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Going to Extremes

Future Health Systems

BY DR. DAVID BISHAI, Johns Hopkins Bloomberg School of Public Health

In his plenary speech on July 9, 2011 to the iHEA pre-session on Private Sector in Health in Toronto, Tim Evans, Dean of BRAC University of the Health Sciences, laid out the poles of the debate on universal access to health care.

At one extreme there would be model of all medical care financed and delivered by the state. At the other extreme there would be no state intervention in private markets for health insurance and medical care.  What is supposed to happen next, according to the standard script of the dialectic, is a triumphal arrival at the golden middle.

However, something has derailed our arrival there.

Neither pole is especially attractive or realistic.  The discussion should have moved on by now. Why does this unnecessary “either-or” debate go on and on?  In my opinion the explanation lies in the advantages of being provocative.

Passion and enthusiasm are critical parts of the communication of ideas: The heat generated by an  idea is inverse to its distance from the middle.

By “heat”, I mean the ability of an idea to generate the excitement of journal editors, conference organizers, and bloggers.  With heat comes a desire by those in agreement to start movements and finance studies. With heat also come movements and finance by those opposed. In the past the mutual desire for truth would have moved the poles closer together. When provocation doesn’t matter, successive thinkers looking for truth would be disinclined to stray further and further from the mass of thought. These days, straining the pole even further away from the middle can be a winning strategy in the struggle to get attention and support.

The irony is that most people who think about health reform benefit more from discourse on non-polarizing options. Textbook economics treatments of the problems of health care do not support either pole. The welfare theorems suggest that unregulated health care markets will fail to provide adequate quality and will fail to protect the poor. Economists’ professional attraction to market solutions is based on shared recognition that they are seldom trouble-free. The public goods problems in health care (and other sectors) warrant collective action of some sort, but do not automatically support a solution based on 100% collective finance and provision.

This week at the International Health Economics Association, professional economists from around the world will gather to discuss and hone their craft. They mostly realize that health reform will have to be based on solving public goods problems. The toolkit for these solutions will need to include the best features of markets and the best features of enlightened collective action. The best solutions will not be the hottest—they will be squarely in the middle.  Let’s hope the light that shines from them makes up for their lack of heat.

* Editor's note: FHS will be participating in a wide variety of activities at this year's iHEA congress. See a list of activities, and stay tuned for future blogs and updates live from the event.