Learning about cost and quality from health care and agriculture

Atul Gawande has a great piece in the 14 December 09 New Yorker. "Testing, Testing" contains hints at two ideas that would help higher ed move ahead on the cost/quality issue.

First, he reminds us that for health care reform to succeed government has to mandate that nearly every American get health insurance. Or, put another way--the best way to ensure access to health care is to require that people get access to health care. Mandated access is important because it is only by expanding the market that the pool of the insured is large enough to make insurance a viable business.

Access to higher education is the sometimes forgotten key to cost and quality in higher ed as well. Millions of new potential university students aren't attending college. And millions more who have dipped their toes into higher ed are no longer pursuing it. Why? Cost is a big factor, along with cultural challenges, and the indifference of much of HE to their plight. So, if we want movement on cost, perhaps we need to move on requiring access. (I know the objections--not every job requires higher ed, many, many people can't afford it, it extends the power of the state well-beyond its current already-impressive reach, etc.)

And who knows--millions more adults, required to get higher education, might be a powerful force for reform of higher education. (Right now students and potential students have a very limited role in pushing reform--they act largely by choosing another campus, dropping our, or never joining up.)

Gawande then explains why access should be a requirement, but there should be no standardized approach to insurance and treatment. To make this point he turns to another mandatory practice--eating. In the late 19th and early 20th centuries food was expensive and access was limited. Farming was outdated, soils depleted, public health poor, life expectancy relatively low, farm work brutal.

Government did not mandate a particular approach to growing food, though. Instead it catalyzed changes through extension agents. One particularly influential agent, Seaman Knapp, traveled to Terrell Texas to try to get farmers to try out some new techniques. Not every farmer adopted them at first. Instead, community leaders (most of them farmers) encouraged one farmer, Walter Porter, to try the new techniques. Terrell's leaders provided support for Porter. In some ways they helped reduce his exposure to risk (of embarrassment, failure, financial ruin) while he experimented. When his changes made a difference, most of the farmers in the area adopted them. Food costs began to decline, access to food improved, as did quality and public health. Based on this success the US government created an army of extension agents, dedicated to doing what Walter Porter did.

Now the history of agriculture since then hasn't been all good. Small farms have died, natural growing techniques have disappeared, agribusiness rules the day.

But in that story there is an important suggestion for higher ed. Experiments on cost are risky when gone alone. But a consortium of schools can help spread risk. The consortium agrees that a particular approach looks promising. One school agrees to try it out. The other schools indemnify the experimental school. If things go poorly the consortium helps fix the problem ( by providing money, support etc.) But if they go well the consortium shares in the benefit and they all adopt the changes. The consortium comes to look something like a mutual aid society--a group of people or organizations committed to the well-being of their members by sharing risk and success.

Today there are plenty of consortia of colleges and university. But few of them collaborate in this way. Instead they gather for meetings, swap stories, produce papers, but when the chips are down members of the consortium are on their own. Perhaps it is time to look to the past when these cooperative organizations were the basis of our social safety net and civic innovation. Couldn't hurt.

or if the historical allusion doesn't work, consider a modern one--venture capital. Imagine 20 college presidents, each serious about cost/quality. They each pitch in $100K to a fund. They fund experiments, and get equity in the results. Something works, all benefit, something fails, no one faces a total crisis.