The challenge of large-scale systems

Aside from all of the personal reasons that people do or don’t like President Barack Obama, his choice (or willingness, or apparent need) to intervene in systems at the highest levels has caused great consternation.  Conservatives seem to see this as inappropriate or unnecessary government intervention.  Liberals have been more supportive, but mostly about the expansion of services to the under-served, which could have been done in other ways without such large-scale change.  So why take on such large and complex issues?  Why not simply work incrementally with existing programs, as suggested by some in Washington?

Fundamentally, we want growth and not decline.  We want things to keep getting better.  We want our incomes and savings to increase.  We want medical technologies and healthcare in general to get better.  Doctors want their practices and incomes to grow.  Hospitals want greater use of patient beds and facilities.  Insurance companies want increased premiums and profits.  Pharmaceutical companies and medical technology firms want more business and better returns on their investments.  We want the care that we need when we need it, and we want that care to be covered so that it costs us individually as little as possible at the time.

The critics of reform seem to operating from one of two assumptions.  First, that doing nothing will maintain things as they are.  If we do nothing, nothing will change.  Or second, that large-scale systems are inherently self-regulating.  The law of the invisible hand and free market competition will drive more innovation at greater efficiencies and bring down costs over time.

While this works in theory, health care is not retail.  If you can’t afford a new computer or the cell phone that you want, you might have to wait for prices to come down.  If you have a heart attack, you probably won’t wait for a sale at your local hospital – and the emergency room at the hospital can’t just turn down your lack of credit.  Uninsured people still get care and still create costs for the system – they just get punished in time and levels of service.  Rationing of care has been happening for decades, we just call it other things.

Functionally, we already have a national health care system – we just don’t manage it as one.  We choose to focus instead on the individual parts of the system, because those represent the constituents and lobbies.  Managing the system at that level, though, is like asking the organs of your body to vote on who you should be as a person.  It’s not just an addition problem.

For those who still adamantly believe that government should stay out of health care altogether, the simplest answer is to do away with Medicare and Medicaid.  After all, they represent almost the same amount in the proposed 2011 US Federal budget as defense and social security (over $1.4 trillion), and projections are that those costs will continue to rise well above inflation for the foreseeable future.  (Then see how that plays out in the next round of elections.)

Taking on something as large as the health care system of the US is audacious.  Either we address the system as whole, though, and come to terms with managing the way that it works – altogether, in reality – or we just wait and hope that it takes care of itself.  It’s kind of like that noise in your car, though.  It might just go away, or it might leave you stranded on the side of the highway someday, if things don’t just blow up completely.

It would actually be good if health care were the only big problem to address.  As noted in a Wall Street Journal article today, though, it’s probably not even close.  According to David Weidner:   “Financial reform has clear similarities to health care reform: a bold plan, an entrenched political opposition and a powerful lobby bent on tamping down or eliminating reform altogether. And it’s an equal, if not bigger, part of the economy. Health care represents one sixth of the nation’s gross domestic product, financial services represents nearly one fifth according to a 2004 study by Carnegie Mellon” (

It seems likely that we are going to have to learn to manage at scales that we haven’t been used to, and expect that to be the norm.

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