Healthcare: Imagine the Possibilities

I’m Bob Graboyes, senior research fellow and healthcare scholar at the Mercatus Center at George Mason University. My modest goal is to completely change the way America thinks about healthcare. I have no delusions about the magnitude of the task, but we need a seismic shift in thinking. America’s healthcare debate has spun its wheels since World War II, focusing on insurance rather than on care.

Imagine if the information technology industry had spent the last half-century squabbling over how to pay for mainframe computers and landline telephones instead of creating laptops, smartphones, email, Skype, Google, Uber, Facebook, Kindle, iTunes, and myriad other applications that define our lives in 2018. That, unfortunately, is where healthcare has been mired.

It’s World War I-style trench warfare. One side pushes the other back a few feet and afterward, the gains are reversed. In 2010, Democrats passed the Affordable Care Act (ACA) by a bare margin. For seven years, the Obama Administration improvised regulatory fixes for unstable portions of the law. Republicans promised to repeal and replace the ACA, but, after regaining the White House and both houses of Congress, couldn’t do so. The Trump Administration improvised regulations to reverse the Obama-era fixes. At end-2017, they just barely eliminated the ACA’s individual mandate.

This eight-year war has changed very little about healthcare. We’ve seen minimal change in the number of doctors, nurses, hospital beds, drugs, devices, and so forth, or in how we use those resources. While more Americans have coverage, health metrics haven’t changed appreciably. Expenditures rise as before.

Fortress to Frontier

My 2014 monograph, Fortress and Frontier in American Health Care, argued that the important philosophical divide is not between liberals and conservatives, but between worldviews I call the Fortress and the Frontier. For the Fortress, public policy has two main purposes: First is imagining every terrible thing that could happen in the healthcare and to throw resources at pre-emptively averting all untoward events. Second is to protect established insiders from outside competition.

The Fortress might seek limits on, say, telemedicine because some doctors fear the technology presents as-yet-undiscovered hazards to patients and because out-of-state doctors might take business away from local providers.

The Frontier would likely encourage telemedicine because patients and providers should be allowed to take reasonable risks—especially if the purported danger is hypothetical—and because additional competition in medical markets is good.

Two factors make it difficult to extricate the healthcare debate from its rut. First, proposed policies rest on a dozen or so tropes, largely believed by all sides, but which are a really menu of falsehoods, half-truths, and non sequiturs. Second, neither healthcare professionals nor the general public have adequately realized the profound opportunities for innovation in the digital age.

My challenge is to debunk the tropes and tout the innovations (while illuminating the obstacles we’ve thrown in the way of innovation).

Debunking the Tropes

19^th century comic writer Artemus Ward said, “It ain't so much the things we don't know that get us into trouble, it's the things we do know that just ain't so.”

Imagine assembling two focus groups, progressive Democrats and conservative Republicans, and reading a dozen statements to both:

• American healthcare spending is excessive and unsustainable.
• American healthcare is inferior to that of other developed countries.
• The health of a nation’s population depends primarily on the quality of its healthcare.
• Being uninsured has a large negative impact on health. 
• The uninsured foist enormous costs on the rest of us.
• Healthcare bills are the leading cause of bankruptcy in America.
• Malpractice litigation and defensive medicine) are among the biggest cost-drivers in American healthcare.
• Public health insurance programs like Medicare have lower administrative costs than for-profit insurers.
• Profits, marketing costs, and executive compensation are outrageously high in healthcare and contribute mightily to skyrocketing costs.
• Competition doesn’t work in health care because the issues are too complex for untrained laypeople.
• Healthcare differs from other industries in that a large percentage of decisions involve life-and-death outcomes.
• We know from opinion polls that people in other developed countries are happier with their healthcare than we are with ours.

Very likely, both groups would agree overwhelmingly with all twelve statements and then disagree vehemently over the solutions. However, I hold that every one of these statements is false, or at least highly misleading, so proposed solutions (largely insurance-related) are mostly chasing phantoms.

So the first Herculean task is to give professionals and laypeople good reason to question these widely accepted tropes. But it’s also essential to give audiences something to aspire to—a glimpse of future wonders—and to expose the obstacles standing in their way.  

Touting the Innovations

For twenty years, I’ve taught medical professionals—doctors, nurses, therapists, insurers, administrators—in graduate degree programs. I’ve also lectured to and spoken with countless healthcare professionals in other settings.

Much of my time with these professionals involves sharing details of recent advances in the delivery of care. It’s often stunning how little the news of these developments has penetrated the medical world. Here are some examples I regularly share:

• My iPhone carries a small device that enables the phone to conduct a clinical-quality electrocardiogram in 30 seconds and provide me with instantaneous analysis of my heart rhythms. Recently, the device helped me avoid a needless emergency room visit costing someone thousands of dollars. The device, an AliveCor Kardia, costs $99.
• Four years back, the least expensive functional prosthetic hands cost around $5,000. Then, a puppet-maker and an injured carpenter invented a 3D-printed prosthetic costing around $50. Since then, the e-NABLE network of amateur builders have constructed hands for thousands of people worldwide, distributing them for free. And these amateur builders have added countless design improvements.
• TeVido Biodevices also uses 3D printers, but their aim is to produce human organs from recipients’ own cells.
• Cerner Corporation developed software—St. John Sepsis Agent—that detects potentially lethal hospital-borne infections hours before any human would notice. Surprisingly, the same software can also flag the onset of post-traumatic stress disorder and suicidal tendencies.
• In 2015, a leukemia patient in Japan wasn’t responding to treatment, and various doctors investigated for months. Then, doctors arranged for IBM’s Watson computer to investigate the case. Watson absorbed the patient’s medical records and genetic data, read 20 million journal articles, and suggested—correctly—that the doctors had misidentified the specific form of leukemia. The patient changed medications, improved, and went home. Watson did its work in ten minutes.
• In the U.S., a coronary artery bypass costs around $100,000. In India, the privately owned, for-profit Narayana Health System has reduced the cost to around $1,400—with patient outcomes on par with the finest American hospitals. One factor is that state-of-the-art management techniques have enabled Narayana to achieve astonishingly low post-operative infection rates. Narayana also opened Health City Cayman Islands, 90 minutes from Miami, where a bypass costs roughly $30,000.
• Rwanda and Tanzania partnered with Silicon Valley’s Zipline to become the first countries with nationwide systems of aerial drones delivering medicines and blood.
• NightScout, a volunteer consortium of parents and programmers, have configured smartphones to continually monitor their diabetic children’s glucose levels and to signal the parents when the children are in danger.
• Opternative’s web-based service lets people perform professional-quality refraction exams for eyeglasses at home, using only a laptop and smartphone.
• Lemonaid is an online prescription service offering medications for birth control, erectile dysfunction, hair loss, acne, and some other conditions. In place of the costly, time-consuming traditional prescription management, a Lemoniad physician can safely handle around 1,000 prescriptions per hour with no office visit needed by patients.
• Heal offers an Uber-like service where patients, can inexpensively summon a doctor to visit their home or office.
• Doctor on Demand allows patients to “visit” doctors from anywhere via laptop, tablet, or smartphone. Physicians are available 24/7, and the cost is a little over $40.
• Surgery Center of Oklahoma offers hundreds of outpatient surgical procedures. Most significantly, the all-inclusive cost of each service is listed to the penny on the center’s website.
• In the northeast U.S., Iora Health offers patients unlimited primary care for around $60 per month. Patients may visit any Iora clinic and have round-the-clock access to doctors via email, telephone, and video.

As promising as all these innovations are, however, almost all of them are limited by legal and regulatory restrictions. That is where we need to focus our attention on the policy front.

The fact that many healthcare professionals are utterly unfamiliar with most of these innovations is actually great news. It makes it easier to challenge the tropes and entice them with the innovations just waiting to be grasped—possibilities far more interesting than endless, futile kerfuffles over the ACA, repeal-and-replace, and single-payer. And the wonders unfolding make it possible to have civilized, productive conversations with people of differing political persuasions—a rare pleasure these days.