Pieces of a Social Medicine Power Map


The goal is not to provide people on the margins a seat at the table. The goal is to move the table of power from the margins (currently called the center) to the center (currently called the margins).

Power and Participation

If power is the ability to act, its relationship to direct participation is complicated. The dream of “perfect democracy” becomes a nightmare when you imagine having to weigh in on every food coop inventory choice, electricity coop budget item, and housing coop policy. Those truly empowered by our system don’t necessarily have a say in every decision affecting them. Rather, they have a reasonable assurance that their basic interests will be represented by the decision-makers. They have an ability to decide when to participate in decisions and when to defer decisions to others. 

So it seems in trying to build a broadly empowering system, the goal is not necessarily to maximize participation but to optimize it. Create negative feedback loops ensuring that when representative roles exist, they are actually representative. Ensure information, financial, and time resources are shared in a way that permits more authentic participation when desired and needed.  

Leverage and Scale 

“People know intuitively where leverage points are” says Forrester. “Everyone is trying very hard to push it in the wrong direction.”

This reminds me of the leverage point of scale in the US healthcare system. Market forces are driving massive consolidation among healthcare providers. Every few months we hear of another local hospital being acquired by a large health system. Meanwhile, healthcare loses its human scale. The system has to think about everybody so it’s hard to think about anybody – especially when that everybody is over one million patients a year as it is in my health system. The old ideal of small, local practices is increasingly being obliterated as insurance companies give their lowest reimbursement rates to small providers and their highest rates to the big providers who have more bargaining power. This is a classic example of Meadows’ “positive feedback loop” that rewards the successful and marginalizes the others. 

There is one key exception to this trend: the neighborhood health center. They are mostly funded by Medicaid, which provides more consistent rates to providers of different sizes. Unlike most clinics, which see a scattered assortment of patients based on their insurance coverage, health centers are geographically oriented with a defined local catchment area. This allows them to make strategic investments in the neighborhood that will benefit their own patients. Their Board of Directors are required to be composed of at least 51% community members. Despite their generally small size, health centers have a large cumulative impact, seeing 30 million patients a year. The health center’s unique financing, incentive to invest in addressing social determinants of health, and participatory governance structure make it a possible vehicle for a paradigm shift within the US healthcare system – not a corporate conglomerates providing commodity care but a federation of small, community-based, social medicine providers. 

One thought on “Pieces of a Social Medicine Power Map

  1. Geoff – there is so much here.

    What do you learn when you write a post like this?

    Where do you experience fear or anxiety when you write a post like this?

    A few lines stick out to me:

    “actually representative. Ensure information, financial, and time resources are shared in a way that permits more authentic participation when desired and needed.”

    “Meanwhile, healthcare loses its human scale.”

    “participatory governance structure make it a possible vehicle for a paradigm shift within the US healthcare system”

    Thanks for going deep into Meadows and leverage points and helping us imagine how the table could really be shifted in healthcare. This is such a remarkable thought experiment. When I read it I couldn’t help but share with 10 other doctors. I feel like 10,000 need to read this. What spaces do you find to share these visions?
    Do you see how much you’re wrestling with and how capably you’re able to synthesize and distill and make such a powerful argument?

    I just want to take a moment to reflect back to you the uncanny ability I see in what you’re doing with this post. You’re showing a way forward through one of the most complicated systems — while trying to paint a grounded alternative. There are tens of thousands of doctors and health professionals frustrated by the system and desperate to follow leaders with real plans and alternative vision.

    Do you see how clearly you have gifts for helping design these alternatives? What’s holding you back? what keeps you in hiding?

    Who are the most powerful people that you’ve shared this kind of vision with? Who have you had these kinds of conversations with?

    It’s a gift to have you here. Thank you.


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