Imagining a Different Future

Two articles have me thinking this week.  One sets up the problem healthcare has (although healthcare is not explicitly mentioned), while the other illustrates it.  They share being about how we view the future. 

Credit: Sanofi

The two articles are Ezra Klein’s Can Democrats See What’s Coming? in The New York Times Opinion pages, and Derek Thompson’s Why Does America Make It So Hard to Be a Doctor? in The Atlantic. Both are well worth a read. 

Mr. Klein struck a nerve for me by asking why, when it comes to social insurance programs, Democrats seem so insistent on replicating what has been done before, especially in Western Europe.  He asks: “But what about building here what does not already exist there?”  He worries “that the Biden administration’s supply-side agenda is stuck in the past and not yet imagining the future.”

Those are exactly the right questions we should be asking about healthcare.

Our most ambitious healthcare reform proposals seem to either be the catch-all “Medicare For All” or the simplistic single payor. Both are rooted in the past, and in what has been done elsewhere.  We debate what coverage for which things who should have, how much they should have to pay at point-of-care versus upfront in taxes/premiums, and how much we should pay healthcare providers.  They are the same questions we’ve been debating since the 1940’s. 

They’re not the questions for the 21^st century. 

Mr. Thompson takes on what a mess our medical education and training “system” is, and wonders why on earth we make it so hard for people to become physicians.  It’s harder, longer, more expensive here than almost anywhere else, and we end up with fewer physicians per capita than most other developed countries. We even make it hard for doctors to immigrate. “No matter what the pandemic future holds,” he asserts, “we need more doctors to be part of America’s health-care system.”

I’ve written previous on reforming medical education and on rethinking primary care, so I heartily applaud those aspects of Mr. Thompson’s article, but I stop short of endorsing the call for an “abundance” of doctors.  What we need, as I’ve argued before, is not more doctors but fewer patients. 

Yes, many people have to wait too long to see doctors, while others never get to see them at all, and most of us pay way too much for all kinds of health care.  Certainly our healthcare system is severely flawed, with huge gaps and inequities at every turn. But more Band-Aids, more-of-the-same is not what we need.  We need to be, as Mr. Klein urges, “imagining the future,” not simply patching up our rickety 20^th century healthcare system.

Umm, yes. Credit: Harvard Health

Here are some thoughts:

Data: if the pandemic has exposed anything, it is that we really have no idea what is really going on with our health or in our healthcare system.  We don’t really know how many have contracted COVID, how many have been tested for it, how many have been vaccinated against it, or even how many have died from it.  People have valiantly done their best to estimate all of these and more, but, let’s not kid ourselves, they’re estimates. And COVID is something we’ve been paying a lot of attention to, and spending a lot on. Imagine the rest of our data.

A 21st century healthcare system needs to start with data, at every stage, from self-monitoring at home to everything that happens to us in the healthcare system. It needs to be built to collect that data, to ensure that it flows easily, and that it is collected in ways that are actionable. Data cannot be the afterthought of care; it needs to be built-in at the ground level, designed into the system.

It’s already 2022, and we don’t have the right data, much less the right ways to capture and use it.

Health, not Medical: it has been oft said, but it bears repeating – we don’t have a healthcare system, we have a medical care system. Things that happen outside of a physician’s care are usually outside of the system too.  We talk about social determinants of health, but they mostly remain outside the system.

Public health has taken a beating during the pandemic, after years of benign neglect, but if we were serious about addressing our health needs, we’d be spending a lot more on it and expecting a lot more from it. Most of our health issues start with public health issues. 

The trick will be reinventing public health for the 21^st century, not just grafting 21^st technology on top of 20^th century public health structures, from physical infrastructures to information campaigns to staffing.

DIY: the miracles of 20^th century medicine further elevated physician to near god-like reverence, but the miracles of 21^st health are going to level that playing field, much more than the internet has already done.  Innovations like AI, 3D printing, synthetic biology, and nanoengineering are already showing how radically different our health care can be, and we’re only scratching the surface of what each can do and how they can be applied to healthcare.

Let the biohacking begin! Credit: Yetisen

Each is going to both get more powerful and cheaper, and each will be in the hands of more people.  We’ll know earlier when we have a problem and how to address it, and we’ll usually have the means to “fix” it.  A topside down healthcare system isn’t going to cut it. Moreover, our healthcare spending is going to be significantly different – lower! -- when we’re using what will essentially be consumer goods instead of taking trips to the healthcare system.

The 21st century healthcare system needs to foster/expect DIY.

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Alec Stapp, cofounder of the Institute for Progress, told Mr. Klein: “This isn’t about government controlling the means of production. It’s about government controlling the ends of production. Deciding what we are producing toward, what we are building for.” Those are the decisions we really need to make when thinking about healthcare reform.

E.g., I’d rather the government be building that data infrastructure instead of spending more on graduate medical education.  I’d rather the government be directing more money to public health infrastructure than in bumping up Medicare payment levels.  I’d rather the government be giving tax breaks to biotech companies than to “non-profit” hospitals. 

Be bold.

As long as our healthcare system looks familiar to those of us born in the 20^th century, we’re not thinking boldly enough. We should be imagining a future that does not yet exist, and that will look familiar to people who will still be alive for the 22^nd century.