I’ve never understood why it is that otherwise intelligent people instantly assume that a simple, massive change is the only solution.
(Brace yourselves. This rant has been building for a while.)
It’s a truism that every single complex problem has a simple, easy-to-understand, common-sense wrong answer. What’s wrong with complex solutions for complicated problems?
It’s like the kids and their periodic love affair with Communism. Now, don’t get me wrong; I’m a fan of everyone getting what they need and giving what they can; that ought to be second nature to humanity. But every few decades, the students all decide that we need to break the old system, throw everything away, and do something that the Paris Commune tried and starved at, Cuba tried and failed at, Russia tried and violently failed at, and China tried and succeeded all too well at until they became today’s answer to Nazi Germany (no hyperbole intended).
It’s not so much that Capitalism is superior, or that Communism doesn’t work; it’s that economies by their very nature are huge complicated things, and dogmatic adherence to purist idealized theory is no way to run a railroad, much less an economy. Complex situations require complicated action.
Healthcare is in the same type of mess the rest of the economy is. And to that I say: So what? So the problem’s tough. We’re Americans. Since when are we afraid of tough problems?
When the country was founded, doctors apprenticed more often than they went to schools. Armies and navies turned out surgeons by the hundred, and they could saw an arm off as easy as looking; if you were very lucky you wouldn’t die of the inevitable infection. Physicians were students of natural philosophy, and rarer than hen’s teeth. But when there were sick people, doctors helped them, or at least tried. Money wasn’t their objective.
Today, we hold the power to cure diseases unimaginable by the minds of centuries past. I know a man with a plastic patch holding his heart together, another who takes a pill every day that keeps him sane. We’ve discovered eight thousand different varieties of cancer, and nearly 7500 of them have multiple effective treatments. A new epidemic comes along and, within months, there’s a vaccine — a little weak, maybe, but extremely effective at keeping people alive.
We’ve never had this before.
On the other hand, right now if I get knocked down by a bus in the street, I can’t afford to ride in an ambulance. The Metro system would never pay without a lawsuit, and my insurance company is little different — not to mention a deductible so high that it dwarfs my annual income. God help me if I break an arm. Cancer? That’s a disease for the rich.
Did I mention I’m insured? I’m one of the lucky ones.
My wife has good insurance, and it paid off. She had a lifesaving surgery that, on paper, cost a million and a quarter dollars. On the other hand, three doctors worked together for a couple of hours, along with a team of four. There were nurses 24/7 for a few days. But all told, even assuming massive salaries, I figure the actual cost to the hospital was closer to $25,000. And that’s paying one heck of a high rate for overnight lodgings. I haven’t even told you the price a band-aid was quoted at.
As Ronnie Reagan once famously said, “Surely, somewhere, there must be some overhead.”
But we know all this. Everyone knows; I’m not saying anything remotely new. Our national healthcare system is a horrible, disgusting, depressing joke, and that despite the best efforts of one heck of a lot of well-meaning, overworked and underpaid nurses, practitioners, attendants, assistants, interns, and doctors. I’m even prepared to admit that some hospital administrators aren’t redundantly useless gin-guzzling golf-obsessed money-grubbing wastrels.
So where oh where does all the money go?
Well, yes, a new MRI machine costs between $1-3 million. But how many do you need? Presumably, they last more than a week or two. The new air conditioning system actually does need those thousand-dollar micro-carbon filters; it keeps the patient in 201 from catching that nasty virus the guy in 301 picked up in Thailand. And so on, and so forth. There are people whose fulltime job it is to examine, control, and trim the costs of healthcare, and they’re good at what they do.
I know this because most hospitals are for-profit businesses, and nothing hurts the bottom line quite like a high cost of doing business.
Some of the money goes to treating Medicare patients. Were you aware that payouts even for approved procedures can take years to get back to the hospital? Someone’s got to tune up that MRI every few months while the check is in the mail. The delays are so bad that, when the COVID pandemic got going, one of the key benefits was a loan program — $100 billion that the federal government set aside to lend hospitals until Medicare got around to paying them. The loans are coming due now, a year later, and it turns out Medicare isn’t paying in time.
That’s not a hospital’s fault; they keep dozens of people working full time to badger the government for money. The government pays as many as all the hospitals combined to pay — slowly. Which is all they can do; Medicare costs several times more than what the Medicare taxes bring in. They dipped into Social Security to help pay, but we no longer have even that luxury now. Bottom line is, the total workforce is 130 million people, and 90 million are permanently on Social Security and Medicare. There’s no way whatsoever that can pay for itself in the long term. Medicare will go bankrupt in 2024; Social Security is scheduled to collapse in the early 2030s.
Is there really nothing we can do to stop this?
Remember what I said: So what? So the problem’s tough. We’re Americans. Since when are we afraid of tough problems?
This is a huge horrible nasty tangled mess, and we deal with it. We don’t pull an Alexander and cut it with a sword; that’s fine in wartime, but in peace all you can do with a sword is put more people into the already overstressed ERs.
No, we handle it the way the man ate the elephant: One bite at a time.
- Tax revenues aren’t enough to pay for even an ideal system. Solutions: Increase tax revenue, reduce costs. There are a hundred million would-be workers turned away at the border every year; let’s take a few and set them to work — and tax them.
- The system generates profits, and these are maximized by treating rather than curing patients. On occasion, we’ll see doctors in court who deliberately, fraudulently prescribed chemotherapy for people who don’t have cancer — because it makes them a ton of money. Imagine all the ones who never get caught, who refer their stable of patients for a hundred needless tests. Let’s remove the profit motive from treatment.
- There aren’t enough doctors, nurses, et cetera. On the other hand, as I describe here, the military trains them by the boatload, and then they aren’t permitted to practice in civilian life without years of redundant education.
- Drug prices are too high. Medicare pays through the nose because they aren’t allowed to negotiate the way private insurance companies can. The uninsured don’t even have Medicare on their side. One way to address this is to prosecute the companies for price-gouging, and assess fines in the form of dividend-bearing shares to be held by the Medicare trust fund. (Or do the same through Congress; that’s fine too.)
You’ll notice, these aren’t small bites. Each is a gigantic problem, and the simplified solutions I propose need to be far more complex than they at first appear in order to be effective. It’s not like waving some sort of magic wand and instantly solving things; it’s going to take hard work, a degree of ruthlessness, and some of the best minds we can find.
On the other hand, we’ve beaten this sort of thing before. Kennedy announced we were going to the moon; ten years later, we were there. Hugely complex; astronomically difficult — and we did it.
So. Let’s fix healthcare. Who’s with me?
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