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companies. Available at: http://www. foxnews.com/story/2009/06/10/manyvitamins-supplements-made-by-bigpharmaceutical-companies. Accessed September 14, 2014. 79. Burns LR, Lawrence DM, Sammut SM. Healthcare innovation across sectors: convergences and divergences. In: Burns
LR, ed. The Business of Healthcare Innovation. 2nd ed. New York, NY: Cambridge University Press; 2012: 515---563. 80. DiMasi JA, Hansen RW, Grabowski HG. The price of innovation: new estimates of drug development costs. J Health Econ. 2003;22(2):151---185.
81. Moyer VA; US Preventive Services Task Force. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014; 160(8):558---564.
82. Moyer VA; US Preventive Services Task Force. Vitamin D and calcium supplementation to prevent fractures in adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(9): 691---696.
Health Policy, Ethics, and the Kansas Legislative Health Academy Erika Blacksher, PhD, Gina Maree, LSCSW, Suzanne Schrandt, JD, Chris Soderquist, Tim Steffensmeier, PhD, and Robert St. Peter, MD
We describe a unique program, the Kansas Legislative Health Academy, that brings together state legislators from across the political spectrum to build their capacity in advancing policies that can improve the health of Kansans. To that end, the academy helps legislators develop new skills to deliberate the ethics of health policy, use systems thinking to understand the long- and shortterm effects of policy action and inaction, and engage in acts of civic leadership. The academy also seeks to foster an environment of respectful open dialogue and to build new cross-chamber and crossparty relationships. Among the most important outcomes cited by program participants is the value of sustained, personal interaction and problem solving with individuals holding differing political views. (Am J Public Health. 2015;105: 485–489. doi:10.2105/AJPH. 2014.302333) HEALTH POLICY OFTEN ELICITS controversy. Recent examples include the uproar over recommendations for mammography
screening for women 40 to 49 years old and human papillomavirus vaccination for adolescent girls and boys. Perhaps the most dramatic controversy relates to the passage of the Patient Protection and Affordable Care Act (Pub L No. 111-148); despite being signed into law in 2010 and found substantially constitutional by the US Supreme Court in 2012 (Medicaid expansion was made optional for states), this legislation remains subject to vigorous dissent. Such controversies, although no doubt a function of interest-driven politics, also reflect deep differences in ethical values. Ethical values and premises underpin all public policy.1,2 Ideas about individual liberty, personal responsibility, solidarity, justice, and the role of the government are just a few of the moral constructs that often clash in the making of policy. Policy analysis often ignores these dimensions of policymaking, although that is beginning to change.3---5 Here we describe a project based in part on the premise that training policymakers to recognize and talk openly about the ethical
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values entailed in health policy might improve its content and process. This project, the Kansas Legislative Health Academy (hereafter Health Academy), brought together state legislators from across the political spectrum to build their capacity to respond to complex health policy challenges in Kansas. To that end, the curriculum sought to help legislators develop new skills in 3 areas: health policy ethics, systems thinking, and civic leadership. The Health Academy also sought to foster an environment of open, respectful dialogue and to build new cross-chamber and crossparty relationships. To our knowledge, the Health Academy is a unique program. Many educational programs exist for legislators to focus on leadership development or specific health policy issues, but none we are aware of are specifically designed to cover a broad range of health policy issues while also addressing underlying barriers to effective policy-making within legislative bodies. In what follows, we describe the Health Academy’s origins, structure, substance, and lessons learned.
ORIGINS In Kansas, state legislators are part time, lack personal staff, share a small legislative research department responsible for all policy issues, and, as with other state legislatures, operate in a context of increasing political polarization. In addition, they face the sheer complexity of health policy, an aging population, and unsustainable increases in health care spending. It is in this context, in 2007, that conversations began among leaders of the Kansas Health Institute (KHI), the Kansas Health Foundation, and the Kansas Leadership Center (KLC), as well as several legislators, about creating an educational program to address barriers to effective policy-making. In 2009, the Kansas Health Foundation awarded KHI a grant of almost $323 000 to develop, implement, and conduct a program that would include 2 cohorts over 3 years (2009 to 2011). KHI also made substantial in-kind contributions, primarily in the form of staff time. KHI undertook 2 preliminary activities prior to program development. Because participants
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were to receive an amount of money for participation equal to their legislative per diem and their travel expenses were paid, it was essential that the Health Academy operate within its legal authority and tax status. Thus, KHI sought legal advice or approval (or both) from the Kansas attorney general, the Governmental Ethics Commission, the Office of the Revisor of Statutes, and the US Internal Revenue Service. KHI also conducted legislator listening sessions through single interviews or group meetings so that the Health Academy could be responsive to legislators’ input. KHI staff had identified some curricular goals prior to these sessions, but the listening sessions helped determine their relevance and how best to achieve them. After these initial steps, KHI brought together a design team that included leaders and senior staff from KHI and KLC along with 3 paid consultants. The consultants, coauthors of this article (E. B., C. S., and T. S), are experts in health policy ethics, systems thinking, and civic leadership, respectively. The team met several times in 2009 to design the structure and substance of the Health Academy’s first cohort; additional design team meetings were held late in the academy’s first cycle to review and refine the curriculum for the second cohort.
STRUCTURE The design team identified one overarching aim for the Health Academy unrelated to its specific curricular objectives: creating a space where legislators could
communicate and interact in ways precluded by the politics of Topeka, the Kansas capital. This overarching objective drove a number of logistical decisions. First, the design team wanted to bring participants together from across the political spectrum for a substantial period of time over the course of a year. This included an intensive 4-day retreat at the program’s start followed by 3 more sessions that ranged from 1.5 to 2 days in duration. These events were all held outside of the time the legislature was in session. Second, to facilitate conversation and relationship development, we did not want more than 15 legislators in any single cohort. In the first cohort of the Health Academy, 15 legislators committed, but a few dropped out owing to personal and professional issues unrelated to the academy. Invited legislators also sometimes declined, typically citing the considerable time commitment. Third, the team chose locations that differed considerably from the places legislative committee meetings and off-site meetings are typically held. Rather than meeting rooms at corporate hotels, the chosen locations cultivated a more casual or “retreat” feeling, including a ranch outside Lawrence, a rustic retreat on a golf course in the Flint Hills, and an iconic hotel in Council Grove. These settings often had a shared living space where unofficial activities (e.g., card playing and cigar smoking) would take place after the official program ended. The 2 cohorts included 9 and 14 legislators who participated in approximately 60 hours of
486 | Public Health Ethics | Peer Reviewed | Blacksher et al.
training over the course of the year. In all, participants each year spent approximately 9 days and 7 evenings together exploring ethics, systems thinking, and leadership through a variety of health policy topics; the aim was to help them develop practices and skills that could be generalized to multiple policy topics. Participants included legislators who identified with more conservative political perspectives and those who identified with more liberal perspectives; they also differed with respect to amount of time served in the legislature. All participants were members of key committees related to health policy (broadly defined) or budget. Several held committee chairs or ranking minority positions on relevant committees.
SUBSTANCE KHI and KLC staff designed and delivered the program content in collaboration with the consultants. Legislative staff members were not involved in either the design or the delivery of the program. The design team chose health policy topics on the basis of their timeliness and their pertinence to Kansas policymakers, and these topics were used as a context for learning about health policy ethics, systems thinking, and civic leadership. Some of the topics addressed included health care reform elements (e.g., healthy behavior incentives, Medicaid reform), smoking bans, and social determinants of health. No topics were officially off limits, and controversial issues did arise (e.g., abortion emerged during a session on civic leadership).
We used interactive, discussionbased teaching methods whenever possible. For example, small group and facilitated discussions, case studies, gaming, and simulations helped participants practice the skills being taught and develop new relationships and ways of communicating with one another.
Health Policy Ethics Many legislators who participated in KHI’s listening sessions identified value conflicts as among the most challenging aspects of policy-making. The nature of that challenge relates to 2 facts. As is the case with most people, legislators are neither practiced at making explicit the ethical values that justify their policy preferences nor necessarily comfortable openly discussing them. In addition, people often hold their values deeply, yet compromise is inherent to crafting public policies in a pluralistic democracy. With these challenges in mind, the health policy ethics module sought to help Health Academy participants (1) identify a plurality of values pertinent to the content and process of making public policy, (2) cultivate respect for one another as “morally serious” individuals,6 and (3) frame policy debates as opportunities for reasoned dialogue in search of collective solutions. Three working assumptions underpinned these objectives. First, a plurality of values is relevant to health policy and the processes of making it. Thus, the ethics curriculum privileged no single value or subset of values. Although public health and health policy analysts sometimes assume
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that aggregate gains in population health are the primary goal of health policies and programs,7,8 scholarly analyses and real-life policy discourse indicate that a host of other values (e.g., caring for the vulnerable, personal responsibility, liberty, equity) may be as or more important.9---11 Second, we assumed that Health Academy participants could identify a sufficiently wide range of ethical values, given opportunities to interact with one another around concrete health policy issues and case studies. Rather than posit these values a priori, the health policy ethics curriculum sought to elicit from participants the values they deemed most relevant. This assumption was borne out, as discussed subsequently in the section on lessons learned. Third, if participants were to have serious conversations about health policy ethics, they would need to view each other as “morally serious” individuals, a phrase used by Larry Churchill to convey the idea that “to have an ethical discussion with someone, I must seriously and respectfully entertain values, both my interlocutor’s and my own.”6(p54) This moral claim frames policy disagreements as a clash of values rather than as one party lacking values, opening up the opportunity to talk about what those values are, their meaning in a particular context, and whether policies might be pursued in ways that address a number of ethical goals rather than just one.
Systems Thinking Legislators continually face policy decisions that have far-reaching
effects in both time and space. In Kansas, decisions made today will continue to influence the health of the state’s residents decades into the future; similarly, decisions made for one group (e.g., uninsured individuals) will have an impact on other groups (e.g., providers). Therefore, if policymakers are to be able to identify, modify, and implement effective (high-leverage) policies, it is important that they be able to recognize that their policies will affect a system (and often a system of systems). The systems thinking module was designed to build systems awareness and provide participants with experience in applying a systems approach to different health policy topics.12---15 The systems thinking module sought to help Health Academy participants understand that: d
d
d
Issues related to health (and all policies) are best resolved when they are viewed as arising from a system (or system of systems). Taking a systemic perspective requires moving from events and anecdotes to viewing behavior over longer time horizons (to identify important trends). Effective policies are highleverage solutions that address the fundamental causes of a system’s poor performance and avoid unwelcome, unanticipated consequences.
The design team’s fundamental assertion about learning systems thinking is that participants, to move beyond a conceptual understanding, must learn and apply a range of systems thinking tools to generate a deeper appreciation of how systems work. The tools included in the
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curriculum provided participants with the ability to visualize interconnections between system elements, frame population health as dynamically unfolding over time, and anticipate when an intervention in one part of the system might have a negative impact on other system parts.
Civic Leadership Civic leadership was included as part of the Health Academy to help legislators make progress on the daunting challenges they face in the political arena. The primary working assumption was that many of the problems legislators encounter are adaptive in nature, requiring new learning and multiple stakeholders to make progress. However, the constraints of policymaking, in particular preferences for immediate action and results, lead to policies that dictate technical responses that fail to address root problems. Moreover, with respect to the health of communities, there is a gap between people’s aspirations and the status quo. The civic leadership curriculum sought to build the capacity of legislators to enact leadership behaviors more often and with more success. Ultimately, the training was aimed at helping make progress on closing the gap between the aspirations and present reality in community health. Specifically, the leadership module sought to (1) orient legislators to a unique leadership theory of competencies developed by KLC, (2) facilitate conversations on how to build a trustworthy process, and (3) provide a space to explore individual and collective purposes. The approach developed by KLC is premised on the notion that
a new kind of leadership is necessary to narrow the gap between the status quo and people’s civic aspirations. This premise was developed, in part, from listening to Kansans talk about those aspirations and learning that a profoundly different kind of civic leadership and civic culture is needed throughout our communities.16 Exercising leadership must come much more from personal interventions rather than mandates handed down from positions of authority. This leadership principle carries into legislative bodies where committee heads have much formal authority, and acts of leadership from various members might be needed to make progress. Another important aspect of the leadership curriculum is that making progress on civic challenges requires courageous collaboration that engages both “usual” and “unusual” voices. In this way, civic leadership must be focused more on processes of engagement than on the content of the issue. Here the legislators expressed their difficulty in engaging others who differed in opinions and policy views, particularly in a political environment where working together with the other party or faction could draw a well-funded and less collaborative primary challenger.
LESSONS LEARNED Outcomes of the Health Academy may be difficult to quantify. Frequent participant surveys conducted during the program indicated substantial gains in knowledge of health policy content and in application of ethics, systems,
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and leadership principles in ongoing policy work; the surveys also revealed high levels of satisfaction with the experience. Anecdotal stories of substantially changed interactions between participants in subsequent legislative settings and references by participants during public legislative deliberations to concepts introduced during the Health Academy suggest some ongoing effects. Participants cited sustained, personal interactions and problem solving with individuals holding differing political views as a major benefit of the program. Beyond these general observations, the following lessons learned relate more specifically to the Health Academy’s structure and substance: 1. Participants need considerable amounts of unstructured time for informal conversations and relationship building. For the first cohort of the Health Academy, we initially overbooked the itinerary and had to make significant revisions over time. The second cohort had more free time for conversation and informal activities. In the case of both cohorts, we held dinner discussions during the legislative session for participants to come together and reacquaint themselves as a group and to learn about and discuss timely policy issues. These events often took place just as legislators were coming off of the state house floor, having debated with one another on a heated issue. We concluded that relationship building among legislators is an essential component of better and
more collaborative policymaking efforts. 2. Participants need a safe space for intensive learning, difficult conversations, and relationship building that would not normally occur in legislative settings. The Health Academy helped achieve this aim by holding almost all of the events outside the capital and requesting that everyone stay in the accommodations provided, even if their home was nearby, to encourage relationship development. Participants created communication norms that invited all perspectives and encouraged respectful dialogue. They also came to expect from each other a high level of commitment and limited their own cell phone and computer use during the workshops. When we inquired about what level of participation should be required to receive a certificate of completion, the resounding answer was that, if the certificate was to mean anything, a high level of investment was needed. 3. Although it can be difficult to engage participants in conversations about the ethical values that inform their policy preferences, in time such discussions generate a wide range of distinct values and may help promote mutual understanding. Discussions sometimes revealed that participants who had the same policy positions or ideological orientations came to their positions from different ethical grounds or that participants who supported opposite policy
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positions on the basis of the same ethical principle had different interpretations of the principle’s meaning and implications. For example, when discussing clean air policies such as public smoking bans, some participants viewed them as a violation of people’s personal freedom to smoke, whereas others supported clean air policies on the basis of people’s freedom from having to inhale secondhand smoke. Although these different interpretations of what values mean often generated vigorous debates, these debates also occasionally brought participants to alternative views or softened their positions. 4. Taking time to examine trends over time, upstream solutions, and the interconnectedness of health issues can influence participants’ thinking and behavior. For example, one participant reported asking for trend data rather than “pointin-time” data, and a number of participants noted interconnections among different elements of the health system. Yet, thinking and acting according to a systems perspective can be challenging in fast-paced political environments. Policymakers frequently face pressures to address policy issues quickly and provide solutions that have immediate effects. Participants discussed making time between legislative sessions to more deeply study health policy issues from a systems perspective. 5. The Health Academy provided opportunities for
legislators to exercise leadership and take risks with one another by engaging in dialogues that were perceived to be nearly impossible in the typical legislative process. An important part of expanding participants’ leadership capacity was honoring the pressures they faced from their own political party, other legislators, constituents, and supporters while challenging them to increase their leadership activities by taking smart risks. 6. One of the more successful exercises engaged participants’ skills in the areas of ethics, systems, and leadership, simultaneously. In the final event of the 4-day retreat, Health Academy participants were grouped into teams of 2 or 3 and asked to explore different health policy approaches via a computer-based tool called HealthBound. Developed by experts at the Centers for Disease Control and Prevention, this simulation model helps users learn about the complexity of the health system and how it responds over time to upstream and downstream interventions.17 Participants chose several different policy approaches and tracked their simulated effects over a 25-year period, looking at mortality, morbidity, health inequities, health care costs, and net benefit outcomes. The teams were then asked to discuss the policy approach they were most proud of and why. Next, the participants discussed all of the proposals and were asked to identify what they thought was
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the best alternative. Participants thoroughly enjoyed the exercise, and priorities sometimes defied political ideologies. We attribute the success of this exercise to the credibility of the model, the experiential learning it enables, and the team-based orientation of the task. Another reason for its success was that it occurred at the end of the retreat and built on all aspects of the curriculum, dynamically depicting systems thinking and requiring participants to justify their policy priorities, make normative tradeoffs among them, and collaborate with colleagues with differing political views.
experienced substantial turnover. As a result of one death, a number of participants who decided not to seek reelection, and a handful of campaign defeats, only 12 of the original 23 participants continue to serve in the legislature. The participants in the 2 cohorts have been consolidated into a single group and continue to be involved in additional health policy---related educational activities. Plans are in place to introduce additional legislators to the underlying concepts of the Health Academy through an abbreviated “boot camp” experience and to continue to support the collective group in its efforts to address complex health policy issues in the state. j
health policy content; she contributed to and substantively reviewed all sections of the article. S. Schrandt contributed to the conception, development, and implementation of the Health Academy and delivered portions of the health policy content; she contributed to and substantively reviewed all sections of the article. C. Soderquist collaborated with the Kansas Health Institute to develop a framework for the Health Academy and to create and deliver the systems thinking curriculum; he wrote the systems thinking section and substantively reviewed and contributed to all sections of the article. T. Steffensmeier collaborated with the Kansas Health Institute to develop a framework for the Health Academy and to create and deliver the civic leadership curriculum; he wrote the civic leadership section and substantively reviewed and contributed to all sections of the article. R. St. Peter contributed to the conception, development, and implementation of the Health Academy and delivered portions of the health policy content; he substantively contributed to and reviewed all sections of the article.
About the Authors CONCLUSION The Kansas Legislative Health Academy is a unique, intensive effort to help state legislators be more effective in their role as policymakers. The program content focused on timely health policy issues and introduced elements of ethics, leadership, and systems thinking relevant to policy-making. The overarching takeaway from our experience is the value of sustained, personal interaction and problem solving with individuals holding differing political views. Meeting away from legislators’ usual political environment and engaging them in subject matter about which everyone has something to learn can facilitate interaction. Another important consideration is the reality of turnover among state legislators. Since the politically tumultuous elections of both 2010 and 2012, the Kansas program has
Erika Blacksher is with the Department of Bioethics and Humanities, University of Washington, Seattle. Gina Maree is with Innovative Leadership Strategies LLC, Kansas City, MO. Suzanne Schrandt is with the Patient-Centered Outcomes Research Institute, Washington, DC. Chris Soderquist is with Pontifex Consulting, Hanover, NH. Tim Steffensmeier is with the Department of Communication Studies, Kansas State University, Manhattan. Robert St. Peter is with the Kansas Health Institute, Topeka. Correspondence should be sent to Erika Blacksher, PhD, A204 Health Sciences Center, Box 357120, Seattle, WA 98195-7120 (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking on the “Reprints” link. This article was accepted September 12, 2014.
Acknowledgments We thank the Kansas Health Foundation for funding the creation and implementation of the Kansas Legislative Health Academy and the Kansas Leadership Center for its partnership in developing and implementing the academy. In addition, we thank the state legislators who have participated in the academy. The legislators’ willingness to engage with colleagues of different political orientations and their openness to new learning are surely the source of any successes the academy can claim.
Human Participant Protection No protocol approval was needed for this project because it was not a human participant study.
Contributors E. Blacksher collaborated with the Kansas Health Institute to develop the framework for the Kansas Legislative Health Academy and to create and deliver the health policy ethics curriculum; she outlined the article, wrote the introduction and health policy ethics section, and contributed to and provided substantive reviews of the entire article. G. Maree contributed to the conception, development, and implementation of the Health Academy and delivered portions of the
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References 1. Callahan D. Health technology assessment implementation: the politics of ethics. Med Decis Making. 2012;32(1):E13---E19.
4. Danis M, Clancey C, Churchill LR, eds. Ethical Dimensions of Health Policy. New York, NY: Oxford University Press; 2002. 5. Kenny N, Giacomini M. Wanted: a new ethics field for health policy analysis. Health Care Anal. 2005;13(4):247---260. 6. Churchill LR. What ethics can contribute to health policy. In: Danis M, Clancey C, Churchill LR, eds. Ethical Dimensions of Health Policy. New York, NY: Oxford University Press; 2002:51---64. 7. Marchand S, Wikler D, Landesman B. Class, health, and justice. Milbank Q. 1998;76(3):449---467. 8. Brock DW. Broadening the bioethics agenda. Kennedy Inst Ethics J. 2000; 10(1):21---38. 9. Childress JF, Faden RR, Gaare RD, et al. Public health ethics: mapping the terrain. J Law Med Ethics. 2002;30(2):170---178. 10. Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York, NY: Oxford University Press; 2006. 11. Turoldo F. Responsibility as an ethical framework for public health interventions. Am J Public Health. 2009; 99(7):1197---1202. 12. Sterman JD. Learning from evidence in a complex world. Am J Public Health. 2006;96(3):505---514. 13. Trochim WM, Caberera DA, Milstein B, Gallagher RS, Leischow SJ. Practical challenges of systems thinking and modeling in public health. Am J Public Health. 2006;96(3):538---546. 14. Meadows D. Thinking in Systems. White River Junction, VT: Chelsea Green Publishing; 2008. 15. Anderson RA, Issel LM, McDaniel RR. Nursing homes as complex adaptive systems: relationship between management practice and resident outcomes. Nurs Res. 2003;52(1):12---21. 16. Chrislip D, O’Malley E. For the Common Good: Redefining Civic Leadership. Wichita, KS: Kansas Leadership Center; 2013. 17. Milstein B, Homer J, Hirsch G. Analyzing national health reform strategies with a dynamic simulation model. Am J Public Health. 2010;100(5):811---819.
2. Pariser DM. Ethics considerations in health care reform: pros and cons of the Affordable Care Act. Clin Dermatol. 2012;30(2):151---155. 3. Dunn WN, ed. Values, Ethics, and the Practice of Policy Analysis. Lexington, MA: DC Health & Co; 1983.
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companies. Available at: http://www. foxnews.com/story/2009/06/10/manyvitamins-supplements-made-by-bigpharmaceutical-companies. Accessed September 14, 2014. 79. Burns LR, Lawrence DM, Sammut SM. Healthcare innovation across sectors: convergences and divergences. In: Burns
LR, ed. The Business of Healthcare Innovation. 2nd ed. New York, NY: Cambridge University Press; 2012: 515---563. 80. DiMasi JA, Hansen RW, Grabowski HG. The price of innovation: new estimates of drug development costs. J Health Econ. 2003;22(2):151---185.
81. Moyer VA; US Preventive Services Task Force. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014; 160(8):558---564.
82. Moyer VA; US Preventive Services Task Force. Vitamin D and calcium supplementation to prevent fractures in adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(9): 691---696.
Health Policy, Ethics, and the Kansas Legislative Health Academy Erika Blacksher, PhD, Gina Maree, LSCSW, Suzanne Schrandt, JD, Chris Soderquist, Tim Steffensmeier, PhD, and Robert St. Peter, MD
We describe a unique program, the Kansas Legislative Health Academy, that brings together state legislators from across the political spectrum to build their capacity in advancing policies that can improve the health of Kansans. To that end, the academy helps legislators develop new skills to deliberate the ethics of health policy, use systems thinking to understand the long- and shortterm effects of policy action and inaction, and engage in acts of civic leadership. The academy also seeks to foster an environment of respectful open dialogue and to build new cross-chamber and crossparty relationships. Among the most important outcomes cited by program participants is the value of sustained, personal interaction and problem solving with individuals holding differing political views. (Am J Public Health. 2015;105: 485–489. doi:10.2105/AJPH. 2014.302333) HEALTH POLICY OFTEN ELICITS controversy. Recent examples include the uproar over recommendations for mammography
screening for women 40 to 49 years old and human papillomavirus vaccination for adolescent girls and boys. Perhaps the most dramatic controversy relates to the passage of the Patient Protection and Affordable Care Act (Pub L No. 111-148); despite being signed into law in 2010 and found substantially constitutional by the US Supreme Court in 2012 (Medicaid expansion was made optional for states), this legislation remains subject to vigorous dissent. Such controversies, although no doubt a function of interest-driven politics, also reflect deep differences in ethical values. Ethical values and premises underpin all public policy.1,2 Ideas about individual liberty, personal responsibility, solidarity, justice, and the role of the government are just a few of the moral constructs that often clash in the making of policy. Policy analysis often ignores these dimensions of policymaking, although that is beginning to change.3---5 Here we describe a project based in part on the premise that training policymakers to recognize and talk openly about the ethical
March 2015, Vol 105, No. 3 | American Journal of Public Health
values entailed in health policy might improve its content and process. This project, the Kansas Legislative Health Academy (hereafter Health Academy), brought together state legislators from across the political spectrum to build their capacity to respond to complex health policy challenges in Kansas. To that end, the curriculum sought to help legislators develop new skills in 3 areas: health policy ethics, systems thinking, and civic leadership. The Health Academy also sought to foster an environment of open, respectful dialogue and to build new cross-chamber and crossparty relationships. To our knowledge, the Health Academy is a unique program. Many educational programs exist for legislators to focus on leadership development or specific health policy issues, but none we are aware of are specifically designed to cover a broad range of health policy issues while also addressing underlying barriers to effective policy-making within legislative bodies. In what follows, we describe the Health Academy’s origins, structure, substance, and lessons learned.
ORIGINS In Kansas, state legislators are part time, lack personal staff, share a small legislative research department responsible for all policy issues, and, as with other state legislatures, operate in a context of increasing political polarization. In addition, they face the sheer complexity of health policy, an aging population, and unsustainable increases in health care spending. It is in this context, in 2007, that conversations began among leaders of the Kansas Health Institute (KHI), the Kansas Health Foundation, and the Kansas Leadership Center (KLC), as well as several legislators, about creating an educational program to address barriers to effective policy-making. In 2009, the Kansas Health Foundation awarded KHI a grant of almost $323 000 to develop, implement, and conduct a program that would include 2 cohorts over 3 years (2009 to 2011). KHI also made substantial in-kind contributions, primarily in the form of staff time. KHI undertook 2 preliminary activities prior to program development. Because participants
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were to receive an amount of money for participation equal to their legislative per diem and their travel expenses were paid, it was essential that the Health Academy operate within its legal authority and tax status. Thus, KHI sought legal advice or approval (or both) from the Kansas attorney general, the Governmental Ethics Commission, the Office of the Revisor of Statutes, and the US Internal Revenue Service. KHI also conducted legislator listening sessions through single interviews or group meetings so that the Health Academy could be responsive to legislators’ input. KHI staff had identified some curricular goals prior to these sessions, but the listening sessions helped determine their relevance and how best to achieve them. After these initial steps, KHI brought together a design team that included leaders and senior staff from KHI and KLC along with 3 paid consultants. The consultants, coauthors of this article (E. B., C. S., and T. S), are experts in health policy ethics, systems thinking, and civic leadership, respectively. The team met several times in 2009 to design the structure and substance of the Health Academy’s first cohort; additional design team meetings were held late in the academy’s first cycle to review and refine the curriculum for the second cohort.
STRUCTURE The design team identified one overarching aim for the Health Academy unrelated to its specific curricular objectives: creating a space where legislators could
communicate and interact in ways precluded by the politics of Topeka, the Kansas capital. This overarching objective drove a number of logistical decisions. First, the design team wanted to bring participants together from across the political spectrum for a substantial period of time over the course of a year. This included an intensive 4-day retreat at the program’s start followed by 3 more sessions that ranged from 1.5 to 2 days in duration. These events were all held outside of the time the legislature was in session. Second, to facilitate conversation and relationship development, we did not want more than 15 legislators in any single cohort. In the first cohort of the Health Academy, 15 legislators committed, but a few dropped out owing to personal and professional issues unrelated to the academy. Invited legislators also sometimes declined, typically citing the considerable time commitment. Third, the team chose locations that differed considerably from the places legislative committee meetings and off-site meetings are typically held. Rather than meeting rooms at corporate hotels, the chosen locations cultivated a more casual or “retreat” feeling, including a ranch outside Lawrence, a rustic retreat on a golf course in the Flint Hills, and an iconic hotel in Council Grove. These settings often had a shared living space where unofficial activities (e.g., card playing and cigar smoking) would take place after the official program ended. The 2 cohorts included 9 and 14 legislators who participated in approximately 60 hours of
486 | Public Health Ethics | Peer Reviewed | Blacksher et al.
training over the course of the year. In all, participants each year spent approximately 9 days and 7 evenings together exploring ethics, systems thinking, and leadership through a variety of health policy topics; the aim was to help them develop practices and skills that could be generalized to multiple policy topics. Participants included legislators who identified with more conservative political perspectives and those who identified with more liberal perspectives; they also differed with respect to amount of time served in the legislature. All participants were members of key committees related to health policy (broadly defined) or budget. Several held committee chairs or ranking minority positions on relevant committees.
SUBSTANCE KHI and KLC staff designed and delivered the program content in collaboration with the consultants. Legislative staff members were not involved in either the design or the delivery of the program. The design team chose health policy topics on the basis of their timeliness and their pertinence to Kansas policymakers, and these topics were used as a context for learning about health policy ethics, systems thinking, and civic leadership. Some of the topics addressed included health care reform elements (e.g., healthy behavior incentives, Medicaid reform), smoking bans, and social determinants of health. No topics were officially off limits, and controversial issues did arise (e.g., abortion emerged during a session on civic leadership).
We used interactive, discussionbased teaching methods whenever possible. For example, small group and facilitated discussions, case studies, gaming, and simulations helped participants practice the skills being taught and develop new relationships and ways of communicating with one another.
Health Policy Ethics Many legislators who participated in KHI’s listening sessions identified value conflicts as among the most challenging aspects of policy-making. The nature of that challenge relates to 2 facts. As is the case with most people, legislators are neither practiced at making explicit the ethical values that justify their policy preferences nor necessarily comfortable openly discussing them. In addition, people often hold their values deeply, yet compromise is inherent to crafting public policies in a pluralistic democracy. With these challenges in mind, the health policy ethics module sought to help Health Academy participants (1) identify a plurality of values pertinent to the content and process of making public policy, (2) cultivate respect for one another as “morally serious” individuals,6 and (3) frame policy debates as opportunities for reasoned dialogue in search of collective solutions. Three working assumptions underpinned these objectives. First, a plurality of values is relevant to health policy and the processes of making it. Thus, the ethics curriculum privileged no single value or subset of values. Although public health and health policy analysts sometimes assume
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that aggregate gains in population health are the primary goal of health policies and programs,7,8 scholarly analyses and real-life policy discourse indicate that a host of other values (e.g., caring for the vulnerable, personal responsibility, liberty, equity) may be as or more important.9---11 Second, we assumed that Health Academy participants could identify a sufficiently wide range of ethical values, given opportunities to interact with one another around concrete health policy issues and case studies. Rather than posit these values a priori, the health policy ethics curriculum sought to elicit from participants the values they deemed most relevant. This assumption was borne out, as discussed subsequently in the section on lessons learned. Third, if participants were to have serious conversations about health policy ethics, they would need to view each other as “morally serious” individuals, a phrase used by Larry Churchill to convey the idea that “to have an ethical discussion with someone, I must seriously and respectfully entertain values, both my interlocutor’s and my own.”6(p54) This moral claim frames policy disagreements as a clash of values rather than as one party lacking values, opening up the opportunity to talk about what those values are, their meaning in a particular context, and whether policies might be pursued in ways that address a number of ethical goals rather than just one.
Systems Thinking Legislators continually face policy decisions that have far-reaching
effects in both time and space. In Kansas, decisions made today will continue to influence the health of the state’s residents decades into the future; similarly, decisions made for one group (e.g., uninsured individuals) will have an impact on other groups (e.g., providers). Therefore, if policymakers are to be able to identify, modify, and implement effective (high-leverage) policies, it is important that they be able to recognize that their policies will affect a system (and often a system of systems). The systems thinking module was designed to build systems awareness and provide participants with experience in applying a systems approach to different health policy topics.12---15 The systems thinking module sought to help Health Academy participants understand that: d
d
d
Issues related to health (and all policies) are best resolved when they are viewed as arising from a system (or system of systems). Taking a systemic perspective requires moving from events and anecdotes to viewing behavior over longer time horizons (to identify important trends). Effective policies are highleverage solutions that address the fundamental causes of a system’s poor performance and avoid unwelcome, unanticipated consequences.
The design team’s fundamental assertion about learning systems thinking is that participants, to move beyond a conceptual understanding, must learn and apply a range of systems thinking tools to generate a deeper appreciation of how systems work. The tools included in the
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curriculum provided participants with the ability to visualize interconnections between system elements, frame population health as dynamically unfolding over time, and anticipate when an intervention in one part of the system might have a negative impact on other system parts.
Civic Leadership Civic leadership was included as part of the Health Academy to help legislators make progress on the daunting challenges they face in the political arena. The primary working assumption was that many of the problems legislators encounter are adaptive in nature, requiring new learning and multiple stakeholders to make progress. However, the constraints of policymaking, in particular preferences for immediate action and results, lead to policies that dictate technical responses that fail to address root problems. Moreover, with respect to the health of communities, there is a gap between people’s aspirations and the status quo. The civic leadership curriculum sought to build the capacity of legislators to enact leadership behaviors more often and with more success. Ultimately, the training was aimed at helping make progress on closing the gap between the aspirations and present reality in community health. Specifically, the leadership module sought to (1) orient legislators to a unique leadership theory of competencies developed by KLC, (2) facilitate conversations on how to build a trustworthy process, and (3) provide a space to explore individual and collective purposes. The approach developed by KLC is premised on the notion that
a new kind of leadership is necessary to narrow the gap between the status quo and people’s civic aspirations. This premise was developed, in part, from listening to Kansans talk about those aspirations and learning that a profoundly different kind of civic leadership and civic culture is needed throughout our communities.16 Exercising leadership must come much more from personal interventions rather than mandates handed down from positions of authority. This leadership principle carries into legislative bodies where committee heads have much formal authority, and acts of leadership from various members might be needed to make progress. Another important aspect of the leadership curriculum is that making progress on civic challenges requires courageous collaboration that engages both “usual” and “unusual” voices. In this way, civic leadership must be focused more on processes of engagement than on the content of the issue. Here the legislators expressed their difficulty in engaging others who differed in opinions and policy views, particularly in a political environment where working together with the other party or faction could draw a well-funded and less collaborative primary challenger.
LESSONS LEARNED Outcomes of the Health Academy may be difficult to quantify. Frequent participant surveys conducted during the program indicated substantial gains in knowledge of health policy content and in application of ethics, systems,
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and leadership principles in ongoing policy work; the surveys also revealed high levels of satisfaction with the experience. Anecdotal stories of substantially changed interactions between participants in subsequent legislative settings and references by participants during public legislative deliberations to concepts introduced during the Health Academy suggest some ongoing effects. Participants cited sustained, personal interactions and problem solving with individuals holding differing political views as a major benefit of the program. Beyond these general observations, the following lessons learned relate more specifically to the Health Academy’s structure and substance: 1. Participants need considerable amounts of unstructured time for informal conversations and relationship building. For the first cohort of the Health Academy, we initially overbooked the itinerary and had to make significant revisions over time. The second cohort had more free time for conversation and informal activities. In the case of both cohorts, we held dinner discussions during the legislative session for participants to come together and reacquaint themselves as a group and to learn about and discuss timely policy issues. These events often took place just as legislators were coming off of the state house floor, having debated with one another on a heated issue. We concluded that relationship building among legislators is an essential component of better and
more collaborative policymaking efforts. 2. Participants need a safe space for intensive learning, difficult conversations, and relationship building that would not normally occur in legislative settings. The Health Academy helped achieve this aim by holding almost all of the events outside the capital and requesting that everyone stay in the accommodations provided, even if their home was nearby, to encourage relationship development. Participants created communication norms that invited all perspectives and encouraged respectful dialogue. They also came to expect from each other a high level of commitment and limited their own cell phone and computer use during the workshops. When we inquired about what level of participation should be required to receive a certificate of completion, the resounding answer was that, if the certificate was to mean anything, a high level of investment was needed. 3. Although it can be difficult to engage participants in conversations about the ethical values that inform their policy preferences, in time such discussions generate a wide range of distinct values and may help promote mutual understanding. Discussions sometimes revealed that participants who had the same policy positions or ideological orientations came to their positions from different ethical grounds or that participants who supported opposite policy
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positions on the basis of the same ethical principle had different interpretations of the principle’s meaning and implications. For example, when discussing clean air policies such as public smoking bans, some participants viewed them as a violation of people’s personal freedom to smoke, whereas others supported clean air policies on the basis of people’s freedom from having to inhale secondhand smoke. Although these different interpretations of what values mean often generated vigorous debates, these debates also occasionally brought participants to alternative views or softened their positions. 4. Taking time to examine trends over time, upstream solutions, and the interconnectedness of health issues can influence participants’ thinking and behavior. For example, one participant reported asking for trend data rather than “pointin-time” data, and a number of participants noted interconnections among different elements of the health system. Yet, thinking and acting according to a systems perspective can be challenging in fast-paced political environments. Policymakers frequently face pressures to address policy issues quickly and provide solutions that have immediate effects. Participants discussed making time between legislative sessions to more deeply study health policy issues from a systems perspective. 5. The Health Academy provided opportunities for
legislators to exercise leadership and take risks with one another by engaging in dialogues that were perceived to be nearly impossible in the typical legislative process. An important part of expanding participants’ leadership capacity was honoring the pressures they faced from their own political party, other legislators, constituents, and supporters while challenging them to increase their leadership activities by taking smart risks. 6. One of the more successful exercises engaged participants’ skills in the areas of ethics, systems, and leadership, simultaneously. In the final event of the 4-day retreat, Health Academy participants were grouped into teams of 2 or 3 and asked to explore different health policy approaches via a computer-based tool called HealthBound. Developed by experts at the Centers for Disease Control and Prevention, this simulation model helps users learn about the complexity of the health system and how it responds over time to upstream and downstream interventions.17 Participants chose several different policy approaches and tracked their simulated effects over a 25-year period, looking at mortality, morbidity, health inequities, health care costs, and net benefit outcomes. The teams were then asked to discuss the policy approach they were most proud of and why. Next, the participants discussed all of the proposals and were asked to identify what they thought was
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the best alternative. Participants thoroughly enjoyed the exercise, and priorities sometimes defied political ideologies. We attribute the success of this exercise to the credibility of the model, the experiential learning it enables, and the team-based orientation of the task. Another reason for its success was that it occurred at the end of the retreat and built on all aspects of the curriculum, dynamically depicting systems thinking and requiring participants to justify their policy priorities, make normative tradeoffs among them, and collaborate with colleagues with differing political views.
experienced substantial turnover. As a result of one death, a number of participants who decided not to seek reelection, and a handful of campaign defeats, only 12 of the original 23 participants continue to serve in the legislature. The participants in the 2 cohorts have been consolidated into a single group and continue to be involved in additional health policy---related educational activities. Plans are in place to introduce additional legislators to the underlying concepts of the Health Academy through an abbreviated “boot camp” experience and to continue to support the collective group in its efforts to address complex health policy issues in the state. j
health policy content; she contributed to and substantively reviewed all sections of the article. S. Schrandt contributed to the conception, development, and implementation of the Health Academy and delivered portions of the health policy content; she contributed to and substantively reviewed all sections of the article. C. Soderquist collaborated with the Kansas Health Institute to develop a framework for the Health Academy and to create and deliver the systems thinking curriculum; he wrote the systems thinking section and substantively reviewed and contributed to all sections of the article. T. Steffensmeier collaborated with the Kansas Health Institute to develop a framework for the Health Academy and to create and deliver the civic leadership curriculum; he wrote the civic leadership section and substantively reviewed and contributed to all sections of the article. R. St. Peter contributed to the conception, development, and implementation of the Health Academy and delivered portions of the health policy content; he substantively contributed to and reviewed all sections of the article.
About the Authors CONCLUSION The Kansas Legislative Health Academy is a unique, intensive effort to help state legislators be more effective in their role as policymakers. The program content focused on timely health policy issues and introduced elements of ethics, leadership, and systems thinking relevant to policy-making. The overarching takeaway from our experience is the value of sustained, personal interaction and problem solving with individuals holding differing political views. Meeting away from legislators’ usual political environment and engaging them in subject matter about which everyone has something to learn can facilitate interaction. Another important consideration is the reality of turnover among state legislators. Since the politically tumultuous elections of both 2010 and 2012, the Kansas program has
Erika Blacksher is with the Department of Bioethics and Humanities, University of Washington, Seattle. Gina Maree is with Innovative Leadership Strategies LLC, Kansas City, MO. Suzanne Schrandt is with the Patient-Centered Outcomes Research Institute, Washington, DC. Chris Soderquist is with Pontifex Consulting, Hanover, NH. Tim Steffensmeier is with the Department of Communication Studies, Kansas State University, Manhattan. Robert St. Peter is with the Kansas Health Institute, Topeka. Correspondence should be sent to Erika Blacksher, PhD, A204 Health Sciences Center, Box 357120, Seattle, WA 98195-7120 (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking on the “Reprints” link. This article was accepted September 12, 2014.
Acknowledgments We thank the Kansas Health Foundation for funding the creation and implementation of the Kansas Legislative Health Academy and the Kansas Leadership Center for its partnership in developing and implementing the academy. In addition, we thank the state legislators who have participated in the academy. The legislators’ willingness to engage with colleagues of different political orientations and their openness to new learning are surely the source of any successes the academy can claim.
Human Participant Protection No protocol approval was needed for this project because it was not a human participant study.
Contributors E. Blacksher collaborated with the Kansas Health Institute to develop the framework for the Kansas Legislative Health Academy and to create and deliver the health policy ethics curriculum; she outlined the article, wrote the introduction and health policy ethics section, and contributed to and provided substantive reviews of the entire article. G. Maree contributed to the conception, development, and implementation of the Health Academy and delivered portions of the
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