THE MEDICAL ADVANCES of the last century—even just the last decade—are nothing short of astonishing. We’re living longer and fuller lives than at any prior point in human history. The things doctors can now do to improve the quality of our lives can often seem miraculous. And with the application of data science and gene technology to medical problems, we can expect this progress to accelerate, perhaps exponentially. For a good part of the last century there’s no doubt that large-scale factory health care enabled health outcomes never before experienced. But we’re in a new century now; science and technology have evolved to make this model out of date. With no more excuses to prop up the big, bureaucratized health system, it’s time we moved on—because ignoring the human side of health care really misses the point.
As Dr. Elaine Goodman will testify.
SOME OF DR. GOODMAN’S most profound lessons in taking care of patients came not from her formal training but from the bedside of her sixty-three-year-old mother, where she sat many days after just having finished the first year of medical school. Though her mom was in the hospital to battle breast cancer, it seemed as if most of the time she was actually fighting the hospital, a nationally ranked facility near Seattle.
“My mom was on a seizure medication that needed the dose adjusted according to her nutritional status,” Goodman recalls. “The physicians probably knew this, but with all the handoffs, a new doctor would come in, see the drug level was low in her blood—without carefully observing her nutrition—and then up the dose.” As a result of these overdoses, Goodman’s mom would sleep for days. “As somebody who has a life expectancy in the order of months, those days were very important to us.”
But it got worse. Dr. Goodman’s mom was being treated with a chemotherapy drug. Normally her oncologist would administer it on the weekend, and the therapy would last the rest of the week. But one weekend when the oncologist wasn’t on duty, the covering physician not only gave her the wrong chemotherapy drug but administered it on the wrong day, a potentially life-threatening mistake: “My mom had effectively gone for a week without getting any treatment,” recounts Goodman. “For her this probably didn’t change her life expectancy drastically. . . . But this event itself was really terrifying. It had the potential to make a huge difference in the life expectancy of other patients.” Goodman is sure that how her mother was treated in the hospital hastened her decline.1
This kind of story is all too typical in our healthcare system today: patient volume is high, physicians and staff are overbooked and forced to multitask, and distraction and fatigue are endemic. According to a recent study in the Journal of Patient Safety, approaching half a million patients suffer from some type of preventable harm that contributes to their unnecessary death each year in the United States. The figure—much higher than was previously believed—makes medical error now the third-leading cause of death in this country, behind only heart disease and cancer.2
It’s easy to think of patients’ poor treatment as an isolated issue or simply to blame doctors and nurses. But it’s much worse than that. These incidents reflect a deeper, structural problem in how we think about health care, a problem that is at least as—if not more—important than our all-consuming debates about its funding. ‘Obamacare,’ ‘single-payer,’ ‘choice of plan’—we never stop talking about how health care is paid for. It’s time we also focused on how it’s provided.
America’s healthcare system is increasingly dominated by vast, bureaucratic, behemoth institutions that are losing touch with the human aspects of health care. By consolidating medical operations in gigantic centralized hospitals, we have created a clinical environment that actively fights intimacy and personalized care. The vast American hospital-insurance-pharmaceutical complex—now roughly the size of France’s economy—that we have allowed to bloat, unchecked, has taken something that should be the epitome of humanity—what could be more human than to care for others?—and sent it down a path of industrialization, mechanization, and dehumanization. It’s not the fault of the doctors, nurses, and support staff; as in so many other areas of life, it’s the structure of the system that’s to blame.
FACTORY HOSPITALS
It’s hard to care in a factory hospital. Go to a hospital today, and it can be an ordeal: navigating the large parking lot, walking what feels like miles through corridors, traveling in giant elevators before finally reaching a soulless waiting room where you have to sit endlessly to be called. Need a test? Walk through another mile of corridors to another soulless room. Then wait hours or days for the results. This only describes the experience of people who are outpatients. For those who are admitted, it gets worse. Patients eat factory food—how else to serve it in such an institution? But the worst part is that they are seen as outputs: treatments are commodified, tests done without doctors ever entering the room, medicine performed on and around the patient but seldom with the patient.
Behind the treatment is a vast and costly bureaucracy. A nationally representative survey of 4,720 physicians found that each spent on average 8.7 hours per week on non-patient-related paperwork—at a total cost of physician time of $102 billion per year.3 Moreover, greater time spent on administrative work correlated with lower career satisfaction. “Our crazy health financing system is demoralizing doctors and wasting vast resources,” Dr. David Himmelstein, one of the study’s authors, noted.4
Meanwhile nurses and medical assistants spend on average 20.6 hours per week interacting specifically with health plans—that is, with insurers and government payers. This compares to just 2.5 hours in Ontario, where nurses need only interact with Canada’s single-payer agency. Reducing our red tape to match Ontario’s would save us $27.6 billion per year.5
According to a study in the journal Health Affairs, hospital administrative spending is also outsized compared to advanced-country peers. In the United States it works out at $667 per person across the entire population. In the Netherlands it’s only $323, $225 in England, and $211 in Wales. In Canada it’s only $158. One reason? Billing in the US system is extraordinarily complex: each insurer has different payment rates, rules, and documentation requirements that only add to the burden.6
And as Big Health gets bigger, the bureaucracy is getting worse. With providers merging and consolidating, the bureaucracy increases, driving costs up further. Doctors who practice in groups of one hundred or more spend more time (19.7 percent) on administration than their counterparts in smaller groups (16.3 percent).7 “Seldom does consolidation result in reduced costs for consumers,” wrote the American Academy of Family Physicians in a letter to the Federal Trade Commission.8 In a study published in the journal Health Management, Policy and Innovation, economists found that the 2007 merger of UnitedHealth Group and Sierra Health Services in Nevada was unequivocally bad: “If there were any benefits to consumers realized from the merger, we could not observe them,” the authors wrote. Meanwhile the merger caused premiums to go up by 13.7 percent.9
But insurers and providers don’t just grow larger to compete against each other; becoming dominant buys political power, which leads to rules and regulations in their favor. The Affordable Care Act was only made possible by a series of backroom deals, facilitated by the $273 million spent on lobbying by the healthcare industry in 2009,10 in which cost savings, such as the government reducing Medicare payments on hospital care or prescription drugs, had to be carefully ‘negotiated’—lest the Obama administration face a nationwide barrage of antireform advertisements from the industry.11 At one point during negotiations in 2009 the five largest insurance companies collectively contributed $86 million to a political action committee to be used for negative ads just in case it became necessary.12
Obamacare is not the focus of this chapter. The Affordable Care Act was not trivial—indeed, just the opposite. But too much of the debate around health care focuses on the economics: How do we cut costs, increase coverage, set up the right incentives? It misses some fundamental points about the kind of care we get. Of course we must debate payment models, funding sources, and coverage limits—these things are vital. But they’re just one part of a much bigger picture. The debate neglects the larger system of which it’s all a part, and in overlooking the system and its foundational structure, we overlook the actual impact it has on the actual care at the point of the actual patient. This human part of health care is rarely discussed.
iPATIENT, OR REAL PATIENT?
The argument for the status quo is that our standardized, bureaucratized, factory hospitals, healthcare providers, and insurers are ‘efficient’: they bring together the expertise, technology, and facilities needed for specialist procedures, operations, and complex treatments. Efficiency, of course, is the argument for many things, especially the role of technology in health care. Used well, technology can be positively transformative in health care just as in other fields. But it can also hinder care by putting efficiency ahead of the patient. Stanford medical professor Dr. Abraham Verghese is an evangelist for the physical examination for this very reason. “I joke, but I only half-joke, that if you come to one of our hospitals missing a limb, no one will believe you till they get a CAT scan, MRI or orthopedic consult.” Technological tests can be invaluable, but not when doctors rely on them too much or even forsake actually examining the patient. “I’ve gotten into some trouble in Silicon Valley,” Verghese says, “for saying that the patient in the bed has almost become an icon for the real patient who’s in the computer. I’ve actually coined a term for that entity. . . . I call it the iPatient. The iPatient is getting wonderful care all across America. The real patient often wonders, where is everyone? When are they going to come by and explain things to me?”13
If technology replaces human contact when healing is what’s called for, it makes health care less human. But interestingly, when it replaces the bureaucracy of health care, technology can make it more human. Used right, technological advances can create more space for doctors to interact with their patients. As technology gets cheaper and smaller, going to a big factory hospital will be less and less necessary; instead, local doctors will be able to use devices like GE’s Vscan. Vscan is a hand-held ultrasound machine that replaces the huge ones otherwise used. Doctors can thus administer ultrasounds personally, even in a patient’s home, and get instant results. The patient need never go into the cold, dark, testing room again.14
Telemedicine, once a pipe dream, is increasingly a reality that frees patients from the burden of cumbersome tests and lengthy hospital visits. In Estonia, digital monitoring is such that doctors often have no need to see their patients for routine tests. Like other European countries, Estonia faces a demographic pyramid, with the population of senior citizens expected to increase greatly. The key then to providing care to the aging and elderly, according to President Toomas Ilves, is to prevent them from getting sick in the first place. That’s why Estonia is looking into telemedicine to monitor people who are especially at risk, like the elderly.15 President Ilves predicts that “in the future, we’ll be monitoring people constantly, certainly older people, so that before you get really sick you go see a doctor.”16
Estonia has already revolutionized health information through its Electronic Health Record (EHR). Started in 2008, the EHR does not centralize medical records but rather integrates them into a standard format readily available for both the patients and their doctors. Estonians, through their national ID system, have digital access to their records and those of their children and can control which doctors can see which parts of their records. And although the government can compile statistical data or track disease outbreaks, that data is anonymized and is never outside a patient’s control.
Electronic medicine needn’t just be a question of digitizing records. Ali Parsa, the founder of a British health startup called Babylon, sees his virtual health service as the solution to several problems that have long plagued the medical system. First is the simple fact that most people in the world have little or no access to health care—and technology can get it to them. But like the Estonians, he also sees a future where medicine becomes preventive instead of reactive.17
Babylon doesn’t preempt the traditional doctor yet—there is still a need for in-person procedures and examinations. Increasingly, though, much of medicine can be performed remotely. And that, Parsa, believes, is actually more human. His patients prefer to have a video conference on a phone or tablet rather than visiting the doctor’s office or the hospital. “Patients appreciate not leaving the comforts of their own home to spend, on average, three hours to get to a doctor’s surgery. My mother, for instance—every time she gets her blood pressure taken at her doctor’s [office], it’s high, while every time she has it done at home, it’s not. We all know it’s because of the stress of getting to the surgery at her age and meeting the doctor too.” With telemedicine “patients use the same medium to talk to their doctor that they use to talk to their friends and family. It’s a much friendlier experience.” Increasingly, too, medicine can be brought to the patient. Parsa concedes that sometimes you need to go in for a test, but why bother if it’s something that can be done at home? If a patient needs a run-of-the-mill blood test, Babylon sends a courier to deliver a simple prick-your-finger test that the patient can do at home and then send back by courier to get the results within the day.
It’s not just with Babylon that we get a glimpse of what the future of medicine could be. Technology can be harnessed to put health care in the hands of the patient through medical apps and social networks. Health-Tap, an American startup, allows users to post questions to be answered by one of more than sixty thousand doctors in its “expert network.” For a monthly subscription, users can connect via video to a doctor, who can write prescriptions, within minutes—twenty-four hours a day, seven days a week. For those with chronic conditions, parents with young children, or caregivers, such a service could be a lifesaver—or at least less of a hassle than multiple doctors’ office trips a month.
Mango Health, a mobile app, ingeniously combines human behavior and technology to help patients better manage their medications and other treatments. Jason Oberfest, the company’s founder and CEO, used to work in gaming and realized that “everything we’ve learned in behavioral design and user interface to keep people engaged in games could be applied to health care.”18 Oberfest and his team designed Mango Health like a game: users enter their medications and other treatments—for instance, specific exercises or reminders to drink water—into the app, as well as when and how to do it. The app will then remind them when it is time to do a treatment or take a pill. But just as a game has incremental rewards, Mango Health gives patients points every time a reminder is complied with. By partnering with third parties, Mango can offer rewards at certain levels of point accumulation.
Mango Health is also an example of how an app can help other areas of medical management. It has a database of every medication approved by the Food and Drug Administration, including negative interactions, so that if a patient enters a new medication that clashes with an existing one, the app will warn the patient of the conflict. It will also, if the patient allows it to, communicate with doctors, sending them real-time data about how their patients are complying with their treatment. The app prompts patients to record how they are feeling (with a few simple options like ‘good’ or ‘so-so’), so instead of retrospectively asking a patient how they’ve been doing, doctors can actually know in real time, to correspond with the introduction of new treatments or failure to follow them.
Social networks are another way that technology is helping to make health care more human. Jamie Heywood’s brother Stephen was diagnosed with ALS, or Lou Gehrig’s Disease, in 2006. ALS is an orphan disease—one not prevalent enough to attract the attention of drug company research toward a cure. In addition to designing solutions to the daily physical obstacles Stephen faced, Jamie, an MIT engineer, set about developing a treatment for the disease itself, founding a research institute with Stephen’s wife. Then he created PatientsLikeMe, a social network that connects patients suffering from the same diseases with each other and their doctors, creating ‘feedback loops’ whereby healthcare providers can quickly learn how patients respond to their treatments. “The faster the feedback loop, the more responsive it is to humans.” So Patients LikeMe harnesses human connectivity to increase responsiveness.19
PatientsLikeMe has designed its system “to discover if interventions have impact in the real world” but goes a step further by actually empowering patients to make that determination. PatientsLikeMe aims to discover the overall efficacy of different approaches to treatment; it is designed to work globally: “Great systems learn across boundaries,” Heywood says, and he is exactly right. If medicine is to get better, its practitioners and their results can’t be walled off from one another. That’s why PatientsLikeMe is so revolutionary: it is “inherently democratic.” And it is intrinsically human. Patients log on and document their outcomes and experiences, giving doctors, drug companies, and everyone concerned a real-time social network to understand their practices better while, for the first time, giving patients a role as true partners, able to learn from and bolster each other in bad times. “Patients contribute research ideas, they are involved in the design of trials and experiments, and they keep doctors honest. They interact around the data themselves, so if there’s something not quite right, they will dive right into that.” Ultimately Heywood hopes to reinvent the healthcare system: “imagine a world where everyone else’s experience can help improve your own.”
HEALTH CARE THAT MAKES YOU SICK
Factory medical systems deliver one type of health care, typically in the form of a procedure or pill of some sort. But in the face of some conditions or diseases, certain behaviors and exercises or nutritional and lifestyle adjustments might be more effective. The factory health system is not designed to prescribe something nonmedical or innovative—or if it does, it’s only after a battery of tests and exams to confirm that a more complicated procedure didn’t work.
Obviously there are many conditions and diseases that are best treated by medical procedures or drugs. But health is not just a function of medicine. More than just optimizing the effectiveness of a particular procedure, a more human healthcare system would optimize individual health and well-being. As Jamie Heywood saw, today’s medical system is based on how well a particular action was executed—“Was the hip successfully replaced? All right then, success!”—rather than its actual, ultimate effect on the patient: “Can you walk without pain since the procedure we did last year, Mrs. Smith?” As a result, the system needlessly precludes nonmedical interventions, not to mention the path almost never taken—nonintervention—from its repertoire of solutions.
Having feedback systems in place based on ultimate health outcomes would also help us see where treatments—even administered with the best of intentions—make us worse. Nassim Taleb talks at length about the danger of this phenomenon, iatrogenesis, the harm caused by treatment, that results from our deeply rooted desire to intervene or, as he puts it, “this need to do something.”20 The problem with this approach is that interventions aren’t costless. There is no drug in the world without an adverse side effect. There is no surgery without risk of greater injury. There are certainly many conditions for which we absolutely need the medical system. Steve Jobs famously tried to treat his pancreatic cancer with fasting and juice diets, later regretting his decision to forsake conventional treatment.21 But without understanding the full, long-term costs and benefits of any one regimen, including less invasive treatment or nonintervention altogether—knowledge that a rigorous feedback system would give us—we take tremendous risks prescribing otherwise healthy people with powerful treatments.
Our bodies are exceptionally complex, and attempts to oversimplify the interactions that happen within them in order to mechanize them courts unintended consequences. Doctors almost automatically prescribe proton pump inhibitors (e.g., Prilosec, Nexium, Prevacid) to people experiencing heartburn or stress (over 100 million times in the United States per year), but around 60 percent of prescriptions are inappropriate according to the Archives of Internal Medicine.22 The drug works by reducing acid levels in the stomach. This certainly eliminates heartburn, but it increases the risk of infection (acid kills germs in the things we eat) as well as vitamin deficiency (acid is also necessary to break our food down) and even heart attack.23 Considering that for many people simple changes in diet or behavior, like eating an evening meal earlier, can eliminate acid reflux disease altogether, altering the chemistry of our bodies so casually for so many people seems haphazard at best.
Now, Nassim Taleb explains, pharmaceutical companies find themselves “scraping the bottom of the barrel, looking for disease among healthier and healthier people, lobbying for reclassification of conditions.”24 Perhaps restless leg syndrome (RLS) really is a medical condition, and for those it seriously afflicts, a treatment is a godsend. But did it require GlaxoSmithKline to run an aggressive marketing campaign promoting prescriptions of ropinirole, usually used to treat those with Parkinson’s? They also lobbied doctors directly to ‘educate’ them about the disease.25 Doctors in the journal PLoS Medicine accuse the company of “disease mongering.”26
Restless leg syndrome isn’t the only disorder with a ‘modern cure.’ The United States spent an incredible $2.3 billion to treat ADHD in children ages five to seventeen in 2007 (the latest year such data were compiled).27 In 2014 we spent $10.1 billion on ADHD treatment overall, a 51 percent increase over the previous five years.28 Dr. Michael Anderson, a pediatrician near Atlanta, Georgia, and an outspoken critic of the overtreatment of ADHD, still finds himself prescribing pills to the low-income elementary-aged patients he treats who are having trouble in school. “I don’t have a whole lot of choice,” he says. “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”29 Our factory health system puts the needs of the children’s factory-school system over the needs of children themselves. We’re taking children with very normal child behavior—being energetic—and categorizing them as ill and in need of treatment for the convenience of the adult world that serves them. It’s a completely inhuman “chemical straitjacket,” says Dr. Nancy Rappaport, a child psychiatrist who works with low-income children.30
Such ‘straitjackets’ aren’t costless. One family with four of its children in Dr. Anderson’s care has a shelf lined up in the kitchen with all their medications: Adderall for the twelve- and nine-year-olds, Risperdal (an antipsychotic mood stabilizer) for the two eleven-year-olds, and—to top it all off—Clonidine, a sleep aid for all four of them to counteract the other drugs. When one of the children started to go through puberty, the Adderall he was on caused him to begin hearing voices and imagining people around him, a recognized side effect of the drug. Having become suicidal at one point, he even spent a week in a psychiatric hospital and was consequently switched to Risperdal.31 This is surely madness, cruel madness.
“LESS MEDICINE, MORE HEALTH”
Dehumanized, factory health care is not just limited to pharmaceuticals. Americans undergo some 80 million CT scans each year, about a third of which are completely unnecessary (incidentally, according to a study in the Archives of Internal Medicine, around 14,500 cancer deaths each year are attributable to radiation exposure from CT scans alone).32 But patients, shielded from the costs of any particular procedure, want answers, and doctors live in constant fear of malpractice litigation, so they err on the side of ‘caution.’ Of course, in a model where doctors and hospitals are paid for every service they provide, more tests mean more treatment, which means more money.
“Often, these are fishing expeditions, and since no one is perfectly normal,” one doctor writes in the New Yorker, “you tend to find a lot of fish.”33
And although this drives up financial costs, we pay the price in our health as well: we’re correctly diagnosing conditions that will never actually bother us and then spending billions to ‘fix’ them, but without the attendant improvements in how many more years patients live or in their quality of life. “When it comes to human health,” according to H. Gilbert Welch, an academic physician and professor at Dartmouth Medical School, “the idea of possibility, chance, or probability typically gets lost and a risk becomes a threat—a threat that must be dealt with by medical care.”34
Screening for screening’s sake is dangerous. According to Welch, “since the mid-1990s the incidence of thyroid cancer detection in the United States has increased threefold, while the death rate has remained stable. That doesn’t sound like an epidemic of real disease; that sounds like an epidemic of diagnosis.” In his book Less Medicine, More Health, Welch writes of a family friend who, having been found to have a small papillary thyroid cancer, was operated on. During surgery to correct the cancer ‘problem,’ his friend had a minor stroke and now has lost sensation and function of his lower arm and lower leg. He has difficulties enunciating words too. “Intraoperative stroke is rare,” Welch points out, “but it is undoubtedly more common than anything bad happening had he left the small papillary thyroid cancer alone and waited to see if it became a problem.”35
ALL THIS IS the entirely predictable product of Big Health, the factory healthcare system we have built: big hospitals operated by big bureaucracies working with big pharmaceutical and insurance companies. Patients—people—take a backseat to the imperatives of the system itself. One way to constrain this baleful trend is to switch from the current, dominant ‘fee-for-service’ medical payments model to some variant of a ‘fee-for-outcome’ model. ‘Fee-for-service’ means, simply, getting paid for what you do. In such a system the incentive is quite obviously to do more. The more treatments, the more procedures, the more you get paid. ‘Fee-for-outcome,’ however, pays for the end result, not the process. Because this encourages only those tests and procedures that effectively improve patients’ health, cost savings, conditioned on meeting some standard of care, are split between the provider and the payer.
This is not a new idea. In 1984 the Texas Heart Institute developed ‘packaged pricing’ for cardiovascular surgery, an arrangement in which the cost of surgery as well as all associated physician and hospital charges were included in one ‘bundled’ rate.36 In 1987 an orthopedic surgeon in Michigan offered a similar flat rate for various shoulder and knee surgeries. A two-year warranty for services following the procedure was even included in the price to cover the costs of abnormally long recovery, complications, or readmission, if necessary. Such ‘episode-of-care’ payment arrangements have been subsequently tried and tested across the country for various orthopedic surgeries, cataract and heart bypass procedures, and even prenatal care. Numerous studies have shown the model to almost invariably lower costs and improve outcomes.37 It’s not hard to see why: with one flat rate, physicians and hospitals are incentivized both to do a good job (so that the patient doesn’t require as much follow-up care) as well as look for ways to reduce waste and unnecessary treatment (as any savings are kept and shared).38 Yet uptake has been slow because establishing the benchmarks that determine what an appropriate payment should be—as well as what level of results indicate success—is tremendously fraught. Moreover, many medical providers still prefer a fee-for-service model because the chance of realizing some savings with a flat fee is a much less powerful incentive than running the risk that costs will go over.
The Obama administration to its credit continues to work with Medicare and Medicaid providers to adopt more outcome-oriented pay schemes. But even if ‘episode-of-care’ payments were adopted everywhere, they still fall short. Because even the highest quality, most cost-efficient knee replacement or heart bypass is far worse than avoiding either in the first place. Our healthcare system should be designed so that payers and providers actively try to help us avoid medical care altogether. Imagine if physicians and hospitals were paid . . . when we don’t show up. To do that is to imagine a system that looks at health as something that goes far beyond the repertoire available at the doctor’s office, emergency room, or operating room.
SLOW MEDICINE
The Slow Food movement, developed as a direct response to ‘fast food,’ (see Chapter 5), has inspired doctors as well. Proponents of ‘slow medicine’ argue that in making medicine ‘reductive’ and ‘mechanical,’ we forget that human bodies are complex organisms that can often heal themselves.
Dr. Victoria Sweet, who was a doctor at Laguna Honda Hospital in San Francisco, America’s last almshouse (which has since closed), is one of those proponents. Laguna Honda Hospital was unique. “It looked like a medieval monastery,” Sweet recalls. “It had cream-colored walls and a red-tiled roof and a bell tower and turrets. The hospital was huge, on 62 acres of land in the middle of San Francisco and it had 1,178 patients. [There was] the chapel, which looked more like a small church with polished wooden pews and real stained glass, and then we went outside and [there was the] greenhouse, the aviary, and the barnyard.”39
Sweet was both a doctor and a historian of medicine. Her subject was the medieval abbess Hildegard of Bingen, who among her many talents as a composer, writer, and polymath also wrote on medicine. Hildegard believed that the human body was like a plant and, accordingly, “took a gardener’s approach to the body. She did not focus down on the cellular level of the body; instead she stood back from her patient and looked around,” describes Sweet. “She followed the patient’s body; she did not lead.”40 Hildegard believed in the body’s viriditas, or vitality, and that, given the right conditions, it was perfectly able to heal itself.
Sweet didn’t really understand this concept until she treated her patient Terry Becker, who was homeless and an addict. Becker, Sweet recalls, had woken up one day paralyzed from the neck down. She was diagnosed with a very rare viral disease, but because it has no treatment and tends to get better with time, she was admitted to Laguna Honda. Medically Terry’s biggest problem was that by sitting in a wheelchair, she had acquired an enormous bedsore. Doctors had tried skin grafts three times, but the bedsore had become too large to operate on.
“When I saw that bedsore for the first time, I was absolutely shocked,” Sweet recalls. “It went from the middle of Terry’s back to her tailbone. It was so deep that I could see the bone at the base of Terry’s spine. It was filled with all this decayed tissue from the failed grafts. It would have to heal on its own. I couldn’t imagine how Terry would survive all the infections she would get.”41
Despairing over what to do, thinking that this bedsore was “probably the end of Terry Becker,” Sweet asked herself: What would Hildegard do? “Maybe Hildegard would just remove what was in the way of Terry healing. So what was in the way? All the dead tissue was in the way and had to be moved. Anything that was uncomfortable, like wrinkled bed clothes or a hard mattress or any medication that she didn’t absolutely need. . . . Then I thought, Hildegard would fortify Terry’s viriditas with the basics: good food, fresh air, deep sleep, sunlight. So that’s what I did. And it was amazing to see how fast Hildegard’s prescription began to work.”
At Laguna Honda, patients weren’t treated mechanically but organically . . . humanly. “Medicine is personal, face to face. And when it’s personal, it works,” Sweet says. In our rush to offer an immediate prescription, a mechanical ‘fix,’ we often forget that time and care can be the most natural—and effective—treatments of all. This is what she calls “the efficiency of inefficiency.” She is fond of a quote from Dr. Francis Peabody, a noted professor at Harvard Medical School in the early twentieth century: “The secret of the care of the patient is caring for the patient.”42 Often what would otherwise be seen as inefficient is actually most efficient. When we put bureaucracy ahead of patients, “in the interest of efficiency, we became less efficient,” she says.43
A PIE IS in the oven, vintage tracks are playing, and half a dozen women are gathered around the kitchen counter at Pathstone Living, a nursing home in Minnesota tailored for those suffering from memory impairment. It’s a typical afternoon there, with staff offering a wide range of activities for the senior citizens in their care. Staying busy, it turns out, can relieve the agitation that’s common among those suffering from Alzheimer’s or dementia. At another nursing home such agitation would be managed with antipsychotic medicines, which are approved to treat serious illness, like bipolar disease and schizophrenia: over three hundred thousand nursing-home residents are prescribed them annually in the United States. But antipsychotics increase the risk of death for those with dementia.44
Beatrice DeLeon experienced overmedication firsthand. An Alzheimer’s patient, DeLeon was sent to a care facility not for her memory but because she had had multiple falls. Even though overprescription of antipsychotics—a ‘chemical restraint’—is banned by law, “they just kept giving her more and more,” says DeLeon’s husband, Manuel. “And I noticed when I used to go see her, she’d just kind of mumble, like she was lost.” Beatrice was administered two very strong drugs that effectively made her a mumbling pile of flesh, writes Ina Jaffe, the NPR reporter who visited her. Doctors prescribe these drugs like sweets; a 2011 US government study found that 88 percent of Medicare45 claims for antipsychotics were for dementia or other conditions for which these drugs were not intended.46
Although enforcement against nursing homes that overprescribe antipsychotics is weak,47 Dr. Tracy Tomac hopes Pathstone Living provides an alternative. Pathstone’s new “anti-antipsychotic” approach came after Tomac, a psychiatrist and medical consultant there, decided with a colleague to see whether they could reduce the drug’s use. They tried it at one of the smaller nursing homes run by the same charity, Ecumen. By six months in, they were successful—everyone was off antipsychotics. So Ecumen decided to scale the approach to all of its nursing homes across the state, about a dozen in total. Their initial goal? Reduce their use by 20 percent. After the first year? Down 97 percent. Now at Pathstone, only 5 to 7 percent of patients are prescribed antipsychotics at all. Shelley Matthes, who’s in charge of quality assurance for Ecumen, says that the numbers were not the only thing that changed: “They started interacting . . . people who hadn’t been speaking were speaking. They came alive and awakened.”
The program, which came to be known as “Awakenings,” derives much of its success from training staff simply to pay attention to people. Although individualized dementia care is not an original concept—the nursing staff borrowed from techniques demonstrated elsewhere—attending closely to patients in a human way eliminates the need to medicate them for the behavioral problems dementia can create.48
DEATH AND DIGNITY
If there’s one aspect of health care most guilty of an inhuman approach, it’s how we care for those at the ends of their lives.
Sheila Marsh was dying. Stricken with cancer, the seventy-seven-year-old had one wish: to say good-bye to her favorite horse, Bronwen, for whom she had cared for twenty-five years at the stables near her home in Northwest England. So the staff at the hospital where Sheila stayed arranged for Bronwen and another of Sheila’s horses to come and visit, wheeling her outside to greet and be nuzzled by them. Though unable to speak due to the ravages of her disease, she “gently called to Bronwen and the horse bent down tenderly and kissed her on the cheek as they said their last goodbyes,” according to Gail Taylor, one of the nurses. Sheila died soon afterward, but her medical staff had helped end her life in quiet dignity, fulfilling her final wishes to bid farewell to the horses that had meant so much to her.49
That Sheila had such a dignified death in a hospital is extraordinary, really. Because death in much of the developed world is a horrendous experience. Most people, of course, want to die a quiet death at home surrounded by their loved ones. But instead, many die in a hospital, hooked up to ventilators and IV drips, surrounded by beeping monitors, lying in a sterile room, clinging to life but drained of soul.
We suffer tremendous indignity in the last years of our lives. Our bodies fail us, but doctors, obliged to preserve life at just about any cost, work to prop up our dying organs, our weakening limbs, our tenuous grip on reality. And we make things worse by letting people die exactly where they don’t want to end their lives: 70 percent of Americans say they would prefer to die at home, and yet only 24 percent who are over the age of sixty-five do—35 percent die in hospitals, 28 percent in nursing homes.50 The sad part is that of those who die in hospitals, many have no medical reason for being there—in Britain the figure is 40 percent.51
It is deeply inhuman that most people’s final moments are not as they’d like them to be. And factory hospitals are inappropriate places for the elderly, as geriatrician Dennis McCullough points out: “Large ‘industrial-scale’ environments like hospitals focus on disease and tend to lose sight of the complexity of an older person. Speed is at a premium and slower-moving, slower-responding elders don’t fit well with the pressured environment of fast medical care.”52 But hospitalizing elders is also, from a public policy perspective, a bad idea for the rest of us. Caring for patients in their final six months of life costs Medicare $170 billion—over a quarter of its annual budget.53 What’s more, approximately one-third of expenditures for the last year of life are incurred in the final month.54 Much of these costs are incurred by unnecessarily aggressive treatment administered in hospitals, often in intensive-care units (one investigation found that acute care accounted for 78 percent of costs incurred in the final thirty days of life).55 So if no one wants to die in hospital and it is so costly to the system for people to do so, why do they? And how can we give people a more dignified and more human end-of-life experience?
One of the great tragedies of end-of-life care is that we simply don’t know what most people want. Erring on the side of the medical principle ‘to do no harm,’ doctors continue to intervene to prolong life, even when we might not want them to. That’s where living wills, also called ‘advance directives,’ come in. Living wills help relatives and loved ones know what to do in case of medical dilemmas in which patients are incapacitated and can’t make decisions for themselves. Most people don’t have them—only 30 percent in the United States56—but having an end-of-life discussion not only ensures patients’ desires are carried out, it also lowers costs.
Communities like the town of La Crosse, Wisconsin, are leading the way. Bud Hammes is a medical ethicist at Gundersen Health System, a local hospital in La Crosse. He found that without living wills, most of his patients’ families had no idea what to do when patients were in a coma or on life-support machines. Despite years of illness, no one had thought to have the conversation. Consequently “the moral distress that these families were suffering was palpable. You could feel it in the room,” he says. Hammes resolved to help families solve the problem in advance and started a program to train nurses to ask people if they wanted to fill out an advance directive. The idea caught on, and now it is the norm in La Crosse to have a living will; in fact, 96 percent of those who die in the town have documentation for their end-of-life wishes, and it is normal for neighbors to gossip about who doesn’t have one. And although this wasn’t the goal, medical costs at Gundersen Health System have declined as patients make clear they don’t want to be kept on dehumanizing—and expensive—life support.57 (One study found that for those patients with advanced cancer who had end-of-life conversations with their physicians, their overall cost of care was 35.7 percent lower than those who never discussed their preferences. And in case you think that lower costs mean lower quality of death, the study found just the opposite: it was those who incurred higher costs that tended to suffer more.)58 By helping patients make their wishes known, Hammes has made death in La Crosse more dignified.
HENNEPIN HEALTH: GETTING CREATIVE ABOUT HEALTH CARE
February 25, 2013. It was a few minutes before 9 p.m. ‘Ron’ was getting ready for bed, and his phone started ringing. He was about to receive some very urgent news.
For four months Ron hadn’t felt his usual self. At fifty-five, he was used to not feeling quite right, having spent his life working hard, physical jobs. But even a hardened construction worker can only take so much. Finally Ron scheduled a visit at a local clinic, and after describing his symptoms, the doctor there decided they should do some lab work. Later, just as he was getting ready for bed, came that phone call: it was the doctor he had seen earlier that day. Ron’s blood sugar was high, so high that he had to go to the emergency room right away. If he went to sleep, she told him, there would be a good chance he would never wake up. Ron, he was told, had a kind of type 1 diabetes that is particularly slow to manifest and progress, and his was acute: his blood sugar would oscillate between tremendous extremes in a single day (one day between 36 milligrams of blood glucose per deciliter of blood to 586; to put this in context, most people’s levels don’t exceed 180). Such extremes complicated Ron’s life beyond just the physical consequences of his condition. He soon lost his job of almost ten years because the now-frequent trembling he experienced made him unsafe (his boss saw him shaking as he descended a ladder). And though he found work elsewhere, because his diabetes could incapacitate him without any prior warning, it was challenging for him to keep even the jobs for which he was qualified, as employers wanted advance commitment to a full day’s work. Finally, after falling into a diabetic coma that summer, Ron used up the last of his unemployment benefits. By September 15 he was homeless.
It’s easy to think of Ron’s case as one of a health problem leading to a social problem. But it was just as much a social problem exacerbating a health problem—a vicious cycle. Being homeless and diabetic is a deadly combination. Kim Evers, a diabetes expert who worked with Ron from his initial diagnosis, witnessed his health deteriorate further after he became homeless. Proper nutrition is paramount for managing diabetes, especially when it’s as acute as Ron’s. But whatever nutrition instructions Evers gave would be almost impossible for him to manage while he remained homeless: meals were irregular and, when available, often highly processed and sugar laden. Not having access to a refrigerator made storing insulin, which requires cold storage to prevent spoiling, almost impossible. Diabetics need somewhere to rest when tired, which happens easily and often, but shelters tend to close during the day. All in all, being homeless and diabetic can be a death sentence.
Thankfully Ron lives in Minneapolis, where he’s part of an incredible healthcare experiment: Hennepin Health. Local leaders created it to serve people exactly like him.
With just over 1.1 million people, Hennepin County isn’t huge, but with Minneapolis at its center (and over one in five Minnesotans), any experiment in healthcare delivery there would be ambitious, especially as this one was aimed at some of the most complicated and expensive users of the healthcare system. The project got its start after the state legislature moved to expand its Medicaid coverage to an additional eighty-four thousand people across Minnesota, as allowed under the 2010 Affordable Care Act, and passed a bill to allow the county to test new ways of serving these new patients. County officials’ response led to one of the most unique healthcare organizations in the country.59 Launched in 2012, Hennepin Health is a four-way partnership between departments or affiliates of the Hennepin County government, bringing together traditional health providers with social services. This hybrid organization receives a predetermined per-member-per-month payment from the state to cover the entire health costs of its beneficiaries. Such ‘capitation payments’ are actuarially determined for each person in the system, and any savings are kept as long as standard of care is maintained. This means that in Hennepin, the four partners, who were accustomed to operating independently, would now jointly share one budget so both cost savings and overruns would be spread equally across them.
Thanks to this incentive structure, the four partner agencies coordinate on nonmedical work as well as traditional health services. For example, although the county’s main social services agency—one of the four—is funded separately from the Medicaid capitation payments, it now makes sure its programs are integrated with the medical services Hennepin Health provides because it receives a portion of any medical savings. The result is practical care aimed at the root causes of patients’ poor health, regardless of how far outside the ‘traditional’ health sphere they fall.
Back to Ron, homeless and suffering from diabetes. In the eyes of his healthcare workers at Hennepin (like Kim Evers), finding Ron safe and stable public housing became a medical necessity. His homelessness was their business. So Evers ‘prescribed’ a team of social service workers trained in exactly this task to find Ron an affordable place to live. Now Ron has a place to rest when his blood sugar spikes or drops (sometimes causing blindness), to cook his own nutritious meals, and to refrigerate his insulin. He’s still far from healthy; the road ahead is long and uncertain. But Ron now has a better shot at staying healthy than he ever would have. For him the best medicine wasn’t in the refrigerator; it was the refrigerator.60
Hennepin is not the first to try a capitation payment model. Kaiser Permanente—a private provider—has shown that its fixed-fee-per-patient business model can improve outcomes and patient satisfaction. But the lesson from Hennepin—for all providers, private or government-run—goes much deeper: In every community, for every population type no matter how well off, there are a variety of components that form the fabric that is a person’s health—all of which must be tended to.
Hennepin provides instructive lessons for all providers. In every community, for every population type, no matter how well off, there are a variety of components that form the fabric that is a person’s health. This is precisely why traditional house calls—virtually killed off by modern medicine because they are ‘inefficient’—are actually vital. Dr. Sandeep Jauhar passionately advocates house calls for some patients, because they can help doctors understand the real impediments to a patient’s recovery. “One patient of mine had severe heart failure that rendered him too weak to come see me,” Jauhar writes. “He lived only a mile from the hospital, so I went to visit him. In his kitchen sink was a mess of dirty dishes. I looked in the fridge; it was nearly empty. There were canned soups on the counter, all loaded with sodium, precisely what he should not have been consuming. . . . It didn’t matter which medications I ordered at the pharmacy; he had no way to get them.”61
Our health system and the providers within it should study the communities they serve to find ways to help enhance their members’ health way beyond providing pharmaceuticals and medical procedures. Some of it is terrifically unoriginal: investing in parks and bike paths and sponsoring farmers’ markets or school nutrition programs. But why stop there? Imagine health providers partnering with cooking schools, investing in adult sports leagues, building gyms and community centers—all of which not only keep people active but, perhaps even more importantly, foster the social relationships that maintain health into old age.62 And given the health benefits of stable families (for more, see Chapters 8 and 9), perhaps one day our health providers will see their role as including parenting and relationship support too. That’s what a more human healthcare system looks like—not just dishing out drugs and carrying out operations.
One nonprofit organization is already working with communities across the United States to do just this. Author and National Geographic explorer Dan Buettner set out in 2004 to document the lifestyles of people around the world who had lived past the age of one hundred. After he and the scientists he worked with interviewed hundreds of these centenarians, they identified five communities—Ikaria, Greece; Okinawa, Japan; Ogliastra Region, Sardinia; Loma Linda, California; and Nicoya Peninsula, Costa Rica—with an abnormally high number. Buettner designated them ‘blue zones,’ and founded a nonprofit, the Blue Zone Project, to spread the lessons. The Blue Zone Project now works with towns in Iowa, California, and Minnesota to identify and invest in projects that have been shown to increase longevity, like additional drinking fountains throughout town, color-coded parking places that add two hundred steps to get to the store, community gardens, community walking clubs, and volunteer programs for local business people to walk kids to and from school.63
Whether these ideas are exactly right is not the point; they represent the right type of thinking about the very human causes of and impediments to good health. We can no longer afford for our doctors, nurses, and carers to be cogs in the machinery of industrialized medicine. They must be stewards of health.
DECENTRALIZING HEALTH CARE
America’s healthcare system needs a transformative reboot to undo the cumbersome factory health apparatus that, although built in the name of efficiency, now serves as a barrier to better—and less expensive—care. The essence of that reboot needs to be decentralization. To bring the human touch back to medicine, we need a system where care is devolved to the smallest practical unit. Of course it’s true that there aren’t enough—and there isn’t enough demand for—specialist doctors to be spread around every community. But equally, there is no need to warehouse them in huge buildings—giant, Kafkaesque labyrinths that impose themselves on sick, frightened, and vulnerable people.
In practical terms this means a radical breakup of Big Health and a radical dispersal of healthcare provision from centralized to community-based locations. If we can make hospitals more human, we can take the first step toward setting a tone that puts people first. By working not in large hospitals or medical centers but small, local ones, doctors can establish a more personal relationship with their patients. For the vast majority of our health needs, a highly localized system is ideal—localized even to the point of your mobile device. We need a system built around people, their needs, and what really works for them—not the medical establishment. We need the direct opposite of the mergers and corporate consolidation creating the giant Big Health Frankensteins we’re seeing more and more of today.
Decentralization would save money too. As of 2013 we spent $2.9 trillion on our health care—17.4 percent of the entire economy.64 In general you could argue there’s nothing wrong with a free society deciding to spend a big chunk of its income on whatever it wants. But the real issue is what outcomes these enormous sums are buying us. And the truth is that American health outcomes are no better than those in other countries that spend far less. The 17.4 percent of GDP we spent on health care is a full 8 percent above the average for developed nations, and 5 percent above the Netherlands, the country with the next highest share of spending. Yet life expectancy in the United States (78.7 years) is 1.5 years less than the developed country average,65 whereas five-year survival rates for cancer are about the same as our best peers (who, of course, spend much less). And although it’s true that we might treat certain highly specialized conditions better and that waiting times in the US system are far lower than in any other country—to what end? For some common conditions, like asthma, mortality rates are actually a lot worse.66 Rather than buying us more health, in the form of longer, healthier lives, our unusually elevated health spending simply buys us more healthcare activity—for example, twice as many MRI scans and 18 percent more C-section births per person than the average developed country.67 But with the right reforms, driven by the right values, I believe it’s possible for the costs—and cost-effectiveness—of the US healthcare system to fall in line with other advanced countries around the world.
A system dominated by a handful of large insurance, hospital, and pharmaceutical corporations, fortified by well-paid lobbyists and politicians, is obviously not going to get us there. We need change, and it needs to be much more fundamental than anything we’ve seen up to now.
TOWARD MORE HUMAN HEALTH CARE
Health care is a human right. It is essential for human dignity and necessary for society to function, making its common provision both a public good and good public policy. In the UK the National Health Service (NHS) is politically inviolable, a settled part of British society. We Brits are rightly proud of the idea of the NHS. Donald Trump once said that his policy on Obamacare was to replace it with “something terrific”; I think it’s pretty terrific that in Britain everyone can receive health care as a right, based on their medical need and not their ability to pay.
As most readers will know, no one has to pay out of pocket for health care in the UK. There’s no insurance bureaucracy for the patient, no applying for coverage. You don’t have to think about it, don’t have to worry about whether you’re ‘covered’ for this that or the other. You don’t have to consider questions of health coverage when you apply for a job or move to a different place . . . the very concept of ‘health insurance’ is alien to most British people. If you or a member of your family is ill, you go to the doctor. That’s it.
Is the British system perfect? Of course not. Is it even, in a narrower sense, more human? Well, partly yes. I do think that the absence of the sheer hassle and anxiety caused by the bureaucracy of America’s health insurance system does make the NHS, in that particular respect, more human. I am continually astonished by the passive acceptance on the part of so many US citizens of the waste of time and energy involved in interacting with healthcare red tape. It is an epic burden on people’s lives, practically Soviet in its style and scope.
But when it comes to the delivery of health care to the patient in the UK, there are severe and well-documented problems. The NHS is tremendously centralized and bureaucratic. Some NHS hospitals have been described as ‘conveyor belts’ that ‘churn’ out their patients, who are treated like ‘parcels.’68 The burden of internal paperwork and an obsessive focus on ‘efficiency’ have led to demonstrably poorer outcomes. In one extreme case, Stafford Hospital, bureaucratic diktats were a contributing factor in the unnecessary deaths of between four hundred and twelve hundred patients over a four-year period. The human neglect in that hospital, despite it being a state-of-the-art facility, was unfathomable. One patient died after being left in her own feces and contracting an infection from three superbugs. Another died after lapsing into a diabetic coma when her nurses failed to provide her with her routine insulin.69
In fact, cases of poor patient care pervade the entire NHS system: long waiting times for routine operations; unpleasant, outdated, often dirty facilities; offhand or downright rude treatment by overworked, underpaid, and poorly motivated staff. Factory hospitals and a factory approach to health care are alive and well in the vast, unaccountable bureaucracy of the NHS, the fourth-largest employer in the world after the US military, the Chinese army, and Walmart.70
There’s no surprise, then, that in discussions of healthcare reform in the United States, the inferior consumer experience associated with a ‘single-payer’ system like Britain’s is often cited as the principal reason to avoid such a structure. American citizens prize the choice they have over their doctor, their coverage, their treatment. Yes, the defects of the US system are pretty widely understood here. But in the eyes of most Americans, it’s still seen as preferable to a top-down, ‘take-what-you’re given,’ ‘socialized’ system. There are some who advocate a health system that is “Medicare for all.” Yes, Medicare is technically a single-payer system. But Medicare is restrictive and bureaucratic, and for many patients it still requires supplemental private insurance. We shouldn’t think, however, that the UK’s NHS as it currently stands (or “Medicare for all”) is the only possible version of single-payer health care.
The former Labour Party Health Secretary in Tony Blair’s government, Alan Milburn, once said that the NHS should be “an idea, not an institution.” The central idea of the NHS—universally available health care that is free at the point of use—is a great idea, worth cherishing. But just because such a system is funded by government doesn’t mean it has to be provided by government in the form of a massive bureaucratic institution. I think this points the way toward the kind of reform we need in America.
To achieve true reform that improves lives and reduces costs, we need to create an outcome-oriented single-payer system with full consumer sovereignty. Make the funding of health care more socialized, but make the delivery of health care more consumerized. This combination would not only drive innovation, but drive it in the direction of patient satisfaction and lowered costs—a huge departure from any system today.
A bumper-sticker version would be this: ‘single-payer, market provider.’ We should aim for the best of both worlds: the security of guaranteed health care for all, free at the point of use, combined with the dynamism and choice of market provision. ‘Single-payer, market provider.’
Let’s look at each element in turn. I know that many Americans might chafe at being part of one single national healthcare network. But they don’t realize they already are. Like it or not, every American is a member of the broader healthcare ‘pool.’ Whether they pay into an insurance plan or they are uninsured, a hospital won’t refuse them treatment if they are in dire condition. As a result, uninsured patients’ primary healthcare provider is not a family doctor but an emergency room in a public hospital, paid—much more expensively—by the taxpayer. The government, in effect, operates a backstop insurance policy that covers those left out of the current system but fails to deliver them anything but the most urgent emergency care. The public already guarantees some form of health care for all.
Second: ‘market provider.’ A more human healthcare system would feature a true market for healthcare services, where many different providers—from small to large, traditional to innovative—compete for patients on a level playing field. Why? Because when patients choose, we’re more likely to have innovation and a focus on quality care. We’re more likely to have a system where the incentives are designed to put people first: to satisfy patients rather than bureaucrats at Big Health insurance and medical companies. But at the moment, in America’s allegedly more market-based system, patients don’t choose—insurance companies do.
Of course, completely free markets don’t really work for health care. For markets to work properly, you need good information available to all participants. In truth, even in the age of Googling your symptoms, patients will not have enough information to make really well-informed medical decisions. They certainly won’t be able to anticipate the kind of care they’ll need in the future, to be able to choose the best provider for themselves today. Even in the moment when care is needed, patients don’t know whether they really need a treatment or not, relying on doctors—and an insurer or hospital company to tell the doctor what they should prescribe. In these ways health is different from education. In health you will always need some sort of provisioning authority to determine the appropriate standard of care for any given diagnosis. And to a certain extent you will always need some sort of rationing of care across the system. In the NHS it is commissioning bodies who decide what level of care is needed. In the United States, Americans experience this when they’re told certain procedures or tests are covered or not under their insurance plans. It’s the insurance companies that act as the government.
These characteristics of health care make it difficult to introduce supply-side choice. But just because a normal market wouldn’t work for healthcare provision doesn’t mean we should write off the use of market features entirely. You can have a single-payer system with a provisioning authority that determines the appropriate levels of care for any circumstance—all while letting a myriad of different organizations compete for the actual provision of care itself. This is a long way from the current model in the United States, which is not really a competitive market at all; it’s a system that is increasingly stitched up by a small number of massive companies.
Wouldn’t it be better if Americans could choose their doctors and other health providers directly instead of having their choice constrained by this cartel of insurance companies? A ‘single-payer, market-provider’ system would move us closer to that.
One clear way to make US health care more like a market would be to eliminate the extremely odd tradition we have of providing health coverage through employers. This makes no sense today. First, of course, not everyone is employed. Second, employer-sponsored health plans unnecessarily restrict personal freedom. If you don’t like what plans are on offer, you’re generally out of luck because it’s almost always far less expensive to buy health care from your employer. And having the ‘perfect’ health plan—if there is such a thing—isn’t just a question of how many checkups are covered per year. For some, it’s deeply—and morally—personal. In 2014 the Supreme Court decided that an employer could deny its employees access to contraception and abortion coverage by not sponsoring plans that included them, based on the business owner’s religious beliefs. Whether you agree with the decision or not, it would never have been an issue if health care wasn’t provided—and determined—by our employers. But say you did have a health plan sponsored by your current employer, one, moreover, that is perfect for you. Now, if you can’t find as good a plan or better from another employer, you’re much more reluctant to leave your job. This is a completely artificial constraint on labor mobility—and the ACA exacerbates this problem further, forcing more employers to offer health care to more workers.
This employer dimension to health care is a massive burden on business. And in any event, why should an employer determine what kind of heath care its workers should have? Moving away from employer-sponsored health care is just one component of the larger, structural reforms that are needed for a more human system—and even that would represent an enormous upheaval. But really, the financial and bureaucratic burden the current system places on individuals—and, shockingly, in the so-called land of free enterprise, on businesses—is alarming and unsustainable.
THE HEALTHCARE DEBATE in America is almost completely stuck. Everyone knows the system is incredibly, unsustainably expensive; everyone can see that it’s indescribably bureaucratic; everyone knows what they don’t like about it. A system based on the broad principle of ‘single-payer, market provider’ could move us in a more human direction, breaking the bureaucratic, extortionate stranglehold of Big Health; opening things up to the kind of fresh, innovative approaches we’ve seen in this chapter; and putting power over health care in everyone’s hands.
By combining the best of both worlds, a ‘single-payer market-provider’ system—with real consumer sovereignty built in—could help break the political logjam around health care in the country. For the left, it would guarantee health care as a right for all. But for opponents of big government, it would massively increase consumer choice over doctors and medical procedures, while driving a stake through the heart of the crony capitalism that so disfigures our health care system today. The right would also surely celebrate the enormous reduction in burdens on business that a ‘single-payer, market-provider’ system would entail.
Health care should not just be more human—it should be one of the most human things we do. This is a way to get there that everyone ought to be able to support.