Earlier this week, Seanly raised an interesting point in comments in a post about multi-million dollar drug costs:
JFC, I avoid saying this Every. Single. Time that we get one of theses posts, but at some point we have to admit that the entire industry is just broken as hell. Wouldn’t it just be 10000 times easier to have a single-payer system? It’s such a big market and there are some many sick people that the greedy bastards who want to get rich will still find a way.
I appreciate the hard work & dedication David puts into these posts, but the unspoken answer always seems to be that we need to shitcan the current system & try again.
I get this, our system, on a good day is an ungodly complex mess that is more kludge than design with massive equity problems inherent in it. On a bad day,it is simply a mess designed by Kafka on a benzo bender. And yet, it is what we have and there is some value in that.
The rest is purely my opinion.
I’m an inherently cautious person when thinking about big changes. A colleague of mine recently noted over coffee that I spend almost all of my time thinking about either what is or what nearly could be instead of what “should” be. They are right. My thought process and experience is really good at looking at a rule set within a given paradigm, find the edge cases and then finding ways to break the system within the paradigm. I am not a good dreamer of big dreams. I never have been. The first woman who I was in a significant and meaningful relationship with made an extraordinary comment about me that is still true twenty years later after that night drinking a pitcher of cheap beer at the Forbes Avenue Primantis — “You’re an evolutionary, not a revolutionary….” as I had mentioned that people like me, my friends and my family would be crushed afterthoughts in the pursuit of glory. And she is still right about that aspect of me.
Shitcanning the system is a major paradigm leap. That, to me, is inherently scary, especially as I know how the current system works and the mechanical infrastructure that undergirds current functionality. It may be a failure of my imaginiation, it may be a nod to my inherent caution, or it may be my fascination with complexity, but that is where I come from when I read those types of statements. We have a system that has some functionality today and it is tweakable in very significant ways and there is also other sets of systems that could be designed to be less of an ungodly mess but are not currently deployed.
Deployment would be several years to a decade long project of transitions with known and unknown challenges. One of the big ones is that the push to single payer usually has two objectives: universality of coverage and reducing total national health expenditures. One of the big known challenges is the guaranteed push back by invested stakeholders who are far more trusted and respected by the public than health economists and politicians. We are seeing this in the surprise billing sausage making process right now:
The folks against surprise billing reforms are the PE firms that own EmCare and TeamHealth. Their bonds are taking a bath as legislators ponder regs.
Their lobbying + ads = WHY WE NEED patient protections. Even ACEP reps PE- their former Pres was Exec VP at EmCare pic.twitter.com/5uyGKlVAwK
— Zack Cooper (@zackcooperYale) August 30, 2019
Surprise billing fixes have broad general, public support, can act as a fairly significant pay-for and actually makes healthcare markets work better as the current system makes a hash of common contract law.
No need for rate setting. I’m surprised that @AEI doesn’t see this as a simple market failure that common law principles can solve. Let’s not overthink this. There’s a reason certain law doctrines last for centuries, and there’s a (bad) reason most health policies increase costs.
— Barak Richman (@BarakRichman) February 14, 2019
And yet, the emergency room staffing firms are likely to be successful in fighting off most of the attempts to pull money out of their owners’ pockets. Universality potentially may only be bought by stuffing the clinical chokepoint holders’ mouths with gold.
This is an obvious example of the difficulty of change and knocking the entire structure down in order to rebuild anew. To rebuild anew, requires almost everyone involved to be on the same page as to what things should look like and that, to me, is an extraordinarily difficult challenge while reworking within the current paradigm has a much smaller set of needed agreement partners and far larger sets of groups that can be rationally ignorant or indifferent at any given time as none of their core interests would be touched.
I get nervous when thinking about complete rebuilds. That is a core aspect of my personality and outlook.