their clothing. So to address the Health Care system problems in the USA, you must first write the basic principles by which needs are identified correctly and with true vision from the start.

To get those of you involved or interested in this process, I’ll provide what I would make as the first principle for the USA Health Care system.

1) Every child under the age of eighteen should have access to complete and free comprehensive healthcare that emphasizes preventive care and includes the entire profile of healthcare services.

So if I was presenting this principle to a roomful of shocked individuals, I would then go on to sketch, like an interior decorator, my vision for that principle. Every child would receive free prenatal care, free pediatric services, inoculations, doctor visits when ill, assistance to the parents about child raising, nutrition counseling (think of the obesity and diabetes epidemics), and mental health services (not to drug them into submission, but to address early behavior, depression, alienation and other issues, especially of adolescence.)

The reason that this must be and should be the first principle is that a people and their society live or die by their children. It is unconscionable that here in 2008 at this stage in human “progress” and prosperity that the USA does not have comprehensive and free prenatal to eighteen years old healthcare and preventive medicine. There really is absolutely no excuse and is simply a reflection in a dirty mirror of where the misplaced priorities of this society have been for far too long.

If I was presenting this principle in a meeting room, and I heard protests about “the cost,” I would say, “I don’t want to hear that crap from you about ‘the cost,’ before you have even developed all of the principles. Whenever you do a wise and comprehensive plan, you find new revenue as you cancel out unjust and wasteful costs. So you just keep your pants on and don’t worry about ‘the cost’ of each component of the new system until you have actually determined what the principles are, and what the costs and offsets truly will be, in all likelihood. That’s what sophisticated computers and financial modeling systems are for, not for running expensive presidential campaigns, looting on Wall Street, and for video games.” That is what I would say!

When you have developed on your new clean sheet of paper the “ideal configuration,” how do you implement it? You overlay it on the existing system and start to behave as if the new plan were in action. The analogy that I use is that you put the new faucet that you want to have in front of the aged and insufficient plumbing system that you must modify behind the scenes. Sure, maybe the new faucet does not have enough pressure behind it to use all the features from day one. I’m not a plumber but I’ll make up an example. Suppose that your new faucet, or shower head, can provide high pressure stream of water, but your plumbing does not provide enough pressure that you can use that feature, you get only a trickle. Fine, you get only a trickle until you change the plumbing behind the faucet, but in the meantime you get all of the ordinary good functions of the faucet, and partial service for some the special features, such as the high pressure stream. Thus the new homeowner of the freaky house should immediately configure the rooms the way they should be, even if they do not yet have the complete set of services from day one. I’m joking a little, but here’s what I mean. If the homeowner realizes he needs three bathrooms, one on each floor, the very next day buy two of those “portable bathrooms” that are used in construction etc and put one on each floor that does not have a bathroom yet, ha! I’m not saying to literally to do that, but I’m saying that you immediately move all the things that you can move, and provide stop gap until you construct the complete supporting system. You do NOT live in a “work around” mode until you have done a string of unrelated “remodeling” projects. You start living DAY ONE according to the “perfect plan,” even if day one means that the occupants of floor one and floor two do not have a shower and hot water running in their “portable-potties.” You move whatever appliances you can from the third floor to the first floor bedroom that will be the site of the new kitchen, even if you only have half functionality there for a while. Your brave and most able family members make their bedrooms in the second floor “attic,” as brave pioneers homesteading, ha, until you can actually implement the fullness of your plans comprehensively and evenly throughout.

Likewise, suppose that everyone agrees with me about principle one for free comprehensive health care for children, and it becomes part of the overall plan, with all of the other thought through principles of the complete new healthcare system, and then they look at me and say, “So, smarty pants, how are you going to do it, provide free health care to children, when the system is now structured this way, that way and so forth.” It’s simple. I implement it right away wherever I can implement it. It does not have to have one and only one way to be provided on day one. Here’s an example.

Suppose you have some idealistic medical students graduating from medical school with huge student loan bills. You could offer such a student an opportunity to, let’s say, set up their practice in a small town that lacks a general physician and you will cancel part or all of their loan if he or she commits that half of their practice provides the free and comprehensive health care to children of that town. Thus the physician has his or her own free market practice, yet because he or she dedicates half of his or her practice to the free and comprehensive care to children, he or she has part of their loan canceled out with each year of service to the community. That community, voila, now has the first implementation of the “new health care.” Genuine change starts immediately, even if one can only be spotty in the first “roll out.” And that is a good thing anyway, since that’s how you identify further opportunities or problems in the implementation of a given principle.

Medical schools might realize that they should re-emphasize pediatrics combined with general practice programs. The local medical schools might now identify and partner with sectors of communities in their states to provide doctors willing to have a half free market/half child based free comprehensive practice. Communities might offer free housing to the doctors, as extra incentive. You find that the free market rolls out in a wonderful way if it is responding to a firm ethical principle of the providing of an essential “subsistence” service (see my previous posts about capitalism and the financial crisis to see what I mean by subsistence.) I argue that free and comprehensive health care with a preventative medicine emphasis is a basic human right and a subsistence service in a true, modern and prosperous capitalist system. Children’s health care should never, ever be viewed, as it has been, as part of the “surplus” and “competitive” capitalist “free” market. And yes, those of you who would whine, “It’s unfair that some communities get this service before others,” well, bite your dumb tongues. How can you refuse services to a portion of children on day one because everyone can’t get theirs “all at once?” It is exactly that selfish mindset that has gotten this country in the mess that it is in. You should be happy and proud with every step forward for every individual and group, not wait for some mythological time when everyone has it all, all at once. You don’t hear members of our analogy family whining that the disabled person has the best room to start with, for example, while the others have to wait or rough it out for a bit until the renovation rollout reaches them.

See? It’s not really that hard. I hope that you have found this helpful.