Dr. Michael D. McDonald’s Perspective

Dr. McDonald coordinated some of the final negotiations between the Senate and the White House during the health care reform process in the 1990s, while managing the National Health Information Infrastructure Consortium. During that time, with an inside view of the behind closed door discussions and negotiations, he was most struck by how political processes undermined legislators’ commitments to their own policy positions. Perhaps, the most significant conversation for Dr. McDonald during the 1990s health care reform process was with then Senate Majority Leader, George Mitchell. Dr. McDonald asked Senator Mitchell if he thought that government-run health care would be able to maintain the tradition of substantial innovation within the U.S. health system. Senator Mitchell started his longer discussion on the topic with the following (paraphrased) introduction.

“The federal government of the United States was designed to keep tyranny from emerging and gaining a stronghold in America, it was not designed to deal with the complexities of American society, as we now know it...”

It is clear that our U.S. health system is failing to optimize the health status of Americans. Despite the past two decades of concern regarding the American Health System crisis, little progress has been made to curb its fundamental problems of uncontrolled cost escalation with diminishing returns in terms of health status improvements. Problems of access for over 50 million Americans without health insurance, compounded with high life-threatening medical error rates, and other problems of quality of care continue to plague American health care. In many cases, historical approaches to health care are perpetuated for financial and other reasons, even when far more effective and efficient forms of improving health status have been demonstrated within our best health systems.

Without reform or transformation, the cost increases of American health care is now actually beginning to diminish health status by forcing Americans to reduce expenditures on food, energy, education, housing, transportation and other critical factors that prevent disease and improve quality of life and functional life capacity. In addition, economic downturn and global changes may erode any health program innovations within this round of reform, if the health system reform/transformation do not take them into consideration and devise health system structures that are resilient in the face of exponential changes and institutional discontinuities. Below are the five key elements of health system reform/transformation Dr. McDonald proposes should be engaged as part of the current round of health care reform:

1) Health System Simulations

Engaging the general public to comment on health care reform is an important part of the process of identifying the needs of Americans. However, providing (serious game-style) simulations of various health care reform scenarios with broad participation by many different stakeholders will provide an important next step in shaping the discourse. The simulations will test multiple scenarios of health care reform under varying social, economic, and environmental conditions that may impact the performance of the different U.S. health system reform / transformation models.

2) Avoid the Mistakes Made During the 1990s Health Care Reform

The mistakes of the 1990s health care reform must be avoided to reach successful legislative and broader societal outcomes crucial to improving health status. Engage popular moderate Republican proposals early along with the Democratic proposals in open forums to improve legislator commitments to collaborative bipartisan plans. It is very important that bipartisan support for the dominant health care reform models emerge as early as possible, before the political process of mid-term elections undermine the advancements expressed within the health system reform/transformation proposals from being codified in legislation.

3) Engage Broad Societal Solutions, Not Just Disease Care Interventions

We know now that medical care only addresses about 20% of what determines health status. Health care reform should ensure that broad societal solutions that address the majority of health determinants are part of the health care reform discourse. A U.S. health system only defined as after-the-fact medical care is unlikely to take advantage of the massive shifts toward proactive consumer empowerment and population health interventions that are now feasible through the internet and community resilience movements. Improvements in community health and resilience through Public Health 3.0 initiatives will ultimately provide the greatest benefits to longevity, quality of life, and functional life capacity for the most vulnerable populations. These programs require new funding streams, that can provide very strong returns on investment in terms of health status improvement and health equity.

4) Ensure the U.S. Health System is Not Prone to Collapse in Challenging Times

The United States has the most expensive health system in the world. It has long since hit the point of diminishing returns, especially for the most vulnerable American citizens. Our productivity in the global market is suffering in competition with other nations with far better health outcomes at a fraction of the cost of American health care system.

Clearly, our economy is in decline, with no clear indication of how protracted the decline will be, or whether the trillions of dollars washed out of the housing market and stock market will recover any time soon, or that our foreign can be turned around in any reasonable period of time. During economic decline (especially if it has roots in peak oil and global changes) the U.S. has to be careful not to make the U.S. health system more susceptible to collapse during rapidly changing socio-ecological conditions while attempting to engage health care reform that espouses to achieve essential improvements to access, quality of health services, and cost effectiveness.

5) Advanced Science and Technology in New Forms of Management & Governance

Online Collaboratories, simulations, and the Semantic Web should be used to shape the health care reform / health system transformation discourse. Americans, and their representatives, have to understand not only the high level objectives regarding access, quality of health services, and cost of services; they must also understand how health care reform or a stronger form of health system transformation may impact the resilience and sustainability of the American health system, and more importantly the health status of Americans under potentially rapidly changing circumstances.

By deepening the debate to truly understanding the wants and needs of the American public in terms of their health, well-being, and functional life capacities, as well as how their key objectives within the U.S. health system can be reached, there is a better chance of engaging legislation and resonant societal effects that reflects these essential elements. By engaging house meetings, town meetings, expert panels and representing them openly within online collaboratories (advanced forums) for further discourse on the World Wide Web, we would have the raw materials to shape a more responsive U.S. Health System, assuming all stakeholders have appropriate rights and responsibilities under a reformed, or transformed health system, with appropriately aligned incentives.

Our science base (especially from the sciences of complexity) and advanced computing and communications technologies now allow us to create intelligent social networks that enable us not only to understand the health system assets, liabilities, and mission critical gaps; it also allows us to engage new, far more efficient and effective models of health management and governance that improves outcomes for more empowered and proactive health consumers with improved fiduciary responsibility. A more agile, dynamically transforming health system more focused on maintaining and improving health status -- even within conditions challenged by economic downturn and global changes – is now essential given the projected socio-ecological and economic challenges of the early and mid-21st Century. The key will be shaping a health care reform / health system transformation process that enables the best possible positive synergy between convergent elements of all of the American health system stakeholders.