community as ideal for healthcare reform

8/6/2019 Community as Ideal for Healthcare Reform

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Commentary'Community" as the Ideal for

Health Care ReformLu Ann Aday an d Stephen H. Linder

University of Texas School of Public Health

The three articles in this special section refiect a recent resurgence ofinterest in the social, political, and philosophical significance of commu-nity. For some commentators, community serves as both a social andintellectual resource for countering the crises attending late modernity incapitalist regimes. Whether individualism, instrumental rationality, ormoral vacuity are to blame, the bonds and stability of community appearto provide a ready antidote. For others, comm unity and its renewal takeon a more romantic cast, as part of a movement away from commercial-ism and contrived notions of progress , to simpler and more meaningfulways of living. For still others, community assumes its classical status asthe locus of self-governance and is understood as synonymous withdemocratic localism and civic activism. All take for granted the superi-ority of communal forms, but each for different reasons. All assume thatcertain human needs and potentialities can best be met in communal set-tings, but each focuses on different needs and potentialities. Few explorethe presum ptions behind these claims, beyond appeals to cultural attach-ments or historical commitments. Few invoke a coherent theory ofaction. Most are reformist and cultivate a sense of dissatisfaction withcontemporary developments as the motive for pursuing communal formsand practices over competing forms. Although the authors whose workappears in this section address altering community's role in our healthcare system, they all manifest elements of each of these more generalperspectives.


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Aside from confidence in communal forms, the authors share a preoc-cupation with organizational and institutional actors over other levels ofanalysis and emphasize the structural features of these actors in the fram-ing and deployment of their arguments. In turn, structural features arecombined in conceptual models, ideal types or paradigms, and forms ofdiscourse. What is distinctive about this is that all identify a priori oneparticular model, type, or form as superior, using community participa-tion as a common basis, and build their arguments around the prospectsfor its emergence. Finally, each of the arguments points to cultural trendsand shifts in opinion as evidence for the prospects it desires.

The model of countervailing powers, once popular in the diplomaticand economic history of the cold war era, enjoys a revival here and playsa prominent role in all three articles. The irony is that, although all threeadvocate community, their constructions of countervailing power for thatpurpose are contradictory. David Frankford (1997) believes that thewhole discourse of countervalency actually suppresses community andthe conditions fostering it; he poses an altemative discourse that eschewsany notion of power balances. For Donald Light (1997), on the otherhand, community can be conceived of as yet another countervailingpower. The prospects for its vitality then are bound up with changes inthe existing balance of power. Ezekiel and Linda Emanuel's (1997) argu-ment extends Light's focus on shifting the power balance among the play-ers to the reform of one particular type of player, managed care organi-zations. In other w ords. Light w ants to add community as a new player,the Emanuels w ant to convert a central player to communal norms, andFrankford wants to subvert the game altogether in favor of one that com-munity can unquestionably win. These differences are m ore than rhetor-ical; they represent fundamentally different strategies for appraising, andthen planning for, community's reemergence on the health care scene.The first part of the comm entary will focus on the ways in which theydiverge in building their arguments about reform. The concluding sectionwill explore how they converge with respect to the priority accorded tocommunity participation in shaping health policy.

Divergences: Conceptual FoundationsThe Frankford piece is the most ambitious and least conventional of the


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jectless" power. For Frankford, subject-centered countervailing power iswhat we already have; subjectless power is what is needed. At severalpoints, he takes an instrumental stance on these competing concepts andclaims that the latter can be cultivated and embraced as a means ofchanging health care practice. The problem with this strategy is thatfrom a Foucauldian perspective, there are no altemative ways of under-standing power or rival forms of power relations, some subject-centeredand others subject/es.s; rather, they all seem to involve pervasive inter-nalized relations of domination and submission encoded in everydaysocial practices, with oppositional possibilities lurking at the margins ofsociety (Foucault 1980). All other ways of seeing power, including coun-tervailing rivalries, formal authority, or economic influence, are illusionsfor Foucault, cormected with the prevailing ways of knowing in a givensociety and its technologies.

Furtherm ore, despite the normatively neutral, but disciplining charac-ter of Foucauldian power relations (Fraser 1989), Frankford offers hissubjectless version of these modalities as a normative ideal and specu-lates on ways of moving closer to it as an escape from the dynamics ofcountervailing power. Frankford finds within his version great promisefor restoring the basic elements of mutuality that he assumes are essen-tial to revitalizing community. Mutuality, in this instance, is to springspontaneously fi-om the recognition of a shared constitutive power and tobe reinforced by empathetic role changes and selfless works. Althoughthe social pragmatists and Rousseauians providefirmground on which tomake such a leap, none can be found in Frankford's version of Foucault,absent a left-Hegelian twist toward solidarity in common struggle(Habermas 1987a). And without mutuality, there is no connection to thechanges in action and social practices that Frankford finds central todeveloping community.The Light piece is more conventional and, in its own way, more suc-cessful in making a case for community, largely on the basis of histori-cal experience and contemporary trends. Community health centers aretreated as hypothetical players in a countervailing power scheme thatappreciates their symbolic value, but finds their populist grounding athrea t to extant concentrations of elite power. Light carefully examines

the tensions in this scheme among the major players and his one, would-be player, the community health center. He builds the first round of com-


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verence of existing com tnunity centers and appraises their suitability forleading the next generation of health ca re reform.The analytical tactic of having the community as an ideal type coun-ters the many weaknesses of the other players; however, Light's confi-dence is based more on faith than on explicit reasoning. He reacheseither to empirical studies and selective examples of individual centers orto more inspiring depictions of cultural and popular sentiments thatappear to bolster the community ideal. For Light (1997: 125), this ideal"resonates with the foundations and deepest sentiments of Americansociety" and bears "a mantle of legitimacy and trust." His empiricalexamples certainly support the contingent viability of the communitycenter as an organizational form, but any move to advance this form asan ideal for the future cannot rely alone on ungrounded assertions aboutcultural and political beliefs. His caution to leaders of the communityhealth movement to tum to their history for clues about their future issound advice.The Em anuels devote much of their analysis to the m eans and pros-pects for rehabilitating the managed care organization, currently thedominant player in the health care system. They share the other authors'

devotion to the cotnmunity ideal butfind t best implemented as a regimeof accountability to discipline the major players. Furthermore, this imple-mentation is to be fostered principally by the intervention of the state, theenlightened self-interest of employers, and the forbearance of the med-ical profession and for-profit providers; in short, all of the players mustbe involved. In this instance, the cultural and political trends found soaffirming of community ideals by the other authors, are viewed as morelikely a product of implementing these ideals under the guise of account-ability. The motive for changes in accountability appears to res t on eachplayer's intemal calculation of comparative advantage, rather than uponthe necessity of their adapting to extemal changes in the larger society.The question then becomes, why m ight the m ajor p layers willingly sac-rifice the forms of accountability that evolved with each of their positionsof prominence?

The distinctiveness ofthe Em anuels' case is that it does not invoke theshifting terrain of supportive political and cultural sentiments as an arti-cle of faith surrounding community's revitalization. Instead, they empha-size the instrumental concems that might best appeal to the functional


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piece offers a persuasive brief for a top-down rather than a bottom-upstrategy for change, making it the most conservative of the three in itsemphasis on incremental change. To do so, however, requires faith, notin the community ideal, but in the good sense of the major players, arather ra re commodity by common consent of these authors.W hereas all of the authors are guarded in their optimism, they cannotall be accurate in their assessments or strategies; conmiunity cannot sup-plant the countervailing power system and at the same time be a playerin it. Nor can it simultaneously transfigure and stand in opposition toother players. These conceptual differences can be either accepted asnominal distinctions that all lead to the same ultimate claims about com-

munity, or confronted as rival interpretations that weaken their apparentconsensus over the future. The preceding discussion has pursued thedivergences that weaken the prospects for a community-centered policyconsensus, and the discussion tha t follows, the prospects for strengthen-ing it.

Convergences: Policy DesignThe three articles introduce and describe useful templates for identifyingthe principal operational approaches to heahh policy design: govern-mental, market-based, professionally dominated, and community-ori-ented paradigms. The articles differ in the specifics that define and dis-tinguish each approach. They a lso, however, share a number of commonobservations and conclusions. The contributors express a unanimousunease with conventional models for heahh policy design, particularlywith respect to the increasing bureaucratization and commodification ofhealth care, and the subsequent implications of these trends for thehealth and health care of individuals and communities. The articles con-vincingly reveal that the rhetoric used in presenting the pros and cons ofpolicy alternatives fails to portray the realities that they are , in fact, likelyto produce. The commonly agreed upon solution to which the respectivearticles allude is a redirection of the locus of power and responsibilityfrom system- or expert-driven to community- or participation-centeredforms of health care organization and policy discourse.

The new directions to which the articles collectively point can be m orefully revealed by an integrative look at the facets of a more conununity-


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tion of articles has for community-centered approaches to defining andaddressing health policy problems. It will (1) identify the theoretical andnormative underpinnings of community-centered approaches; (2) distillthe evidence, based on the respective articles, regarding how the failureto attend to more comm unity-centered norms has compromised the real-ization of desired health policy goals; and (3) based on the frameworkand evidence presented, suggest how these principles might be mademore manifest in health policy design and practice.FrameworkContemporary social critics, such as German philosopher Jtirgen Haber-mas, have argued that the rational, technical, and instrumental underpin-nings of the institutions and systems that dominate modem life such asthe economy and the state fail to acknowledge the intimate, affective, andinteractive lifeworlds of family and community, for example, in whichindividuals most immediately lodge and find meaning (Habermas 1984,1987b, 1996). Habermas suggests that people's lifeworlds have, in fact,become "colonized" (or dominated and constrained) by these bureau-cratic-rational systems, with the attendant consequences of a sense ofdisempowerment and corollary withdrawal from, or cynicism toward, thepublic (policy-making) sphere. Similarly, U.S. social scientists RobertBellah et al. (1985), John M cKnight (1995), and Robert Putnam (1993)cite the severing of the ties that have traditionally held individuals andcommunities together, due to the dominance of the individualistic ori-ented normative ethic or destructive bureaucratic intrusions into com-munity life.

Social philosophers Michael Sandel, Alisdair Maclntyre, Charles Tay-lor, and Michael Walzer (discussed in Mulhall and Swift 1992) and soci-ologist Amitai Etzioni (1993) have contributed to the emergence of com-munitarianism as a school of thought and social movement that has as itscentral focus the revivification of a sense of the community norms andcontext that shape human action and organization. Feminist and othercritics of communitarianism have, however, cited its tendency eitherovertly or implicitly to suppress differences and marginalize those whodo not represent or reflect the views of the dominant majority (Frazer andLacey 1993; Young 1990).


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comparative assessment of govemmental, market-based, professionallydominated, or community-oriented policy mechanisms. Certain technicalcapabilities (e.g., cost containment, quality contro l, access improvement)are attributed to each, trade-offs are recognized, and the choice of pol-icy instruments is ultimately made on political grounds. To move suchanalyses further, the normative foundations of hese ihstitutionaf mecha-nisms and the commitments underlying them must be surfaced and eval-uated. These commitments not only dictate the relevant parameters of pol-icy design, but may also constrain the policy implementation process.

The principles used to guide the m ore community-centered frameworkemployed here are based on Habermas's (1984,1987b) theoretical insightsregarding the structure and function of communication in attainingmutual understanding, as a normative foundation for evaluating the per-formance of competing altematives in achieving desired health policygoals. As mentioned earlier, Habermas has argued that in modem societythe technical-rational systems (the state and the economy) that have beentraditionally charged with accomplishing essential resource distributionand societal maintenance functions appear to be failing in achieving theseobjectives, as well as producing other unintended negative consequences.He highlights the loss of meaning (alienation) and freedom (sense ofpowerlessness) that seem to characterize contemporary society, as well asdramatic disparities in the d istribution of economic resources and envi-ronmental degradation as evidence of these trends. These large andimpersonal systems have also entered and come to dominate (or colo-nize) the lifeworld or private and public spheres in which individualshave been most likely tofindmeaning, validation, and a sense of personaland public efficacy: family, neighborhoods, voluntary organizations, andcivic life.Habermas (1987b) suggests that the remedy or counterweight to thesetrends and consequences is the formulation and practice of more com-munication-oriented, rather than technically oriented, rationality. In con-trast to the objectives of the govemment and the market that focus onstrategic (systems maintenance) or instrumental (ends-oriented) objec-tives, comm unicative rationality focuses on comm unication and mutualunderstanding. Communicatively rational discourse is essentially char-acterized by assuring that all those who are likely to be affected by orinterested in the issues being deliberated are free to participate, to miike


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ment to taking on the role of (or attempting to fully understand) the other.This process, he argues, can offer transformative possibilities for reinvig-orating both the private and public spheres within the lifeworld, as well asenhancing the power and potency of these spheres for remedying thedominance and dysfunction of administrative and corporate systems.

Habermas (1987b) sees the power and promise of this mode of com-municative action in major social protest movements, such as the femi-nist and civil rights movements, and more recently in the environmentalprotection and gay and lesbian identity m ovements. Through conscious-ness-raising discourse, participants in these movem ents have identifiedtheir shared interests and come together to offer challenges to traditionalways of doing business around these interests on the part of governmentand the market. The institutionalization and legitimation of this processis also evidenced in the em phasis both in the governmental and marketsectorson involving affected populations in the formulation of pro-grams and policies, and in the focus on collaborative and team-based,rather than hierarchical (or top-down), planning and management. Com-munity-centered policies and programs also emphasize the importance ofcommunity capacity, participation, and empowerment.

In summary, the communicative ideal proposed by Habermas (1996)provides an innovative alternative conceptual, empirical, and normativereferent for delineating a new community-centered perspective on healthpolicy, calibrating the extent to which it may be present in conventionalpolicy solutions, and evaluating the likely success of policy alternativeswhere these transformative norms are (and are not) in place.A com municatively oriented perspective on the norm ative underpin-nings of the transactions between and among individuals, and the com -

munity contexts in which they occur, highlights the notions of reci-procity, interdependence, and mutual benefit. This point of view seesindividuals as essentially connected through the roles, statuses, and rela-tionships that govern their social interaction and discourse, as well asthrough the cultural and environmental background that gives shape andmeaning to these exchanges. Trust is the major resource upon whichthese transactions rely, and authentic and open communication is themeans through which they are sustained. A sense of personal and collec-tive empowerment around affective (relational) or instrumental (rational)aims is the principal legacy of these exchanges, and the benefits that


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interdependence, and m utual benefit are de facto obscured by the collec-tively derived barriers erected in defining us versus them in debatingwhat's best for us (Frazer and Lacey 1993; Young 1990). Failures of con-ventional approaches to health policy design may be evaluated by theextent to which the communicative norms oriented to mutual under-standing, identified by Habermas (1984, 1996), are either muted orabsent.

EvidenceThis comm unity-centered framework can be used to guide a look at theevidence presented in each of the articles on the failures of conventionalpolicy approaches to achieve desired policy goals: (1) the increasingtechnical-rational focus, (2) the muting of community-centered norms,and (3) the prevalence of inauthentic and power-centered discourse inhealth ca re policy debates, design, and practice.Increasing Technical-Rational Focus. The increasing technical-rationaldevelopment of medical care is manifest, the Emanuels argue, in both thepervasive focus on accountability in the public and private health carespheres and the evolution of increasingly complex institutional mecha-nisms for providing and paying for medical care. Formal, explicit sys-tems of professional and financial accountability have come to dominateor supplant informal, collegial norms of practice and oversight in assess-ing whether desired policy goals are achieved. The dominance of themarket economy in the health care marketplace has, they argue, essen-tially transformed medical care into a commodity and the doctor-patientrelationship into the sum of economic transactions between suppliers andconsumers of services.

In Light's article, the reigning model for health policy debate anddesign, that of countervailing pow ers, provides complementary evidenceof the increasingly instrumental and power-centered model of competi-tion for the highly valued gains of money, markets, legitimacy, infiuence,or prestige among contending parties (corporate, professional, and gov-ernmental players) in the gargantuan and growing "medical-industrialcomplex" (p. 107). For Light, a technical-mechanical analogy of a "tetra-hedron . . . with cables coming in from each com er to a ring," (p. 107),


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cal, hierarchical, accountability-focused underpinnings for the design ofmajor health policy instruments w ith the value-centered, intersubjective,and interactive lifeworld in which individuals and families most imme-diately experience and cope with illness. The subject-centered essence ofthe model of countervailing powers supports the reign of the "experts"over those whose lives their decisions most immediately affect throughvaluing objective, technical-rational knowledge over subjectively livedand intersubjectively validated personal and communal experiences.Muting of Community-CenteredNorms. The Em anuels note that commu-nity benefit considerations are largely left out of the formulations ofaccountability driving contemporary health policy design. They arguethat the conventional professional model, as well as its reconfiguredform, in the context of increasingly complex practice settings, has failedto attend adequately to more community-centered values. They do, how-ever, miss an opportunity to explore the transformative possibilities forboth reinvigorating and restoring trust in the profession presented byincorporating more communication-centered norms in medical caresocialization and practice. The profession's defining demands for profes-sional autonomy and dominance based on expert knowledge could, forexample, be wisely amended by a recognition of the essentially interper-sonal nature of the doctor-patient relationship. Attention might bedirected to the form and content of patient-provider interactions, as wellas the environmental contexts from which patients emerge and to whichthey return after "treatment." Both in training physicians and designingthe systems in which they practice, the caring and curing functions theprofession is ostensibly charged with assuming, might be enhanced as aconsequence.Light sharply contrasts a more participatory model of health policyand program development with the model of countervailing powers thatdominates contemporary health policy design. This participatory modelis, he argues, more community centered, democratic, and coUegial inprinciple and practice. He also, however, documents that this model has,in essence, been largely marginalized in the design of national healthcare policy. The ideal types that Light employs to contrast this morecommunity-oriented policy template with other approaches to healthpolicy are, however, a relatively static analytic device for suggesting


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Frankford's critical analysis of the modes of power that characterizecontemporary health policy design surfaces a useful means for accom-plishing this: analyze the form and content of the discourse employed indebating options. His scrutiny of subject-centered and subjectless power,which underlie technical-rational versus participatory models of policydesign, respectively, points out that the former serves to disempowerpatients and consumers through the dominance of scientific and expert-centered discourse. Subjectless power, on the other hand, values the com-mon wisdom immanent in lived experience and the empowering potentialthat exists when people speak to and from these experiences. This is rem -iniscent of the community empowerment thrust of the writings of Brazil-ian social activist Paulo Freire in health education and health promotion.Friere contends that by individuals giving voice to their concerns in theirown syntax and semantics, they leam together how best to address theseconcerns (Freire 1970, Robertson and M inkler 1994). What Frankford'sanalysis fails to acknowledge is that social and political discourse is inher-ently intersabjectivs, not subject/e.s.s. Communicative rationality does notrequire that either the sovereign or the subjects be slain, but that theygather together to talk, to create new forms of social organization.Prevalence of Inauthentic and Power-Centered Discourse. All of theauthors, however, express considerable skepticism with respect to theextent to which contemporary policy discourse conforms to the elementsHabermas (1984, 1996) identifies as essential to mutual understandingand, thereby, constructive and relevant social change. The rhetoricregarding the promised benefits of market- and competition-dominatedhealth care reforms is jus t that: "rhetoric." The numerous imperfectionsin the m edical care m arketplace relative to the theoretical ideal of a com-petitive market rem ain essentially unexamined in the hyperbolic aggran-dizement of the merits of profit-centered reforms in both the public andprivate sectors. Governmental initiatives "b y" and "for" the people may,in fact, fail to acknowledge the means through which powerful stake-holders buy their way into the policy-making process, and that designing"benefits"/*?/- others may produce consequences that neither the confer-rer nor the recipient would deem "beneficial." A focus in community-oriented planning efforts on formalizing community accountability andrepresentation fails to recognize that accountability is not the same as


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I mp l i ca t i o n sThe authors conclude that the current discourse regarding health policyalternatives must be subject to critical and revealing scrutiny. They par-ticularly express serious doubts about the authenticity of the claims madeby proponents of the dominant market, governmental, and professions-based approaches to policy design, and the overshadowing or suppres-sion of the voices of those most affected in these debates. The likelyconsequence, each argues, is the continued failure of conventional healthpolicy approaches to achieve desired policy aims. What they all suggest,although none adequately develop or convey, is how more-comm unity-centered norms might serve to address these shortcomings.

The arguments and evidence presented here are that attending to theway we talk about health policy problems, the parties involved in thatdiscourse, and the ability to challenge the meaning and intent of theaccompanying rhetoric offer the greatest promise for innovating newapproaches to health policy design. Community-centered norms evokethose that most directly govern discourse oriented toward mutual under-standing: interdependence, reciprocity, mutual benefit, and trust. Thesenorms would then serve as signposts for signaling the extent to whichmarket-based, governmental, professionally driven, or conventional com-munity-oriented policy approaches diverge from more comm unity-cen-tered principles.

References

Bellah, Robert N., Richard Madsen, William M. Sullivan, Ann Swidler, and StevenM . Tipton. 1985. Habits of the Heart: Individualism and C omm itment in AmericanLife. Berkeley: University of California Press.

Emanuel, Ezekiel J., and Linda L. Emanuel 1997. Preserving Community in HealthCare. Journal of Health P olitics, Policy and Law 22:147 - 1 8 4 .

Etzioni, Amitai. 1993. The Spirit of Community: Rights, Responsibilities, and theComm unitarian Agenda. New York: Crown.

Foucault, Michel. 1980. PowerlKnowledge. Ed. Colin Gordon, trans. Colin Gordon,Leo Marshall, John Mepham, and Kate Soper. New York: Pantheon Books.

Frankford, David M. 1997. The N orm ative Constitution of Professional Pow er. Jour-nal of H ealth Politics, Policy and Law 22:185-222 .


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Freire, Paulo. 1970. Pedagogy of the Oppressed. Trans. Myra Bergman Ram os. NewYork: Seabury.

Hab ermas, Jiirgen. 1984. The Theo ry of Commu nicative Action. Vol. 1, Reason and theRationalization of Society. Trans. Thomas M cCarthy. Boston: Beacon.

. 1987a. The Philosophical Discourse (rfModernity. Trans. Frederick La wren ce.Cambridge: MIT Press.

. 1987b. The Theory of Communicative Action. Vol. 2, Lifeworld and System:A Critique of Functionalist Rea son. Trans. Thomas McC arthy. Boston: Beacon.

. 1996. Between Facts and Norms: Contributions to a Discourse Theory of Lawand Democracy. Trans. William Rehg. Cam bridge: MIT P ress.

Light, Donald W. 1997. The Rhetorics and Realities of Community Health Care: TheLimits of Countervailing Powers to Meet the Health Care Needs of the Twenty-first Century. Journal of Health Politics, Policy and Law 22:105 - 1 4 5 .

McKnight, John. 1995. The Careless Society: Community and Its Counterfeits. NewYork: Basic Books.Mulhall, Stephen, and Adam Swift. 1992. Liberals and Communitarians. Cambridge,

MA : Basil B lackwell.Putnam, Robert D. 1993. Making Democracy Work: Civic Traditions in Modern Italy.

Princeton, NJ: Princeton University Press.Robertson, Ann, and Meredith Minkler. 1994. New Health Promotion Movement: A

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