Design Matters - Healthcare Systems Edition

Design Matters – Healthcare Edition

In his book The Opioid Crisis Wake-Up Call, Dave Chase quotes Dan Munro by writing, “The [healthcare] system was never broken, it was designed this way.”

 

I’m a fan of Debbie Millman’s podcast, Design Matters. When we are making something that other people will use and engage with, it is important to think about all the various aspects of how the thing will be used and how it can meet the needs and expectations of others. Whether what we are producing is art, a branding campaign, or a national healthcare system, design matters.

 

Unfortunately, the Untied State’s healthcare system wasn’t built on a design matters philosophy. We see inefficiencies everywhere, with some people getting care they don’t need while others can’t get routine basic care that could save their lives. Dan Munro says that the system was built this way, meaning that the inefficiencies, the inequalities, and the high costs were part of the system from the beginning, intentionally built in. The dysfunction we see in the system, according to Munro, is not so much a bug but rather a feature, helping someone make a profit or get priority access to the healthcare they want.

 

I think Munro is a little wrong. I think the system is a hodgepodge of pieces smashed together over the years. It is an incoherent patchwork of tools and players that has been haphazardly assembled over the years, with some working to truly do good, and others taking advantage of design flaws for their own aims. The system, in my argument, was never designed at all.

 

Design matters and what needed to happen decades ago was a real conversation about how the country would design a healthcare system that could innovate, that could meet the needs of citizens, that could ensure basic access to medical services, that could help provide preventative care rather than just emergency interventions, and that could be sustainable. Instead, doctors went about providing medical services, insurance companies popped up to help pay for some pieces here and there, and eventually businesses got in the mix and offered health insurance to employees. Each new step in healthcare in the Untied States has happened almost randomly, without a lot of deliberate planning.

 

Now the system is so large and complex that planning feels impossible. Legislation to address the challenges of the system is thousands of pages long, and because the most comprehensive law to restructure the program adopted the namesake of the nation’s first black president, a Democrat that became a polarizing figure, half the country derided the attempt to design something better. We can try to reshape bits and pieces of the system now, but design matters, and I understand why so many want to hit a restart button and rebuild a system from scratch.

Start High School After 8 A.M.

I’m a super early morning person and I have been since high school, but I was definitely a bit of an anomaly in high school and throughout college. Most high school students, not necessarily through their own poor decision-making or bad habits, go to sleep a lot later at night and don’t wake up very early. It is a pattern that is made fun of in families and in popular culture, but it is a pattern that seems to be pretty stable and should be considered when we think about designing a school system for teenage children that maximizes their educational opportunities and efficiency.

 

This is an argument that Dan Pink presents in his book When. In most places in the United States, my hometown of Reno being one of them, our high school students have the earliest start time. Middle school students head to school next, and our elementary age children start school the latest. This allows us to have three different bus schedules that pick up the oldest kids in the early morning, then get the next youngest group, and finally get the little guys. What we prioritize is an efficient bus schedule that feels safe for our youngest kids, not necessarily our kids learning.

 

The problem with this schedule is that it is a bit backwards for our oldest and youngest children. Our younger kids tend to wake up a little sooner and would actually do better than our teenagers with starting school early in the morning. Teenagers need just as much sleep as kindergartners, but rarely get enough. Moving school back for them would actually help them get more sleep and be better students. Their learning would improve, their driving would be safer, and hopefully outcomes for our high school students would be better in the long run.

 

Pink references a study of start times for schools writing, “one study examined three years of data on 9,000 students from eight high schools in Minnesota, Colorado, and Wyoming that had changed their schedules to begin school after 8:35 a.m. At these schools, attendance rose and tardiness declined. Students earned higher grades in core subject areas of math, English, science and social studies and improved their performance on state and national standardized tests. At one school, the number of car crashes for teen drivers fell by 70 percent after it pushed its start time from 7:35 a.m. to 8:55 a.m.”

 

I understand that we don’t want to encourage teenagers to stay up all night on phones and computers, and I recognize that many people would be afraid that pushing the start of school back would do just that, but as it is now, we force teenagers into settings that are not conducive to learning. We make them start school early, prevent them from getting enough sleep, and put them in dangerous situations due to fatigue. What our current system reveals is that we value efficient bus schedules and perhaps a feeling of safety for our smallest kids over the actual learning that is supposed to take place in school. Perhaps it is fine to express our values this way, but we should take a critical look at the learning taking place in our schools and make sure that we are ok with the values we prioritize when it comes to our children’s school schedules. Making a switch would likely help our students learn more and save lives, two outcomes that should be high priorities for society and our education systems.

Cities and Environmentalism

Cities can look like dirty places with no greenery or living plants among the concrete, asphalt, and towering buildings. At the same time, however, cities can be much more efficient and environmentally friendly than rural or suburban places. I live in the Western US and we expend a lot of energy just to move things from one place to another. A lot of the energy we produce just goes into moving water around. For us to get from our homes to our places of work can require a lot of driving by ourselves in a car. And because the West has so much open space, we have built large neighborhoods with houses spaced out from one another, requiring more concrete for sidewalks, more asphalt for roads, and more copper for electric lines.

 

The amount of resources needed to build suburban and rural connections between people is much greater than the per capita need within cities. As Jeremy Nowak and Bruce Katz write in The New Localism:

 

“The linkage between culture and cities also has to do with environmental sustainability and how its associated values translate into imperatives to re-purpose legacy places. Cities are ideal places for environmental stewardship, which is important to the culture: urban dwellers are not as car dependent as people in the suburbs, and urban life can be more energy efficient. Urban dwellers can use public transportation, walk, or ride a bicycle to work. Thus urban civic activism based on retrofitting the older built environment emerged in concert with an environmental ethos.”

 

I live in Nevada which is a state with a lot of rural space. I live in one of the two major metropolitan regions, but in the smaller of the two and toward the outskirts of town where the suburban starts to give way to the rural. I currently have an incredibly long car drive to work. The people I live around generally don’t seem to be as worried about environmental concerns, or if they are, then like me they may chose to ignore them or to accept living with a feeling of guilt because our way of life is in some ways very costly and resource demanding. The challenge is that it is hard to change and do much about our environmental impact, and we like our space, our quiet neighborhood, and our affordable homes.

 

People who live in the middle of a city don’t have as many of the same barriers to living a more energy efficient and environmentally considerate life as I do. When car reliance is less pronounced, it is easy to go without a car and decry the damage done by cars to our environment. When you spend less time in traffic and have more ability to use your time, you can engage in more pro-social and pro-environmental movements. Given the state of climate change, this is a positive aspect to cities. People can live more efficiently and be more inclined to advocate for a more environmentally considerate way of life. A shift in what we view as a good life (away from the picket-fence-two-car-garage-and-a-dog-in-a-yard to a life of greater connections in a city with less individual space) is a change in values, and is something that is leading to a revival of city centers and urban societies across the country. As networks and connections matter more and more, living close to people and having more interactions is becoming more valuable than having one’s own space and things.

 

Another important aspect in Katz and Nowak’s quote is the focus on rebuilding and re-purposing. Cities have existing infrastructure that needs to be updated as people move back into and begin to redifine their cities. This gives cities the chance to establish themselves as cleaner and better versions of what they have always been. The way that streets, buildings, and open spaces are used can be reimagined during this transition, allowing them to become more environmentally sustainable and more economically inclusive. This helps reduce the overall carbon footprint of city residents and helps them become places where people can actually live, work, and enjoy their time.