The discussions in the US this week surrounding the constitutionality of health insurance payment mandates and the fact that my terminal degree is in health policy helped me to choose a topic for this week’s post. The US Supreme Court question that the Justices are examining this week has to do with the issue of insurance payment mandates for individuals—is it constitutional? The goal of Obama’s The Affordable Care Act is a goal of healthcare for all within the existing system.
One primary argument of those supporting the plan is that, while not perfect, the plan is a good start in transitioning to a universal healthcare system. Yet the plan and the current discussions make a number of unstated assumptions about a healthcare system embedded within a capitalist, free market economic system of the wealthiest country on the planet. These assumptions need to be exposed in order to view the problem systemically. I would suggest that these assumptions are not even correct to begin with for the existing system, and that the assumptions will become even less true in a permanently declining economy associated with peak oil.
Rousseau said, “Good laws lead to the making of better ones; bad laws bring about worse.”In my opinion, creating bad laws now that assume that the current system can grow infinitely only lead to further catastrophe.
Flywheel from MT Brown 2004 Picture Worth a Thousand Words (from Odum, 1976)
Public policy is whatever governments choose to do or not do (Dye, 1995). Policy is the authoritative allocation of values for the whole society (Easton, 1975). Politics, then, is the act of how we get policy done. In our current western economies, policy resistance is occurring due to embedded vested interests of powerful corporate players in the policy arena. Reinforcing feedback loops (autocatalysis) creates an imbalanced system and dominance, which then creates more imbalance, eventually leading to a sort of super-circulation such as our exponentially growing flywheel economy.
As we expand the current healthcare system, autocatalysis causes an extreme super-circulation similar to that found in the economy at large. A market-based healthcare system gives the strongest shareholders the most power to garner even more profits (Kuttner; Hsiao, 1994; Arrow). A crowded policy environment with too many players creates gridlock, allowing only incremental expansion instead of significant needed reform. As in the economy at large, too many powerful vested interests create more inequity, more debt, and more consumption (treatment) with less regulation and more profit.
Meadows (2008) describes policy resistance as an attempt by various actors to pull a system stock towards various goals. “Any new policy, especially if it is effective, just pulls the stock farther from others’ goals and produced additional resistance, with a result that no one likes but that everyone expends considerable effort in maintaining” (Meadows, 2008, p. 116). Thus, defining the goals of the system and the assumptions embedded within those goals becomes critical. While the trigger for this post is American healthcare as the extreme case, some of the systemic issues can be applied to various sectors in other countries, too. The unstated assumptions regarding growth of any economic sector at this point in time need to be stated and examined from a systemic perspective. I would like to expose healthcare assumptions as an example du jour, using a framework of the traditional triad of health policy values: quality, access, and cost.
General Structural Assumptions/Goals of the Current U.S. Healthcare System
- Healthcare is a commercial commodity that can be developed and sold
- Healthcare can support profit while providing adequate care for all
- Healthcare allocation is unnecessary; rationing is effected by market costs
- Healthcare policy can continue its expansionary growth in the face of peak oil and economic contraction
- The current healthcare system (HCS) in the US is functional and is worth expanding
- The current level of bureaucracy and complexity can be incrementally expanded
- Insurance linked to employment works in low employment situations such as recessions as well as vibrant, high employment situations
- Just in time efficient healthcare is resilient to impacts of increased needs for healthcare
Quality Assumptions:
- The current HCS in the US is effective in promoting health, healing the sick, and prolonging quality life in the elderly
- The current HCS places the interests of patients as primary
- Insured patients receive the proper amount of care (not too much or too little treatment)
- Libertarian ethical emphasis on individual autonomy and personhood assume infinite capabilities of our healthcare system to expand and provide for all
Access Assumptions:
- Healthcare should be a right for all, whether we pay for it or not
- The US has the ability to incrementally expand the current system and support additional complexity and profit while meeting the needs for all
- There is no political or ethical need for restraint of healthcare
- The US has the ability to expand the healthcare and the economy in the future
- The US has the ability to provide infrastructure (hospitals, intensive care units, healthcare workers (HCW) to meet expanded demands from increased numbers (from healthcare reform and aging boomers) at the current level of intensity of care
Cost Assumptions:
- US healthcare is a mix of private, public, and mixed produers embedded within a capitalist economy, favoring private solutions wherever possible
- Debt and entitlements to the future ($200T?) do not matter
- Copayments for those with insurance are affordable
