Why don't great options make great systems?

The town hall health care blow-ups have gotten attention mostly as theatre and "decline of America" hand-wringing. But like many great confrontations, they have brought paradoxes to the fore. And paradoxes are valuable things. One of the most valuable paradoxes is this: how can we simultaneously have "the best health care in the world" and a crumbling health care system? (The same paradox exists in lots of fields--best lawyers but horrible legal system, best athletes but horrible national physical fitness, etc.)

Educators are familiar with this paradox because we have it too. How can we have great teachers, (or programs, or schools, or universities) and at the same time a system of schooling that by all accounts is falling short? Here are some possible explanations, all of which are in circulation in both the health care and education debates:

1. Discrimination--The best educational options are available overwhelmingly to white, well-off people. If you have money, you can afford the best (teacher, lawyer, doctor), if you don't then you get underfunded, overcrowded schools.

2. Bad information--You have to know about the best options to know how to take advantage of them. Even the wealthiest often get bad (health care, schooling, whatever) because access to information is uneven and options are hard to judge.

3. Crisis-mongering--Perhaps the gap between the top option and the system isn't that large, but it is in the interest of some people to make it seem that way.

4. Bad choices--It isn't the system that is ineffective, but the day-to-day choices of the people acting in the system that are ineffective. If people want good outcomes, be they in health or education, they need to make and stick to good choices.

I imagine that all of these explanations have some power, especially in the national debates. But they cover up a few other explanations that I see popping up frequently in my work. Here they are:

1. Innovation is a sign of excellence--whether in health care or in higher education, the new thing gets the most attention. This isn't bad in itself, but it does lead to situations where excellence does not become widespread because leaders have already moved on to the next new thing. This is particularly true with pedagogy, but also with other parts of higher education. Without staying with an innovation for a long time, it is impossible to understand how it can spread out to the rest of campus, or the rest of the system.

2. Excellence is designed not to work at a system level--think about honors programs, or athletic teams, or undergraduate research. These aspects of higher ed are rarely designed to serve all students, or even to produce lessons that can be applied across the campus. When was the last time that a campus, seeing that honors students flourish in team-taught classes, decided to make that resource available to all students?

3. There is no such thing as a system--This is my particular hobby horse. We talk all the time about health care systems, or school systems, or campus communities. But are they really systems? Are the pieces connected? Do they give feedback? Do they have ways of self-correcting? Almost always they are not. Just as there is no meaningful connection between Harvard Medical School's cutting edge cancer treatments and the doctors who treat regular people in Pleasant Grove, UT, so is there no system that works together (even without overall leadership--I'm not calling for the creation of a "President of all Higher Ed" position) as a whole.

Without an actual system, there is no way that the two parts of the paradox--excellent options and poor systems--can even be considered together.