One reason for the recent failure of the U.S. Congress to pass a bill to replace the Affordable Care Act (ACA) has to do with the process by which the legislation came about: very quickly, with little input from those most affected by it, and with a lot of compromises and internal contradictions needed to get it passed. That top-down, sausage-making way of making public policy no longer works with ordinary legislation, let alone something as central to most people’s lives as healthcare.
This failure, though, opens up an opportunity to approach healthcare reform in a new way. We can keep trying for a wholesale replacement, which as recent events show, will likely never appeal to the diverse points-of-view surrounding healthcare in America – or we can do what designers do when facing a system not working well and initiate a number of small-scale, innovation-oriented explorations to test our fundamental assumptions and see what ideas work best for scaling up to a national level.
To start such a process, we need to get past the almost singular focus in healthcare reform on who pays for it and how. While payment innovations will likely emerge from a redesign effort, they alone cannot address the complex issues of cost control, inconsistent quality and restricted access that have plagued U.S. healthcare for decades. We cannot create something truly new and more effective with the same flawed assumptions and approaches that have brought us to this point in the first place. What if, instead, we approached healthcare reform less as a political debate and more as a design challenge?
The debate around healthcare typically centers on perceived scarcity, but the problems in healthcare persist not because a lack of resources or vision, but because of a chronic lack of creativity. Other sectors of our economy have addressed this creativity gap by engaging in design thinking and those who argue that government can learn from the private sector might find design thinking equally useful. We do not claim that the public sector can or should function exactly like the private sector, but done well, design holds even more promise to address complex problems in the public realm. In our work applying design thinking to public sector problems, we have identified key design principles most applicable to healthcare reform:
- Design suggests that problems are never black and white. Healthcare challenges do not lend themselves well to universal ‘right’ answers, which is the primary focus of government practices and which perpetuates an endless debate of ‘us’ being right and ‘them’ being wrong.
- Design also acknowledges that no solution is ever final and no issue forever settled. Another fatal flaw in black-or-white thinking lies in its assumption that once a law is passed, the problems go away, regardless of the immediate or long-term feedback loops that might suggest otherwise.
- Design places significant emphasis problem seeking and problem framing, recognizing that new solutions rarely arise out of old ways of understanding a problem. Yet healthcare reform keeps getting framed in the same way, ripe with the same assumptions as all the previous reform efforts.
- Design starts with the people most familiar and affected by problems. While government claims to be ‘of the people’ the disenfranchisement expressed in our most recent elections suggests that government decisions may not reflect the lived experiences of those who it claims to serve.
- Design, like democracy, is an inclusive and participatory process on an on-going basis. The occasional town-hall meeting, focus-group discussion, or one-day event does not produce the best public policy and can lead to outright resistance from many sides.
- Finally, design knows that the best ideas come from diverse groups with a wide range of experiences and perspectives. The public sector tends to give too much power to the “expertise” model where those who have benefited most from a flawed system continue to have the most influence on its revisions.
Given these design principles, the process of healthcare reform could benefit greatly from a design approach, but what would that look like? We think it should involve activities and principles driven by: empathetic engagement, radical collaboration and rapid prototyping.
The current state of civil discourse may make it seem as if empathy is dead, but we suggest quite the opposite. Because of how decentralized information sharing and communications have become, individuals and communities can now readily share their lived experiences. This has resulted in a growing awareness of the economic, social, and ecological challenges of many communities that had otherwise no forum in which to speak. And while it is easy to attack someone else’s ideas as is so often the case in policy debates, it is far more difficult to attack their lived experience. Empathetic engagement allows us to simplify and humanize otherwise enormous and abstract issues like healthcare policy.
Empathy does not mean simply asking people what is wrong with or how to fix the healthcare system because the system itself may not be well suited to provide the services they truly need. Instead, it is about direct engagement of individuals and communities facing health challenges and gaining an appreciation for their reality; their deeply held values, beliefs, and needs. This requires that we do three things:
- Get outside of our day-to-day routines,
- Get outside familiar settings and into the community or living room of others,
- Most importantly, get outside of our comfort zone to learn something new.
Engagement cannot only be with those who we already know or agree with; that is the least productive place to start. Instead start with the skeptics, the disenfranchised and those who approach health in un-conventional ways. Looking at the ‘fringes’ of a situation remains one of the best ways to understand it as it really exists, to reframe it in new ways, and to find entirely new paths forward.
As mentioned earlier, many efforts at healthcare reform lack creativity in part because of widespread misunderstanding of what it means to be creative. Contrary to popular belief, creativity mostly involves combining existing ideas and experiences in new ways by hearing, seeing, exploring, and connecting diverse perspectives, values and experiences. Think of the limited set of perspectives often included in debates about healthcare reform. Even though we know that 80% of our health involves what we do in our daily lives, we continue to focus almost exclusively on reforming acute care and to pay much less attention or make much less investment in preventive care or public health. How might health outcomes improve and healthcare costs decrease, for example, if we included housing and education as part of health payment models? How might this approach spur marketplace creativity and entirely new economic opportunities?
Ideas like that come from radical collaboration, involving people with knowledge and experience outside of the healthcare fields and working with ideas from other sectors and disciplines, even those that may not have a logical connection. The radical nature of this isn’t really radical at all: it simply demands that we get outside the artificial political, organizational, and disciplinary boundaries that we set for ourselves.
The most significant design practice for healthcare reform involves rapid prototyping. Look at how most reform efforts currently get developed and deployed. First, groups of ‘experts’ spend a lot of time and resources developing what they think will be the best idea or approach, from a top-down hypothesis, and leave very little opportunity for testing or feedback. The initiative gets rolled out with incredible investment and fanfare and immediately induces both positive and negative responses from communities. But because such reform initiatives are often so large, generic and expensive to change, leaders can’t do much with the feedback and typically press ahead until the flaws in the design and the failure to achieve its goals become so apparent that the whole operation collapses – until the next such effort begins.
The healthcare system often works at far too large a scale and at far too slow a pace for initiatives to respond and adapt to the realities faced by individuals (the people providing services as well as those receiving them) and communities. As an alternative, what if we attempted healthcare reform at a smaller and more local scale, and agreed to learn our way forward, which is the only way to navigate an unknown like health policy? We have 50 state governments, for example, that have very different health needs, perspectives, and constraints and have taken different approaches to the implementation of the ACA. How might efforts of prototyping numerous different reform ideas, with each state as a different test condition, help find more appropriate and relevant responses to individual and community health? How might this approach better inform the role of the federal government rather than the other way around and how might it lead to better results by scaling up or refining the prototypes that produce the best outcomes?
If healthcare reform were a static problem that could be solved through traditional means, we would have done so a long time ago. When the same people approach the same problem in the same way, as has happened with healthcare reform, it generally does not succeed, even as it promotes significant divisions among communities that often deal with similar problems. Design has always been most successful when deployed from the bottom up, involving the people most familiar with and affected by a problem. And design is most valuable when an existing situation no longer works and needs a major shift in thinking and doing, something that characterizes a complex issue like healthcare reform. By reframing healthcare reform as a design challenge, we suggest that the government, which has become increasingly inaccessible to those most in need of its services can once again become ‘of the people.’
Professor Thomas Fisher is the Director of the Minnesota Design Center, at the College of Design, University of Minnesota. Jess Roberts leads the Culture of Health by Design initiative at the Minnesota Design Center and is Affiliate Assistant Professor at the School of Public Health, University of Minnesota.