Deliberating about Hard Choices in Massachusetts

All societies must set limits on health care. But how can they do it in a clinically informed, ethically justifiable, and politically acceptable manner?

In “Setting Limits Fairly,” Norman Daniels and I argued that pluralistic societies lack shared principles by which resource allocation and limit setting decisions could be made. We concluded that a fair process is required. Deliberation that considers individual needs, population needs, and medical facts is at the heart of that process.

A deliberative process that considers the relevant reasons for and against policies will not yield answers that everyone likes. But if we know that our positions have been listened to, we are likelier to find decisions acceptable, even if disappointing.

In societies with universal coverage and national or regional budgets (essentially all developed countries except for the U.S.) deliberation typically takes place in government bodies and public commissions. Often the national parliament oversees and signs off on the process.

But how on earth could “deliberation” take place in the fragmented U.S. public/private health system? The Massachusetts health care reform process is struggling with that question right now.

The Massachusetts program is based on a concept of shared responsibility. Individuals who are deemed capable of affording insurance are required to purchase it or pay a penalty on their state taxes. Health plans are asked to offer less costly programs. Employers with 11 or more employees who do not offer insurance pay a penalty into the insurance fund. Government contributes substantially. (Providers, uniquely, have no explicit expectations placed on them.)

Massachusetts is making excellent progress in reducing its uninsured population. But the program is costing more than predicted. That’s where the rubber meets the road in terms of shared responsibility. Who decides how to handle the cost problem? How does it get decided?

Legislatures are imperfect structures, but debating, deliberating, and deciding are their basic function. In Massachusetts, the Connector Board, which I will write more about in the future, is the entity that oversees the reform process. Minutes and the materials for its monthly meetings are posted on its website.

What currently stands out for me in Massachusetts is the way print media and the blogosphere are providing a public space for deliberation. The central meeting ground is the Commonhealth blog, hosted by WBUR, a public radio station. I don’t know how many hits it gets, but the blog is read widely by a broad swath of politically concerned citizens – not just policy wonks.

The Commonhealth blog is a virtual form of the Athenian agora. A wide range of civic, political, industry and policy leaders speak their mind, at enough length to get beyond slogans and sound bites. In recent weeks Reverend Hurmon Hamilton, President, Greater Boston Interfaith Organization, made a powerful moral appeal for shared responsibility, Nancy Turnbull, a former insurance regulator and now a dean at the Harvard School of Public Health, presented a well documented argument that health plans could be doing more, and Richard Lord, CEO of the Associated Industries of Massachusetts, argued in detail that the impact of new funding proposals on employers is unfair.

The Boston Globe has had a comparable range of articles, editorials, and op-ed pieces.

The civility and reflectiveness of the public blog and print dialogue are impressive, and important to understand. There isn’t a referee enforcing constructive debate or a charismatic leader for the process like John Kitzhaber for the formation of the Oregon Health Plan.

My take is that we are seeing disseminated leadership at work. A critical mass of leaders is playing by the rules of constructive political collaboration. This supports the work of the Connector Board, which steers health care reform, conducts its own monthly public discussions, and sets an example for productive public debate.

Massachusetts health care reform is two years old. The honeymoon period is over. The next year, in which the state has to get a grip on the cost of the program, will test the durability and effectiveness of the disseminated leadership and public deliberation that have functioned well in years one and two.