According to a recent Gallup poll, 55 percent of Americans want Congress to put health care reform aside for a while. Only 39 percent want the Democrats to struggle on.
The majority is right. The problem isn’t that the bills in the House and Senate are too sweeping. The problem is that they are so timid and stale that they can’t address the crippling problems our health care system faces just a few years down the road. The cold, hard reality that Congress has so far ignored is this: if we don’t radically and totally restructure health care over the next thirty years, we go belly up. The stakes in health care reform aren’t about covering the uninsured — though that is a worthy goal. At stake is whether and how this country can continue to provide good quality health care to anybody who isn’t rich.
Look at the chart below.
In 2007 roughly 15 percent of America’s GDP went to pay for our health care. By 2035 this cost of health care will be 31 percent of our total GDP. By 2082 health care will cost half our GDP. In other words, by the time today’s twenty-somethings are in their forties, Americans will be paying one third of their income for health care. Maybe they will pay it in taxes for a single-payer, government funded system. Maybe they will pay it in insurance premiums for a private system. Maybe they will pay it in fees and co-payments. But one way or another, one of every three dollars they make will go to pay health care bills. By the time today’s preschoolers hit their retirement, everyone in the country will be forking over half their income to pay for health care.
Medicare is going to be a particularly nightmarish problem. Medicare now constitutes roughly 20% of federal government spending. Project that thirty years into the future as the proportion and number of older Americans grows and as the costs of treatment for each older American rise, and the spending on Medicare is slated to grow from 4.1 percent of GDP in 2007 to 9 percent in 2032 (page 1), and almost 20 percent of GDP in 2082 (page 2). The federal government’s tax revenue has only rarely gone as high as 20 percent of GDP; barring enormous tax increases by 2032 roughly half the government’s tax revenue would go to Medicare alone and by 2082 Medicare would consume virtually every penny the government takes in — without very large tax increases or massive sustained deficits.This is just the cost of Medicare–health care for those older than 65.
Back when I was a hopeful young sprout in Pundit School, they taught us to be careful about making predictions. But I’m willing to go out on a limb here: this won’t happen. Come 2032, Medicare will not be eating up 9 percent of GDP, and health care overall will not be costing 30 percent of the country’s total income. The American people will not be paying over one of every three dollars they make to buy health care.
Something will happen. Either we will ration health care much more aggressively than we do now, or we will find much more efficient ways to provide health care. I vote for the latter, and I think most Americans agree.
This means that change, not stability has to be the number one goal of serious health care reform. This isn’t about propping up the current system for a few more years, or even about getting more people under the tent. It’s not even about ‘bending the cost curve’; it’s about whether the system will break down before today’s college students hit middle age. We have to learn to do health care in fundamentally new ways in the next twenty years. The changes needed are much more radical and sweeping than anything envisioned in the current legislation — and it will take a very different mindset to make them happen. The current bill is a classic example of steady state, blue social model thinking: it is more interested in keeping the status quo going by pumping more money into it than it is in the basic restructuring needed to build a system that will work in the future.
The health care of the day after tomorrow isn’t going to look much like the system we have today. Futurist Ray Kurzweil and a lot of other people believe that thirty years from now computers more powerful than the most powerful supercomputers that exist in today’s world are going to cost less than $1000 and fit in a device smaller than one of today’s laptops. On present trends, at some point in this century a $1000 computer will have more processing ability than the combined brainpower of the entire human race; it will run software enormously more sophisticated than anything that now exists; it will store your complete medical records, your genetic scans and health information about you and your family’s allergies, drug reactions, medical conditions and so on.
Someday, that computer is going to be your MD. It will have real time access to every published study around the world — and thirty years from now the number of medical researchers and research centers around the world will be vastly greater than anything we have now. This ‘doc in a box’ will be able to diagnose and prescribe and it will be connected to even more powerful computers at the local medical center. The doc in the box will be able to lay out the treatment options and provide individual prescriptions and drug cocktails shown to work best for people with your medical history and genetic makeup. The world’s medical system will in any case be constantly updated as the outcomes of treating billions of people around the world are constantly fed into the system and evaluated; the treatments the doc box recommends will be tailored for your genetic makeup, your medical history, your height, your weight, and all your prescriptions and medications will be automatically adjusted to take any changes in the research or your health into account.
Right now you have to be rich and well connected to have access to the world’s smartest doctors; with the doc in the box the average person will have direct contact with the most comprehensive and best medical knowledge the world has. More, patients are going to have a lot more control over what happens with their health care. The doc box will tell you what your choices are and give you all the information you need to make a decision among the options: the choice will be up to you. You won’t go to the doctor’s office much; a lot of the work will be done at your home as blood tests and other basic procedures can be done directly with the machine.
No human doctor will be able to match the medical technology of the future. The function of the people in the system will be less to make decisions than to help patients make decisions based on the information from the computers: they will be more like flight attendants than pilots. Human beings will still be involved at both the low end and high end of medical work; depending on the way technology advances it would seem that both orderlies and neurosurgeons might still be human.
Nobody, not even a graduate of Pundit High, really knows what the new system will be like. Still, it is overwhelmingly likely that training for people in the health care system by and large will shift from packing all the knowledge needed for scientific diagnosis into their heads into providing them with skills to carry out special functions that machines cannot do (like, perhaps, surgery) or to provide the emotional support and bedside manner that people need. Machines will drive the health care train; people will help you feel better about the journey.
This system will no doubt still be very expensive, but it will provide much better health care to many more people than anything we have now at a cost that the old system can’t match. There is no other way to build the health care system of the future than to move in this direction, and the faster we get there the faster health care will become as good and as accessible as we need it to be.
If we are serious about health care, we need to figure out how to facilitate the transition to this kind of system. It’s not really something that can be planned; it will be unknown and unexpected technical and intellectual inventions that get us from here to there. But there are three keys to success: first, to align incentives and redirect resources as best we can so that progress toward this system is rewarded and facilitated. Second, we must do our best to ensure that the health care system works as well as possible during the transition for as many people as possible. Third, we must manage the inevitable trade-offs between the two objectives. On the one hand, we don’t want to get in such a mad rush toward the future that we make health care now even more difficult than it needs to be; on the other hand, we simply cannot let our efforts to keep today’s system on life support choke off the process of change towards what we will desperately need for tomorrow.
At the core, building the health care system of the future involves the increasing use of IT to reduce cost and enhance efficiencies in health care. For now, that might mean using more outsourcing — having tests read by (cheaper) doctors and technicians outside the US. But we must also be moving to encourage a major increase of health care R&D into the field of IT-enabled service delivery. There are, as I understand it, some features of the current bills that move in this direction, and the emphasis on better electronic patient records that many reformers support is an essential step if we are going to build a health care system that can work in the future. There is much more to be done; getting health care right is one of our most important national priorities and ensuring that the federal government’s full weight as a consumer of health care, as a regulator of the system and as the chief source of R&D funding is deployed to accelerate and facilitate the transition to a new system at a new level of both better service and lower price has got to be main goal.
This is going to require some hard work. For one thing, established interests are going to fight much of this agenda tooth and nail. Ultimately the new system will ‘deprofessionalize’ many people in the health care industry; doctors will feel a bit like John Henry who lost his life trying to compete with a steam drill. Think of a clinic in a Walmart, no appointment needed, in which as the IT components of the system improve, the human staff become progressively less and less well trained and less and less in charge. We will be gradually moving toward a system in which human beings are functioning more as aides — managing the emotional and physical business of caring for patients while the decision making shifts more and more to the machines and the system. This won’t be universally popular with either medical professionals or patients. Over the long run, however, it is the only possible way to provide the quality and the quantity of health care that our society needs.
But if restructuring our health system to enable it to cope with its future requirements is going to be a difficult and expensive challenge, it also represents an immense opportunity. Getting this right won’t just help solve two of our most pressing problems (controlling federal spending long term and developing a better and more inclusive health system); it will position the United States for economic and technological leadership in the next generation.
Everybody needs the new health care system, not just us. Rich ‘developed’ countries with declining and aging populations need a system that can provide better care to more people without breaking the bank; rapidly growing countries like China and India will desperately need affordable ways of increasing access to health care for populations that will be hungry for a better standard of living; poor countries need technology and delivery models that can help them leap-frog over several stages of development — just as cell phones made service available in countries without the money or the means to install national land line networks so an IT-based health care system can deliver unimaginably improved levels of care to countries whose overall infrastructure remains spotty and weak.
The United States is better positioned than any other country to develop the technological and managerial infrastructure necessary for the health care of the future. We have the resources and the internal market to fund the research and make it profitable. Precisely because we don’t have a national, single-payer system, we have the kind of fragmented system that is more open to the kind of experimental innovation that the development of a new system requires. We have the base of experienced and skilled researchers and thinkers that a multi-decade, many-sided effort like this requires. And because our system is closer to the breaking point financially than that of the other rich countries, we have more incentive to make the necessary changes.
If we do this, and develop technologies and business methods (and companies) that can provide significantly higher quality, more patient-empowering and individualized health care on a more affordable basis than the current system, the American economy will enjoy some decisive advantages well into the future. Our health care companies and technologies will become leading exporters of both goods and services — and a more efficient and effective health care system will provide a competitive boost to every firm and factory in the United States by lowering the drag of health care costs.
These advantages could last for some time. First, other countries are going to resist change more than Americans do. The national health care systems of Europe are deeply embedded into the ideology and culture of their societies; it will likely be very difficult for them to embrace new models (which will surely not be without warts and shortcomings) until the old ones are well past their sell-by dates. Second, having developed an innovative, forward looking health care technology sector, the United States will likely remain a font of innovation and creativity in this field. Just as Hollywood and Silicone Valley maintained global positions of leadership long after other firms in other countries got into their line of work, so the American high tech health sector can be a dominant industrial player for decades to come.
Innovation is America’s greatest strength. It’s what we most need to build the kind of health care system we and the world will desperately need not far down the road. The goal of health care reform — and we need reform, urgently — must be to smooth the path for the kind of innovation our society can produce. The solution to our health care problem is not to edge closer to an old-fashioned, European style health care system or to stumble along as best we can with the awkward and expensive public-private hybrid we now have; it is to break the mold, do something new, harness the power of technology to solve age-old human problems — to be, as I wrote in an earlier post on this blog, radically American.
The national conversation about health care has a long way to run; trying to rush something through that, whatever its merits, doesn’t get to the heart of the matter is not the best way for Congress to go.