Oh. Another Moonshot

If all goes well, in a couple days NASA will be sending astronauts on their way to the moon, for the first time since – gulp – 1972. They’re not landing, mind you, they’re just doing a fly around, something Apollo 8 first did way back in 1968. Given the advances in microchips, computing power, AI, a robust private space industry, and Elon’s grand plans to inhabit Mars, it doesn’t really sound all that ambitious, hardly a “moonshot” in the sense that we’ve come to use that term, but I guess we should be glad that NASA hasn’t entirely conceded space to the billionaires.

Artemis II Space Launch System Credit: NASA/Jim Ross

The Artemis II mission will send four astronauts – including, if you are counting (and many are), the first person of color, the first woman, and the first Canadian to reach the moon -- on a ten day, 230,000 mile trip that won’t actually orbit the moon but just loop around it, not getting closer than a few thousand miles. “Things are certainly starting to feel real,” Christina Koch, one of the four, said during a news conference Sunday morning.

Last week NASA unveiled its “Ignition” strategy that Artemis II is part of. It includes not just the fly-by, but also a follow-up mission in 2027, a manned landing in 2028, and a permanent moon base in the 2030’s, committing $20b over the next seven years to accomplish the latter. “NASA is committed to achieving the near‑impossible once again, to return to the Moon before the end of President Trump’s term, build a Moon base, establish an enduring presence, and do the other things needed to ensure American leadership in space,” said NASA Administrator Jared Isaacman.

He added: “Today, we are providing a demand for frequent crewed missions well beyond (previously announced moon landings in 2028). We intend to work with no fewer than two launch providers with the aim of crewed landings every six months, with additional opportunities for new entrants in the years ahead. America will never again give up the moon.”

I knew Elon and Jeff were going to get something from all this.

I hope the mission goes according to plan. I hope I live long enough to see a successful manned landing on the moon and even that lunar base. Then again, President Obama launched the Cancer Moonshot in 2016, aiming to “end cancer as we know it,” and there still seems to be plenty of cancer around. Sure, much progress has been made, but we’re still seeing disturbing trends like  “skyrocketing” increases in colorectal cancer rates in young adults.  

You might call Operation Warp Speed a moonshot, developing effective vaccines against the global COVID pandemic in a matter of months, but it has had the paradoxical result of a new wave of vaccine hesitancy generally, aided and abetted by the MAHA team heading up HHS in the Trump Administration. You wouldn’t consider our measles outbreak as what we’d expect from a vaccine moonshot.   

Similarly, Alphabet has a whole “Moonshot Factory” aimed at big breakthroughs, but none of its successes have revolutionized society or even been the Next Big Thing for Alphabet. "We have a 2% hit rate," CEO Astro Teller told a conference last fall. "Most of the things we try don't work out, and that's okay." Waymo and Wing are considered its big successes, but, I don’t know about you, neither is in my market yet.

A couple weeks ago I wrote about the U.S. military seems to have failed top learn the lessons of the way in Ukraine, continuing to rely on expensive weapons systems that are ill-equipped to deal with flights of AI-driven drones. A couple days ago Simon Shuster wrote in The Atlantic about his visit to Rheinmetall, the German arms manufacturer. He told his guide about how tanks in Ukraine had changed from being killing machines to being easy drone targets, and so had been modified to have nets and other anti-drone protections. His guide was abashed. “No,” he said. “We don’t have something like that.”

The Rheinmetall CEO was dismissive of Ukrainian innovation: ““It’s Ukrainian housewives. They have 3-D printers in the kitchen, and they produce parts for drones. This is not innovation.”

I beg to differ.

I think of all this in the context of an updated KFF analysis of hospital concentration. The key takeaways:

• “One or two health systems controlled the entire market for inpatient hospital care in nearly half (47%) of metropolitan areas in 2024.
• In more than four of five metropolitan areas (83%), one or two health systems controlled more than 75 percent of the market.
• Nearly all (97% of) metropolitan areas had highly concentrated markets for inpatient hospital care when applying HHI thresholds from antitrust guidelines to MSAs.
• Most hospital markets in metropolitan areas (80%) became less competitive from 2015 to 2024 or were controlled by one health system over that entire period.”

I first wrote in 2015 about how hospitals were the biggest source of health care spending – as they had been in 1960, and as they are today. KFF says they accounted for 40% of our national health care spending growth from 2022 to 2024. With such concentrated market share, it’s easy to see why.

This is not innovation. Those are not the result of any moonshots. That is not the future.

Hospitals, to use an overworked analogy, are the health care system’s tanks (or aircraft carriers). Powerful but hugely expensive, relatively slow, steeped in traditions of prior wars. They should not be the mainstays of 21^st century medicine.

21^st century healthcare should not be “fought” with big, expensive, slow-to-produce assets. Even aside from hospitals, I mean, how long does it take to train physicians, at what expense? And once they are practicing, how long does it take to bring the new clinical findings into their actual practice? It’s ridiculous, especially in an AI era.

Similarly, how many billions does it take to develop new drugs, leaving how many years of patent protection?  With genetic manipulation, AI-assistance, and 3D printing, why aren’t we in the era of inexpensive, more effective prescription drugs?

We need the kind of innovation that Ukraine has brought to 21^st century warfare. Those are the kind of moonsho