My chief complaint about the health care reform of 2010 was its apparent failure to include active citizens as designers of the bill (the public could have been asked to deliberate about health reform, as Senators Wyden and Hatch proposed), or as proponents of the bill (the administration could have unleashed a grassroots movement to demand passage), or as active participants in administering health care (the bill could have empowered health insurance co-ops).
Yet the bill actually contains many excellent provisions that have received little attention. One reform is a major increase in the authorized funding level for Federally Qualified Health Centers (FGHC). The extra money should raise the number of such centers to 15,000. An FQHC is a local provider, serving a needy community, that gets favorable Medicare and Medicaid reimbursement rates, access to the National Health Service Corps, and other federal supports. It must be a nonprofit organization or a public entity, and it must have a board of which more than half are current clients of the center who demographically represent the population that the center serves.
Overall, the trend in public administration has been toward centralization and expertise. Based on data collected by Elinor Ostrom, I estimate that the proportion of Americans who serve on any public board has declined by three quarters since the mid-20th century, due to consolidation of public authorities and the replacement of elected offices with professional positions. This means that we have lost powerful educative experiences for our citizens. At the same time, our public institutions have grown remote and distrusted, and we have missed the energies and ideas of people not deemed to be “experts.”
Controlling health care costs is a classic “wicked problem,” involving complex, interconnected systems, rapid and unpredictable change, valid but conflicting values and interests, and misaligned motives. In general, wicked problems are best addressed by decentralizing control and empowering mixed groups of people, including those most affected by the problem. The administration’s support for Federally Qualified Health Centers promotes this populist approach and deserves recognition.