Health care is a sticky issue. As the president pushes for reform legislation, the conversation has grown heated and rhetoric increased.  We are inundated with phrases like: bending the curve, rationing, single-payer plans, government mandates, employer-provided insurance, etc.  Everyone seems to have an answer, but no one seems have a solution.  Why?  In part, it’s because people view the role of government differently.  But this familiar debate describes just a small piece of the puzzle.  The larger issue is this: The outcome that the strategies and tactics being debated are designed to advance is poorly defined.  We discuss the ‘who’, ‘when’, ‘where’, ‘why’, and ‘how’ while taking the ‘what’ for granted.  Until and unless there is agreement about the ‘what’—the ends—we will continue to disagree about the means.

So what exactly is the desired outcome of these efforts?  I imagine many people’s minds go straight to ensuring access to health care for everyone.  That’s certainly the popular frame for the conversion.  But I would ask “why?”  Health care itself is a means to an end, not the end itself.  Rather, the outcome is ensuring good health for everyone.  That’s the ‘what.’

You might be asking, why make this distinction?  Without an outcomes-based approach, it can be extremely difficult to come up with a cohesive strategy.  By agreeing upon the outcome that we want to create, we establish a common lens through which we can view possible strategies.  And through this lens we are able to ask better questions.  The right question is not “how do we provide better, cheaper health care” – that’s a conversation about the tactics regarding a single strategy.  No, the right question is “what is the right strategy to better health outcomes given our available resources?”  Put more simply, how do we go about buying the most health for the most people?  That is the question.

Much of the current discussion centers on providing affordable access to health insurance.  A laudable goal, perhaps, but that assumes insurance coverage means access to quality health care (which may or may not be true) and ignores the reality that “health care,” defined primarily as the treatment of illness, is only a small part of the health equation.  When we take an outcomes-based approach, when the challenge becomes using our resources to improve health outcomes and not just treating illness more efficiently, a new universe of strategies unfolds. 

Maybe we’d produce more health through incentivizing healthy behaviors.  Maybe we’d produce more health through preventative care.  Maybe we’d produce more health through nutrition education.  Maybe we should clean our air and water.  Maybe we should build more parks.  Maybe we should subsidize more vacation time.  There are all sorts of ways to spend money that could improve our health.  Without an outcomes-based approach, we have no way to consider these alternatives.  How much health can we buy with $100 billion spent on these strategies?  How does that compare to the amount of health gained by spending $100 billion on health care?  I certainly don’t know the answer.  But it would be nice if somebody was asking the question.

This is hardly an uncommon problem.  Grant makers face this decision constantly.  Which grants will produce the greatest results given the investment?  How do you compare the value of the results from different programs?  Is it better to help somebody write a resume’ or to give them food and shelter for the night?  Better teachers or new textbooks and computers?   We live in a world of scarce resources.  In the pursuit of social impact, be it as funders or service providers, the federal government or a local community theater, it’s important we ask the right questions.  It’s easy to get lost in our own histories, the accumulated programs, activities and relationships that we’ve developed in the course of doing good.  But those activities are not our mission. 

Take that step back and ask “why are we doing these things?”  Not just the purpose, but the method.  Once you know the outcomes you seek ask “Given our resources, are our current strategies (programs) and tactics (activities) really the best approach to make progress so that we may ultimately create as much impact as possible?”  Consider that the right question may not be “how do we do what we do, better and cheaper?” but rather “Given the results we seek, what are the ways in which we can get the most bang for our buck?

The United States spends more per capita on health care than any other advanced nation and yet lags behind on indicators of good health.  Unfortunately, it seems that most of the discussion about this problem is focused on the provision of health care services and the funding of those services through insurance.  This myopic view focuses on a specific strategy and its related activities borne of an unusual history of market and legislative forces.  But these are only a small part of the picture Instead, let’s use an outcomes-based approach to identify and support the strategies, in proper proportion, which best support the most health for the most people.