Sunday, July 13, 2008

Access Versus Security

I'm at East Wind, a 34-year-old community in southern Missouri, where we've just completed Day One of four days of meetings to discuss the policies and future direction of PEACH, the self-insurance fund created 22 years ago to protect the member communities of the Federation of Egalitarian Communities (FEC) from catastrophic health care costs. [See my blog of July 4 for more about PEACH.]

Today the main topic was whether to open the door for non-FEC communities to participate in the program—and if so, how wide. In thinking about it, groups face some version of this dilemma all the time: breadth versus depth; inclusivity versus purity; quality versus quantity, etc. The PEACH flavor of this question was whether to cast the net slightly wider in the hopes of increasing the numbers of people in the program (which translates to greater revenues and increased security against future health care needs) versus the potential awkwardness of working out program issues—such as assessing loan applications, evaluating personnel, and
validating claims (not at all like validating parking)—with people holding a slightly different set of core values. These were tough conversations, cutting to the bone about who we are in the world and the best way to both secure funding for our future health care needs and to use our program as a vehicle for social change work.

There are currently eight participating groups in the program and seven sent representatives to these meetings. Though the program has been around for 22 years, we have not had a face-to-face meeting in more than 12 years (while it's amazing what geographically dispersed groups can accomplish via email and conference calls these days, there are limits) and this particular configuration of representatives had never all sat in the same room before today.

While PEACH has a culture of making decisions by consensus, it was an extra challenge to be attempting that process with tough issues on the table and with people who barely knew each other. To everyone's credit though, we came through the first day well. People did not back away from voicing their concerns and everyone seemed well grounded in the need to hold a cooperative attitude. While we repeatedly bumped into some deeply held positions, there was also room for creative

This was all the more interesting in that we'd been laboring over this fundamental issue of whether to open the gates or circle the wagons for more than 16 months, encompassing two fairly frustrating conference calls and enumerable emails. What made the difference? I think the biggest factor was making the commitment to being in the same room, and giving people enough time and attention to make and digest full statements. If people feel heard—especially on their core concerns—listening improves markedly.

For those holding a more cautious position on the proposal to open up the program to non-FEC communities, there were concerns that groups who did not practice total income-sharing would see the world differently:
o They would, as a bloc, favor a different loan strategy.
o They wouldn't be as committed to preventative health care.
o Recuperative care would be more expensive because group members would not be as committed to collective support.
o They wouldn't be as careful in monitoring how health care dollars were spent, because it would be seen more as the individual's money (and choice) than as the group's choice.
o There wouldn't be as broad a base of common values to draw on when we disagreed, making it harder to work through issues to find consensus.

For those wanting to open things up, these factors were in play:
o A bigger pool is a safer pool (less likely that a few big claims would compromise the fund's ability to handle future claims).
o Extending our health care umbrella to the next ring out was walking our talk about cooperative values.
Because a basic tenet of the program is that participating entities must take primary responsibility for the health care of the members they are covering, non-income sharing groups will need to move in the direction of greater sharing to be eligible and this will promote a higher level of resource sharing in the world (something the FEC stands for).

A major sticking point was the extent to which it was appropriate to ask PEACH to promote egalitarian principles (as opposed to the more modest objective of simply supporting the health care and financial needs of egalitarian groups). While there's no doubt that FEC communities care a great deal about egalitarian principles, the truth is that there's considerable variety in the way that FEC member communities go about practicing them and PEACH has not made any appreciable difference in promoting new egalitarian communities the last 20 years—there are about the same number today as there were when the program started in 1986.

My concern is that by insisting that all groups participating in PEACH be income-sharing (and eligible for FEC membership) we will be sharply limiting our ability to increase the risk pool, which has the inadvertent consequence of increasing our risk. For some, the greater risk was diluting our commitment to egalitarianism (read commitment to creating a more just and fair world). For others (myself included) the greater risk was in not creating a sufficiently robust health care fund.

We ended the day with a decision to open the door as an experiment, and I think that was the best balance possible.
While there's still a lot of issues yet to be addressed in the next three days, we're off to a good start. And if you start to think that meetings are going well, you're much more likely to actually manifest that experience. Hurray for positive thinking.

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