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In this issue of JAMA, 3 Viewpoints, by Powers et al,1 Fuchs,2 and Fisher and Corrigan,3 address problems, possibilities, and mechanisms for reshaping the US health care enterprise to better meet community needs at an affordable cost.
In their Viewpoint, Powers et al1 grapple with a question as old as democracy: How can productive collective action, which is required for a state to succeed, emerge from the factional divisions for which protection is required for democratic principles to succeed?
The founding fathers of the United States debated this vigorously. In the most famous Federalist Paper,4 Madison favored a large republic in the hands of a meritocracy to counterbalance the passions of a majority “faction” that might overwhelm legitimate minority interests. Others wanted to protect states’ powers, arguing that smaller political units could be more responsive to local groups.
Madison defined a faction as “a number of citizens, whether amounting to a minority or majority of the whole, who are united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community.”4
Health care is ground zero for this problem, and the stakes are immense. Health care is a behemoth “faction” that controls one-sixth of the US economy and distorts the nation’s economic and political future. I recently ran as a candidate for governor of Massachusetts, and, in the course of an 18-month campaign, I saw vividly the effect of this dominating industry on the opportunities for the total well-being of a population of nearly 7 million people.