The Eisenhower Principle

I’ve finally come to understand why the U.S. healthcare system continues to be such a mess, and I have President Dwight Eisenhower to thank.

I’ve been paying close attention to our healthcare system for, I hate to admit, over forty years now. It has been a source of constant frustration and amazement that – year after year, crisis after crisis – our healthcare system doesn’t get “fixed.” Yes, we make some improvements, like ACA, but mostly it continues to muddle along.

Then I learned about President Eisenhower’s approach to problems:

That’s it!  All these smart people, all these years; they didn’t know how to solve the problem that is our healthcare system, so they all took the Eisenhower approach: enlarge the problem.  Let our healthcare system get so bad that not addressing it no longer is possible.

If, indeed, there is such a point.

The actual Eisenhower quote is more nuanced than the above version. It was:

Whenever I run into a problem I can't solve, I always make it bigger. I can never solve it by trying to make it smaller, but if I make it big enough, I can begin to see the outlines of a solution.

I guess we’re not yet at the point when the outlines of a solution are clear (Bernie Sanders notwithstanding).

Instead, we’ve been chipping away at the problem, trying to make it smaller. For example:

• Employer-sponsored health insurance tax preference (WWII)
• Hill-Burton Act (1946)
• Medicare/Medicaid (1965)
• Federal HMO Act (1973)
• Stark Physician Self-Referral Law (1989)
• DGRs (1983) & RBRVS (1992)
• CHIP (1997)
• Medicare Modernization Act (2003)
• Affordable Care Act (2010)

ACA signing. Credit: Doug Mills/NYT

I could add a plethora of non-legislative efforts, largely private sector driven, such as second surgical opinion (1970’s), PPOs (1980’s), centers of excellence (1980’s), disease management (1990’s), value-based purchasing (2000’s), or digital health (2010’s).  Each was well-intentioned, each was expected to make a dent in a problem, and each was subsumed into the maw of our healthcare system. 

But we still pay way more than any developed country for our healthcare system, for health outcomes that put us, at best middle of the pack. Tens of millions of us still lack health insurance, in part because some states refused to expand Medicaid and in part because people still can’t afford/don’t see the value of health insurance, despite subsidies. Health inequities abound, particularly for people of color.

Yes, some of the best care in the world can be found here, but most people shouldn’t expect to receive it – it takes luck, money, and/or the right location. Our malpractice system penalizes physicians without protecting most victims of malpractice.  “Public health” has at best been ignored (like most other of our infrastructure) and at worse seen as some sort of Communist plot.

One might have thought that a global pandemic would make the problem big enough. We’ve got over 800,000 people dead already, we’ve overwhelmed many of our hospitals, we’ve burned out large numbers of our healthcare workers, we’ve exposed the fragility of our healthcare (and other) supply chains. Yes, we’ve thrown trillions of dollars at the pandemic, yes, our scientists have developed very effective vaccines in record time, but too many people refuse mitigation measures that might finally bring it to an end.

Yet still the outlines of a solution continue to elude us. It seems there is no health problem so big that we can’t turn into a political issue, not even a pandemic.

Even before the pandemic, we were facing epidemics of chronic diseases, such as diabetes and obesity, as well as gun violence, opioid addiction, and mental health. We know we should address these, we know we could, but mostly we just shake our heads and offer “hopes and prayers.”

How many Americans will have to go bankrupt from the cost of healthcare they received? How many Americans will have to suffer or die from the care they didn’t receive – or from the care they did receive? How embarrassed are we willing to be about our health disparities? How reluctant do people in other countries have to get about living/visiting here due to the risk of getting caught up in our healthcare system?

In Gen Z’s lifetimes, much less those of millennials or Baby Boomers, the problems in our healthcare system have grown from huge to unfathomable.  When it comes to healthcare, we’ve let the problem get big enough. It’s been enlarged to the point it is hurting us, our economy, and our futures.

Yet here we are, still fumbling for solutions.

It’s possible that the pandemic will cause our healthcare system to collapse and force us to take action on fundamental reforms. More likely, due to the valiant efforts of our healthcare professionals, it will survive this too, and the pandemic will just be one more insult added to our injury.

It’s possible that when health spending reaches 20% of GDP – as it is projected to do by the end of the decade – we’ll decide we’d had enough, but I remember when we thought 10% was the limit.

It’s possible that we’ll suddenly recognize that, hey, our declining mortality – which is not all due to COVID -- is a real problem, but that’s probably too slow and subtle an indicator for us to act.

By now, we shouldn’t just have shadows of solutions. By now, the problem is so big that solutions should be crystal clear to everyone. But they’re not.

We shouldn’t be surprised. We’re very good at kicking the can down the road. We should be very concerned about the national debt, but we add to it blithely. We should be terrified of the impact that climate change is already having and how much worse it will soon be, but addressing it would require us to make too many changes.

Our infrastructure is aging, brittle, and outdated, but even the recent Infrastructure and Investment Jobs Act is much smaller than it really needed to be. The racial wealth gap is a consequence of shameful historical patterns, yet continues to widen; it is not survivable for a democracy.

We’ve learned only half of Eisenhower’s adage: we’ve got the letting the problem get bigger part down, but we’ve forgotten the part about how/when to come up with solutions.

Where’s Eisenhower when we need him?