Tag Archives: Spiral Dynamics

Some Final Thoughts On “Health Care under the Knife”

Last month, I wrote two articles about the book by Howard Waitzkin et al. entitled, “Health Care under the Knife: Moving Beyond Capitalism for Our Health.

The first article was a review of the Introduction to the book. The second article examined the Affordable Care Act (ACA), also known as “Obamacare”, as the last stage of neoliberal health care reform.

In this article, I will critique the overall message of the book and give some reasons as to why I believe radical change in American health care and radical change in American society in general cannot take place until one key condition is met for that change.

This will also apply to the rest of the world where neoliberal policies have taken root. But since much of the impetus of these policies comes from the US and institutions the US created after World War II such as the International Monetary Fund (IMF), the World Bank, and the United Nations’ World Health Organization (WHO), as well as many international financial institutions and the Gates Foundation, it will be difficult, but not impossible to turn back those policies and effect the necessary change to secure universal health care for their citizens. Some have already done so.

The authors have made a very convincing case for their argument that the failure to achieve universal health care is a result of neoliberal policies enacted over thirty years ago both here in the US and in the UK under both Republican and Democratic administrations, and under the various Conservative Party Prime Ministers, from Thatcher, Major, Cameron, and now Theresa May, and Labour PMs, Blair and Brown.

However, their prescription for how we overcome these policies assumes that social change is necessary before there can be change in health care. While technically correct, their understanding of the conditions necessary for that change is flawed.

Economic determinism, the socioeconomic theory that underpins much of Marxist thought about Capitalism and the relationship between workers and owners of the means of production is central to the thesis in “Health Care under the Knife.” But can economic determinism really explain why the central thesis of Marxism has not materialized, since Marx predicted that the contradictions inherent in Capitalism would bring about the revolution that would free the working class.

The truth is more complicated than that, because Capitalism has a nasty habit of reinventing itself, or in the case of the New Deal and the Great Society programs of the 20th century, reform the system to improve the lives of those most affected by the inequalities of the Capitalist system.

Many American families, mine included, benefitted from those reforms. Whether we are talking about Social Security, the GI Bill, student loans guaranteed by the federal government to cover the cost of college for those in the working and middle classes, job training programs, other forms aspects of the social safety net, millions of Americans have moved upward in social mobility.

Anecdotal evidence from friends and relatives, stories of celebrities rising from humble beginnings, and lately, the rise of a biracial male from the State of Hawaii, whose father was an African immigrant and whose mother was a White American, and reached the highest office of the nation, is indicative of this upward social mobility. He did it by working hard and proving that if he could do it, given his background and personal tragedy of losing his father early in his life, anyone can.

The long-predicted revolution, therefore did not happen because many working people, to use a euphemism, “made it”. Some have made it into the middle class, and some have made it into the upper middle class. And some others managed to make it into the lower strata of the upper class. They are not the proverbial “1%”, but nevertheless, they are wealthy. And happy, well-off people don’t make revolutions.

We are however, seeing a reversal among some of the middle class and working class, and that is most definitely due to neoliberalism. And the opioid crisis is decimating the White working class and economic dislocation is one reason for the increase in suicides among White males.

So, to base the argument for single payer solely based on economic determinism and the change the authors contend is necessary for that to occur, is only looking at one side.

After the ascendency of Ronald Reagan to the Presidency, I realized that there was something else besides his charm and ability to communicate effectively that made Americans vote for him overwhelmingly. But I was unable for many years to understand why beyond believing that they did not want to be poor, as many living in Socialist nations were.

However, in the evolution of my consciousness, I have discovered that a socioeconomic theory only tells part of the story. Some years ago, I learned of a biopsychosocial theory of development called Spiral Dynamics. I have written about it before in other posts.

Without going into detail, suffice it to say that Spiral Dynamics is the theory that explains how people think, either as individuals or as a collective. And the reason is it called Spiral Dynamics is because the adult human mind is an oscillating, dynamic spiral from lower order to higher orders of thinking.

Based on the research of Clare W. Graves, Don E. Beck and Christopher Cowan, patented their ideas into Spiral Dynamics. Spiral Dynamics is concerned with the life conditions and coping measures used to solve the problems life conditions present to individuals and collective societies. It also reveals the deep codes about how people think, and what they value.

Using Graves’ labels for the first six levels of existence, they borrowed the term “meme” from Richard Dawkins, the British biologist, and color coded them for better mnemonic effect, as shown in the table below. Beck and Cowan labeled their version of memes, vMemes, or value systems, as they are concerned with the values individuals and collectives manifest at any given time in their development. Individuals and collectives can exist at more than one level at any time.

The table illustrates the last three levels as they currently are represented in the American population, along with the percentage of the world population at each, and the percentage of social power they have. The US is included in these figures, and only at Green do we see what percentage of Americans are at Green. But we can use them nonetheless for our purposes here.

By adding the percentage of population at both Blue and Orange, which in today’s America represents the Republican Party’s bases’, we notice that Blue/Orange has 70% of the population. Conversely, adding the percentage of power for each gives us 80% of the power, meaning that 70% of the American population controls 80% of the social power. Given that fact, to effect any change, either in society in general, or in health care, those percentages must change.

Blue has throughout history viewed the delivery of health care as a form of charity. The word hospital comes from the Knights of the Hospital of St. John, who provided care for poor, sick, or injured pilgrims coming to the Holy Land. And more recently, several Christian denominations have established hospitals for the same purpose. Catholic, Baptist, Methodist, and Presbyterians are but a few of the Christian churches that have built hospitals in cities across the country. Jews also have built hospitals, even the one this writer was born in.

Orange, on the other hand, sees the delivery of health care as a commodity that can be purchased for a price through the instrument of an insurance policy issued by a for-profit insurance company. If one can pay for it, then health care is easily accessible, and available when needed. But if one is not able to do so, then they should have planned accordingly. It is not their responsibility to provide them with health care by using their hard-earned income for such care, is their reasoning.

Green, therefore believes that health care is a right, and that is how it should be. It should be no surprise that one of the areas where the Green meme is seen is in Canadian health care. Many progressives point to Canada’s system as a model for the US.

But what prevents the US from moving forward towards that model is exactly how both Blue/Orange sees health care delivery. And since Orange has most of the power between the two, it is Orange’s Capitalism and Neoliberal policies that dictate how health care is delivered, paid for, and who can get it.

Thus, the one flaw in the argument the authors of “Health Care under the Knife” have is not understanding the value systems that underpin opposition to universal health care. It is not enough to discuss the economic reasons, as they have so successfully done, but to examine the psychosocial aspects as well. Taken together, economic determinism and Spiral Dynamics, in my opinion, explains in greater detail why change cannot happen as the authors would wish, until most of the US population evolves up the spiral.

One of the outgrowths of Spiral Dynamics as theory has been its merger with economics which Said Dawlabani has termed, MEMEnomics. MEMEnomics has been defined as a new branch of social science that studies patterns of economic policies and practices by taking an integral, whole-systems approach to economic sustainability.

According to Dawlabani, the US has entered what he called the Third MEMEnomic Cycle and it is expressed as the “Only Money Matters” Meme. This period began in the 1980s, the same time when neoliberal policies began. It led to what Dawlabani called the perfect Memetic storm. It is at this juncture where we find ourselves, and it his belief that a new paradigm is needed to move into the next cycle.

So, despite polling favoring single payer health care, as the authors rightly note, powerful interests will block any movement towards single payer. Until Orange has diminished in its social power and Green’s has increased, nothing will change. And the radical change they prescribe for this to occur will not, so long as social mobility for some prevents it, and profit can be squeezed out of the system.

Nevertheless, I highly recommend this book as a significant resource for understanding the dysfunction of our broken health care system despite its one flaw of being only one part of the story.

What’s Really Wrong With Health Care?

Book Review

Health Care Under the Knife: Moving Beyond Capitalism for Our Health

by Howard Waitzkin and the Working Group on Health Beyond Capitalism

Monthly Review Press
e-book: $18.00
Paperback: $27.00
Hard cover: $45.00

Americans commemorated the assassination of Martin Luther King fifty years ago on Wednesday. Two years earlier, Dr. King, in March 1966, said the following during a press conference in Chicago at the second convention of the Medical Committee for Human Rights (MCHR):

“…Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.”

The part of the quote up to the word ‘inhuman’ begins the Introduction of a new book I just began reading called, Health Care Under the Knife: Moving Beyond Capitalism for Our Health by Howard Waitzkin and the Working Group on Health Beyond Capitalism, published by Monthly Review Press, the publishing arm of the Monthly Review, an Independent Socialist magazine.

Those of you who know me, and those of you who have read many of my previous posts, know that my educational background is in the Social Sciences, as my B.A, is in Political Science and History, with Sociology and African-American Studies thrown in, along with some Humanities coursework. My M.A. is in History, with emphasis on American Social History, especially post-Civil War until the mid to late 20th century. In addition, I also have a Master’s degree in Health Administration (MHA).

But what you may not know is that my leanings have been to the far left, and I am still proudly and defiantly so, even if I have tempered my views with age and new insights. I think that is called wisdom.

So, as I set out to read this book, much of the material presented in it will not be new to me, but will be perhaps new to many of you, especially those of you who got their education in business schools, and were fed bourgeois nonsense about marketing, branding, and other capitalist terms that are more apropos for selling automobiles and appliances and such, but not for health care, as this book will prove.

In this book, there will be terms that many of you will either find annoying, depending on your own personal political leanings, or that you are unfamiliar with. Words such as alienation of labor, commodification, imperialism, neoliberalism, and proletarianization may make some of you see red. So be it. Change will not occur until many of you are shaken out of your lethargy and develop your class consciousness.

“Capital is reckless of the health or length of life of the laborer, unless under compulsion from society.” Karl Marx

While the publisher of the book is an independent socialist foundation, it is no means a Marxist or Communist organization. And from my perusal of the names of the contributors to the chapters of the book, I have found that they are all health care professionals or academics, as well as activists.

Two of the contributors of one chapter, David Himmelstein and Steffie Woolhandler, are familiar to many in the health care industry, as they have co-authored many peer reviewed articles in health care journals that I have cited in my previous blog posts.

Be warned. This book may piss you off. Too bad. The future of health care is at stake, as is the health of every man, woman, and child in the U.S. and around the world.

This will probably be true no matter what part of the health care industry you work in. Physicians, insurance company personnel, pharmaceutical company executives, Wall Street investors and money managers, service providers, vendors, consultants and many others will discover inconvenient truths about the businesses that provide their livelihood. As stakeholders in the status quo, you will be resistant to the prescriptions the writers offer for correcting the mistakes of the past, and the recommendations they suggest for the future of health care.

This book will not only be relevant to the health care industry, but also to the workers’ compensation and medical travel industries, as each is a subset of health care.

And if you do get upset or angry at me for what I have to say about health care, then you are part of the problem as to why health care in the U.S. is broken. Those of you around the world will also learn that your own countries are moving in a direction that sooner or later will result in your health care system mirroring our own, as the authors will point out.

This is a book that will shake you to your core. So, sit back, relax, and keep an open mind. It’s about to be blown.

The book is divided into five parts, with each part containing at most five chapters, as in Part Five, or two chapters, as in Part Two. Parts Three and Four, each contain four chapters. Part One deals with Social Class and Medical Work, and focuses on doctors as workers, the deprofessionalization and emerging social class position of health professionals, the degradation of medical labor and the meaning of quality in health care, and finally, the political economy of health reform.

Throughout the book, they ask questions relating to the topics covered in each chapter, and in Part One, the following questions are asked:

  • How have the social-class positions of health workers, both professional and non-professional, changed along with changes in the capitalist global economy?
  • How has the process of health work transformed as control over the means of production and conditions of the workplace has shifted from professionals to corporations?

These questions are relevant since medicine has become more corporatized, privatized, and financialized. The author of the second chapter, Matt Anderson, analyzes the “sorry state of U.S. primary care” and critically examines such recently misleading innovations such as the “patient-centered medical home”, “pay for performance”, the electronic medical record, quantified metrics to measure quality including patient satisfaction (“we strive for five”), and conflicts of interest as professional associations and medical schools receive increasing financial support from for-profit corporations.

Part One is concludes with Himmelstein and Woolhandler responding to a series of questions put to them by Howard Waitzkin about the changing nature of medical work and how that relates to the struggle for a non-capitalist model of a national health program. Himmelstein and Woolhandler comment on the commodification of health care, the transformation that has occurred during the current stage of capitalism, the changing class position of health professionals, and the impact of computerization and electronic medical records.

Part Two focuses on the medical-industrial complex in the age of financialization. Previous posts of mine this year and last, reference the medical-industrial complex, so my readers will be familiar with its usage here. In this section, the authors tackle the following questions:

  • What are the characteristics of the current “medical industrial complex,” and how have these changed under financialization and deepening monopolization?

Two corollary questions are raised as follows:

  • Are such traditional categories as the private insurance industry and pharmaceutical industry separable from the financial sector?
  • How do the current operations of those industries reflect increasing financialization and investment practices?

Once again, Matt Anderson authors the first chapter in Part Two, this time with Robb Burlage, a political economist and activist. Anderson and Burlage analyze the growing similarities and overlaps between the for-profit and so-called not-for-profit sectors in health care, considering especially the conversion of previously not-for-profit corporations such as Blue Cross and Blue Shield to for-profit.

The second chapter in Part Two is authored by Joel Lexchin, an emergency care physician and health policy researcher in Canada and analyzes monopoly capital and the pharmaceutical industry from an international perspective.

Part Three looks at the relationships between neoliberalism, health care and health. Before I go any further, let me provide the reader with a definition of neoliberalism in case the authors assume that those who read this book understand what it is.

According to Wikipedia, Neoliberalism or neo-liberalism refers primarily to the 20th-century resurgence of 19th-century ideas associated with laissez-faire economic liberalism. Those ideas include economic liberalization policies such as privatization, austerity, deregulation, free trade and reductions in government spending in order to increase the role of the private sector in the economy and society. These market-based ideas and the policies they inspired constitute a paradigm shift away from the post-war Keynesian consensus which lasted from 1945 to 1980.

These neoliberal policies have been associated in the U.S. with the Republican Party and the Conservative movement since the election of Ronald Reagan. In the UK, the rise of Thatcherism ended the long dominance of the Labor Party’s left-wing until Tony Blair’s New Labor took over. Bill Clinton’s election in the U.S. in 1992, diminished some of these policies, and implemented others such as welfare reform, a goal Republicans had wanted to achieve for decades.

Returning to Part Three, the questions asked here are:

  • What is the impact of neoliberalism on health reforms, in the United States and in other countries?
  • What are the ideological assumptions of health reform proposals and how are they transmitted?
  • What are the effects of economic austerity policies on health reform and what are the eventual impacts on health outcomes?

In the next chapter, Howard Waitzkin and Ida Hellander, a leading health policy researcher and activist, trace the history of the Affordable Care Act initially developed by economists in the military during the Vietnam War. International financial institutions, the authors say, especially the World Bank, promoted a boilerplate for neoliberal health care reforms, which focused mainly on privatization of services previously based in the public sector and on shifting trust funds to private for-profit insurance companies.

Colombia’s health reform of 1994, Hillary Clinton’s in that year as well, Mitt Romney’s plan in Massachusetts in 2006, which led to the ACA, are examples cited by the authors. The chapter also clarifies the ideological underpinnings of the neoliberal model and shows that the model has failed to improve access and control costs, according to the authors.

Economic austerity is closely linked to neoliberalism and have led to drastic cutbacks in health services and public health infrastructure in many countries. As I have recently written in my post, Three Strategies for Improving Social Determinants of Health, economic austerity policies have also affected health outcomes through increased unemployment, food insecurity, unreliable water supplies (Flint, MI), and reduced educational opportunities. Recent teacher protests in West Virginia, Oklahoma and other states are examples of this.

In the second chapter in Part Three, Adam Gaffney and Carles Muntaner, focus on social epidemiology, especially the impacts of economic policies on health and mental health outcomes. They also document the devastating effects of austerity in Europe, focusing on Greece, Spain and England. The authors analyze four dimensions of austerity:

1) constriction of the public-sector health system, 2) retreat from universalism, 3) increased cost sharing, and 4) health system privatization.

This trend would seem to have a negative effect on medical travel from Europe and to Europe, as Europe’s health care systems, long touted as a less expensive alternative to medical care in the U.S., begins to suffer.

Part Four examines the connections between health and imperialism historically and as part of the current crises. The question in this part is:

  • What are the connections among health care, public health, and imperialism, and how have these connections changed as resistance to imperialism has grow in the Global South?

The authors are referring to those countries in the Southern hemisphere from Africa, Asia, and Latin America as the Global South. The Global North refers to Europe and North America, and some other industrialized and advanced countries in the Northern hemisphere.

The authors in Part Four focus on the forces and institutions that have imposed a top-down reform of health care in the Global South. Such organizations as the Carnegie, Rockefeller, and Gates foundations, the World Bank and International Monetary Fund, trade agreements such as NAFTA, CAFTA, TPP, TiSA, and health organizations as the World Health Organization (WHO) and the Pan American Health Organization (PAHO) are all termed “philanthrocapitalism” by the authors, and have implemented policies that have weakened public health standards and favored private corporations.

The final part, Part Five focuses on the road ahead, i.e., the contours of change the authors foresee and the concrete actions that can contribute to a progressive transformation of capitalist health care and society.

The authors address these questions:

  • What examples provide inspiration about resistance to neoliberalism and construction of positive alternative models in the Global South?
  • Because improvements in health do not necessarily follow from improvements in health care, how do we achieve change in the social and environmental determinants of health?
  • How does progressive health and mental health reform address the ambiguous role of the state?
  • What is to be done as Obamacare and its successor or lack of successor under Trump fail in the United States?

Howard Waitzkin and Rebeca Jasso-Aguilar analyze a series of popular struggles that focused on the privatization of health services in El Salvador, water in Bolivia, as well as the ongoing struggle to expand public health services in Mexico. These struggles are activities David and Rebeca participated in during the past decade.

These scenarios demonstrate an image of diminishing tolerance among the world’s people for the imperial public health policies of the Global North and a demand for public health systems grounded in solidarity rather than profit.

In the U.S., the road ahead will involve intensified organizing to achieve the single-payer model of a national health program, one that will provide universal access and control costs by eliminating or reducing administrative waste, profiteering, and corporate control.

Gaffney, Himmelstein, and Woolhandler present the most recent revision of the single-payer proposal developed by Physicians for a National Health Program (PNHP). They analyze the three main ways that the interests of capital have encroached on U.S. health care since the original proposal:

1) the rise of for-profit managed care organizations (MCOs); 2) the emergence of high-deductible (“consumer-directed”) health insurance, and 3) the entrenchment of corporate ownership.

The authors offer a critique of Obamacare, explain and demystify innovations as Accountable Care Organizations, the consolidation and integration of health systems, something yours truly has discussed in earlier posts as they relate to workers’ comp, and the increasing share of costs for patients.

The next two chapters concern overcoming pathological normalcy and confronting the social and environmental determinants of health, respectively. Carl Ratner argues, that mental health under capitalism entails “pathological normalcy.” Day-to-day economic insecurities, violence, and lack of social solidarity generates a kind of false consciousness in which disoriented mental processes become a necessary facet of survival, and emotional health becomes a deviant and marginalized condition.

Such conditions of life as a polluted natural environment, a corrupt political system, an unequal hierarchy of social stratification, an unjust criminal justice system, violent living conditions due to access of guns, dangerous working conditions, and so forth, Ratner dissects as the well-known crises of our age in terms of the pathologies that have become seen as normal conditions of life.

Next, Muntaner and evolutionary biologist Rob Wallace show how social and environmental conditions have become more important determinants of health than access to care. They emphasize struggles that confront social determinants through changes in broad societal polices, analyze some key environmental determinants of health including unsafe water (Flint again), capitalist agribusiness practices, and deforestation in addition to climate change. And they refer to the impact these have on emergent and re-emergent infectious diseases such as Ebola, Zika and yellow fever.

Lastly, Waitzkin and Gaffney try to tackle the question of “what is to be done.” They outline four main priorities for action in the U.S. and other countries affected by the neoliberal, corporatized, and commodified model of health care during the age of Trump:

  • a sustained, broad-based movement for a single-payer national health program that assures universal access to care and drastically reduces the role of corporations and private profit, 2) an activated labor movement that this time includes a well-organized sub-movement of health professionals such as physicians, whose deteriorated social-class position and proletarianized conditions of medical practice have made them ripe for activism and change, 3) more emphasis on local and regional organizing at the level of communal organizations…and attempted in multiple countries as a central component in the revolutionary process of moving “beyond capital”, and 4) carefully confronting the role of political parties while recognizing the importance of labor or otherwise leftist parties in every country that has constructed a national health program, and understanding that the importance of party building goes far beyond electoral campaigns to more fundamental social transformation.

In their book, the authors try to answer key and previously unresolved questions and to offer some guidance on strategy and political action in the years ahead. They aim to inform future struggles for the transformation of capitalist societies, as well as the progressive reconstruction of health services and public health systems in the post-capitalist world.

Throughout this review, I have attempted to highlight the strengths of the book by touching upon some of the key points in each chapter.

If there is a weakness to the book, it is that despite the impressive credentials of the authors, they like many other authors of left-of-center books, cling to an economic determinism as part of their analysis, which is based on theories that are more than one hundred years old.

As I stated in the beginning of this review, my views have been tempered by examining and incorporating other theories into my consciousness. One theory that is missing here is Spiral Dynamics.

Spiral Dynamics is a bio-psycho-social model of human and social development. It was developed by bringing together the field of developmental psychology with evolutionary psychology and combines them with biology and sociology.

In Spiral Dynamics, biology is concerned with the development of the pathways of the brain as the adult human moves from lower order thinking to higher order thinking. The social aspect is concerned with the organizational structure formed at each stage along the spiral. For example, when an individual or a society is at the Beige vMeme, or Archaic level, their organization structure is survival bands, as seen in the figure below.

At the Purple vMeme, or Mythic level, the organizational structure is tribal, and so on. There is, among the authors of the book, an evolutionary biologist, but it is not clear if he is familiar with this theory and what it can bring into the discussion at hand.

It would not only benefit the authors, but also the readers to acquaint themselves of this valuable theory which would present an even more cogent argument for better health care. As the book concludes with a look at the future of health care after capitalism, knowing the vMemes or levels beyond current levels will enhance the struggle.

As I continue reading the book, I hope to gain greater insight into the problems with privatized, corporatized, free-market capitalist health care. My writings to date in my blog has given me some understanding of the issues, but I hope that the authors will further my understanding.

I believe that anyone who truly wants to see the U.S. follow other Western nations who have created a national health program, whether they are politicians like Bernie Sanders, his supporters, progressives, liberals, and yes, even some conservatives who in light of the numerous attempts to repeal and replace the ACA, have recognized that the only option left is single-payer. Even some business leaders have come out and said so.

I recommend this book to all health care professionals, business persons, labor leaders, politicians, and voters interested in moving beyond capital and realizing truly universal health care and lower costs.

 

Integral Healthcare

Doubling down on contentious issues is not just confined to the realm of politics.

An article in Monday’s Journal of the American Medical Association (JAMA) states that single payer for the United States is politically infeasible, and concludes that to achieve universal coverage without single payer, enforcing the individual mandates and assessing real penalties for not purchasing insurance is the best option.

To bolster their argument, the authors, Regina E. Herzlinger, Barak D. Richman and Richard J. Boxer, point to three countries that have a private-sector insurance system. These countries are Switzerland, Singapore, and Germany.

After exploring two other options, creating risk pools for enrollees with preexisting conditions, and pooling costly patients into Medicare, the authors contend that the individual mandate, which the Supreme Court characterized as an annual tax, would be assessed against individuals who did not purchase health insurance within that calendar year.

The authors believe that while it is vilified by some, it is attractive for the following reasons: it is easy to implement, is effective in pooling risk, and reflects the values of individual responsibility (more on values later).

But the authors are mistaken. Many Americans will balk at paying for health insurance, with or without penalties, for individualistic, libertarian reasons. Also, those individuals who are unemployed and who have not filed tax returns for several years, at least under the ACA as it is now enacted, will not be able to get even a subsidy to pay for it. (my own situation that I contacted my Congressman about twice)

Per the authors, Swiss citizens must purchase health insurance, if they do not, the government does it for them. And the insurers can implement debt enforcement proceedings against anyone failing to pay for insurance, collect a penalty and any back premiums.

Singapore has compulsory contributions from employers on behalf of their employees to create medical savings accounts, and it is up to the employee to maintain these accounts for expenses such as health and disability insurance premiums, hospitalization, surgery, rehabilitation, end-of-life care, and outpatient services. Failure to do so are subject to garnished wages and other legal actions. The unemployed, or poor are eligible for subsidies.

Lastly, German insurance is funded by compulsory contributions to private insurers levied as 7.3% of income. Those who are unemployed have theirs taken out of their benefits plus means-based sliding-scale subsidies, and uninsured, self-employed individuals who try to purchase insurance are faced with payment of back premiums for the uninsured period.

Some of the methods described above have been suggested here in the US, or are part of the ACA already, but is not sufficiently strong enough for the authors, or maybe part of the “repeal and replace” packages now stalled in Congress. Therefore, the authors have decided to double down on the one part that the GOP wants to eliminate and that many Americans find onerous, paying a penalty for not having insurance.

But is this really the right way to go, as I mentioned in yesterday’s post, “Damned If You Do, Damned If You Don’t.”

To answer that question, I would like to introduce you to Spiral Dynamics and the next generation economic system, MEMEnomics.

Spiral Dynamics is a biopsychosocial theory of human development based on the research of the late psychologist, Clare W. Graves. Graves was a contemporary of Abraham Maslow, whose “hierarchy of needs” was the first psychology model of a hierarchical nature of human development.

Graves’ framework, called the “Levels of Human Existence”, relates to Maslow’s needs, but Graves realized that Maslow’s model did not adequately express the dynamics of human nature, the process of emerging systems, or the open-endedness of the psychological development of a mature human being.

“Briefly, what I am proposing is that the psychology of the mature human being is an unfolding, emergent, oscillating spiraling process marked by progressive subordination of older, lower-order systems to newer, higher-order systems as an individual’s existential problems change. Each successive stage, wave, or level of existence is a state through which people pass on their way to other states of being. When the human is centralized in one state of existence, he or she has a psychology, which is particular to that stage. His or her feelings, motivations, ethics and values, biochemistry, degree of neurological activation, learning system, believe systems, conception of mental health, ideas as to what mental health is and how it should be treated, conception of and preference for management, education, economics, and political theory and practice are all appropriate to that state.”

Graves proposed that all the forces shaping the marketplace, whether individuals, groups, or cultures, should be looked at from a more integral view that includes the biologic, psychologic, and sociologic aspects, and to examine them in an ever-evolving dynamic culture. He placed these dimensions into eight known hierarchical levels of existence called value systems.

Graves’ ideas would have remained confined to the academic world if it was not for his colleagues, Don Beck and Christopher Cowan, who patented Graves’ work into what they called Spiral Dynamics, taking the name from Graves’ explanation of human psychology. They even wrote a book by that title, which should be read first to gain full understanding of the theory.

When they began their work, they translated Graves’ levels (he used pairs of letters starting from “A” to “H” and from “N” to “U” to represent the life conditions and ways in which humans solved their existential problems) to colors (Beige, Purple, Red, Blue, Orange, Green, Yellow, and Turquoise). This was a way to better memorize the vMEMEs, borrowing the term, meme, from Richard Dawkins, or value systems.

The following table shows the vMEMEs and the percentages found in the population, plus the percentage of power they have in human society. It is important to note that the American population can be found in the last three levels. It is the Blue/Orange vMEMEs that control much of the political, social, and economic agenda of the US, and explains why Green’s values have had a hard time getting accepted, which is why the US is unable to make the leap to the next tier.

sd-population

Colors of thinking.png

Dawkins described memes as “a unit of cultural information that is capable of self-replication and uses the human mind as a host.” For Beck and Cowan, vMEMEs, or value-systems memes begin to shape how individuals, organizations, and cultures think. Along the way, Beck partnered with philosopher Ken Wilber, whose Integral approach was adapted to Spiral Dynamics into Spiral Dynamics Integral.

The following chart illustrates the AQAL model of Spiral Dynamics Integral.

sdi-aqal-1024x690

There are two alternating types; individualistic and expressive, and group-oriented and sacrificial. Both types alternate, and with the passage of time, existential problems arise within each value system that can no longer be solved at the current level. The pressure and energy created by the value system’s inability to solve its problems leads to the emergence of the next level, spiraling upwards and alternating between the types.

So, for example, Capitalism is an individualistic vMEME system, whereas Socialism is a collective vMEME system.

Which brings us to discussing MEMEnomics. MEMEnomics is a composite of the words “meme” as we have been discussing, and economics. The book titled MEMEnomics, by Said W. Dawlabani, is sub-titled, “The Next-Generation Economic System.”

I have read it once, and in the process of re-reading it for better understanding, and explains clearly through Spiral Dynamics why the financial difficulties of the last decade occurred, and guides us to a better, integrated, and holistic future. Dawlabani says that the difficulties the US is facing today (published in 2013) are a result of the evolution from one system to another.

But most importantly, Dawlabani examines the history of the American economy from colonial times to the present day through a memenomic framework, that corresponds to the levels of human existence found in Graves’ work.

These two charts illustrate MEMEnomics and Spiral Dynamics better.

memenomics

memenomicsspiralchart-e1388953833163

Already, there are changes occurring in the economy that signal that there is an evolution. The emergence of the sharing economy found in companies like Uber and Lyft, and Airbnb, are just some of the examples of this emergence. The green economy, as in environmentally friendly, is an example of the healthy side of the Green vMEME, and even exhibits some aspects of Yellow Sustainability.

So where does health care fit in all this?

Health care as it is provided for in the US, is mostly through employers, government programs aimed at specific demographic groups such as the poor, elderly, and children, and through private insurance sold by insurance companies.

The reason for the passage of the ACA was to eliminate some of the disadvantages in employer and private health insurance plans, and to ensure coverage for all by making people purchase coverage. But that has angered many, and is the main reason for the repeal and replace rhetoric in Washington.

The authors of the JAMA article, like many before them, are doubling down on a method of providing coverage that is trapped within the Orange vMEME system. Yet, as Spiral Dynamics and MEMEnomics has shown, there must be an evolution in the way we think about many aspects of human life, health care and its provision included.

We must build the health care system of the future now, not the health care system of the past. Spiral Dynamics and MEMEnomics points us to a future where all aspects of human civilization is integrated and holistic, and health care is a part of that integration.

Any doubling down on the value systems of the past as human development spirals upward is unhealthy and must be avoided. If we continue to require the purchase of a commodity such as health insurance (Orange vMEME – value system) when human development has transcended and included Orange and moved on past Green into Yellow or Turquoise, it would be like Americans living today living like their ancestors did back in Roman times.

I don’t think that is possible, nor is it desirable. And neither is the solution the authors have recommended. We must integrate all our current health care systems into one integrated system, including Workers’ Comp, not because it will save money (which it will), but because human development is headed in that direction.

Not to do so is harmful to the spiral and to human development.

Of ‘Aged Statutes and Old Case Law’ — Why Workers’ Comp Must Change

Last week, Dave Dias of Insurance Thought Leadership.com published an article by J. Bradley Young, a partner with a St. Louis law firm that handles workers’ compensation cases for self-insured employers and insurance companies.

The article, What Happens When Technology and Workers’ Comp Law Collide?, discusses the intersection of modern communication technology with the application of existing workers’ compensation law.

I mention this because of something Mr. Young said in his first paragraph that got me thinking about what to write for this week’s post. Mr. Young said that technology can break out of the boundaries created by aged statutes and old case law. I found that part intriguing, and decided to use it in the title.

Those of you who have read my blog for some time know that I advocate a new approach to the way workers’ compensation handles expensive surgeries by opening the system up to medical tourism. This advocacy was recently mentioned in Joe Paduda’s post, I Heart Workers’ Comp.

In this post, Joe listed the reasons why he likes workers’ comp, and said that workers’ comp was great because there are many smart, loud, and committed folks talking and writing about what needs to happen and why, and included my name in that list. I am very grateful for the inclusion.

But what you and Joe may not know about me is that I have been interested in the future of human civilization in all aspects: economic, historical, political, psychological and sociological, for a very long time, ever since high school when I took an elective called “Future Studies”. In college, I took a course called “Global Politics” way before anyone ever heard the term, “globalization”.

Just over ten years ago, I became aware of a theory called Spiral Dynamics, a “bio-psycho-social” model of human and social development when I read a book by the New Age philosopher, Ken Wilber. And late last year, I accepted the position as a Board Member of a new, non-profit organization whose mission is to study globalization and its economic impact. The organization was created by a fellow alum of NYU who is an economist, and has taught economics and worked for the UN in New York. So there is more to me than what you find in my blog and on my LinkedIn profile.

But getting back to Spiral Dynamics, Wilber’s book, A Theory of Everything explained what Spiral Dynamics was and included Wilber’s own Integral approach and his “all lines, all quadrants” map of the Kosmos [Wilber’s term]. In addition to reading Wilber’s book, I have read more than a dozen or so articles on Spiral Dynamics and other related subjects.

Spiral Dynamics was developed by Don Edward Beck and Christopher Cowan, and is based on the work of psychologist, Clare W. Graves, a contemporary of Abraham Maslow. Graves’ theory of human psychology fits alongside a continuum of other psychological theories like Maslow’s Hierarchy of Needs and Lawrence Kohlberg’s Stages of Moral Development. However, Graves believed that:

“Human nature emerges along a developmental path from one equilibrium state to the next. These can be viewed as stages wherein each layer adds new elements to all that came before; in turn, each stands in preparation for a next phase which may or may not come. Every “level of human existence” offers a particular viewing point for the real world as defined by its unique set of perceptual filters, These diverse reality views lead to very different decision-making approaches, organizing principals for business, economic and governance models, and ideas of what appropriate, effective living means.”

Graves developed what he called “the emergent, cyclical, double-helix model of adult biopsychosocial systems development”, and he further defined his model thus:

“Briefly, what I am proposing is that the psychology of the mature human being is an unfolding, emergent, oscillating spiraling process marked by progressive subordination of older, lower-order behavior systems to newer, higher-order systems as an individual’s existential problems change. Each successive stage, wave, or level of existence is a state through which people pass on their way to other states of being…His or her feelings, motivations, ethics and values, biochemistry, degree of neurological activation, learning systems, belief systems, conception of mental health, ideas as to what mental illness is and how it should be treated, conceptions of and preferences for management, education, economics, and political theory and practice are all appropriate to that state.”

Graves discovered eight stages or levels of existence, and labeled them with pairs of letters, starting from A to H, and N to U. A-H represented the life conditions, and N-U represented the ways a human being solves his existential problems.

Beck and Cowan, when developing their theory, took the unfolding, emergent, oscillating process and called it Spiral Dynamics. They co-authored a book also called Spiral Dynamics, which I have also read.

To help understand the levels of existence better, Beck and Cowan borrowed the word “meme”, which was coined by Richard Dawkins, the English biologist, and called their levels, VMEMES, or value-systems, and to further assist in remembering them, used colors for each of the levels of existence.

Image

The first six levels of existence belong to the First Tier, or the Subsistence Tier, and the next two levels belong to the Second Tier, or the Being Tier. The last two levels are speculative, and may belong to the Second Tier or Third Tier.

Spiral Dynamics posits that human beings are primed for a great leap from First Tier to Second Tier thinking, but at the present time, most of the developed world is at the Blue, Orange or Green VMEMES. This is because Spiral Dynamics says that a person or culture can be at more than one level at a time, so that the US at the present time has elements of the Blue, Orange and Green value-systems among its population. And there are still people and cultures that are operating at the lower-order levels, especially in the so-called “Third World” and developing world, and there are those same people and cultures in the developed Western world, although operating in different ways than those in the Third World or developing world.

According to Spiral Dynamics, the only way to solve problems at the Subsistence tier value-systems is to apply Second Tier, Yellow value-system solutions. That is what many far-sighted individuals are trying to do in many areas of human society, and is what the author of another book I am currently reading recommends business leaders and others to do.

The book by Said Dawlabani, is called MEMEnomics, and examines how the United States and the rest of the world got into the economic crisis of the past two decades, and how we need to form a “smart model” of government from the values of the current emerging seventh-level value-system.

What does all this and my interest in globalization and the future of human development have to do with transforming workers’ comp? A lot, because globalization is happening and like it or not, there is not that much that any of us can do about it.

Are you going to stop using a computer or cell phone because the components were made in another country, or even assembled in a third country? No, just as none of us are going to go around naked just because all of our clothing and shoes are made elsewhere. What about food? Would you really rather starve to death or go hungry because some of the food you eat is grown in Mexico, Chile, Thailand or other countries, or that your meat, chicken, fish is raised or caught in foreign waters? No to that too.

So just as everything is globalizing, and I admit not all of it is good or has had the best results, the simple fact is that the world is getting smaller and nothing can stand in the way of globalization, not even ‘aged statutes and old case law’ (or was that old cole slaw? But I digress).

Now, I can hear the howling from certain quarters about my comment above regarding statutes and case law. But before you all condemn me, let me say that I believe that there are many laws, regulations, rules and statutes that have been created in the last one hundred years of workers’ compensation in the US that serve a definite purpose and ought to be retained in the law books for workers’ comp. And I also believe that many of these laws, regulations, rules and statutes were put in place not to protect workers injured on the job, which was their intent, but to benefit those who stood to gain financially from the process of workers’ comp claims handling.

These are some of statutes, regulations and rules that I think should be looked at because they stand in the way of providing an injured worker the best medical care available. I mentioned some of these barriers in my White Paper on medical tourism and workers’ compensation.

One barrier is the requirement that the treating physician be less than 50 miles from the claimant’s home. A hundred years ago, when most people rarely travelled long distances, that 50-mile limit was reasonable. But today, millions of people travel longer than 50 miles for medical care, and yet there are no restrictions placed on them under health insurance plans. But there is for workers’ comp.

Another example is the licensing of the physician in the state where the claimant lives. What is the difference if an individual goes to the Mayo Clinic for heart surgery performed by a physician licensed in Minnesota, but if that person was injured on the job in Wisconsin and needs knee surgery and goes to the Mayo Clinic for that surgery, the orthopedic surgeon must be licensed in Wisconsin? I know about reciprocity, but that only applies if a physician moves from one state to another. Is the practice of medicine different in Wisconsin than in Minnesota for injured workers, or does this apply to all patients, regardless of where they live and who is paying the bill?

I mentioned in my White Paper that there are laws that make it illegal for a physician to consult with a patient online without an initial face-to-face meeting. In the age of Skype and telemedicine this sounds like our laws have not caught up with our technology. I also mentioned that it is illegal for a physician who is outside of the state and who has examined the patient in person to continue to treat via the Internet after the patient goes home.

Really, with GoToMeeting and other software being developed for that very purpose? And finally, it is illegal in most states for a physician outside that state to consult by phone with the patient residing in that state if the physician is not licensed to practice there. Again this sounds like early twentieth century laws are still dictating how medicine is conducted in the twenty-first century.

In the course of writing my blog, I have gotten many comments, both positive and negative, about my ideas. Those that were positive have been published to my blog, but some of the comments that are negative border on racist and bigoted. This is especially true when I discuss medical tourism to countries like Mexico and Brazil, which one individual called “backwaters”.

First off, I don’t consider any country a “backwater” because once upon a time, this country was called a backwater by people in Europe, and while there may be some rural and isolated parts of this country still around, they are nowhere near as bad off as some people imagine our neighbors to the south to be.

All countries have problems. Some countries have good problems, and there are countries that would love to have those problems. Then there are countries that have bad problems, and there are countries that have really bad problems. But at no time, have I ever advocated that patients go to such places for medical care. I do advocate that patients go to medical facilities that are the best in a particular country and in a certain region of that country. I would never advocate someone to go to a facility that is not the best or in a region of a country that has problems.

We need to stop demonizing other people and other cultures and reach out to them and help them move along the spiral so that they can reach the value-system level we are currently at; while we are moving higher up the spiral to the next level. We need to understand that where they are now, we once were; as we will be, so too will they, but in their own good time. I heard that on a science-fiction show once where enlightened beings help humans look for a new home after their home was destroyed by war.

We also need to stop relying on outmoded ways of thinking and on outmoded rules and regulations that were formulated during the Industrial Age, for an industrial society, and create new rules and regulations that open up all human systems to the vast potential that lies ahead as the human race becomes a global community. Ken Wilber talks about the four worldviews: Egocentric, Ethnocentric, Worldcentric and Kosmocentric.

We are moving out of the Ethnocentric worldview and into the Worldcentric worldview. It would help if we opened up our minds to this new worldview. We can start by doing so in workers’ comp and let some fresh air and fresh ideas into the workers’ compensation system that was created one hundred years ago after the tragic Triangle Shirtwaist Factory fire. But first we must recognize that we are all in this together and must do all we can to make the lives of our brothers and sisters better, even if that means throwing out the old rules and starting over with new rules and new regulations, instead of going around in circles created by ‘aged statutes and old case law’.

Now that’s an idea we should all embrace.

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Richard