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Sunday, June 28, 2009

Health care: Super Wicked Problem

Even though the economy remains in the tank, the health care debate has gone cycle up. Like the past episodes, there is a sense of urgency that something must be done now driven by stories of human tragedy and financial calamity.

The discussion is unfocused to say the least, although this is not surprising since the health care quandary is the quintessential "wicked problem" as described by Hans Rittel in 1973. (See http://en.wikipedia.org/wiki/Wicked_problem#endnote_1). Wicked problems have been succinctly defined by the following characteristics:

  1. The problem is not understood until after the formulation of a solution.
  2. Wicked problems have no stopping rule.
  3. Solutions to wicked problems are not right or wrong.
  4. Every wicked problem is essentially novel and unique.
  5. Every solution to a wicked problem is a 'one shot operation'
  6. Wicked problems have no given alternative solutions.
Before one can even begin to address how to solve such problems one needs to frame or define the problem. Individual stakeholders in the process will invariably have radically different world views and different frames for understanding the problem. When people discuss health care issues, what problem(s) do they identify? Is the major and most important problem in health care the large number of uninsured or is it the frightening growth of health care costs which threaten to consume our economy?

The solution to one aspect of a wicked problem often creates or aggravates another aspect of the same problem. Health care spending has growth explosively at a rate faster than underlying economic growth or inflation at least since Medicare was introduced. This growth has taken place despite many attempts to restrain it. If the priority for health care reform is to expand benefits to cover those who are not presently covered, growth in expenditures will undergo even more substantial growth when benefits are expanded to cover a larger segment of the population.

As difficult and at odds these two elements are, they alone do not even close to fully define the contradictory complexity riddling the health care debate. Each of the individual stakeholders when patients, health care providers, other elements of the health care industry, private payers, public payers, or politicians, has something at stake and a unique agenda.

What is the major problem that health care reform should address?

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