The health care delivery system has many stakeholders, with many screaming for attention bringing into question the accuracy of the “wisdom of the crowd” (see Lee et al. 2011). What was interesting about the Lee et al. (2011) research was that decision making was seen as a collective negotiation where no one knows the correct answer. But not having “the correct answer” at any point of the development of policy can be unnerving and ripe for protest. When strategy is involved in creating public policy, it is less advantageous to be the “first bidder” (initial vocal responder) as everyone else will be able to calibrate their responses to one-up in response to the first (see Lee et al. 2011). Unless the first “bidder” holds power over the collective that would nullify any effectiveness of subsequent bidding, the subsequent bids (as contributions to the policy discussion) may have more influence than the earlier bids (contributions). So is it best to be the maverick that starts a revolution or the later martyr that solidifies its success by piggybacking on the initial civil agitation?

For the most useful aggregation of information across people, we have to average what they know, not what they say (Lee et al. 2011).

Bidders when applying strategy abide by two decisional assumptions according to Lee et al. (2011). First, people make decisions by bounds based on collective “inexact knowledge.” Second, we make decisions either strategically (in light of other people’s actions) or we purely throw an idea out there to see if it sticks which has it obvious shortcomings (Lee et al. 2011). Americans across the country have a profound investment with the state of the present health care system, but those voices are not created or advised equally. You must have an acknowledged voice to be an influential citizen. Where is the political tip that cascades change? Who is expected to be a part of the deciding consensus? When a reality is deemed in need of repair, communities of like-minded individuals might organize, seeking power through numbers. What cannot be lost in the rendering of “health in America” is the structural reality in which it exists and which PAC commercials litter the boob tube. As long as policy is the ligand to the political substrate, there is no imaginary enchanted land of making policies that work unencumbered by politics. Too often we divorce decisions from health altogether, opting exclusively for passion and political stalwartness.

“Typically, the expert knowledge of the people who actually operate the system is required to structure and parameterize a useful model” (Ford and Sterman 1997).

“We are unaware of the majority of the feedback effects of our actions. Instead, we see most of our experience as a kind of weather: something that happens to us but over which we have no control” (Sterman 2002).

Health policymaking, in particular, involves several people each with differing prestige and vocal assertiveness. The powers often listen to the wealthiest and most well-positioned voices. Rebekah Herrick (2013) wrote in a timely article published in State Politics and Policy Quarterly that often agreement between constituents’ desires and the legislator’s outcomes is defined as the pinnacle of policy success. Absolute agreement among constituents will never happen. However, Herrick said that legislators must constantly reassess the opinions of their publics to inform their legislative decisions. Larry Bartels (2009) presented a correlation of “unequal responsiveness” of legislators to the articulated desires of muffled constituents. In addition to identity and retrospection, Weick (2005) adds that choosing an appropriate sensible environment in which advocates and policymakers act helps to determine what one might choose to do in the future. Some may argue that politics makes this requirement of outside engagement less than realistic.

How might this be of consequence to health policy? But who is the “expert” in one’s own experience with their illness—the policy maker or the members of the public? Experts often serve as proxies that are vested with the power to serve the pareto efficiency of society. These experts can only be held by what they know and perhaps, more importantly, what he or she is willing to act upon based on inexact knowledge which may counter the wishes of the collective. Imagine the moment of the “front” of society meets a “front” of a public policy. For simplification, we will ignore any other forces in the environment so as the two forces that are only ones colliding. A velocity of the policy front strikes the societal front, possessing its own energies and momentums. Energy is never lost in the physical sense. It may possibly change into a less productive form of energy toward the intended purpose. The trick in policy is to acknowledge that social forces will work for and against a policy’s energy and momentum. Or as Forrester (2007) would add, wait until the storm subsides to pass judgment on the policy. But this is easier said than done when medical bills pile up and lives become more compromised in the meantime.



Bartels L (2009). Economic Inequality and Political Representation. In Jacobs L, King, D (eds.) The Unsustainable American State. Oxford University Press, New York.

Ford D, Sterman JD (1997) Expert Knowledge Elicitation to Improve Mental and Formal Models. Syst Dynam Rev 14: 309-340.

Herrick R (2013) Listening and representing. State Politics & Policy Quarterly 13(1): 88-106.

Lee MD, Zhang S, Shi, J (2011) The wisdom of the crowd playing The Price Is Right. Memory & Cognition 39(5): 914-923.

Sterman J (2002).All models are wrong: reflections on becoming a systems scientist. Syst Dynam Rev 18: 501-53.

Weick K (2005). Sensemaking in organizations. Sage Publications, Thousand Oaks, CA.

Feature image courtesy of Pixabay.

About The Author

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Adjunct Assistant Professor, Wright State University Boonshoft School of Medicine

Michele Battle-Fisher is an Adjunct Assistant Professor at the Wright State University Boonshoft School of Medicine and the author of Application of Systems Thinking to Health Policy and Public Health Ethics: Public Health and Private Illness (Springer), a 2016 Doody's Core Title. Ms. Battle-Fisher is a Health Systems/Complexity scholar and bioethicist. She has researched and taught in the medical and policy fields, ranging from public health, science and technology, bioethics, systems theory and its application to health. She was a speaker at TEDxDartmouth 2018 where she discussed the "Paradigm Shift" of Health Systems Science curriculum in health and clinical medicine. She was selected as a finalist in the 1st annual MIT Press “Pitchfest”, the “Shark Tank” of book publishing.