Businesses and Healthcare Solutions

Businesses and Solving Healthcare Problems

We often overlook businesses when we think about the problems in American healthcare and how we can fix the issues that plague our system. But about half of all American’s receive their health insurance as a benefit provided by their employer. Businesses purchase and provide health insurance for millions of Americans, and must think about employers and the plans they offer when we think about the problems in the American healthcare system.


Everyone will tell you that healthcare is complicated. We know that insurance is hard, getting to a doctor can be hard, understanding what you have to pay is hard, and trying to guess what kind of plan you need for the next year is hard. All of this makes the solutions to our healthcare problems hard, but for a majority of Americans, the person who is shaping the structure in which they will make these decisions and figure out what is available to them is someone at their job. And for a lot of those Americans, the person at their job is probably in HR, and their main goal is not to find a great healthcare solution for the employees, but to just not get yelled at by the CEO for raising health insurance coverage costs and to avoid being yelled at by unhappy employees. Nevertheless, businesses can step up and play a role in making changes for the positive in the American healthcare system.


Dave Chase in his book The Opioid Crisis Wake-UP Call writes, “The opioid crisis is a complicated issue over 30 years in the making. But companies have played a major role in creating and sustaining the crisis. And a vanguard of employers are realizing that they have a major role to play in solving it, and that the solutions fall well beyond what the government alone can do.”


Companies, since they control the healthcare of half of Americans, can start making real changes to the care available to people. Employers who set up their own plans can make primary care access, physical therapy, and nutrition services virtually free to their employees. By providing a greater selection of preventative services, they can improve employee well-being and reduce the likelihood that an employee will deal with chronic pain and develop an opioid addiction. This is an over-simplified example of what companies can do, but it is important that we realize that the employer is a major player in the fight to improve the American healthcare system, and if we don’t step up to demand better from our employers, we won’t see the changes we want.
Humans are Not Automobiles

Metaphors and Similes of the Human Body

Human beings think in metaphors and similes, especially when it comes to thinking about ourselves. We come to understand one thing by comparing it to another, and we describe something as being like something else, to help us understand how we should relate to it. A metaphorical way of thinking that Sam Quinones is critical of in his book Dreamland is the description of the human body as an automobile, or more generally as a machine.


We think of ourselves as if we were the most advanced technologies we have developed. We imagine that we could have parts swapped, that we just need little tune-ups here and there, that all we need is a mechanic to tinker with a few things and we will be back to running smoothly if we are ever out of whack. However, this metaphor, like all metaphors, is an incomplete way to understand the reality of what we are.


Our minds are only so good at holding lots of complex information. We use metaphor and simile to simplify our thought process. Metaphors and similes serve as heuristics to understand and conceptualize complex structures and relationships, but they don’t actually capture the full scope of reality. To say that the human body is an automobile, or operates as an automobile, misses key aspects of human dynamism, plasticity, adaptability, and function. We respond to the world and our environments, change and adapt to new settings and structures, and move in ways that no machine that we can create today can. We share some things in common with machines, but we are not machines.


In Dreamland, Quinones quotes a physician at the University of Washington Center for Pain Relief named John Loeser who explains why this type of thinking is dangerous, “Usually the patient says, ‘I come to you, the doctor. Fix me.’ They treat themselves like an automobile. People become believers in the philosophy that all I need is to go to my doctor and my doctor will tell me what the problem is. That attitude has been fostered by the medical community and Big Pharma. The population wants to be fixed overnight. This is the issue we addressed with chronic pain patients. They have to learn it’s their body, their pain, their health. The work is done by them.”


The automobile metaphor manifests falls apart when we project a quick scientific and technical fix for ourselves. The idea that all we need is a special additive to make our body work better is what fuels our desire to have a pill to solve all our medical problems, and it is emboldened by the idea that we are basically automobiles.


We always compare ourselves, our brains, and our bodies to the highest technology of the time. If we don’t consider ourselves automobiles anymore, we probably think of ourselves as technical space ships or precision fighter jets. Humans once thought of the brain as a complex system of pulleys and levers, and now we think of our brains as supercomputers.


What Quinones uses the quote from Loeser to show is that we are living systems. We are not machines that can be isolated from our environment, tinkered with, and tuned for optimal performance. We have to be responsible for how we live and the systems, structures, societies, and institutions that we all build and live within. If we don’t truly think of ourselves as more dynamic than machines, and if we don’t consider our interconnectedness, we will never understand ourselves properly, and we will never fix the problems we face, like chronic pain. We will turn to cheap tricks and remedies, and we will face the consequences of living in a way that praises quick fixes and pills to try to solve our problems.

Problem Solving to Fit the World

In The New Localism Bruce Katz and Jeremy Nowak argue that political decision-making, solutions to complex problems, and innovations in progress and economic development occur more at the local level than at the national level in the world today. Their argument is that national politics is complex and cumbersome, with too many large and disconnected voices and opinions to tailor policy solutions to problems in ways that actually make sense. More local structures, on the other hand, are better suited to find and implement real solutions to the specific problems taking place in a given region.


“Cities and other localities,” the authors write, “can craft and deliver better solutions to hard challenges since they match problem solving to the way the world works – integrated, holistic, and entrepreneurial rather than compartmentalized and bureaucratic.”


Sometimes we think about our challenges and problems as being distinct from each other. We tend to think  the opioid crisis is a healthcare failure, that unaffordable rent in San Francisco is a housing policy failure, that a factory closing is an economic failure. We try to find individual solutions to each of these problems such as, introducing databases to monitor opioid prescriptions, or capping the price of rent in a city, or by trying to attract a new business to fill the old factory with tax breaks. In reality, however, all of these policy areas are interconnected. Economic development can influence the price of housing, and stable housing (or the lack thereof) can influence community dynamics which make people more or less likely to misuse drugs. Trying to tackle any individual problem from a broad national level, without considering the specific details that contribute to the problem in a given place would be unlikely to succeed.


Local problem solving, as Katz and Nowak suggest, is able to look at problems in a more comprehensive way since it tailors solutions to the local environment. Solutions can be integrated instead of compartmentalized and localities can bring entrepreneurs into the fold to mix business interests and development with social responsibility and support. The policy that is likely to succeed in reducing opioid misuse San Francisco is unlikely to be the same solution that would succeed in Dayton, Ohio, but both communities could share what they learn and take advantage of local resources to build coalitions to address the problems in a manner consistent with the local experiences. National level policy cannot introduce such individualized solutions and cannot be as responsive to the local variations on a given problem.

Designing for Two Goals

“Savvy institutional designers,” Write Kevin Simler and Robin Hanson in The Elephant in the Brain, “must … identify both the surface goals to which people give lip service and the hidden goals that people are also trying to achieve. Designers can then search for arrangements that actually achieve the deeper goals while also serving the surface goals-or at least giving the appearance of doing so. Unsurprisingly, this is a much harder design problem. But if we can learn to do it well, our solutions will less often meet the fate of puzzling disinterest.”


In public policy research, there is a framework that is used to understand the legislative process called the Social Construction Framework (SCF). When examining the world through the SCF, we look at the recipients of particular policies and ask what social constructions are at play that shape the type of legislation surrounding these recipients. We also group the recipients into four broad groups: Advantaged, Contenders, Dependents, and Deviants.


Advantaged are those who have strong political power and public respect, like veterans and small business owners. Contenders have lots of political power, but are not viewed as warmly in the public eye, such as big business or unions. Dependents are socially sympathetic groups that don’t have much political power, such as sick children who can’t vote but evoke sympathy. The final group, Deviants, are socially scorned and politically weak, such as criminals or drug users.


The way we think about who belongs to which group is a social construction. That is, we attribute positive or negative qualities to groups to make them seem more or less deserving. Businesses always highlight the jobs they bring to communities, the innovations they create to make our lives better, and the charitable activities they contribute to. This is all an effort to move from a Contender status to an Advantaged status. Similarly, we see movements where people look at drug addicts and criminals in new ways, seeing them more as victims of circumstance than as entirely bad actors, moving them from Deviants to Dependents.


The reason this is important is because we introduce policies that either reward or punish people based on the groups they belong to. It all ties in with the quote from the book because we can either openly distribute a reward or punishment or distribute it in a hidden manner. Our policies might have stated explicit goals, but they may also provide a big business a hidden tax break. Our policies might be unpopular if they directly provide aid to former felons as they leave prison, but offering policy that is nominally intended to help the poor may provide a greater benefit to formerly incarcerated individuals than anyone else.


Hanson and Simler call for more sophisticated policy design that addresses our stated high-minded motivations and at the same time helps fulfill our more selfish and below the surface policy goals. SCF is a powerful framework to keep in mind as we try to develop policies and think about ways to actually enact policy that has both open surface level implications and addresses our deeper hidden purposes. This can, of course, be used for good or for ill, just as the tax code can be used to hide tax breaks for unpopular companies or help new homeowners, and just as social programs can be used as cover to assist individuals who are typically seen as Deviants.

The Ego and Fairness

I am constantly interested in discussions, arguments, and complaints about fairness. defines fair as “free from bias, dishonesty, and injustice” but I think we all know “fair” to be more complex than that definition suggests. What I suspect we often mean when we say fair is equitable, which is a far more complex understanding of the world, events, people, and our interactions with all three. Another quick Google search gives us a definition of equitable as fair and impartial (not much help here), but Deborah Stone in her book Policy Paradox identifies nine different dimensions of equity. Things can be equitable by membership, so  that something is equal among a group, but not necessarily equal between groups. Things can be equitable by rank, where different segments within a group receive different treatment, but within a given segment everyone receives something equally. And things can also be equitable based on how they are distributed, with people all having equal chances of obtaining something or with people having equal opportunities to try to obtain something.


What got me thinking again about fairness and equity is a quote from Ryan Holiday in his book Ego is the Enemy. He writes “Ego loves this notion, the idea that something is “fair” or not. Psychologists call it narcissistic injury when we take personally totally indifferent and objective events. We do that when our sense of self is fragile and dependent on life going our way all the time. Whether what you’re going through is your fault or your problem doesn’t matter, because it’s yours to deal with right now.” What I take away from this quote is the idea that (1) we spend a lot of our time and energy trying to figure out if we deserve something or not, (2) we feel personally injured or attacked when something we deem to be unfair happens to us, and (3) we often don’t have much control over whether we receive what we deserve or not.


I started with a definition of fairness because I think it is important to get to the root of what we mean when we say something is not fair. We want our life outcomes and the things that happen to us to be commensurate (corresponding in size or degree) with the kind of valuable person we see ourselves to be. We want good things to happen to us and other good people, and we want bad things to happen to bad people as if our lives are constantly judged and adjusted by an independent arbiter weighing our live on a balance.


However, I introduced Stone’s perspectives on equity to show that fairness is not a simple black and white consideration. Sometimes, equity depends on your position relative to society and the events within society that impact you. Would it be fair for everyone in your office to get an equal sized slice of cake on your birthday? Should you get the biggest slice because its your birthday? Should your boss get the biggest slice because they are the big kahuna and after all, if they had not hired you then you would not be there celebrating your birthday with everyone? Or should Cheryl get a bigger slice of cake since she was technically the company’s founder years ago, even though now she mostly sits in her office half asleep not really doing much? There are a lot of dimensions of equity and fairness that are hard to sort through, especially when our own self-interest is involved.


When we begin to complain that something is not fair, we should take a minute to step back and think about the various dimensions of equity and try to understand what aspects of equality are in play. Rather than focusing on whether we think we have been harmed, we should try to better understand the system within which we operate. Going further, we should recognize that we have little to no control over many of the things that happen in our lives. We cannot control a cancer diagnosis (for the most part), we cannot control whether a texting teen rear ends our car, and we don’t always have as much control over our income as we would like to believe. Sitting and constantly questioning why something happened to us, complaining that things are not fair, and arguing that something more fair should have occurred is useless. Often, there are different aspects of equity at play (if a social decision has lead to the outcome we don’t like) or we are trying to ascribe meaning to a random event over which we had little influence or ability to shape and avoid. We can think of what happened to us rationally, and then move on without having to critique the abstract universal balancer that we would like to have watching over our lives and adjusting our scales accordingly.


Remaining focused on whether something is fair and complaining that it is not fair will hold back us and our society. To move forward we must accept that fairness and equity are more complex than they feel in the moment, and we must accept that we have less control in our lives than we often believe. We can do our best with the hand we are dealt, and if we do not think that something is equitable, we can examine the ideas laid out by Stone to advocate for a different dimension of equity. Or if we don’t have any control over the event we can bear our situation nobly and move forward without feeling personally injured.

Whats the Real Challenge

Yesterday I wrote about how easy it can be to solve the wrong problem. When we go to meetings, chat with someone during a lunch break, or are working in a group on a project, it can become very easy to start complaining about whatever thing happens to be annoying us at that moment. Whatever issue we just had to deal with can be a bit overwhelming and can come to dominate our thoughts. However, the issue we just dealt with may not actually be the big thing at the heart of our problems. We might be annoyed by the way a particular form is being completed by another person or by a team’s inability to come together to finalize a draft of a new project, but the real challenge may be something deeper and more significant. If we don’t access that deeper level, then we are not actually doing anything that will help us or our organization improve when we complain at a surface level about some annoyance.

In his book The Coaching Habit, Michael Bungay Stanier has a recommendation for us to get to this deeper level. Throughout his entire book he encourages us to be better listeners and to ask the right questions to get our conversations moving in the right direction. His advice to get to the big issue is to ask, “What’s the real challenge here for you?” Whether we ask this to ourselves or to someone we are coaching, the result is a more deep consideration of the situation that is leading to frustration or bad outcomes. Bungay Stanier describes the question this way, “This is the question that will help slow down the rush to action, so you spend time solving the real problem, not just the first problem.”

Bungay Stanier explains that we will always have multiple problems to deal with, but that not all problems are created equal. Some will be more pressing then others and some will stem from larger more structural problems. Asking what the real challenge is can help develop thoughts on the larger issues at the core. Adding the “for you” part of the question dials in on the specific details that are in the individual’s (or your own) control, as opposed to details that are too vague and general to be something we can address directly. It also helps the question be more personal and aim toward individual growth and opportunity.

The Coaching Habit helps us get beyond simple venting and complaining to have more constructive and thoughtful discussions. Learning to listen and understanding how questions can help shape the direction of our conversations is crucial for successful coaching and even for successful introspection. Understanding our real challenge and then helping others dial in on their real challenges can drive new growth and productivity.

Solving the Wrong Problem

I work for a growing but still small tech start-up in the healthcare space based out of the bay area. The company has a great mission and is amazing to work for, but we have certainly had a lot of growing pains and unanswerable questions over the last four years that I have worked for the company. One of the biggest challenges we have faced is making sure we answering the right questions and getting the right solutions to the right problems in place.


Michael Bungay Stanier looks at these types of problems and takes them on in his book about coaching, The Coaching Habit. His book is full of recommendations to be a more effective coach and manager, and one of the benefits of his techniques is an improved understanding of the problems and questions that organizations must face. In the company I work for, things have always been in flux, and that means that sometimes it is hard to know what the real issue is and where we should be focusing all of our energy. If you polled the entire office about what the biggest problem is right now, you would get different answers from everyone. Bungay Stanier described the situation like this:


“You might have come up with a brilliant way to fix the challenge your team is talking about. However, the challenge they’re talking about is most likely not the real challenge that needs to be sorted out. They could be describing any number of things: a symptom, a secondary issue, a ghost of a previous problem which is comfortably familiar, often even a half-baked solution to an unarticulated issue.”


Effective leaders don’t just jump in when a team is discussing the issues they are facing and they don’t just take on all the problems in an attempt to solve everything themselves. Good leaders try to drill deeper to understand what is really at the heart of the collective issues facing the team, and then work to empower the team to tackle the problems they face. In my next post I’ll describe the conversation that Bungay Stanier recommends to help us find the right problem to solve, but for now I’ll describe the question he uses to get to the heart of the issue, “What’s the challenge?”.


In my career I have solved a lot of problems and fixed a lot of issues, but often times I have spent a lot of energy on problems and issues that end up not being very important. Something might be a little bit off and something might be an inconvenience, but that doesn’t necessarily mean that I need to spend a lot of effort fixing that individual thing. Perhaps what everyone complains about is frustrating and annoying, but it may just be part of a larger problem or something that would go away altogether by solving a bigger picture item. This is definitely an area where growth is possible for me, and is something that all organizations struggle with, especially if we are quick to action and don’t make real efforts to dive further. Asking ourselves and our team, “What’s the real challenge?” and looking upstream from the stated problems to possible larger causes is one way to make sure the work we do matters and is one way to galvanize our team around the most important solutions.