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by Nancy Kari, Harry C. Boyte, and Bruce Jennings
with Treacy Colbert, Michael Garland, Harold Hassin,
Miaisha Mitchell, Edward O'Neil, Ellen Severoni, and Carmen Sirianni
Prepared for the American Civic Forum
November 28, 1994

A civic approach to health reform offers the opportunity to address the general crisis of politics in this country. If we shift the nature of the discussion from "What's in it for me" to a richer, more dynamic understanding of health care needs; if we can connect individual self-interests to a larger view of what we can accomplish by working together to reform health care, we will simultaneously address the most basic questions of citizenship in a democratic society: Who deliberates? Who acts? Who is responsible? Who are the architects of our common fate?

The quest for a just health care system is stalled by a lack of civic vision. Political leaders and pundits will make a serious mistake if they equate doubts about President Clinton's reform plan with grass roots satisfaction with the status quo and fear of change. In fact, exit polling in last November's election found health care at the top of people's primary concerns. Its absence from campaign rhetoric dramatized how poorly "politics as usual" is addressing the question. The debate is caught between skepticism about government and politicians, on the one hand, and an escalating sense of grievance and unfulfilled claims for more services and benefits, on the other. Today, more than ever, a civic perspective on health is smart politics, and it is also good politics.

Making health care a civic question offers important possibilities for breaking out of the current stalemate. Treating health as a civic question brings forth creative, new ideas from a variety of sources—a lesson that emerges time and again from the experiments with public discussions about controversial issues. Wide public deliberation can lead to discernment of which proposals for reform people are likely to find comprehensible and legitimate. The experiences of civic discussions about health policy sponsored by American Health Decisions groups have illustrated this. Oregon's health reform plan, which from the outside seemed controversial, passed with overwhelming bipartisan support—57 to 3 in the Assembly and 24 to 2 in the Senate. This was only possible because of the tens of thousands of hours of citizen discussion that created a wide public consensus about core health values.

Seeing health as something that involves us all will be essential for generating widespread behavior change and for reworking public stereotypes about those with chronic and disabling conditions. This lesson emerges with special clarity from recent developments in community-oriented health and in the disability movement which have brought people acting from their own immediate self-interest into a larger context, tied to civic understandings of health. Such changes are essential for creating a healthier nation.

The concept of health raises profound issues of our lives and our society: how we individually and collectively deal with aging, chronic illness and disability, the results of accidents or violence, our power over our own destinies and death itself. In contemporary society, the quality of our collective health depends upon an intricate web of cooperation and interdependence . This relational fabric of health is rendered virtually invisible by the conventional language of health services, private choice, and also by the growing fragmentation and lines of divisions in our society. Our health care crisis presents us with a dramatic moment and a chance to confront the limits of what any health care system can do to cure chronic diseases, sustain life through technology, or alleviate the deleterious consequences of stress, pollution, and violence in everyday life. At the same time it opens up new possibilities to make explicit the imperative that citizens must be actively engaged in health problem-solving and in developing health policy. Here the lesson drawn from a wide variety of American civic experiences is important: our commonalty is often best achieved through common work.

The following paper is a collaborative effort among a diverse group concerned with reframing our understanding of health and the health reform debate. It is part of the larger American Civic Forum, an effort to revive strong practices of citizenship in America.

We ask, how can health reform become a civic question? Answering this will require a shift from a strategy for political mobilization around a single sweeping reform package to a longer range approach. In the coming health debate, citizens need to take center stage. The policy process needs to move outside the Beltway. It should undertake a "journey of civic discovery" that draws lessons from successful experiments in the rest of the country. Moreover, the process needs to redefine the role of government as civic catalyst and provider of tools for people to solve their own problems rather than the main problem-solver or the regulator.

A major redefinition of the roles of government and citizens' roles will require a great deal of experimentation, trial and error. No blueprint exists. However, innovative civic practices in health do not have to be invented. They have begun to appear on an often significant scale in the formulation of health care policy, in examples of community problem-solving, in creative design of service programs, and in strategies for highlighting the civic and community contributions of those with disabilities. These developments have not been visible in the national discussion.

We must reclaim health reform as something that involves us all. We must see it as a civic question, not a question simply for experts, professional policy makers, or partisan political interests. This means seeing experts and professionals as citizens themselves, citizens in need of conversation with other citizens. It requires a different model of health professional education that teaches relational patterns of interaction, one that is attentive to work in community contexts. It also means engaging the broad public in a variety of ways, from consideration of individual responsibilities, to community-oriented health and prevention practices, to public deliberation on health priorities.

After a background discussion on the health reform debate, this paper looks at obstacles to a strong citizenship perspective that are intrinsic in the dominant ways health is conceived and practiced in America. It explores in some detail changing patterns in provider-patient relationship, arguing for a shift from a relatively narrowly drawn expert-client pattern to contextually enriched, more fluid patterns of interaction. The paper highlights examples of civic approaches to health in individual and community action, through institutional and professional practice, and in policy discussions. Finally, it concludes with several questions which are critical if citizenship is to reframe health reform.

The health reform debate to date has focused on the exclusion of 40 million Americans from adequate health care coverage—the medical disenfranchisement of 15% of the total population, including much of the lower middle class, large numbers of children, and those most medically vulnerable. For poor and minority populations, issues of access are compounded by the low representation of minority health care providers and general inattention to cultural resources. This disenfranchisement is deeply troubling and needs to be addressed in any serious reform effort. Yet when this remains the center of attention, health reform also encounters significant political obstacles. Questions of equal access to services and universal coverage speak to middle class fears of loss of coverage involved in job change and catastrophic illness. At the same time, these issues potentially raise middle class worries about cost, choice, and quality of care. In a climate cluttered with the massive mobilization of special interests, the public became easily confused, skeptical, and weary of discussion.

Moreover, the health debate failed to address adequately two other critical dimensions of health: (1) the challenges of chronic illness and disabling conditions; and (2) strategies for prevention and health promotion. Addressing these issues seriously will require dramatic changes in the nature and extent of citizen participation in problem-solving and health policy discussions. Simply, we cannot achieve a healthier or safer society without widespread civic involvement in health. Such involvement has been largely neglected by conventional policy discussion.

In the past 50 years we have embraced the notion that expert medical knowledge can somehow fix the consequences of unhealthy lifestyles no matter what choices we make and rescue us from the pain and fear of death. In the process, we have created a system that pushes at the edges of technological possibility and creates an extraordinary range of medical options. This emphasis on technology and specialized professional knowledge has produced a health system that is heavily weighted toward acute care rather than preventive and long term care.

There are obvious advantages to putting resources into specialized training, knowledge, and technology. From a civic perspective, however, there are also serious costs involved when people believe that health care decisions should be turned over to the "experts." The scientific mystique leads ordinary citizens too readily to avoid the complex, troubling issues surrounding human aging, chronic illnesses, and mortality. By avoiding these difficult questions, the people also cede authority for making the critical decisions that affect us individually and collectively. Moreover, the "expert" model leads to a psychological, social, and sometimes a physical separation of professionals from those receiving their services. For providers, it is often too easy to lose touch with the lives and concerns of ordinary people. When this happens, important cultural dynamics and resources unwittingly can be ignored.

Citizenship in health care will require far ranging change in the ways in which we typically think about our health. It will involve a shift from seeing health care as a commodity to be consumed to emphasizing health as a common responsibility for us all. In addition, it will require changes in the nature of the relationship between provider and consumer.

Citizenship as a concept holds potential to reframe our thinking and actions. Citizenship has many definitions from voting, to paying taxes, to sharing values like patriotism and concern for one's community. In its most expansive sense it can best be understood as public work . Public contribution through productive and useful work, paid and unpaid, is critical to active citizenship. Citizenship understood as the work of public deliberation and collaborative problem-solving in community contexts has much promise for addressing complicated, long term issues in health. A civic approach can tap different resources and highlight aspects of health that are largely invisible in the now dominant model of health care. A consciousness of the civic dimensions of work also expands people's sense of possibility. Such understanding liberates expert knowledge—it does not diminish or deny its importance—by creating more productive, creative and satisfying sets of relationships between providers and consumers. Moreover, as people gain knowledge and learn civic skills, behaviors can change dramatically. New understandings of health behaviors can, in turn, shift the emphasis in the health care system to health promotion and disease prevention. Finally, understanding the public dimensions of work creates new experiences of freedom and meaning through the awareness that people working together can make a difference in the larger world.

Health care is both a professional practice and a social institution. Without the special training, expertise, and commitment of individual professional practitioners medicine could not exist. Nor could it exist without an organized social structure and social support. When people think about the extraordinary technological advances of modern health care, they often forget how "public" an achievement this has been. Without a vast social infrastructure of education, government research funding, and extensive industries in pharmaceuticals and health care facilities, most of these advances would not have been possible. Medical knowledge and practice have taken shape and developed not just by accident, but because of deliberate public decisions in the form of laws, governmental regulations, and public policies. Health care is also public in that what it can do and how it is used does not just affect one individual patient at a time, but has large ripple effects in the culture and the society as a whole.

At the same time, because it is often a potent force in the lives of individuals at a moment of great need, helplessness, and vulnerability, health care has intensely private and intimate aspects as well. In recent times, the private face of health care has been at the forefront of attention. Today this emphasis is rapidly changing. For the past half century health care enjoyed an extraordinary period of prosperity and abundance. We are now entering a period of relative austerity and scarcity of resources. In this new climate, health will have to fight for its slice of the economic pie. Systemic issues such as efficiency, cost containment, and rationing have already become central to the policy agenda. The next stage will be the exploration of what it means to think about health as a "public good", created and sustained through the work of citizens. There remain, however, significant obstacles to a civic approach, built into the ways in which health's "publicness" is now conceptualized.

Thus far the health care debate has focused on financing and access. Health care has been cast mainly as a public commodity to be distributed, not as a public work to be shared. Public work means an occasion of common endeavor and shared problem-solving that involves both providers and patients, and that takes place in the context of a larger community. We have trouble seeing public work in this sense in our society, even when it is right before our eyes. We suffer from civic myopia, perhaps in health care matters most of all. We do not see well because we are looking through ill-fitting glasses. We need a new prescription.

The glasses we wear are the framework of macro- and especially micro- economics. A powerful lens it is too, through which to view health policy and medicine. Moreover, this perspective is reinforced by individualist moral and legal notions of rights. Operating within such a conceptual framework, the recent health policy debate has been largely cast as a choice between allocation guided by government regulation versus allocation guided by a competitive market influenced in part by interests of pharmaceutical companies, hospital corporations, and private insurers. However, the underlying privatized notion of health care as a commodity that is privately consumed by paying (i.e. insured) individuals remains unquestioned.

In such a framework, it is natural to talk of health care professionals as "providers" and of patients as "consumers." Citizen "empowerment" then becomes a matter of individual market choice. The language and assumptions that remain bounded by rights and economic goods constrain our political imaginations, narrow social roles, and conceal the civic and public aspects of health. Furthermore seeing health care as a public commodity, privately consumed, sharply limits our ability to address health in the present context of an aging society faced with challenges of multiplying chronic health problems.

Today specialized professional knowledge and sophisticated technology are the primary tools of problem-solving in health. Indeed, Americans' general deference to expert authority, shaped over time by broad social, educational and economic forces, is especially striking in health care. In health, an expert model has been associated with the erosion of communal authority and connection: the necessary activities of ordinary citizens in making communities healthier places to live have become increasingly invisible. Health professionals' training in many fields—preeminently medical doctors—has reinforced the notion of health provision as a specialized activity, beyond the knowledge of most people. Moreover, health professionals are socialized to identify almost completely with their particular discipline or specialty, removed from the social environments, cultures and concerns of those they "treat."

The distancing of professionals and highly educated "conceptual workers" from the lives of most other Americans is a general social pattern that is vividly demonstrated in health care. Throughout the fabric of civic and social institutions—not just government—service provision has replaced more interactive problem-solving. Throughout the 20th century, as large government agencies and corporate structures have grown, a new stratum of managers and technical specialists has emerged who draw their basic metaphors and language from science. This contemporary "culture " of professionalism, evident in most disciplinary areas, emphasizes rationality, methodical processes, and standards of "objectivity" in place of public deliberation and active citizenship. Today, experts define and diagnose the problem, generate the language and labels for talking about it, propose the therapeutic or remedial techniques for problem-solving, and evaluate whether the problem has been solved. There are few opportunities for citizens to learn the skills of public action, deliberation and evaluation through which ordinary people move to the center of public problem-solving and everyday politics.

Civil society can be conceived as an arena of voluntary associations, community groups and public practices distinct from government. Civil society in this sense has shrunk in recent years. Voluntary groups' goals have shifted from public deliberation and problem-solving to service provision that treats people as individual clients with deficits and problems that need fixing. There are many examples. The local union has moved from the center of community life to a marketing operation for a series of specific benefits. Teenage programs have de-emphasized citizenship and developed programs to promote self-esteem and career skills. Schools have come to focus on personal expressiveness and "feeling okay about oneself."

A civic perspective in health begins with a simple premise: health professionals are also citizens. Moreover, health providers need a variety of interactive, civic skills, as well as technical skills and disciplinary knowledge. Raising the question of civic agency --recognizing citizens as significant actors engaged in collaborative public work, rather than simply as experts or clients or customers—has a double challenge. A civic perspective confronts the general problem of civic disengagement and also the ingrained patterns of expert-client interaction that can render people spectators to their own health care. For example, so-called consumer-oriented reforms—permitting a wider range of providers to prescribe drugs, or publishing "scorecards" on hospitals, nursing homes, and individual providers—must be placed in a civic context. They do little good if they serve merely to heighten adversarial conflicts between doctors and patients. People need more than additional statistics; they need new patterns of partnership and translation between ordinary citizens and experts with technical information. A civic perspective also will require health personnel at every level to understand much more fully the contextual dimensions of health practices, incorporating questions of culture and social interaction that are now often neglected.

When providers learn about community cultural traditions and values, traditional patterns of outreach and service delivery are altered. A hospice program in Austin, Texas illustrates how collaborative problem-solving with members of the community can identify new resources and open opportunities to address a range of community needs. Because minority participation in this hospice program was very low, a minority access committee was convened to address the problem. Several new strategies changed the picture. For example, Hospice Austin decided to "raise their own nurses" and established minority scholarships, obtaining the dollars through local foundations and challenge grants. Students supported by the program give back to their community by working part-time in the hospice program while they are in school. Receiving small stipends, each student gives almost 600 hours a year to hospice. At the end of their educational preparation, the graduates commit to work at full pay for two years in the hospice program. Also, the program invests in the community by putting $100,000 of hospice dollars into the NAACP credit union and making it available for hospice members. As the director said, "If you take care of the living, you take care of the dying."

Hospice Austin also reached out to the local ministers, who asked the challenging question, "What do you have that we don't have?" In response, hospice staff brought their message to churches during Sunday services. Powerful ideas emerged out of these discussions. Over three years, minority community volunteers increased from almost none to 26% of all volunteers.

Opening up to the community and understanding its needs, in turn, changed the way hospice works with and provides services to the minority community. For example, in the Hispanic community, providers discovered that talking to the man in the home first and making sure he understands, even if he is not the caregiver, saves a tremendous amount of time in the long run, since without his cooperation everything else can be extremely difficult. In this instance, understanding patterns of bereavement, grief services, and the culture-specific health care beliefs such as the role of curanderos and folk medicine helped the hospice workers to be far more effective in serving the community and using their resources well.

A civic approach to health care can generalize from the kinds of lessons illustrated above to influence the nature of health policy. Currently, public policy, in health as in other arenas, is based on a "deficit" perspective that emphasizes individual deficiencies, needs and inadequacies. In contrast, a civic perspective emphasizes capacity. It helps develop individuals' potential to solve problems, and it also highlights both informal and formal social institutions and networks that are critical to community health. A civic perspective identifies strengths, amplifies and develops skills, and multiplies and deepens connective links among civic associations, local institutions and knowledgeable individuals that can be found in any community. Attention to contextual resources, therefore, results in a far richer and more productive approach to health than does reliance on professional expertise alone.

The provider role embodies the complexities of the health system today. There has always existed within health care a tension—and sometimes a dramatic clash—between two cultures, one specialized and technical, the other more holistic and community embedded. The latter will need significant deepening and expansion in a systematic way, building on the trends in health provision and preventive medicine toward more community-oriented approaches that can be formalized in professional standards of practice.

Rethinking professional roles in civic terms opens up new possibilities. It is essential to an understanding of health that includes the whole community. Health providers (i.e. health educators, social workers, physicians, nurses and assistants, allied health professionals, dentists), like others in society, hold many simultaneous affiliations which usually are not mutually exclusive. Since the dawn of medicine, for instance, the physician's duty to minister to patient needs has been a central tenet. However, the complexity of this relationship has increased with factors such as specialization, advanced technology, increased knowledge of biomedical systems, managed care, and powerful financial implications. The traditional model of the doctor-patient relationship no longer functions autonomously.

In response to alarming health care costs, managed care has emerged recently as one solution to the problem of efficiency in health care delivery. It has had unintended consequences. For example, as health plans, hospitals, insurance companies, and large medical groups compete for patients, individuals themselves become a commodity bought and sold in bulk. At the same time, accepting financial risk for large populations requires closely monitored access to services which can potentially deny patients necessary care. For a while, insurance paid by employers masked the financial implications. Many people, secure with seemingly free employer provided insurance, did not notice the changes. But now an alarm rings to alert us that in the process of protecting the medical commons, we have unleashed incentives that may restrict even beneficial services and will almost certainly introduce stark elements of bureaucratic impersonality into health care for many middle class patients. For minority communities, such impersonality is compounded by disruption in continuity of care when minority physicians are not included on the list of managed care providers.

In this changing environment important questions arise: How can we address problems of delivery and access to care in cost effective ways? Are there alternatives to conserving community resources without placing a gatekeeper between people seeking health services and their doctors? How can health providers advocate for the individual while at the same time helping to create a health care system responsive to health issues of the broader community? How can providers work with their patients and others in the community to build capacities for problem-solving? How will health providers' education need to change in order to facilitate skills of collaborative work and deeper understandings of the cultural and community contexts in which they operate? Asking such questions also highlights the limits to the traditional ways of conceiving the provider-patient relationship.

Important changes in that relationship have been taking place for some time. In recent years the provider-patient relationship has become decidedly less "paternalistic" and more "contractual" in nature. While this shift entails important ethical gains, it also has limits, and a further shift is needed. According to the paternalistic model the patient occupies what sociologists call "the sick role." This means that society does not expect the patient to "be himself;" the patient is temporarily excused from normal obligations and responsibilities, while focusing on following orders to get well. The provider, in turn, is expected to adopt an authoritarian and benevolent role, using expertise to promote the patient's welfare, even if this involves some manipulation. This one way pattern of interaction is often exacerbated by a lack of understanding of cultural differences.

A consumer oriented patients-rights movement emerged in the 1960s and 1970s in opposition to the paternalistic model, initiated by several trends: women's concerns about the medicalization of pregnancy and child birth, revelations about unethical medical experimentation on human subjects, and a growing sentiment that many modern physicians and other providers were no longer benevolent paternalists, but rather specialists motivated more by the technological imperative than by patient well-being. Out of this dissatisfaction arose a much more active, rights-oriented image of the patient. In this cast the patient did not so much come to the physician as a helpless person in need of support and assistance, but instead as a customer with a problem. Thus the parent child model turned into a more collaborative, "contractual" relationship between provider and patient, freely agreed to by both parties.

Both the paternalistic and contractual models have in common the assumption that the problem bringing provider and patient together is discrete, potentially curable and of relatively short duration. This is the image of acute and infectious illness, where the emphasis of medicine has been in the past fifty years and where its greatest triumphs have taken place. Issues of prevention, mental health, disability and chronic disease do not lend themselves well to these models, however. They require much more active and sustained involvement by the patient, and they necessarily include family and community contexts. For an individual, long term care and issues associated with disability involve critical educative and transformative processes of self-definition and reintegration into community life. Health strategies that emphasize "abilities" and the full complexities of people's lives, rather than their deficits, become central. These complicated adjustments to disabling conditions cannot be accurately understood in terms of a commercial transaction or as an instrumental agreement for the exchange of services for payment. In the years ahead we must move from the contractual model to a civic model of provider-patient relationship, just as we must reconceptualize health and health care from commodities to public works. Integrating a civic framework with disciplinary theories in professional health education and continuing education is key to such reconceptions of health care.

As people understand health as a function of settings and communities in which they live and work, health outcomes will shift to include measurement of community well-being and civic capacity. In turn, these changes will help policy makers, providers, and communities more effectively address preventive and chronic care.

It is important to note that in pursuit of a civic perspective in health, a continuum of simultaneous practices is necessary. The range of activities can occur within a variety of contexts. These include: commitment to individual action; involvement in public deliberation and problem-solving at the community level; focus on the civic capacities within health organizations; reform in professional education; exploration of new forms of civic relationships between health organizations and communities; and participation in state and national policy discussions which lead to changes in legislation.

The Pew Health Professions Commission's polling of several thousand people in Georgia in the spring of 1993 showed not only that people were willing to sacrifice for health reform, but also that people recognize they must take on new responsibilities if our country is to improve the health care system. A citizenship message thus begins at home in simple ways—when children are taught habits of good nutrition and regular exercise; when parents take advantage of immunization programs and well baby clinics; when young people find alternatives to drug and alcohol use. Because health is strongly affected by educational levels, commitment to schooling is a factor in a healthy life. Moreover, a person's health is strongly enhanced by civic involvement itself. Research suggests that those with active public commitments live longer and have robust, healthy lives.

A citizenship perspective also broadens personal responsibility beyond individual action and well-being. Again, the Pew Commission's extensive sifting of polling data on health issues over the past 30 years shows a notable shift. Through the seventies, people expected their health to be "taken care of" by experts. Beginning in the 1980s, there was a strong countertrend showing support for civic involvement in many forms. Self-help, self-care and informal support networks are examples, including efforts to keep elderly in homes through block nurse programs and hospice care.

It is not hard for people to imagine larger contexts for participation in deliberation and problem-solving beyond individual empowerment, such as involvement in community prevention campaigns. When health questions are embedded in everyday life situations, there are always larger policy and civic dimensions that can be drawn out. In a rural county in North Florida, for example, an initiative now in its planning stage will increase awareness and participation of African-American males in issues of reproductive and child health. Using beauty parlors and barber shops as public spaces, young men from the community will be trained as coaches to facilitate discussions among residents to identify their knowledge, perceptions of roles and responsibilities and attitudes about male participation in support of maternal, child, and reproductive health. The discussion leaders, called preventive health care activists, will learn processes of civic action. After participating in the discussions, community men and women will work with providers and policy makers to identify the sociocultural barriers that inhibit participation in primary care for child, maternal and reproductive health. Community involvement in decision-making will result in culturally relevant approaches to educate people about reproductive health. At the same time, participants develop their capacity for public deliberation and community problem-solving which is useful in many contexts.

Long term reform requires a fundamental change in relationship between health organizations and the general public. Already there are promising stories that illustrate collaborative, reciprocal patterns of interaction that serve both the community and the organization.

For instance, Central Medical Center (CMC), an African-American hospital in St. Louis, used its buildings as public spaces for community problem-solving. They brought more than 30 organizations and community programs into the hospital: GED classes; block clubs; women's groups; AA groups; AIDS groups; and church groups. This action opened opportunities for a variety of new collaborative efforts with the community and increased use of the hospital. The police department worked with CMC to create a training program for community patrols and a joint chaplaincy-police project on violence.

The centerpiece of these joint efforts was the Saturday School program which combined civic and health education for young people. Volunteer physicians, nurses, and parents participated in the Saturday School program. Children learned to teach other children how to talk with their elders about family life and about their health histories. They created comic books which illustrated their own history, culture and values in relation to health concerns in the community such as alcohol, drugs, and AIDS.

"We found that the more partnerships we developed, the greater the community involvement with the hospital," says Miaisha Mitchell, then Vice President for Corporate Community Development. "We were able to develop relationships with public housing groups for on-site alcohol and drug case management and counseling and acupuncture services. Citizenship training was always a central theme. Local artists and ministers, for example, integrated citizenship training with initiatives on art and healing. "

There are other examples of innovative, reciprocal partnerships between institutions and communities. The University of New Mexico's School of Medicine has been a leader in developing effective relationships with communities across the state. The school has helped low income communities both identify critical health needs and mobilize political resources to secure them. In New York, the Columbia University School of Nursing has created an extensive initiative in the Upper West Side of Manhattan that involves young people and others in health prevention and health delivery campaigns. The Sisters of St. Joseph in St. Paul, Minnesota, sold their hospital and worked with fifteen city neighborhoods with high numbers of working poor to establish neighborhood clinics. Staffed primarily by volunteer medical personnel, these clinics offer low cost or free care to uninsured and underinsured people who are not covered by Medicaid.

Health professionals themselves strongly influence the culture of health institutions. Although health professional commitment to civic engagement and change is not widespread, there are signs that within some professional groups there is a growing recognition that without a reframing of their practice, roles will continue to narrow as resources are reallocated. In health professional education, voices like the Pew Health Professions Commission have called for development of what are essentially civic skills among the workforce. The Commission has argued that to meet society's needs in the immediate future, health workers will need to work both collaboratively and flexibly to address community health problems and their root causes.

Over the last several years, National Easter Seals in collaboration with disability organizations has organized a major national campaign through its Corporate Communications Division to emphasize the civic contributions and potentials of people with disabilities. Its "EDI" (Education, Dignity and Independence) Awards is now a high level event each year that involves hundreds of national media leaders, who honor media efforts that stress the civic capacity of people with disabilities. The organization has recently undertaken a long range initiative in partnership with the Center for Democracy and Citizenship at the University of Minnesota's Humphrey Institute, aimed at civic leadership development among people with disabilities.

In a similar vein on the professional side, the American Occupational Therapy Foundation completed a major study of what researchers termed "underground practice" associated with such skills. Currently, a civic initiative involving higher education and clinical education sites is developing to explore possibilities for new civic models in professional education and community practice for occupational therapists.

Indeed, patterns of professional education will require significant change if citizens are to be directly involved in the development of health care programs and health policy. Health professional education is an expensive and time consuming process. It currently utilizes over $30 billion of resources annually to educate the next generation of physicians, nurses, dentists, and allied health workers. The social investment in health education is predicated on an underlying covenant that this investment will benefit society. But the nature of this covenant cannot be limited to just "doing good." Taking this commitment seriously means that professional schools will need to engage in a genuine and ongoing conversation with communities about the nature of community health problems and the ways in which educational resources might best be allocated to address them. Such conversation grows from specific interests, as well as larger moral imperatives. Public support for health institutions will only be sustained over time through such interactions. Moreover, only this kind of dialogue can generate the in-depth knowledge of community issues, concerns, perspectives and patterns of relationships that are essential for adequate research and education.

Situations will vary. Sometimes there may be direct ways that colleges can help address a problem by focusing research. In many situations there can and should be a direct investment in the problems faced by the community with the full range of research, educational, and technical resources available to the university. Different colleges and universities have different missions which need to be taken into account. Some are more focused on research; others have a broader community service orientation. Ultimately, the success of health professional schools, regardless of orientation and mission of parent university, will be determined by their ability to recast and reforge the civic relationships between themselves and the communities they serve.

A genuine civic dimension in health involves citizens in creating and implementing policy. This is largely missing in the current national health debate. Without this dimension, however, it is very difficult to develop policies for which the public will claim ownership. If citizens are to accept reforms that effectively address the knotty questions of universality of coverage, minimum benefits, equitable funding, and freedom of choice, it is necessary to deliberate about the meaning and importance of the underlying values of equity, dignity, and choice.

For more than a decade, the American Health Decisions network of state organizations has been pioneering new methods of involving the public in community dialogues about health values and responsible tradeoff options. Results of these dialogues are then brought into the policy making process in ways that have been able to break the health reform deadlock. Most of the original state Health Decisions groups emerged from the Health Systems Agencies (HSAs) that were set up with citizen participation in 1974. As the federal government withdrew its support for the HSAs in the 1980s, independent and nonpartisan Health Decisions groups appeared in many states. They have demonstrated the practical wisdom of widespread civic forums on health in diverse communities.

Oregon Health Decisions held hundreds of community meetings and two statewide health care parliaments in the 1980s. These public forums prepared the ground for a state reform process beginning in 1989 that was triggered by the spiraling costs of Medicaid and the widespread public concern about who and what are covered. The process continues today with extraordinary success and involvement among a broad array of local and state groups and individuals: seniors and those with disabilities, poor women and children's health advocates, medical and nursing associations, insurance companies and small businesses, those with preexisting illnesses and many others, some of whom were previously uninsured.

The Oregon Health Plan which emerged from the forums, enlisted unusual bipartisan support. In less than two years since the plan went into effect, some 35,000 people have left the AFDC rolls, largely because they no longer need to be affiliated with AFDC to receive health coverage. While there was strong opposition to the plan from some national advocacy groups, state reformers are addressing their concerns about priority setting and rationing procedures under Medicaid. Support for the plan continues to grow, both among the general public and among the constituencies that some feared would be most harmed. (See also Community Meetings Shape Oregon Health Plan.)

In 1990, Georgia Health Decisions began a similar process of community dialogue. Today, the Georgia Partnership for Health, representing stakeholders from every constituency in the state, is developing a state health reform plan. In the initial phase, this grass roots, nonpartisan group held 257 community forums in 104 counties, many of them in conjunction with churches and synagogues, senior centers and League of Women Voters chapters, local chambers of commerce and professional associations. They then conducted 60 focus groups to clarify health values and concerns within specific demographic clusters. People identified "loss of control" in the health system among the most important problems. They emphasized that health care was not just about providing services, but was "a relationship based on dignity, respect, and compassion." They ranked environmental protection among their top five health concerns and the right to sue among their bottom five. Participants expressed willingness to accept some limits on their choice of doctors, use of high technology, and schedule of access for routine care.

Face to face discussions were very important in clarifying values and choices. For example, people learned that imposing limits would save money that could then be used to extend health care to everyone in the state. This was a commonly held value. There was also a strong consensus that everyone must contribute something in return for the care they receive, even the poorest. That there should be "no free ride in Georgia" was a value shared by a wide diversity of people from all income levels and ethnic groups. (See also Community Forums Bring Georgians' Values to Health Debate.)

California Health Decisions (CHD) has utilized similar deliberative processes to determine health values for the past decade. Like several other state chapters, CHD developed civic partnerships with newspapers and public and commercial television stations to broaden the discussion. Recently, CHD has begun to work with large medical systems to help them establish deliberative processes as part of their decision-making. In Orange County, for example, CHD initiated a collaborative process among the county's supervisors, medical association, legal aid society, foster care network, AIDS services and others to reform Medicaid. The process involves beneficiaries in the design of the new system. Because CHD has held extensive dialogues with recipients of Medi-Cal who want the system to respond to concerns for respect and fairness and with people in the broader population who are concerned with costs, CHD can help clarify the "health care divide." This important information gathered from many public discussions provides a starting point for reform of Medical that can respond to multiple concerns. (See also California Health Care Divide - Involving the Public in Health Choices.)

In sum, the American Health Decisions experiences illustrate that citizens can enter into serious discussions about complex health policy issues and priorities with thoughtfulness and creativity. Such citizen involvement is indispensable to the credibility and success of health reform.

Can all of society's demands for cost restraint be attained without sacrificing its members' welfare? Can we achieve a healthier society? To accomplish these goals will require involvement of all sectors of America to create a health policy which supports prevention, treatment of chronic illness, and the full integration of people with disabilities into public life. Involvement of stakeholders --individuals, communities, providers, insurers, higher education, policy makers—will necessarily entail not only specific interests but a larger civic vision, made concrete through public work.

Revitalizing a robust conception and practice of health as the common product of our lives together generated through rich, interactive practices of public work forms the centerpiece of a civic understanding of health. In some ways, this is a translation of older American practices into a radically different context of our time. It is the path for real health reform.

Rethinking health reform with a civic framework is a way to regenerate momentum toward substantial change. Putting adequate resources toward civic capacity development can essentially reorient the health system toward health promotion and disease prevention. An overall strategy for making health a civic question must build on the stories and experiments already in place. Now the challenge is to take the next step.