Health care is the surliest corner of American politics. For decades, a bitterly partisan debate — dueling monologues, really — has hung like smog over public discourse. Facts, misconceptions, half-truths and non sequiturs have congealed into conflicting sets of pre-packaged talking points.
Nearly five years after President Barack Obama signed the Affordable Care Act (ACA) into law, the rancor and accusations still swirl, turbulent but immovable, like the Great Red Spot of Jupiter. Maddeningly, the perpetual storm barely touches the great issues that actually determine our health and what we spend to acquire that health.
This is a pity, but the upside is that it suggests an enormous opportunity to shift the debate, dissipate reflexive partisanship, and in doing so, save lives, ease suffering and cut costs.
In short, since World War II, the health care debate has focused almost exclusively on coverage — the number of people with insurance cards. Quality of care and improvements in health have been afterthoughts.
The two sides bicker over how to distribute today’s health care rather than empowering others to create tomorrow’s health care. In focusing exclusively on coverage, both sides do much to suppress technological and managerial innovation — delaying the arrival of better, less expensive care.
Find the Pattern, Change the Conversation
All of this can change in a flash, if only we decide that it should. This requires us to examine health care from a vantage point well outside the pro- and anti-ACA talking points.
Why has health care been so much less innovative than information technology over the past 25 years? My study draws answers from diverse quarters, citing, among others, the high-tech weaponry designed by actress Hedy Lamarr, the 1910 destruction of African-American medical education, and a carpenter and a puppeteer who in 2013 collaborated to slash the costs of functional prosthetic hands by 99.9 percent.
Beneath those questions lies a pattern that reveals a philosophical demarcation I label“Fortress versus Frontier” (defined shortly). For decades, the political left and right ensured that information technology was free to innovate on the Frontier while health care was restrained within the confines of the Fortress.
In those industries, two roads diverged, and that has made all the difference. But the roads are converging once again. Innovative technologies are soon likely to render medicine as unrecognizable to our eyes as today’s Internet and smartphones would be to our own eyes as recently as, say, 25 years ago.
If we welcome and prepare for the new medical technologies, America can retain (and in certain sectors reclaim) its preeminence in health care innovation. If we resist, America’s position in medical innovation may come to resemble the 1940s steel industry – a powerful force barricading itself against competitors, followed by decline and rust. First mover’s advantage lost.
Ebola is part of the same story. While many seek individuals to blame for the chaotic response, I would argue that the accusatory headlines are what happens when 20th century institutions, designed for a world of scarce data, confront a tsunami of 21st century data flows. I personally witnessed the new century’s arrival a bit early — in 1993, when a truck contaminated with rodent droppings rolled in from the Navajo Reservation to the Federal Reserve Bank of Richmond. More on that later.
Fortress and Frontier
Since World War II, the health care debate has been a struggle of left versus right. The left has tended to favor federal solutions, plus increased public provision of care and coverage. The right has favored state-level solutions, plus private provision of care and coverage. The left employs more pro-regulation rhetoric, while the right professes to favor freer markets. (The latter distinction is largely illusory. Both sides favor powerful regulation and merely disagree on who regulates what and through which means.) A more meaningful distinction is between worldviews we can call the Fortress and the Frontier.
The Fortress has two goals. The first is to imagine every terrible thing that might happen to someone receiving health care and then to focus public policy on preventing any of those things from happening. The second is to protect health care insiders — doctors, hospitals, insurers, drug and device manufacturers — from outside competitors who might threaten their turf.
The Frontier focuses on innovation. It understands that we cannot obtain great quality improvements and massively reduced costs without allowing consumers and producers to take calculated risks. The Frontier also understands that innovation requires constant, uninvited input from unknown dreamers. The IT revolution did not emerge from credentialed insiders anointed by public officials or titans of industry. It came from obscure figures in garages who were allowed to challenge and defeat multinationals in skyscrapers.
From his garage, Steve Jobs challenged IBM. Jeff Bezos sold books from his garage and his business — Amazon.com — changed the way the world purchases just about everything. Smartphones did not originate with telephone industry giants like Western Electric; the BlackBerry came from a couple of engineering students with some venture capital.
Health Care versus Information Technology
In the same years that IT exploded, changing how billions of people live their daily lives, health care was painfully slow to innovate.
Step into a time machine and travel back to 1989. Gather a group of people and tell them of the advances that medical science has made in 25 years — statins, new vaccines, face transplants, and so forth. The audience will be pleased and gratified by the news, but there is little that will shock them.
Date: January 9, 2015