The Wall Street Journal reported that the American Dental Association (ADA) opposes expanding Medicare to include dental benefits. My reaction was, well, of course they do.
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| Credit: Harvard Health |
They apparently don’t care that at least half, and perhaps as many as two thirds, of seniors lack dental insurance, or that one in five seniors are missing all their teeth. The ADA prefers a plan for low income Medicare beneficiaries only, although state Medicaid programs were already supposed to be that, with widely varying results between the states.
The ADA is following blindly in the AMA’s opposition
to enactment of Medicare, ignoring how fruitful Medicare has turned out to
be for physicians’ incomes. It’s all
about the money, of course; the ADA thinks dentists can get more money from
private insurance, or directly from patients, than they would from Medicare,
and they’re probably right. 
Credit: Nathalie Lees for the New York Times
As is typical for our healthcare system, good design is
no match for interfering with the incomes of the people/organizations providing
the care.
By the same token, I suspect that the real opposition
to “Medicare for All” is not from health insurers but from healthcare
providers. Health insurers, a least the
larger ones, have done quite nicely with Medicare Advantage, and would probably
welcome moving members from those balkanized, largely self-funded employer plans
to Medicare Advantage plans.
No, the bloodbath in Medicare for All would be the loss
in revenue of health care professionals/organizations missing out on those lucrative
private pay rates. As Upton Sinclair
once
observed, “It is difficult to
get a man to understand something when his salary depends upon his not
understanding it.” Or, as Guido tells Joel in Risky Business,
“never, ever, fuck with another man’s livelihood.”
You could design a
worse system, but it wouldn’t be easy.
Fast
Company recently
featured 32 design experts sharing their thoughts about the most important
issues facing designers today. Most of
the issues were not related to healthcare, at least not directly, but I want to
highlight a few of the quotes and suggest how they might apply to the design
mess healthcare is in.
I’ll start with Robert Wong, vice president, Google Creative Labs:
Too often, design optimizes for solving the immediate problems at hand or immediate user needs and wants. It is more important than ever to slow down, zoom out, look at things from all different perspectives, and consider the long-term and broad societal impact of anything we make. Good design makes our lives better. Great design makes the world better.
In healthcare, we’re usually trying to solve for an
immediate crisis, one that has finally gotten so bad that we’re forced to take
action. We did it with the pandemic, with
some triumphs and many failures (e.g., vaccines: triumph; vaccine
cards/tracking: failure). Now Congress
is trying to rush through major changes in Medicare in record time, with no time
taken to “slow down, zoom out,” much less to “consider the long-term and broad
societal impact.”
I get the “never waste a crisis” mentality, and the
hyper-partisanship that causes Democrats to try to seize the Congressional advantage
they currently have, but we’ll be lucky if we get, in Mr. Wong’s words, good
design, much less great design that will make the world better.
Ma Yansong, founder, MAD Architects, pointed out: “Design
over-complies on commerce, making people consume unnecessary things. If design
is to lead the future, it should focus more on the important, necessary things,
not making the unnecessary look better.” Similarly, Albert Shum,
corporate vice president of design, Microsoft, believes: “If we
can design conspicuous consumption, we can design sustainable consumption with
the levers we have to shift behaviors.”
Drawn Ideas/Ikon Images/Getty Images
Healthcare has way too much conspicuous consumption—some
driven by patients, some done to patients – and it is way too hard for
even professionals to distinguish between the necessary and the unnecessary. We need to stop making the “unnecessary look
better” – do we really need that test, that pill, that procedure, that stay -- and
start designing for “sustainable consumption.”
Céline Semaan, founder, Slow Factory, said: “Waste
is a design flaw.” I love that adage. Imagine what a healthcare system that treated
waste, in all its forms, as a design flaw might look like!
Meanwhile, Don Norman, founding director emeritus, Design Lab, UCSD said: “Design must change from being unintentionally destructive to being intentionally constructive.” Too often, our design decisions in healthcare have been unintentionally destructive. For example, Andrew Ibrahim, surgeon and chief medical officer, HOK Healthcare, pointed out:
At every level of design—user design, product design, process design, space design, policy design, neighborhood design—it has become more and more clear how our design decisions can mitigate or exacerbate disparities.
So back to the original question: should dental – or hearing,
or vision – be included in an expanded Medicare? It’s the wrong question. The real question is, why does our healthcare
system believe that medical, dental, vision, and hearing are all separate in
the first place? They’re each important
to our health, and each has impacts on the other. Good design would start from there, not from
simply layering on new benefits. Great
design would factor in all of the social determinants of health.
I don’t know what “great design” for healthcare look
like. I’m no longer confident that we
can even achieve good design. But I’m pretty
sure that continuing to play Jenga with our
current system will inevitably cause it to crash.
