I read the New York Times, Washington Post, Boston Globe, and the Kaiser Health News Service and follow their various links that take me to a variety of different sources. I tune in to NPR and watch breaking news on CNN. I follow links all over the Internet trying to sift reliable sources of information from the Commonwealth Fund and the Brookings Institute from less reliable sources from the alt right and the alt left. It’s a full time job.

I make the effort because I care about the future of healthcare and not because of my own individual worries about my specific situation. As recipients of federal employees’ health benefits through my wife’s former employment as a nurse practitioner in a VA hospital, we are all set with pretty good healthcare. I am surprised by the relatively high deductibles and other out of pocket payments we do make, but put into the perspective of our overall income and the plight of others, we have no legitimate complaint. With relatively good healthcare coverage and the security of a steady retirement income from a reasonable pattern of savings over many years, you could say that considered as individuals, we should be all set and able to ignore the current cacophony of strident voices in Congress and the administration. I am a protected individual unless our whole society fails or there is some universal calamity of the sort that doomed the dinosaurs. So why don’t I just use whatever time I have left to take up painting, learn a new language, practice piano and guitar more so that I can move from beginner to intermediate status, or just spend more time fishing?

To borrow language from Robert Sapolsky’s book, Behave: The Biology of Humans at Our Best and Worst, that I have been reading, some combination of my genetic make-up, my environment, my prior experience, the culture into which I was born or the different one I have been exposed to as an adult, and other influences, perhaps beyond my control or at least buried somewhere in the circuitry of my prefrontal lobes and limbic system, I have a collectivist world view. That should be a surprise if you consider where I come from and my medical training with its focus on clinical autonomy. Family, religion, my region of origin, and my professional training considered, the data might predict that the mix of my “nature and nurture” influences, would have given me an  individualist world view.

Terms like collectivist and individualist are perhaps useful when academics are doing gross characterizations of groups or societies, but are inadequate to give a complete understanding at the individual level. Like you, I am a mix of both individualist and collectivist feelings and responses. In moments of decision where what I should do is uncertain, when the subject is healthcare I sense my own internal conflict between the poles of individualism and collectivism. A full understanding of the context of the issue is required to predict what I will say or do. Long ago my outlook on healthcare was framed in such a way as to make me principally a collectivist.

Framing and context do matter in both the presentation of an idea and the process of decision making, strategy development and strategy deployment. Most of the time when we talk about how we frame a subject we are talking about what we are including in the subject. I learned from my son, the song writer who has a masters degree in communications, that “framing” can be used to exclude rather than include important factors. Roland Barthes, the French literary critic, author, and philosopher used the word decoupage that is usually associated with the art of decorating by framing or cutting away distractions “to describe the way a picture frame cuts away that which is outside of it. In that way, every act of attention (think of how an individual looks at healthcare) is a simultaneous and inverse act of inattention.”

Following the idea of “what we individually cut away” when we frame the healthcare questions that plague us may be beneficial as the Senate continues what is and has been a very divisive process where conservative and liberal mindsets talk past one another as they attempt to sell their point of view to enough votes in the middle to win the day. I was involved in an email exchange recently with a few healthcare leaders and was startled by a comment from one of the participants. The comment below registered with me because I was already thinking about writing this essay about how conflicts between individualist and collectivist world views are an explanation for much of what prevents a consensus solution to the nation’s healthcare problems.  My colleague wrote:

The fundamental issue for many of the Republicans is that they don’t care if everyone is covered adequately or if they are actually reducing the cost of care – they just don’t want to spend that much and view this as an entitlement program for the lazy, hence the directive to work if you can in order to earn Medicaid. It is a big stretch to go from there to how to organize the healthcare system which does not seem to be their goal at all.  

Any scrutiny of the Better Care and Reconciliation Act of 2017, the amendments that were announced by Senator McConnell, the House version of repeal and replacement that was passed in early May, or the comments made by the president and members of his administration like Vice President Pence or Secretary Tom Price of HHS adds credence to the view that Republican concerns about the ACA are mostly related to the high spending on entitlements that it represents. I am not sure if I totally agree that they do not care about the total cost of care, but I do know that when one looks at the impact of their bill on healthcare what you see fulfills Barthes’ concept of decoupage. Their bills and their comments betray that they are “inattentive” to the real needs of people and more attentive to how to cut payments to the states for Medicaid. Their bill is not written from a collectivist world view. It is certainly American because it celebrates the rights of the individual to reject the mandate that is applied to everyone as a shared burden that produces a better outcome for the community or collective.

It is easy for me to celebrate the collectivist worldview and philosophy of the ACA and the people who wrote it, but they also operated with elements of decoupage. The part of the picture that they framed best was the access and patient care part. They elected to be less attentive to the total cost of care.

If we are lucky enough to have an opportunity to seek a bipartisan solution to the healthcare needs of the nation we will need to begin with some attempt at drawing a picture that both sides believe represents the problem. If you have ever had an exposure to Lean, you probably know this exercise. Lean thinking is built upon the wisdom that the first step in solving problems and coming up with effective solutions is a collaboration where everyone understands the issues in the same way. There must be consensus about the “reason for action.” That is “Box 1”of the problem solving process that we call the A3. A great way to facilitate consensus on the reason for action and promote a shared understanding of the problem is for those involved to really draw a picture on a big piece of paper of the problem and what a good outcome would look like.

When or if the bipartisan discussions do begin we will need to combine the Republican and Democratic views of “current state” because it is clear that the majority view of Republicans is that the ACA is a huge failure that needs to be repealed, and the Democratic view is that the ACA has achieved much despite Republican opposition and could be improved to do more. If the bipartisan idea ever gets past the issue of agreeing on what the current state of healthcare really is and what it is important to do, then we face the very positive task of envisioning together what might be better. I hope that the Senators will take the time to hear a lot of testimony at this juncture. It is possible that they can consider both short and long term goals. Perhaps they can agree to better fund the exchanges while they work on something better.

The biggest challenge in any Lean process is the “Box 4” analysis of the barriers to be overcome to achieve the vision. Those barriers are discerned from the analysis of the difference between the “current state” and the shared concept of what would be better as described in the picture of the “target or ideal state.” A Box 4 discussion of healthcare in a Senate committee would be a beautiful thing to see. Oh wait, we did see something like that back in 2009. It was just that after participating in the process and contributing to the Box 5 development of solutions, Republicans refused to vote for what they had helped develop.

The process leading up to the ACA did share many similarities to a Lean process. We now know the outcome of many of its experiments. We have learned some valuable lessons and have evidence that some of the plausible solutions that it offered are not so easy to execute in a partisan world. What draws me to Lean is that it is a philosophy that seeks to make great progress through cycles of incremental change accomplished through collaborative processes. Japanese culture is a very collectivist culture. Perhaps that is why Deming had to take his ideas about continuous improvement to Japan to have them really develop.

I believe that the most important part of the cycle of improvement fostered by Lean is the “deep reflection” on what has been learned from the last cycle before the next cycle begins. Perhaps deep reflection together between Republicans and Democrats is where any future efforts at discovering bipartisan solutions to the complex problems should begin. If the minds and interests of Democrats and Republicans do honestly differ, and I believe that they do, there is no hope without a bilateral process of finding ways to understand and respect one another. After respecting and making some attempt to understand the point of view on the other side of the aisle, we will be challenged to relearn how to trust each other. Bipartisanship is easy to envision but will be hard to achieve. It is best developed in a context of hope that extends to everyone. It is a dream, but it is not foolish to believe in the eventual possibility of  

…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time,…in settings that support caregiver wellness..