What’s up with the US health system?? (What I’m doing in 2019, episode 1)

I haven’t been blogging nearly as much as I did five years ago, largely because my early blogging was all about trying to figure out “what the heck is up with the American healthcare system???” and it’s now been two years since I had any new realizations. Here’s a summary of that, then some quick hits on recent and upcoming events.

No, wait – this part turned out long, so I’ll continue tomorrow with the “quick hits.” For today, here’s the baseline I reached two years ago.

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1. What’s up with the American healthcare system??

Note my careful wording – what’s up with the system. The behavior of a complex system tells you how it’s actually structured. These three images sum it up (explained below).

What’s up with the US system – uniquely in all the world – is that for historical reasons, US healthcare developed as a set of independent businesses (which includes “not for profits”), each managed by a board of directors who are obliged to protect the org’s financial assets. In 2017 I summarized these findings in an invited post on Patient Power, American Healthcare: A Malignant Tumor That Can’t Stop Killing Its Host, using the three images above.

Please think about that “malignant” title. I chose it seriously.

Here’s what that post said you should know:

1. The system wants to grow, and is good at it. (That’s the graph at top left from Kaiser Family Foundation; here’s my 2013 post about it, including a famous 2006 article about US hospital prices: “Chaos, behind a veil of secrecy.”) (Nothing’s changed since 2006! ObamaCare gave more people access to care, but didn’t make a dent in the structure.)
2. Yet, that system’s not necessarily getting the job done. (The firetruck in a sinkhole.) This 2017 post has astounding global statistics from the Gates Foundation on how the US system is distinctly unreliable at getting care that we do have available in the US to people who need it – in some cases we’re worse at it than any other developed nation.
   1. Why do we fall short? See #1: none of the independent orgs in the US is accountable for getting the job done. (One good thing about a national health system is that if the system doesn’t get the job done, you know who to yell at … without that, America’s results speak for themselves.)
   2. This doesn’t mean national health systems are perfect; it just responds to why the US system falls short more often than others: in the US, nobody’s responsible for getting the job done.
3. Bottom line, price and value are out of whack – the graph with the deviant red line, from this related post.

Please let that sink in: 1) The system has evolved to encourage ever-increasing spending, and it’s good at it. (2) Although spending does increase endlessly, nothing in the system is designed to ensure care reaches the people in need. When care does fail to reach people, nothing kicks in to fix it.

[This doesn’t mean doctors and nurses are trying to kill you. They’re largely under the same systemic pressures: the system doesn’t exist for their benefit, either, so articles about burnout are rampant. People don’t get burned out if they don’t care!

[Medical mistakes do happen around the world, and there are a very few bad apples, but the distinctly American economic problems affect care providers as well as patients.]

This was all coming together for me at the end of 2016, then it was sealed when I read the 2017 book An American Sickness, which made everything clear. Nothing I’ve learned since then has been an additional revelation; the above is all you need to know, to understand the situation.

The one thing I disagree with in American Sickness is the part about “what you can do to take [the system] back.” I am truly not sure there’s anything we can do to change the system; every little attempt to fix a bill meets enormous resistance, never mind if we try to pry a billion out of hands that want it. I now believe we may have to wait for it to collapse or kill the whole US economy, and I’m not kidding.

Researching this post, I ran across this 2013 post from college classmate Paul Levy, former CEO of my hospital. If you want more signs of how things are, read it and its comments. It won’t take long.

Mind you, that was four years before I concluded in 2017 that I understand the system. Until then it was hard to believe that the system that saved my life (with my help) could have such a perverse structure.

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So, as far as I can tell, that’s what’s up with the US system; now I’m looking at the future through different eyes. See ya tomorrow!