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What’s scary — and hopeful — about ‘health reform’

“Health reform” isn’t really about creating health. It’s about reforming insurance and the delivery of hospital and medical services.

What does it say about our current situation when the most useful analogy about public policy that I’ve seen in years comes from a horror movie?

Sean Kershaw

“The Others,” a 2001 release starring Nicole Kidman, taps into deep personal and social anxieties. Sense of isolation? Check. Nicole and her children are nearly alone in a drafty manor home on the island of Jersey following the end of World War II. Fear for our families? Check. Her husband is MIA, and her children have an illness that makes them deathly ill from exposure to sunlight. Fear of others? Check. Strangers show up to help her, but can we trust them? Lack of control? Check.

Nicole’s character is paralyzed by fear and an inability to have any impact on the world around her. Scene by scene, the director slowly ratchets up the audience’s anxiety level as we wait for ghosts to suddenly appear from behind drawn curtains. The film’s entire artifice finally falls apart — and back into place — when we realize that Nicole and her family aren’t being haunted by ghosts; they are themselves the ghosts and are haunting the real-life family that occupies their former home. Nicole’s character couldn’t let go of her former reality, no matter how much her world had changed. And she couldn’t move on until she accepted her new reality.

It’s a brilliant movie — and an apt metaphor for why we need a new model for public policy in Minnesota, especially surrounding “health care” and “health reform.”

The ghosts of ‘health care’

The Citizens League’s past policy successes on health care were in part due to the fact that we could pull back the curtain, metaphorically, on important policy issues and show people what was really happening. Policy impact and success began with an honest conversation about the facts and their implications. Without the right definition of a problem, solutions are destined to fail.

One of the ghosts we have to confront is that our entire conversation about “health care” and “health reform” isn’t really about creating health. It’s about reforming insurance and the delivery of hospital and medical services.

This isn’t to say that medical system goals of access, quality and affordability aren’t critically important to improving the delivery of these medical services. Lack of access is ultimately unjust. We can significantly improve the value of our already high-quality medical services in Minnesota.

Most of the costs in our current system are wrapped up in five chronic conditions (diabetes, cancer, heart disease, stroke and Chronic Obstructive Pulmonary Disorder) and end-of-life care. Reforms in the delivery of medical services and insurance can improve the treatment and maintenance of these conditions — thereby bending the cost curve — but they can’t prevent or avoid these conditions. If we don’t reduce the need for these hospital medical services, we won’t have any money left for any other public good — from schools to parks to roads.

That’s scary. And unsustainable.

Reimagining health policy

The Citizens League is developing a new model for public policy that we call “civic policy making.” As we endeavored to apply this model to “health care,” we realized that, in addition to reforming medical and hospital services, we need to reimagine — and create — a new infrastructure for achieving health.

We have to redefine what we mean by “health.” Is it more than the absence or maintenance of disease? Luckily, dozens of conversations we’ve had throughout Minnesota, sponsored by the Bush Foundation and reporting to the bipartisan Health Reform Task Force, confirm that there is surprising agreement by the public (across partisan differences) on what we mean by “health.”

It involves an inherent sense of balance in our lives. Minnesotans agree that we have a role in co-producing our own health and an obligation to improve our health. How can health be the default opportunity in our daily lives, rather than something we have to go out of our way to achieve? What is the role of creating health within families, workplaces, neighborhoods and schools? Are we putting too much responsibility for this on medical service organizations and government?

Most of our resources are spent on 10% of the problem

As it turns out, the quality delivery of medical services accounts for approximately 10 percent of longevity gains and healthy aging. Environmental and social circumstances and individual choices affect 60 percent of these outcomes, and genetics are another 30 percent. We spend most of our time and resources on 10 percent of the problem.

This conversation is both new, with profound implications for all individuals and organizations, and one that the public wants to have. It’s also an example of why we need a new model for policy making that recognizes the roles we all have in achieving policy outcomes.

When it comes to imagining and creating new systems of health, we first must realize that “the others” aren’t someone else, somewhere else. They’re all of us. Only then will we be able to create the infrastructure for everyone, everywhere to achieve healthier outcomes. Only then will we have truly exorcised our health-care-reform ghosts.

Sean Kershaw is the executive director of the Citizens League. He can be reached at, 651-289-1070, @seankershaw (Twitter), or Facebook.


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Comments (5)

  1. Submitted by Greg Kapphahn on 09/13/2012 - 08:53 am.

    Thanks, Mr. Kershaw and The Citizen’s League

    For this thoughtful approach to health and healthcare.

    I suspect it will be helpful, and even necessary to explore the psychological dysfunctions which lie beneath so many of the unhealthy behaviors which are so common in so many of us,…

    but which are so strongly programmed into us by earlier experiences of our lives, and function at such a deep, subconscious level as to resist all our attempts to change them.

    This deep, unconscious psychological programming means that when we are stressed, or tired, or lonely, or broke, etc.,

    we respond with physical inactivity, overeating, drinking too much (or using other chemicals), running up our credit cards, or pursuing a wide variety of other behaviors which may feel rewarding for the moment,…

    but are exactly the things which exacerbate rather than alleviate the problem(s) we started with,…

    and create related long-term problems of health and well being.

    It is these programmed, dysfunctional behaviors that more often than not, end up with us needing expensive healthcare which would have been unnecessary if we had not had such dysfunctions.

    Indeed, unless and until we start training ALL our youngsters in how to care for, feed, and keep healthy their own human psyches, rather than just hoping they’ll magically have easy, happy, lives (which is HIGHLY unlikely), we will be hard pressed to get the majority of our citizens to live in ways that keep them healthy in other ways.

  2. Submitted by Jon Kingstad on 09/13/2012 - 09:13 am.

    Spot on

    but isn’t “health reform” really about reforming the FINANCING of the delivery of hospital and medical services. Our elastic language sometimes is highly efficient at the expense of clarity in communication. “Delivery of hospital and medical services” is a more efficient expression for “keeping enough hospitals built, open, equipped and staffed with adequately paid personnel for people who need them and having enough doctors, nurses, medical technicians and others to be available for all the people who need to make appointments for their health concerns and needs.” But it sacrifices communication of a key idea, that we are not talking about a certain physical reality- the hospitals, equipment, doctors, nurses and all other things and people presently involved in “delivering health services” at the present are not going to go anywhere. What we are talking about is paying for these things in a way that the real problems and needs are met. That’s finance. Health insurance is one way health care services are financed today for people who can afford it or who are allowed to purchase it by the health insurers. Government subsidies are another. The ACA will begin to change this if events in the next few months don’t change things.

  3. Submitted by Connie Sullivan on 09/13/2012 - 04:19 pm.

    This is a good article. My wish is that the Citizens League could make its voice heard more broadly out there, to clarify the fact that health care reform is really about reforming the financing of health care (and broadening access to it, for everyone). So many people are ignorant of the specifics of even the ACA! Once they find out what’s in it, compromise with true reform that it is, they like it. But they’ll vote for politicians who want to destroy it, because they confuse health care for each person with health insurance reform that changes how that care is paid for.

  4. Submitted by Elizabeth Frost on 09/13/2012 - 05:27 pm.

    I wish the Citizen’s League had some integrity.

    I have a few things to say about this article. First, reforming healthcare financing is an absolute must in this country. I felt like this article was belittling the problem of access without offering any real substance in its place. My uncle died in 2002 because he was uninsured. Yes there is a lot about healthy lifestyle that does not entail going to the doctor, but if you need it you need it.

    The article notes that ‘quality delivery of medical services accounts for only 10% of longevity gains and health aging’ — so does that mean we should ignore our brothers and sisters who can’t afford their copays on their asthma medications? If we focused on the environment and obesity maybe we could reduce asthma, so why should we worry about how the pharmacies are jacking up the price of inhalers?

    The fact is is that ordinary citizens’ lives are destroyed on a daily basis due to the nasty and pernicious activities of insurance companies and their allies. It is time for someone to stand up to them, but clearly the Citizen’s League is not willing to do that.

    Single payer – eliminating private health insurance – was actually the most popular solution discussed at the Citizen’s League meetings, however you don’t see that mentioned in any of their reports or summaries. You can see it reported in Appendix A on their website.

  5. Submitted by Steve Janusz on 09/17/2012 - 03:31 pm.

    Lack of Affordability Biggest Challenge

    The Citizens Solution report identified the “lack of affordability is seen as the biggest health care challenge”. We must contain the costs and provide access to all Minnesotans before other health policy changes can be made. A significant cost to our health care is the waste that is not health care.

    The Institute of Medicine has issued a report stating that $750 Billion dollars is wasted every year in our health care system. This is 30 cents of every dollar spent on health care! The Kaiser Health News summary identified the following media reaction to the report. It was interesting to note how much attention was given to this report. I believe reforming the payment structure to a unified one payer approach would start us on a path to a huge reduction in this waste.

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