I Was Wrong

The New York Times had an interesting set of op-eds last week under the theme “I Was Wrong.”  For example, Paul Krugman says he was wrong about inflation, David Brooks laments being wrong about capitalism, and Bret Stevens now fears he was wrong about Trump voters.  Nobody fessed up about being wrong about healthcare, so I’ll volunteer. 

I’ve been writing regularly about healthcare for over a decade now, with some strong opinions and often with some pretty speculative ideas.  I’ve had a lot to be wrong about, and I hope I will be wrong about many of them (e.g., microplastics).  Some of my thoughts (such as on DNA storage or nanorobots) may just be still too soon, but there are definitely some things I’d thought, or at least hoped, would have happened by now.

I’ll highlight three:

I thought we’d care more about our health  

Twenty plus years ago I was an evangelist for what we’d now call digital health.  Give people more, better health information and some useful health tools, then certainly they’d  use them to improve their health. If I’d known about smartphones or wearables I’d have been even more sure.

But, it turns out, not so much. Yes, we’re all pretty good about googling health information, many of us have health apps on our phones, and wearables are cool, but we’d be hard pressed to pinpoint exactly how our health has improved, generally speaking.  Our epidemics of obesity, diabetes, and other chronic conditions continue to grow, and our mortality rates were an embarrassment even before the pandemic’s effects.

The pandemic exacerbated, but did not cause, health disparities that fall along racial, ethnic, and socioeconomic lines, ones that most countries would be embarrassed about but which the U.S. seems to tolerate without much political will around addressing them. ACA helped, but it was only a finger in the dike, and that dike is cracking.

Even worse, the pandemic proved that we care more about politics than our health, to the point many resist taking vaccines that have been proven safe and effective, or following simple public health measures like masking or social distancing. Even worse, many states are weakening public health departments’ powers generally.  How did taking care of our health become a political litmus test?

We’ve also shown that religion also trumps health, as evidenced by abortion restrictions. Some people’s religious views that a fetus is a person, even at conception, outweighs a woman’s rights to her own body, or even her own life. And those so-called “pro-life” believers only seem to care about the fetus during the pregnancy. 

I thought we’d care more about patients than profits

Silly me.

Twenty or even ten years ago seems like such a simpler time.  Hospitals hadn’t, for the most part, consolidated, franchised, or gone overseas.  Physician practices hadn’t been bought up in large numbers.  Private equity didn’t see specialists, air ambulances, nursing homes, or ER docs as huge profit opportunities.  Pharmaceutical companies hadn’t fully mastered how to extend their patents almost indefinitely in order to keep prices high.  Health insurers were happy if they could eke out margins in the low single digits. 

The healthcare system has gone all Martin Shkreli, finding profits anywhere and everywhere, the more the better.  There’s no evidence that hospital consolidation improves patient care and plenty of evidence that it raises prices. Medical school students see the income differentials and are increasingly opting to go into specialty fields.  Everyone has horror stories about prescription drug prices, yet Congress seems powerless to act, no doubt due to the pharmaceutical lobbying clout. No one thinks that private equity is looking to do anything but line their investors’ pockets. Health insurers have become so diversified that they have more revenue streams than we can count.

We’re closing in on health care at 20% of GDP. I remember people being alarmed when it hit 10%; how much more does it have to get before we recognize we’re chasing the wrong things?

I thought someone would figure out how to wreck healthcare

Mark Zuckerberg’s famous motto was “move fast and break things,” and Facebook did both, somewhat to everyone’s chagrin (and, yet, we keep using Facebook…).  That attitude has never caught on in healthcare, ostensibly because it’s too dangerous for patients. But, I’ve come to suspect, it’s more that it is too dangerous for healthcare’s many vested interests.

I’ve been looking for several years for healthcare’s Uber, the entrant(s) that don’t care about how the industry has been structured (or regulated) and want to introduce a new, better consumer experience.  Big Tech was going to come in (especially Amazon). Walmart was going to come in.  Other retail companies, like Best Buy or video game companies, were going to come in. Well, they’re in, but I’m not seeing that much disruption.

We’ve got scores of digital health companies getting ridiculous amounts of money, and many of them are doing interesting things, but I don’t see many industry-wreckers among them.  They’re more in the “if we can just get 0.x% of healthcare spending, we’ll all be rich” mindset.

Again, Uber didn’t come along to improve the taxi industry’s technology or even its rider experience. It said, the taxi industry is a 1950’s model, with very restrictive regulations, so we’ll invent a new industry that replaces it. There’s a lot to criticize Uber for, but most of the “innovators” I see in healthcare are in the “improve taxi industry technology” category, not the blow-up-the-antiquated-healthcare-industry-model(s).

I’m convinced there is a healthcare system out there that is much cheaper, much more effective, much more convenient, and much more equitable.  But continuing to graft on to our healthcare system’s existing edifices isn’t going to get us to that.   

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Barring some sort of miraculous life extension technology, I’m not going to live long enough to se what a 22^nd century healthcare system looks like.  I have high hopes for it, and none of those hopes include it being similar to today’s system.  

I hope that is barely visible to us and that we don’t even necessarily think of it as a health care system (or, at least, a medical care system), because health is so woven into our lives.  I definitely hope that health is no longer a function of your income, race/ethnicity, gender, or location. 

I just hope I’m not wrong about all that too.