Sunday, July 1, 2012

Supreme Questions

Thanks to Kathryn Gunderson for the yummy flag!

The Supreme Court of the United States has affirmed a new and hopeful framework. In effect what they have said is that it is appropriate and constitutional for the United States to have an inclusive health policy. But….we don’t know what to do about poor people. “What to do about poor people” was poorly thought throughout the negotiating and passing the Accountable Care Act by the Democrats in Congress. The vast majority of that negotiation blather and drama was focused on keeping the insurance and big pharmaceutical industry from going into full-blown attack. They were paid well for their reluctant complicity. They looked eager to revert to the other side throughout. The rest of the time was frittered away trying to get one or two Republicans to cast a thin veil of bipartisanship over the process. It is not surprising that the final Act was wobbly in its detail about poor people—they were not the point. Everyone was thinking about what the rich people could be persuaded to allow, not what was ideal and effective for the poor.

I wanted—and still want—a simple, inclusive universal coverage amplified by the strong multi-sector prevention and public health framework, especially tuned to the fundamental determinants of health that affect the poor the most.  That was never the point of the negotiation that produced the Affordable Care Act so it is appropriate that the Supreme Court choked on the parts of the bill that were, in fact, poorly thought through. If we thought as hard about the poor as we did about the insurance and pharmaceutical people, we could figure that out.

The historic gift Thursday was that we can focus on finishing, not restarting, the hard work of extending health to all.

Good Samaritan with Medical Center in the back.
It was a profound experience to watch the news in the presence of 18 health systems who were meeting in Loma Linda University Health Science Center to talk about exactly this bold hope. Loma Linda University is the thought leader of the Adventist faith-health movement—the belly button of the global movement. And Adventists tend to live pretty much forever. But two miles away their people do not; indeed, nearly every possible health indicator is terrible. So they are crossing the moat (the I-10 freeway, actually) reaching for every possible kind of partner to achieve a “collective impact.” They are modeling and learning in real time.

That is pretty much what the other 17 health systems are trying to learn to do, too. Each is way above the norm in terms of spending their own money on “community benefit” and care for the poor. But we gathered out of humility, not pride, for we know that none of us has “succeeded” in aligning our mercy, justice and science as is so obviously possible. Now that we know that we will be working in a context of pretty decent health policy, we can really get to work by answering four questions:

1. What do we have….to work with. Not just money, although, we are each spending dozens of millions of dollars providing very expensive care—mostly in our emergency rooms—to people whose health could be dramatically improved much cheaper by going to neighborhoods proactively. We have a lot more than money to work with—the heart and brain of the idea of “religious health assets.” ( The most interesting assets are relationships, science, trust, thousands of paid and unpaid humans and the qualities of trust. This broader view shifts the role of “management” from carefully titrating “our scarce stuff” to aligning the superabundance of complex partnerships and assets. This is way more fun and useful, but a new skill for most of us.

2. What do we know? We have more data than any platoon of wonks has time to read. But that is just the beginning, as we have even more intelligence among our partners. Blending this –hear the word againsuperabundance of intelligences is the challenge. Organizing this knowledge—and teaching partners—depends on smart compelling questions. Such as….

3. What can we do? Aaahhhhh, the magic question. The pool of pretty good, if not “best” practice is deep and wide; accumulating for many years (at least since 1992 when the Interfaith Health Program started at The Carter Center).  We learned at there that once you figured out how to ask the question, every single imaginable problem has been addressed with some degree of success by someone somewhere, usually in places even tougher than your neighborhood. But so much of what is possible rests on a social infrastructure that blends complex shared effort sustained over time. The hard part of the question is not finding the “do” but nurturing the “we.”

4. The question of “we” links the other three, not just the doing part. Understanding assets and knowledge also depends on the illumination of multiple bright minds. So the critical question throughout is “how are we connected.”

We came within one vote of devolving into competing tribes with radically different human prospects. But the Supreme Court narrowly decided that we could be one people, albeit with profound and continuing tribal tendencies. Dr. Fred Smith told us Friday afternoon that even after the decision we were like David facing Goliath. “You are 18 health systems, 228 hospitals, $43 billion in revenue, but you are not big enough!!! You must go out in the name of the Lord, vanquish the giant of disparities, crash the gates of privilege and claim the land.”

Feel the five smooth stones; know they are enough and go out. It is our time.