For Health Reform Success, Follow the Culture!

As the American culture goes, so goes America. It’s the culture, stupid!

Bobby Jindal, Governor of Louisiana, Speech, American Values Summit, October 12, 2011

November 28, 2011 - I have spilled more ink than most on the pitfalls, pratfalls, and bear traps of health reform – in Obama, Doctors, and Health Reform (IUniverse, 2009), The Health Reform Maze (Greenbranch Publishing, 2011), and 2044 Medinnovation blogs (2007 to present).

In these various verbal outpourings, I have been consistent about one point. To succeed, health reform will have to satisfy and meet beliefs inherent in American culture.

We have all heard the negative litany of health care problems – skyrocketing costs, medical bankruptcies, U.S. businesses paying twice that of foreign counterparts, uneven quality, 50 million without insurance, too many specialists, too few family physicians, mediocre health outomes compared to other nations.

What we have not heard is how the American culture operates and how we think.

• We distrust centralized federal power.

• We revel in virtues of self-improvement.

• We seek freedom of individual choice.

• We believe in equality of opportunity for all citizens.

• We prefer a multipayer to a single payer system.

• We reject a federal- imposed individual universal mandate.

• We want to make our own health decisions in concert with our doctors.

• We seek immediate access to medical high-tech.

• We believe market-based institutions and public-based institutions (VA, Medicare, Medicaid, Tricare) can co-exist.

• We consider regional diversity a good thing.

These cultural roots and beliefs may be exceptional, regrettable , counterproductive, conflicting, and wasteful , but they create a climate of freedom and opportunity that draws millions of immigrants and entrepreneurs to our shores.

But how to resolve problems of cost, access, and unevenness these cultural beliefs create, and how to design a system consistent with these beliefs,that is a horse of a different color.

I like the solution suggested by David Dranove, a professor of health industry management at Northwestern’s Kellogg School of Management. In The Health Care Blog, “The Constitution Is Not a Turkey", he recommends Congress give each state block grant conditioned on expanding health coverage. No expansion, no grant.

Let Massachusetts be Massachusetts, Texas be Texas, and so on down the line. Let states learn from one another. Keep the feds out of it. This approach, says Dranove, would be constitutional, conservative, constructive, consistent with each state’s culture, and put everybody’s pet theory to the test.

Tweet: Let Congress give each state a grant conditional on each state expanding coverage. This would be constitutional and culturally acceptable.