Gladwell and Minister Harney
I really like Malcolm Gladwell. I had the privilege of listening to him speak when UCD hosted the writer a little over a year ago. On that occasion, he even kindly answered a question I put before him as he signed my copy of Outliers. Days later, while reading the book, I remember disagreeing with something he had written (the first and only time that I’ve seriously disagreed with Gladwell). Mixed in with stories about Mozart, Steve Jobs, and Korean pilots, while defending his 10 000 hour thesis, Gladwell makes the case for charter schools.
Charter schools seem to me to be a particularly American solution to poverty. A testimony to the mastery of the market, they demonstrate what can be accomplished given the right incentives. Typically, inner-city American children fall behind their better-off cohorts academically. The root problem is that social issues keep these children from devoting as much time to their studies as others. Charter schools therefore start early in the morning and end late in the day. They also offer shorter vacations since they aim to keep their pupils in active learning for as long as possible. The idea is that if these children are in school for a sufficient period of time, they will cover as much ground as children in better social circumstances and will therefore be more likely to succeed academically. And they do just that, making the schools very popular in poor areas, despite being almost cruelly taxing on their pupils.
I don’t like the idea of charter schools. An old paediatrician once called me a bleeding heart liberal, but on this issue, I think we would agree. Charter schools, in my opinion, treat the symptom rather than the underlying pathology. If poverty is the issue, I don’t see how allowing a few to keep up academically can be thought of as anything but a temporary bandage. Reading Gladwell hold up this bandage as a potential solution makes me more than a little uncomfortable.
That same feeling was evoked in me by the minister for health, who wrote:
…The critical question is how we use all resources, particularly public resources, to help people stay healthy and to get best outcomes for patients from healthcare…
…It’s a critical question for all developed countries because the hospitalisation model of healthcare is financially unsustainable…
…I invite people to recognise that it’s more important how money is spent than how it is raised from the public…
…Our policy is equity of access to publicly-funded health services. We are open to using all providers who meet quality and value for money standards to contribute to public services…
A comparison between Gladwell and Minister Harney isn’t quite fair. I generally tend to agree with the former while I mostly disagree with the latter. I just don’t share her faith in the market. Gladwell believes in charter schools because he believes that if you spend long enough at something (10 000 hours), you’ll do well at it given some aptitude. Minister Harney on the other hand, from what I can gather, believes in the market.
But even before we get to the question of service delivery, an important question must be answered. What does ‘equity of access to publicly-funded health services’ mean? We can even simplify that. What is equity? Does it mean that people get what they pay for, such that those who are willing to pay extra are entitled to more or better or faster services? Does it mean that absolutely no distinctions should be drawn between patients, so that regardless of one’s ability to pay, or how expensive one’s treatment may be, each will be treated ‘equally’? Or does it mean that each citizen will be allocated a fixed sum of money, health credits so to speak, and will be entitled only to their fair share such that when those credits run out, they are no longer eligible for state health services? Or that the state’s health services will be structured so as to serve the greatest number; meaning that those whose ailments are expensive to treat will have to access their healthcare elsewhere?
And what about the suggestion that ‘the hospitalisation model of healthcare is financially unsustainable’? Isn’t it only unsustainable if one holds to a certain set of values? The Cubans (I know, this example is well worn now), seem to value healthcare above modern consumer goods. I imagine that the idea that the hospitalisation model is unsustainable, on a budget of €15 billion, when far greater sums can be found to prop up the financial services sector, would make no sense to them.
Doesn’t the question of what is or isn’t financially sustainable then really rest on what we take as our foundational principles? Isn’t the same true of what we mean by the word ‘equitable’?
I suppose what worries me most about the minister’s article isn’t so much the matter of our ideological differences, or my fear that, as Dr Christine O’Malley suggested on radio today, the subtext is a desire to privatise health. No, the real worry for me is that we make Gladwell’s mistake and fight over which bandage to apply rather than engaging in debate over the real underlying issue. What are our views on justice? What does equity look like? Who should get what and why?
The only way €15 billion isn’t enough to sustain the health of less than 5 million people is when there is an attempt to throw money at the issue instead of directly addressing those difficult core issues.