My friends, we are like explorers of yore standing at the edge of a known continent, looking out at the vast ocean in hopes of finding new, unspoiled, better lands across it. True, we may have despoiled the continent behind us, but certainly things will be better in the new lands.
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| When it comes to getting to the 22nd century healthcare system, we're going to need a bigger boat |
In the
metaphor I’m thinking of, the known continent is our shambles of a healthcare
system. For all the protestations about the U.S. having the best health care in
the world, that’s manifestly untrue. We don’t live as long, we have more
chronic diseases, we kill each other and ourselves at alarming rates, we pay
way more, we have too many people that can’t afford care and/or can’t obtain
care, we have too much care that is ineffective, inappropriate, or even harmful,
and we spend much too much on administration.
We don’t
trust the healthcare system, we don’t
think its quality of care is good, we have an unfavorable
opinion of it, we think it fails us.
The vast majority of us think it should be fundamentally
changed or completely rebuilt. That’s what we want to flee, and its no
wonder why.
Across
that metaphorical ocean, in the distance, over the horizon, lies the 22nd
healthcare system. It will, we hope, be like magic. It will be more equitable,
more effective, more efficient, more proactive, less invasive, more affordable.
We don’t know exactly what it will look like or how it will work, but we’ve
seen what we have, and we know it can be better – much better. We just need to
get there.
This leads
me to the next part of the metaphor. I recently read a great quote from the
late nature writer Barry Lopez, from his posthumous book of essays Embrace
Fearlessly the Burning World. Mr. Lopez laments: “We are searching for
the boats we never built.”
The boats
aren’t coming to save us, to transport us to that idealized 22nd
healthcare system. Because we never built them. Because we still don’t
have the courage to build them.
We’ve
never built a system to ensure universal coverage. We rely on a hodgepodge of
coverage mechanisms, each of which is struggling with its own problems and
still leaving some 25 million people without insurance – and that’s before the
10-20 million who are predicted to lose coverage due to the “Big, Beautiful
Bill” – plus the tens of millions who are “underinsured.
We’ve
never built a system that was remotely equitable, just as we never did for
housing, education, or employment. Money matters, ethnicity matters, geography
matters. Discrepancies in availability of care and in outcomes show up clearly
for each of those, and more.
We’ve
never built a system that prizes patients above all. We deferred to doctors and
hospitals, not calling them out when they gave us substandard care or when they
charged us too much. Now health care has gone from a “noble calling” to a jobs
and wealth creator. A recent
New York Times analysis found (among other things):
- Health care is the nation’s largest employer;
- In 1990, health care wasn’t the largest employer in any state; now it is in 38 states;
- We spend more on health care than on groceries or housing.
The adage
about Big Tech comes to mind: we’re not the customer, we’re the product (or, as I’ve written
before, we’re simply the NPCs.).
We’ve
never built the systems to make administration easier. So many codes, so many rules,
so many types of insurance, so many silos, so many administrators. By now you’ve
no doubt seen the chart of the growth of administers versus clinicians in our
health care system, and are aware that around a quarter of our healthcare
dollar goes to administration. It doesn’t have to be this way, it shouldn’t be
this way, but administrative
bloat is getting worse, not better.
We’ve
never built the systems to properly track our health or risks to it. From wastewater
monitoring to tracking of diseases/outbreaks to adverse impacts from
prescriptions drugs, medical devices, we’re relying on haphazard methods that
leave us with no effective warning systems. The various public health
mechanisms we had in place were woefully unfunded prior to COVID, crashed (and
were burned) during COVID, and now are gleefully being defunded.
Worst of all, we’ve never built a system to track what care actually works. Sure, there are gold standard controlled studies that are supposed to do that, but much care that is delivered is not based on such studies, the impacts of such studies take years to permeate actual practice patterns, and practitioners aren’t really monitored to ensure they are delivering the “right” care or in the “right” way. We submit to care, we pay for that care, without really knowing if it is the care we should be getting or from the person/institution who should be giving it to us.
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Without
building all those boats, we’re not getting to the 22nd century
healthcare system that we want, and deserve.
Sure,
there’s lots of exciting technology that will help make things look more
like a 22nd century healthcare system. AI, robots, genetic editing, nanobots,
smart cells, synthetic biology, and more – these are all exciting, and will all
be useful in that 22nd century healthcare. But they won’t get us to
the 22nd century healthcare system we should get. They’ll just take us
to a slicker, more expensive version of the one we have.
You may
have seen that a couple weeks ago was the 50th
anniversary of the initial release of Jaws. One of its most iconic
lines was the Chief Brody’s reaction when he first glimpsed the size of the
shark he and two companions were foolishly hunting: “You’re gonna need a bigger
boat.”
When it
comes to getting us to the 22nd healthcare system we should want, we’re
gonna need a bigger boat too – and we better start building it now.
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