The Immunity to Change Health Care in America

Don Berwick, during his time at CMS, had the opportunity to hear about health care from the point of view of consumers. Many times, he noticed the irony that Americans who would benefit most from health care reform were most vehemently against it. The message that health care reform is not only bad, but evil, has aroused the most basic fears – including fear of death – in a distrusting public.

Meanwhile, the message that health care reform is good for our country is falling on deaf and unbelieving ears. Why is that?

IHI staffers recently had the opportunity to hear Robert Kegan speak. In his book Immunity to Change, he points out that there are hidden and powerful assumptions that stymie people from changing habits and attaining stated goals. The inability to reach these goals is due to the reality that our current behaviors are a perfect response to these hidden and powerful assumptions. For example, a child can understand that it's good to share, but if there is an underlying fear that there's not enough, the logical commitment is not to share. It is an emotional response to the assumption of "not enough."

Most people, when asked, would conceptually favor attainment of the Triple Aim – better care for individuals, better health for populations, and lower per capita costs. However, health care in the United States is strongly counterproductive to achieving this: technology and hospitals are overused with resultant waste, access to high quality care is inconsistent at best, and unsafe care remains a problem. What are the hidden assumptions that drive Americans to hang on so dearly to a dysfunctional and unsustainable health care system?

Americans have been led to believe that good health care is a life-giving, but expensive and limited consumer product. The assumption is that health care has to be purchased. It is not a societal right. "Don't take away my Medicare" is a response to the awareness that health care must be purchased. In contrast, we generally expect education to be provided, not purchased. In the United States, people have vastly different expectations of health and education. The assumption is that this is the way it has to be.

How do you think we can alter this assumption? In other words, how can we remove this immunity to change? And how can we create a message for better health care that Americans hear clearly?

- Warren Wong, IHI Fellow