I am writing to ask for your thoughts on some specific issues. We have had a robust conversation about “principles” but at some point we have to try to incorporate them into a legislative concept. In other words, we need to think about what these principles mean in practical terms if they became part of a new system. And it will be in this transition from principles to a more practical application where people’s enthusiasm and commitment to reform will have to confront a number of legitimate concerns about change and the “unknown.”
Our ability to keep people engaged around finding solutions rather than simply rejecting proposals is key to the success of the Archimedes Movement – and, I believe, to changing the U.S. health care system. We cannot realistically expect our legislative bodies to successfully deal with these concerns if we are unwilling or unable to do so ourselves in our own communities. This is the point at which I believe we have a huge opportunity to reengage as citizens rather than simply as members of “stakeholder” groups.
There are probably a dozen key issues which will have to be confronted and worked through if we are to be successful. Your input is crucial if we are to move from general principles to a more specific legislative concept. I have listed two issues in this post that we need your thoughts on now. These are “individual responsibility” and “setting priorities.” I know that some of you have already begun to discuss these and post feedback on the site. Let me elaborate on each of these.
Individual Responsibility
At every community meeting the issue of “individual responsibility” came up – the notion that individuals have a responsibility to make healthy life style choices that will reduce the likelihood that they will need the health care system. We need to give some thought to what this means in a practical sense. Does it involve financial incentives/disincentives to influence behavior; does it involve education; or does it mean that a person who smokes or makes other unhealthy choices won’t get treatment?
This is obviously a complicated issue with ramifications that go well beyond our traditional view of “health care.” For example, if a person has limited income and no transportation –and if there are no grocery stores in their neighborhoods but only fast food outlets – there are some mitigating circumstances that make it hard for them to follow a healthy diet.
Setting Priorities
At almost every meeting people brought up the issue of limits – the reality that we cannot afford to pay for everything for everybody. In other words, priorities must be set. Finding a way to reconcile unlimited demand with limited resources is one of our central challenges, and we must discuss and examine the process we’ll use to accomplish this.
In 2003 I spoke at a conference in Melbourne, Australia that was trying to deal with exactly this issue. The conference was called “Public Participation in Resource Allocation Decisions: Prioritization and Accountability” and was organized around the following statement:
Our public health care system can never completely meet the demand that exists for care and the cost of that care. It is morally and ethically complex to make choices and set priorities that impact on people’s lives and well being. However, choices are made and priorities set. The process by which that happens is not always clear. The challenge is to make the decision making process open and to find effective ways to include the community in that process.
As I said in my remarks at the time, there are three points inherent in this statement – all of which are relevant to the work we are doing with the Archimedes Movement.
- First, we are dealing with public resources, not private resources.
- Second, public resources – for health care or for anything else – are finite. And since public resources cannot be allocated to health care at the expense of everything else – like education, transportation and public safety – it follows that the public health care budget is also finite.
- Third, the fact that public health care budgets are finite means that those who depend solely on public dollars to finance their health care will face some limits as to what can be paid for. Or, to put it another way, if we cannot finance everything for everyone, something will be denied to someone. In other words, publicly financed health care will inevitably be rationed.
Given these parameters, it seems to me that we need to answer five basic questions:
- Who will be denied something?
- What will be denied?
- How will this decision be made?
- Who will make the decision?
- How will the decision be validated by the public?
I am not suggesting that we need to follow this particular structure – it is simply the one I recommended in my speech in Melbourne – but these are the kinds of things we have to be thinking about as we confront the challenge of reconciling unlimited demand with limited resources.
There are two ways to contribute to the discussion. You can go to the Document Forums and comment in the sections set up for Individual Responsibility and Setting Priorities. If you are part of a local chapter you can to share your discussion in the area of the site for community reports from each local chapter. It’s very important to this process that the chapters share notes from their discussions with the rest of us in the Archimedes Movement. If you have trouble posting or uploading your notes, please see the instructions here or contact Rick Ray, our web publisher.
If you have other questions, please contact Liz at Liz@ArchimedesMovement.org. She’ll get back to you as quickly as possible, or connect you to other chapter leaders who have developed approaches that seem to be working for them.
There are more areas that we need your input on, and we’ll post those soon. Again, thank you for your leadership and commitment to this effort. This movement cannot succeed without you.
Best Wishes,
John
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