Chapter Six. Complexity of Health Reform and of the American Culture

This is chapter six in my new book Health Reform in Perspective

Prologue: Those favoring government control are slow to accept the notion that health care and society are complex. They think centralized government simplifies health care by making it comprehensive and universal. The British aren’t so naïve. After 62 years, their socialized system remains in flux as costs escalate and demands grow. They have decided to shift power away from bureaucrats and put doctors in charge (“Remaking British Health Care: The Doctor is In, and in Charge,” NYT, July 24, 2010).

Complexity of Health Reform

In today’s July 21 reading of The Health Care Blog, I ran across this passage by Alan Weil, JD,, director of the National Academy of State Health Policy. In his piece, Weil comments,

“The Affordable Care Act’s guarantee of coverage is actually a patchwork quilt that includes Medicaid, the Children’s Health Insurance Program, employer-sponsored coverage, and plans purchased with subsidies through the new insurance exchanges. While almost everyone will be eligible for some form of coverage, the source of coverage matters because it determines the benefit package, the cost-sharing provisions (deductibles and co-pays), and how costs are allocated between state and federal governments.”

“This complexity must be invisible to the person seeking coverage. We need to build a system where a person provides basic information about his or her own circumstances and linked databases instantly verify that information and convert it into a set of coverage options. Manual processes, reserved for complex functions like determining if someone has a disability, must become the exception, not the rule.”

“Simplification of the enrollment system is the linchpin of success for the reformed health care system. Failure to achieve this vision will leave millions of people without insurance coverage even though low cost or no cost options are available to them. And failure to achieve this vision will mean more money spent on administrative processes when we need every available resource devoted to providing needed health care services.”

What are the lessons to be learned from the new health reform law – now redubbed at the Affordable Care Act?

Here is my take:

• Complexity is, well, complex, so complex that not even the “experts” comprehend or anticipate its consequences.

• Health care is an intimate part of a complex world, and is not immune, isolated, or protected from its vicissitudes.

• Health care’s complexity is what makes it so resistant to change.

• In the complex interconnected worlds of humankind and health care, not everything, not every little detail can be planned linearly from the top.

We will remember 2010 as the year Health reform passed, and complexity, the Internet, and globalization overcame and overwhelmed humankind.

Everything is complex, and not everything can be simplified. You cannot cover everyone, completely control human behavior, or demand prevention, or plead for rationality in all things, and you must heed informal relationships, gossip, rumors, and sidebar conversations, and these shadow behaviors – these completely human, sometimes irrational, reactions, are important because they foretell workable health and business models and subsequent actions with any chances of success.

The human world, and its health care derivatives, work by “chunking,” by allowing complex systems to emerge out of links with simple things, out of convenient, simple, inexpensive, predictable, patient-centered, physician-accepted disruptive innovations capable of operating independently rather functioning seamlessly as dictated by centralized bureaucracies.

Success usually flows from cooperation and competition rather than simplifying complexity.
National Health Outcome Rankings: It’s the Culture Stupid!

Philip Musgrove, PhD, who was editor-in-chief of the 2000 World Health Report, Health Systems: Improving Performance, says the report, published under his editorship, ranking the U.S. 37th in the world, was a mistake (“Health Care Rankings, “ Letter to the Editor, New England Journal of Medicine, April 22, 2010). “It is long past time,” he says,” for this zombie number to disappear from circulation.”

Musgrove was responding to a New England Journal article critical of U.S. health care by two medical academics, Murray, C;l. and Frenk, J.: Ranking 37th – Measuring The Performance of the U.S. Health Care System,” New England Journal of Medicine, 2010, 362:98-88.

Mosgrove argues that 37 is a”zombie number”because it predisposes national health outcomes depend only on access and ignore cultural, geographic, and historical factors.”

I’m with Mosgrove. These examples supporting his position spring to mind.

• Medical care accounts only for about 15 percent of the health status of any given population (Leonard Sagan, The Health of Nations: True Causes of Sickness and Well-Being, 1987). Life style accounts for 20 percent to 30 percent, and income differences, and lack of social cohesion for the other 55 percent(D. Satcher, and R, Pamies, Multicultural Medicine and Health Differences, 2006).

• If one were to eliminate violence and accidents from the statistics, the U.S. would rank near the top in longevity. John Holcomb, M.D., the U.S. Army’s top trauma surgeon is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s a useful statistic to keep in mind when comparing national health systems. If one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country. Civilian trauma and deaths are largely beyond the health system’s reach.

• The U.S. is the number one destination for the world’s immigrants. The U.S. receives some 85 percent of the world’s immigrants. Because of such things as poverty, cultural differences, poor prenatal care, and discrimination, the non-white population, a disproportionate number of whom are immigrants, have lower life expectancies as follows; whites 81.0 years, black 63.6 years, Hispanic 74.0 years, Asian 75.2 years. (Abstract of the United States, 200-2004). From 1993 to 2003, the U.S. population exploded by 12.3 percent, due in large part to newly arrived immigrants with and their subsequent fecundity. This unexpected growth contributed to the physician shortage, lack of access to care, and dismal statistics.

• Life expectancy in the United States, a vast continental nation, depends on where you live . If you are black man in Harlem, your chances of surviving past 40 are less than if you lived in Bangladesh or other third world countries. If you live in Minnesota, you will live on average to 80.5 years. If you live in Mississippi, you are likely to die by 73.9 years. These various statistics are largely due to socioeconomic factors beyond the reach of health care professionals, who do not control what goes on in the streets or immigration patterns.

Top-down health care social engineering is a fine and wonderful bundle of good intentions worth pursuing, but it has its limitations - such as achieving uniform improved outcomes across all cultural groups.