The following are the President's Messages from Health Planning Today , 3^rd and 4^th Quarter 2006 issues .

My temperament is that of an idealist and my education prepared me to teach moral philosophy, so it shows in how I now write on health policy. It leads me to want to address the categorical shortcomings I always find in the otherwise growing body of serious writing on universal healthcare and the healthcare system this nation deserves, and to do so the way I used to teach philosophy in graduate school.

To teach is to show others how to think clearly, and that can't begin unless we have questions in mind. So what I'm asking is, "What questions should guide us in determining how to describe the healthcare system that would provide optimal benefits for the American people?" To answer that we must have a context in which we see the whole picture: Our nation, its people, and our values.

With what tools do we proceed? Clear thinking requires that logic governs thinking driven by moral values, for we must begin with the insight that we are raising major moral questions. And beginning with a vision, we must proceed from the general to the particular, from our goals for our society to the means for reaching them – the healthcare system we would design. It will save time if we list our questions simply as, "who, what, why, and how" though logic requires that we address them in a somewhat different order. The context for our thinking will be developed in considering how to answer them:

• What: Good health. What are the conditions that produce good health in a society?

• Why: Because health is fundamental to enjoyment of the "life, liberty, and the pursuit of happiness" that we hold to be our birthright. Compassion for our fellow man and concern for our communities as places supportive of the flourishing of those qualities implies that health is to be seen as an important national goal. This imperative can be expressed by promoting health as a human right.

• How: By maximizing the ability of individuals, families, and communities to define and realize their own well-being.

• Who: It will require the participation of everyone to realize these benefits.

These are questions that can be addressed by national health planning, the sort of questions that were raised by the World Health Organization in producing its World Health Report 2000. The ultimate questions for a discipline must be answered by principles from another, more fundamental one. Commentators usually refer to the roles played by competition and regulation, business and government, but these are political and economic policy questions that need to be addressed in the same way as our questions about what kind of a healthcare system we ought to have. Because ours are moral questions, they must be answered by each and every one of us, and to do so effectively, we need education in clear thinking.

We Americans need to relearn responsibility for our own development and the role of education in empowering that process. With better education comes more personal discipline and greater participation in public life. Only then can the universal aims of public health be realized through a society that holds education and government in high esteem. There are many excellent articles on improving health in our society in our most informative newspapers, magazines, and journals, not to mention books, but these are all written by and for those well-educated individuals we've come to see as an elite. The distances between people need to be reduced by closing the economic, social, and political divides that we've allowed to develop through a deficiency of caring.

Of paramount importance is how these values are perceived. The business sector fully understands W. I. Thomas's principle that "if men define situations as real, they are real in their consequences," and they spend enormous sums ensuring that we see their products in the best light, and remain blind to their faults. To counter this, we must all teach each other to see more clearly what we've been missing – the big picture. For a society as for an individual, its ultimate expression is the face it puts on itself.

More than any other nation, throughout our history we have revered the freedom and the initiative to maximize profits, and we have celebrated those who succeed. But having succeeded, the best of them acknowledged their debt to the nation that offered such opportunities. Rather than setting them apart, wealth opened their eyes to their connectedness to all those who helped to earn it for them. In this, they saw themselves as trustees for the interests of the communities that truly owned the resources they had tapped and expanded.* They still knew how to ask, "If I am only for myself, then what am I?"

Education is key to this because these are the ultimate questions for all of us: What is the healthy life? So it all leads back to Socrates/Plato and Aristotle. Are you surprised? And from them we get some fundamental clarifications for our thinking. One is that nothing requires us to adopt a moral perspective for our vision. It has to be our own bent as a person to see these questions within a moral context, and to use a moral compass in deciding them. How else to see compassion and reverence for life as the greatest human qualities, and good government's fostering of egalitarian principles of human rights and social justice through public health as the right healthcare system? For it is universal health caring that we most lack in our country now, and the effort to revive it should have what William James called "the moral equivalent of war."

Winston Churchill's prosecution of World War II solidified his small nation through such an approach, and at the time he stated that "Americans always try to do the right thing – after they've tried everything else." Haven't we done that by now? And, if not now, when?

In the last issue, I wrote about "asking the right questions." A report has just been published in which some of those questions are implicit. It is Why Not the Best?

Results from a National Scorecard on U.S. Health System Performance, Commonwealth Fund Commission on a High Performance Health Care System, September 2006 [ http://www.cmwf.org/publications/publications_show.htm?doc_id=401577 ] and it is associated with an article, "U.S. Health System Performance: A National Scorecard," by Cathy Schoen, Karen Davis, Sabrina K. H. How, and Stephen C. Schoenbaum in Health Affairs 25 (2006): W457 – W475. [ http://content.healthaffairs.org/cgi/content/abstract/25/6/w457 ]

The questions I raised there were about the healthcare system that would provide optimal benefits for the American people. And I was led to editorialize about it because, although I was pleased to see so many articles and commentaries on the subject, none of them addressed it as a question of good governance. Their writers implicitly accepted the economic and political "upstream conditions" that are most responsible for the mess we're in! Perhaps I need to ask whether we're still the "can-do" nation we've always been, or if we've become so disillusioned over political stalemate and mendacity that we no longer believe in the values we thought defined us. I think that those of us who speak or write owe it to our fellow Americans to be uncompromising in attempting to dispel the ignorance of all the great civic lessons that now retards our progress as a nation. I suggested that the way to begin answering the healthcare question is by asking ourselves what sort of a society we wish to be.

Ask a health planner what is wrong with our healthcare system, and you're likely to hear that we don't have one. That is precisely the right answer, for it avoids blindly making a multitude of assumptions. If we all looked at our nation in relation to comparable ones that way, we could better understand the situation. What we have is like a patchwork quilt where the pieces don't fit together, leaving large gaps, and where groups continually conduct a tug of war with it, as it becomes ever more expensive to try to rent access to it. And so it gets ever more expensive in human terms.

If we were actually to plan and design a healthcare system, might we not wish to see what works well elsewhere and why? Would we want to make the profit motive the genie that runs it, or would we prefer to encourage public service with compassion, the ethos of public health? And would we breathe life back into the mantra of "government by the people, and for the people?"

This new report measures how well we're doing by looking at what works well anywhere. Its Scorecard contains 37 scored indicators, although many of these are composites. The way its measurement of performance is organized is based in large part on the framework used by the Institute of Medicine in its series of reports on quality and insurance coverage, but its specific indicators draw on those developed by the U.S. Department of Health and Human Services, the Agency for

Healthcare Research and Quality (AHRQ), the National Committee for Quality Assurance (NCQA), and other experts. The report also includes many new indicators developed for the Scorecard, including efficiency indicators, and is the first to combine indicators for quality, access, efficiency, and equity in one scorecard.

The indicators are grouped into five broad "domains:" health outcomes, quality, access, efficiency, and equity. A score of 100 on a given indicator represents not perfection but rather benchmarks set by top-performing countries or the top 10 percent of U.S. states, hospitals, health plans, or other providers. By comparing indicator scores from up to two dozen countries, the report places American healthcare in a global perspective, one in which our performance can be seen as mediocre.

The report's Overview begins, "Once upon a time, it was taken as an article of faith among most Americans that the U.S. health care system was simply the best in the world." Its principal finding about our nation is summed up as follows: "For the 16 percent of its gross domestic product that the United States spends on health care… it achieves neither the best outcomes nor the best quality of care when compared to other nations. Wide variations within the United States in quality, access, and costs pull national averages down to well below benchmarks achieved by top-performing states, hospitals, or other providers." U.S. ratio scores to benchmarks for the five domains range from 51 to 71 percent. Across the 37 indicators of performance, the U.S. achieves an overall score of 66 out of a possible 100 when comparing actual national performance to achievable benchmarks. Scores on efficiency are particularly low just as they were in the World Health Organization's World Health Report 2000.

The Scorecard findings show that if the U.S. improved performance in key areas, the nation could save an estimated 100,000 to 150,000 lives and $50 billion to $100 billion annually.

U.S. Score for "Outcomes" = 69
The Scorecard includes five system-level indicators of health outcomes: two on potentially preventable mortality, one on life expectancy, and two on the prevalence of health conditions that limit the capacity of adults to work or children to learn. Among 19 industrialized countries, the U.S. ranked 15th on "mortality from conditions amenable to health care," or deaths before age 75 that are potentially preventable with timely, effective care – 115 per 100,000 people, compared with 75 per 100,000 in France. Out of 23 industrialized countries, the U.S. was lowest in life expectancy at birth and tied for last with Portugal, Ireland, Denmark, and the Czech Republic on healthy life expectancy at age sixty. The most damaging finding: the U.S. ranked last on infant mortality as of 2002, with rates 259 percent of the average of the three leading countries (Iceland, Japan, and Finland).

U.S. Score for "Quality = 71
This domain includes getting the right care (71) that is well-coordinated (70), safe (69), patient-centered, and timely (72). The lowest scores were for: Ability to see doctor on same/next day when sick or needed medical attention (58)^*; and Very/somewhat easy to get care after hours without going to the emergency room (53)^*.

U.S. Score for "Access": 67
This domain includes participation in the health system (65), and affordability of care (69). In 2003, 35 percent of adults under 65 (61 million) were either underinsured or were uninsured at some time during the year. And 34 percent of all adults under 65 have problems paying their medical bills or have medical debt they are paying off over time.

U.S. Score for "Efficiency" = 51
Scores for these indicators tell the story about: Potential overuse or waste, an indicator for multiple related measures (58); Went to emergency room for condition that could have been treated by regular doctor (23); Hospital admissions for ambulatory care sensitive conditions (57).

U.S. Score for "Equity" = 71
The report's authors state that, "Having an equal opportunity to lead a healthy and productive life is consistent with the founding principles of this country. In fact, the elimination of disparities in health and health care has for years been a national policy priority." Belying that is our performance on the four indicators: Uninsured (66), Low-Income (62), African American (76), Hispanic (80).

Many of the scores for the above areas reflect variations in performance among the 50 states that are even greater than found among all the nations studied. For example, with respect to potentially preventable deaths, the five lowest scoring states were all below Portugal, the lowest scoring of the 19 industrialized countries, while the highest scoring states were equal to the highest scoring countries.

Future editions of the Scorecard will assess changes in performance on this initial set of indicators and will also include new indicators as data become available.

The report concludes with this prediction: "In the future, transformative change within the U.S. health care system will likely come from innovations in the way care is organized and delivered, and from better research in support of evidence-basedmedicine."

But only if we are asking the right questions.

^{* The Nobel Laureate (1978) economist Herbert A. Simon wrote: "Access to the social capital – a major source of differences in income, between and within societies – is in large part the product of externalities: membership in a particular society, and interaction with other members of that society under practices that commonly give preferred access to particular members. How large are these externalities, which must be regarded as owned jointly by members of the whole society? When we compare the poorest with the richest nations, it is hard to conclude that social capital can produce less than about 90 percent of income in wealthy societies like those of the United States or Northwestern Europe." "Universal basic income and the flat tax," Boston Review, 25(5), 9-10 (2000). Simon understood social capital to include good government and the educational, organizational, and technological skills of a nation in addition to its natural resources. His arguments for a just society are presented along with differing ones in Joshua Cohen & Joel Rogers, eds., What Is Wrong With a Free Lunch? (Boston: Beacon Press, 2001).}

By John Steen, Consultant in Health Planning, Health Regulation, and Public Health
jwsteen@expedient.net