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Health care reform: through the lens of change.

RECENTLY, WHILE TEACHING A course on leading change to a group of smart hospital managers, I found myself reflecting on the parallels between social systems change theory and the current events playing out over health care reform. In an attempt to make sense of the heated rhetoric that is reverberating across the country over healthcare reform, there is value in using the lens of change theory. Although the policy arena is a more complex and amorphous context than ah organization, both respond to and are influenced by environmental drivers and constrained by institutional structure. Both face similar challenges regarding adaptive abilities to manage change. Change theory concepts--, vision, current and future states, and social buy-in--provide some analytical leverage in understanding current reform challenges.


In change theory, drivers are defined as forces (either internal or external) that influence the success or failure of a change effort. External factors are forces outside the control of an organization. Examples of external drivers include the media, the global economy, and swine flu. What we believe about a change is framed by our basic ideological views. That being said, political ideology reflects a spectrum of liberal and conservative ideas regarding the role of government. While it's never ideal to make generalizations about what a certain group thinks, for the purposes of describing the current turmoil over healthcare reform, these distinctions can provide some direction for analysis.

A common contemporary definition of a liberal (left) is someone who advocates change and new ideas. A conservative (right) is generally defined as someone who avoids change, instead preferring to stick to things as they are (Messerli, 2008). These two positions are clearly reflected in the debate over healthcare reform as Republicans rail against many of the proposed changes in healthcare policy and the Democrats push toward different healthcare reform visions. The public option is a left-of-center idea that advocates greater government involvement and stronger social policy, while the right argues that "more" government is not the answer and change in health care reform needs to be strengthened through a strong free market. The healthcare debate also captures the divisive issue of personal responsibility. Democrats promote coverage for all Americans while many Republicans argue that people must take responsibility for obtaining their own healthcare and a strong free market economy can make health care more affordable for all. If that isn't discordant enough, let's not forget that abortion, medical malpractice, and physician-assisted suicide ("pulling the plug on granny") are all contentious issues that have been thrown in the mix of this health care reform battle. These issues have long served to polarize stakeholders and differentiate conservative and liberal positions.

The Change Message

Successful change efforts are led by the development of a compelling vision. A compelling vision has certain attributes. Kotter and Cohen (2002) describe an effective vision statement as easy to understand, creates a sense of urgency, reflects the impact on the individual, and can be visualized both through head (analysis) and heart (emotionally charged). President Obama provided a vision for healthcare reform early in his Presidential campaign. The vision of quality, affordable healthcare for all Americans including reducing overall healthcare costs may be a shared vision, but when taken up by Congress it became blurred as proposed legislation (action steps) produced a melee of divergent interpretations.



We know that resistance to change is often a natural reaction for all of ns. Change theory postulates that if there is not strong dissatisfaction with the current state, the future state is less feasible. Usually people must be in a great deal of pain or discomfort to seek change. The statistics indicating that approximately 45 to 47 million Americans under the age of 65 are uninsured (U.S. Census Bureau, 2009) represents a great deal of pain. Yet, there are many more people who have health insurance, including all of Congress. Sadly, there are also many Americans in a great deal of economic pain as job losses have increased. Over the last 13 months, our economy has lost a total of 3.6 million jobs, and this trend is expected to continue (Bureau of Labor Statistics, 2009). Because health insurance and employment often go together, this year's devastating job losses are estimated to have increased the ranks of the uninsured by four million people (Families USA, 2009). Maslow taught us that people respond to a basic hierarchy of needs. The values for what people stand for and the reality they face can quickly lead to a change in priorities. When voters perceive that the choice that must be made is between helping others and taking care of their own financial survival, support for health care reform can swiftly shift in magnitude and direction.

This evolving economic reality pushes hard against the vision of health care reform. Even as respected economists argue that the rising costs of healthcare are unsustainable, initially a positive driver for reform, the immediate outlay for a transition to broader healthcare access is being reframed as greater debt. Day after day, the number $1 trillion is repeated; a number that most of us can't even comprehend. The questions of who will pay for healthcare reform and how, form the strongest claims for resistance. With the national debt at ah all-time high, costs and benefits take on new meaning. The expectation that a plan be designed to meet the contradictory requirements of oversight, cuts and new outlays in understandable terms was a task of Sisyphus proportions. The Senate Finance Committee experienced painful scrutiny over the summer as legislation that would pay for healthcare reform was exhaustively honed amid contrasting notions of the state-economy nexus. The recent rebirth of a public option is seen by some as a way to create competition and drive down healthcare expenditures while others argue that a public plan will do nothing to drive down the price tag, citing other government programs like Medicare as unable to control cost inflation (The Economist, 2009). This leads to a final change concept that provides a constructive frame for looking at the media's communications regarding health care reform.

Communicating for Social Buy-In

Kotter and Cohen (2002) observe that the communication of a vision can fail for many reasons, the most obvious being lack of clarity. Communicating for buy-in on a large scale requires that leaders have clear ideas, and respond quickly and with conviction. And leaders must be able to handle tough questions without becoming defensive. In part, this is crucial because the audience receives not only information but their feelings are being addressed and sometimes modified. Emotional not rational messages have achieved new heights (or new lows depending on how you see it) as the political discourse over health care reform has often become destructive. As someone trying to understand the policy reform issues, I am enraged. The loss of public trust in mainstream journalism coupled with the economic drive to fill the TV and radio mediums with 24-hour news has led to ah increase in listeners to talk and radio show hosts who offer propaganda more than news. Opinion talk on the left and right does not serve to inform citizens or find common ground but tends to isolate and polarize. The ability to engage in civil discourse appeared to be a lost art as witnessed this past August during healthcare reform town hall meetings. Critics would argue that historical perspective is required. Sharp opinions, hyperbole, and yelling have always been a part of political entertainment. This is a different time; not only bas the medium changed bur the number of people receiving data points without context provides nothing but greater confusion and distrust for any political endeavor. The need to promote public patience and understanding over the policy building process rather than entertainment over political issues is a force to be reckoned with if our democracy is to be informed rather than diluted.

The current 24-hour information flow provided on healthcare reform is overloaded with emotional messages. Whether you still read a newspaper and note the full-page ad stating that current health care reform legislation is "the worst bill ever," see the television ad showing a man moving into an apartment then going to the hospital with flowers in hand to visit his ill wife with a final message that no one should lose their home to health cafe costs, or hear a commentator discuss his concern that revolutionaries are trying to destroy the nation, finding balanced reporting has become nearly impossible. Some journalists argue that the public is smart enough to get through the morass of news media dogma. I challenge that stance. We lead busy lives; we need to trust there are sources dedicated to developing an educated public respectful of different views. Change initiatives require social buy-in; If that process is compromised, successful adoption is nearly impossible. Healthcare reform legislation must reflect a middle ground and be communicated responsibly.

Social systems change theory is another way to conceptualize and broaden our understanding of health policy as a form of social change, how environmental of external forces influence policy design, and how the ongoing media presentation of a policy influences direction of the outcome. Heifetz (1994) notes that a social system will typically honor some mixture of values and that competition or simply difference within the mix largely explains why adaptive work involves conflict. We can only hope that there will be strong efforts between Republicans and Democrats to engage in constructive adaptive work to produce healthcare reform legislation that Americans can believe in and support. Greater involvement from nurses in developing and communicating a vision of healthcare reform that will result in successful public buy-in is critical. As nurses, the outcomes of this battle will frame our future as professionals and as citizens.


Bureau of Labor Statistics, Office of the Speaker. (February 6, 2009). What 3.6 million jobs lost over 13 months looks like. Blog posted by Karina. Retrieved from

Messerli, J. (2008). Political ideology definitions. Retrieved from

Kotter, J.P., & Cohen, D.S. (2002). The heart of change. Boston: Harvard Business School Publishing.

Families USA. (2009). The one-two punch: Unemployed and uninsured. Retrieved from resources/publications/reports/one-two-punch-findings. html

Heifetz, R. (1994). Leadership without easy answers. Cambridge, MA: The Belknap Press of Harvard University Press. The Economist. (2009). Back from the dead. The Economist, 393(8655), 20.

U.S. Census Bureau. (2009). Income, poverty and health insurance coverage in the United States: 2008. Retrieved from archives/income_wealth/014227.html

DEBORAH GARDNER, PhD, RN, is Chief, Office of Organizational Development, National Institute of Health, Clinical Center, and a Nursing Economic$ Editorial Board Member, Bethesda, MD.
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Title Annotation:Health Policy and Politics
Author:Gardner, Deborah
Publication:Nursing Economics
Geographic Code:1USA
Date:Nov 1, 2009
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