A BA’s View of the Root Causes of U.S. Health Care Conflict

After bearing the unbearable sausage-making that passes for problem resolution and debate in our currently polarized political environment, it is time for a BA to speak up on the matter of the Health Care Debate (what, no one asked you either?).

The biggest divide in the debate seems to be between the idea that Health Care should be a free market institution versus the idea that Health Care should be run as a public good available to all.

Let’s ignore the misrepresentation that employer provided health insurance (the primary vehicle for accessing Health Care in America) is a free market in itself.  When was the last time you took a job but rejected the insurance in favor of a personal choice?  In addition, health insurance is so heavily state regulated that, in effect, local oligopolies form, and choices are restricted (try to get catastrophic insurance in Maryland sometime – it can be done, with persistence).

Let’s also ignore the misrepresentation that consumer “spending” out of their insurance plans creates a “free market” in purchasing Health Care.  Once your employer takes potential wages so you get health insurance, your out of pocket costs are typically small enough that it distorts the real price of care, and causes over consumption (ask your local economist what happens when prices are distorted).

Having ignored these misrepresentations, we are now in a position to consider what is missing in this debate that the BA toolkit could possibly help with.

How about Feasibility Analysis?  We can ask questions like “Has this been done before?”   Answer – Yes, by most of the developed nations of the world.

How about Root Cause analysis?  We are the only advanced nation that still has a strong political commitment to the idea that each citizen should have to negotiate the price of their health and lives with mathematical, marketing and manipulation experts, and that this negotiation is “free”.  The whole assumption around free markets is that all parties have the same information, and that each is unconstrained by any coercion.  When my life, or my family’s life is at stake, and I am negotiating for those lives, am I truly “un-coerced”?  When the only “affordable” health insurance is money that I must negotiate away as part of taking a job, am I really free to choose.  SO – ROOT CAUSE – MY LIFE, MY JOB, are SO IMPORTANT to me, and so trivial to the insurance company, that we cannot negotiate from an equal footing.

How about Making the Business Case?  The cost of uninsured, emergency room users is well known.  The cost of health insurance is well understood, including the fact that the U.S. spends more for less than any other developed nation.  The cost of an unhealthy population is trickier, but has been estimated by many economists.  The cost of people being meek on their jobs because they are afraid of losing their health insurance, in addition to their incomes, is even harder to estimate. However, as a BA committed to making things better, it is my observation that people with jobs are mostly afraid, and don’t like to speak up or join in change, leading to the increasing “smoking” of the U.S. by other nations economies and capabilities.

The benefits are harder for people to see, at least at the level of the common good, especially because we have never experienced them, and our culture encourages selfishness first, except in case of disaster. Some still don’t think health care is a disaster, otherwise I am sure they would do the American thing and pitch in.  Nonetheless, these benefits can be estimated, have been estimated, and have been demonstrated in other nations.

How about a little BPR?  I am sure if someone analyzed the time and effort and overhead that goes into delivering a simple freaking checkup, one would conclude that there is a lot of wasted heat and light.  Indeed, a quick and dirty think through would immediately get rid of the “adversarial” fault-based process for deciding to give health care. And it would streamline the process by using rapid expert decision making between doctors and patients. It would also provide quality measurement data on the performance of doctors and hospitals.

Alas, the last issue I mention is the toughest – building consensus and managing the discussion of requirements.  The current environment in Congress and the political landscape is full of “meeting killers”, people who are not interested in solving the larger problem, but only interested in their own turf.

As BAs, we have all seen this, and sometimes we have been able to negotiate good requirements in spite of bad behavior.  If only Congress had a BA – any candidates?

By the way, if you disagree with my analysis, please know that as a BA I am not attached to it – I am happy to sit back and watch those who disagree get what they get, until the crisis is great enough that they can blame me for naming it, and kill me for being the messenger – Sigh!

Keep the discussion coming – I can hardly wait on this one!

Don’t forget to leave your comments below

Marcos Ferrer, CBAP has over 20 years experience in the practice of business analysis and the application of Information Technology for process improvement. Following graduation in 1983 from the University of Chicago, Mr. Ferrer joined IBM in Chicago, where he worked on requirements and systems implementations in diverse industries. His recent projects include working requirements for the Veteran’s Administration, introducing BA practices at the Washington Suburban Sanitary Commission, and creating bowling industry models for NRG Bowl LLC. In November 2006, Marcos Ferrer is one of the first CBAPs certified by the IIBA. He has served as an elected member of the DC-Metro chapter of the IIBA, most recently as President, and assisted in the writing of the BOK 2.0 test.

© Copyright 2010 Marcos Ferrer