A Modest Proposal

For Healthcare Reform and such

We all know there's an iron triangle of healthcare: cost, accessibility, and quality. I think we occupy the overall correct position on that triangle - cost and accessibility - for a first world nation. With that said, there are a slew of realistic changes we can and must make.

This is not just about someone's grandmother not having a fancy new treatment covered by medicare. This is about systematic over-investment in healthcare, which is now the single largest category of spending for our federal government and a large yet growing chunk of private dollars. This isn't just a problem of whether people can afford things, it's a millstone around the neck of investment in useful sectors, things that will grow our nation's power and economy and ensure a better quality of life decades down the road.

I'll likely update this at some points as I continue to think of possible problems and solutions.

Regulatory Capture

Wherein certain private bodies have monopolistic control over a profession (nurse, doctor, anesthesiologist, dentist). This also applies when you take your boards; yet another private organization. These organizations generally require onerous, costly processes to educate, train, and certify new people. They are comprised of and run by professionals in a field where professionals tend to believe deeply in the purity of their work and don't think much about costs or what's a reasonable minimum, so much as what's the possible maximum amount to cram into a new person. Outstanding idea if you are having a sensitive and non-routine surgery; terrible one if you need someone to place a stent and prescribe you BP meds after.

Solutions

Keep the AMA. Let them be a certification body. Do not let them be the only certification body. If someone wants to create some organization that attests to basic competence, fine. Let them. Consumers with more money and knowledge will gravitate towards the certifications of higher quality.

Insistence on "Fairness"

People have come to a belief that markets are fine and rich people will generally get a lot of something if they want it while poor people will get little. Healthcare has become an exception. It's either a "human right" or it's simply "inhumane" not to do everything under the sun to save a life. There is a surprisingly large group that believes that it's simply wrong to not pay for some million-dollar biologic for anyone. As for who will pay, that varies. Some say "the rich". Others, "the government". A sizeable number seem not to have considered that aspect at all; while they don't know, what they do know is it's basically wrong not to do everything one can to save the life of everyone. Full stop.

Solutions

I'm not exactly sure how to turn shouting "grow up" at such people into a policy proposal. Perhaps we should have the IC run a propaganda campaign. We already spend 18% of our GDP on healthcare and that number is rising. We must spend less, not more, on healthcare.

People are Retarded

The current system is not tard-friendly. Getting something covered, even a costly or niche thing, is generally possible. However, it requires a level of basic competence and executive function that I've come to believe a chunk of America lacks. Blame the education system, blame genetics, I don't care. The system assumes participants have an IQ over ninety, can keep documents organized in a binder, can track things in excel, can do basic math, and have a decent english vocabulary with which to comprehend all this. That seems like an unrealistic assumption and leads to people complaining pieces of the system are "evil", when they should not attribute to malice that which can be explained by stupidity (be it their own or that of a corporate functionary.) N.B. there are some bad insurers who are aggressive about denial - UNH has been known as one of the worst for years - but most also offer cheap insurance to people who cannot afford better. This is done by compromising either quality or availability; you will not get the same medical care for less money. Like any system, there will also be cases where people fall through the cracks and things that genuinely should be covered, are not.

Solutions

We probably need a stronger system of "care managers" or medical advocates who have the executive function to handle paperwork, are able to read and comprehend industry information to solve problems, and have a basic level of medical knowledge. This seems like the only way to make the system adequately tard- friendly. Otherwise, they will continue bitching that, "My insurance won't cover this!" not realizing that yes, it will, you just didn't think to ask for the appropriate documentation or couldn't keep and organize it properly.

"Insurance" is HaaS

Healthcare as a Service. People hear "insurance" and they expect a reasonable premium. But what we today purchase is not. This "insurance" is meant to cover your $75 monthly refill on your blood pressure meds. It covers your $150 weekly visit to a shrink. It also covers insurance things, like your $75k open-heart surgery. This is not insurance, it's a subscription payment that people think represents all-you-can-eat healthcare. On good plans, this is true. That will always cost a lot of money.

Solutions

We should allow retroactive tax-free status, including a potential tax refund, on healthcare expenses. Don't force Americans, a people who are famously bad with money, to calculate how much they should keep in an HSA to ensure they can cover costs while also not locking up capital that could otherwise grow in the market.

Trial limited single-price legislation, perhaps in one state. I'm guessing this will work but it's not a commonly-proposed policy so I don't have a ton of thinktankbros to faux-source this idea. Currently out-of-pocket payers are screwed, insurance companies do okay, and both of the same subsidize the hell out of medicare/caid. The latter demands outrageously low prices which means the margin is made up on the other two. Reducing or eliminating this price discrimination should allow people to more easily pay for things out-of-pocket.

Malpractice Insurance

Incredibly expensive these days because one can sue for nigh on anything and get at least a healthy settlement, often a huge one. Jury awards have gotten ridiculosuly large. Malpractice cases are generally negligence bad enough to be charged criminally/legitimate malice, an honest mistake, or ambulance chasing. These need to be treated separately and insured differently, if at all.

Solutions

Create a separate federal criminal statutes for criminal negligence and malice in medicine. Establish an office within the DOJ that has very little prosecutorial discretion and is required to prosecute essentially everything it can. Ban malpractice insurance from covering anything where the doctor is found guilty. He goes to prison and the victim or family can go after him, potentially his practice, for a settlement. More on controlling that later, but that contains the damage and doesn't force other well-run shops to subsidize the garbage ones.

In case of legitimate mistake, this should be the design point for malpractice insurance. Payouts are often too high but that is fixable; see below. It is currently not mandatory for malpractice policies to include a deductible; make it so with, say, a $10k minimum, indexed to CPI inflation.

We need major tort reform for medical malpractice. Ambulance chasers and irrational jury awards are costing Americans staggering amounts of money. Although a huge payout is not an everyday occurrence, the possibility of that event has an outsized impact on the premiums of malpractice insurance and the risk-aversion of medicine. Humans are risk averse; massive, bureaucratic institutions are moreso. Exact structure is a matter for a full policy paper, but I see little reason why the total payout for any person should be greater than, say, $2-4mm. This also needs to be targeted to discourage ambulence- chasing, perhaps with the English Rule implemented here specifically.

Aggressive Practice Consolidation

This is driven in no small part by the increasing paperwork burden of the past decade and change. Obamacare played a huge role in this. The system requires a high level of executive function and many man-hours not just from patients, but from everyone involved. This makes running a small or medium practice very difficult, leading to consolidation. It's axiomatic that consolidation in an industry increases prices. Since insurance has a lot of bargaining power and the feds have even more, the out-of- pocket payer ends up getting even more badly screwed for basic care.

Solutions

We need an aggressive reform of paperwork burden. Abolish Obamacare, no replacement. End per-state insurance coverage. Policies to be offered and purchased nationally. Supremacy clause allows the feds to trash competing state laws as needed. In case something is unavailable in one's state - minor sex changes, abortions - assign no liability to insurers if they pay and all to the doctor and individual.

Liberalize HIPAA. This is a huge contributor and frankly unnecessary. It makes keeping things electronically difficult. Medical information is semi-unique in that it's deeply personal yet not quantitatively that sensitive; i.e. we really, really don't want it leaked but the consequences of that happening are in practice very low. The risk/convenience trade-off we make must reflect that. They layman has no clue what's going on anyway; we can brand damn near anything to make him feel safe. Find a way to shut up "activists" who throw a conniption fit about "data privacy". On the other hand, we probably need stricter penalties for misusing health data. This is something of an aside but a therapist visit for depression can cause problems if you want life insurance, key man insurance, a gun permit in some places, etc. It creates a perverse incentive against seeking some kinds of very important care.

Make it known to developers of healthcare software - Epic and the like - that they will standardize on one EMR/EHR format. Currently, options include HL7 V2 and V3, CDA, and FHIR. We can probably just keep FHIR and kill the rest. Legislation/strings to pull to create this TBD, but Plaid has the right of it. EMR/EHR should be stored in one place and accessed through a standard API where you can see what they want and why. Get this done and pressure the hell out of everyone to do it. Data should probably live with your insurer and be updated directly there; takes further paperwork out.

Perhaps ban fax machines by a cut-off date. There is no excuse for, in the year of our Lord 2024, still using this. Apart from regulatory/legacy BS which this should fix.

I usually am not much of an antitrust advocate but we do need some fairly liberal use of Sherman, Clayton, and FTC to undo what the policies of the past years have done.

The Myth of Drug Prices

If you asked about healthcare costs on Family Feud, "Big Pharma" would rank first on the board. This is a lie. Pharmaceuticals constitute less than one- fifth of American healthcare spending. They are still too expensive and there should be regulatory and industry reforms to fix it. That does not change the fact that our healthcare system would still be four-fifths messed up.

Everyone please stop lying. I am not big pharma's strongest soldier but I am tired of the convenient scapegoat drawing attention away from real problems.

Baumol's Cost Disease and Man-Hours

Healthcare is this problem reified. Hospital services in 2018 cost more than three times what they did at the turn of the millennium despite CPI growing by around fifty percent. In brief, this is due to the fact that some sectors of the economy experienced lots of productivity growth while others experienced almost none. Medical care services weren't quite as bad but still outstripped CPI by more than double as they doubled in cost. This is due to continued reliance on labor and too little growth in technology in the sector.

Solutions

So we must automate, automate, automate. I cannot stress this enough. We needn't take the human out of the loop, not just yet, but we can have one man- hour do the work of ten by adding a few pounds of metal, gigabytes of software, and a barrel of oil. This can start at the software level but must rapidly expand to robotics. The lion's share of our NIH dollars should go straight to this. Tax-advantage private investment in healthtech.

Garbage Health

There's no getting past the fact that Americans are a horribly unhealthy people. Most adults over thirty are fat. Most are sedentary junk food addicts. I have little interest in shelling out, as a tax payer, scads of money to make up for their poor lifestyle choices.

Solutions

Force these people to assume the financial burden of their own decisions. Drunk or junkie? Pay for your own rehab and replacement organs. Fat? Pay for your own triple bypass. Type-two diabetic? Pay for your foot amputation and metformin. Ban private insurance from covering such things on traditional policies and require that if they wish to offer coverage for them, it must be under a separate rider.

Make GLP-1 agonists very, very cheap. These are the closest thing we have to a free lunch in terms of treating an obese, dopamine-sick population. Maintain the FDA shortage declaration indefinitely and allow importing tirzepatide from el cheapo Indian manufacturers. Make it $25/month not $1k. The incentives for the feds to do this are huge.

Require all physically able recipients of federal health insurance to get a certain amount of exercise each month. Give them all a fitbit and if they don't do it, policy terminated. Private insurers may wish to do this too.

Marijuana usage is a huge risk here, making people generally more lazy and prone to eating junk food. I'm of the opinion it's horrible for mental health and poses greater risks than most people appreciate, but that's a story for another day.

Zoomers are already consuming less alcohol; let that trend continue.

Permanently end daylight savings time. More dark time in the evenings will encourage people to go to bed earlier. The Floridians and their tourism sector can cope harder.

RFK can do his MAHA thing. He doesn't yet have a clear policy framework but we'll see if additional work here is needed in a few years. The answer will likely be yes.

Consider curtailing food exports. This will drop the prices of, say, staple grains farmed at industrial scale. More importantly, it will allow space- intensive cultivation of healthier produce (using regenerative farming techniques, fewer or no pesticides/herbicides/fungicides, etc.) at a reasonable price and make quality food more affordable.

Consider packaging restrictions on highly-processed food. Same thing many countries have done with cigarettes and appears to work. Companies would sell a lot fewer fantas and lays if they were packaged in tastless, generic muddy brown bags.

The two lattermost suggestions are distastefully heavy-handed and statist. They aren't actual things I want implemented, more ideas that I'd like to find more palatable ways to do. There are a few other proposals on here that follow that pattern; they align incentives correctly or make a needed change but may do so in a way or to an extent I dislike. In case someone spies severe retardation, someone hacked me and edited this and I disclaim the bad parts.

John the Cappadocian

About the author

What did you do to get into heaven today, anon?