Never Waste a (Design) Crisis

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. 

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. 

Credit: Nathalie Lees for the New York Times

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.    

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.”

Very little about our healthcare system has been consciously designed.  It’s a patchwork of efforts – legislative/regulatory initiatives, tax provisions, entrepreneurial choices, independent design decisions -- and many unintended consequences.   We should be less surprised at how poorly they all fit together than that some of them fit at all.   Find someone who is happy with our current healthcare system and I bet that person is either making lots of money from it, or not receiving any services from it. 

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. 

Drawn Ideas/Ikon Images/Getty Images              

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.”

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.

The disparities in healthcare -- whether they are all those seniors without teeth, all those people of color having worse health, all the women suffering from third-world maternal health, or all those low-income people lacking access to care or adequate financial support when they do receive it – are outcomes of design designs.  Admittedly, not always intentional decisions, but design decisions nonetheless.  We haven’t thought through the consequences -- or haven’t cared enough about them.

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.