Politics. A good tragedy is hard to resist. So found the late septuagenarians that now rule the roost in Congress. About the time today’s political leaders were recognizing the link between their personal health and political influence, health care was released from the dry data at public health agencies into the wild tropics of narrative. And there it has flourished with the prospect, always right around the corner that the U.S. would one day join minuscule Nordic nations in providing universal health insurance coverage.
Individual anecdotes presented in hearing rooms on Capitol Hill and on the pages of national newspapers have fueled near endless justification for more money and more regulation that, yes, have delivered some powerful therapies. Cancer has gone from a death sentence to a chronic disease. It has also made the rare and tragic appear as commonplace. It turned eliminating tail risk into the raison d’etre of federal health policy instead of elevating good health to a national priority.
From that has sprung a spigot of money which delivered inflation, a drag on cash wages and, most important of all, no meaningful innovation to advance productivity. Although vast and more technologically advanced than any other health care system in the world, which has served us well these last two years, the U.S. Medical Economy is largely dependent on labor to function. It has become a modern serfdom, especially for low wage/low skill workers, shackled to a central authority wary of change.
All that has been ignored until now. If it was not clear last summer when the monthly rate of change in health care employment was cut in half, it is probably well understood after Friday’s jobs report that health care is not likely to employ the 17M people it was on track to attract in the pre-pandemic era.
Health care workers, particularly in the low wage/low skill areas of home health, hospice, inpatient substance abuse facilities, nursing facilities and dialysis clinics, are finding high paying, safer working conditions and opportunities for advancement at Walmart and scores of other places that have the power to raise their prices.
If the Supreme Court delivers a split decision on vaccine mandates, as oral arguments suggested last week, nullifying one for employers with over 100 employees and upholding the other for health care, the decision to seek opportunity in another field may become even more attractive.
The fragile state in which health care finds itself is a self-inflicted wound. Another example of how the power of narrative overwhelmed common sense and judicious use of resources.
Policy. The health care policy apparatus now hobbles along repeating the heuristics from a happier day when the realities of economics – specifically the long-term imperative to balance scarce resources against demand – were suspended.
Through the largess of the federal treasury, policymakers have never had to consider how the system would function if a couple of million workers retired or found something else to do. Mandates of all types have moved workers from bedside to keyboard. In a story often related by Marty Makary at Johns Hopkins, a physician can spend 7 min delivering a baby and 45 minutes documenting it.
Political leadership has been no more creative. The prospect of “middle class jobs” in health care has proven far more tantalizing than the same in manufacturing, as one example. Ironically, while an obsession with consumer prices drove a form of economic nihilism that offshored critical manufacturing capabilities, there was no corresponding concern for patients and their families.
The NGOs, think tanks, trade groups and all other influencers of health policy have thought little of this world in which we find ourselves. The lobbying apparatus, broadly defined here, has been content over the years to focus on maintaining the status quo, protecting their turf and making sure as little as possible changes.
And they continue to do so. The Federation of American Hospitals is hard at work begging the Federal Trade Commission to investigate the high prices commanded by that fraction of the workforce that are travel nurses, as if that would matter.
Nonetheless, hope abounds.
As they did early in the pandemic when it became clear the hapless Centers for Disease Control were not there to help, the health care providers across regions collaborated on data, treatment protocols and looked not to Washington but the Governors’ offices for help and support. Rules were suspended that allowed, in the words of many health care leaders, the true practice of medicine.
In other words, it is the health care industry, while admittedly supported by gobs of federal cash, that solved many of the problems presented by a pandemic. It is hard to imagine a world where health care is once again chained to nonsensical and counterproductive policies that enabled the U.S. Medical Economy to balloon but did little to serve the goals of good health.
Let’s watch the state legislative sessions that begin this month for signs of change.
Power. What a long, strange trip it has been.
Much of the health policy in place until COVID, despite hard evidence that a large portion of it is not particularly salutary, has persisted through the imposition of conformity that would make the anti-communist of the 1950s and 60s, blush.
It is ironic, of course, that many of those policymakers spent their youth railing against the stifling standards of their Depression-era parents. We got some great music, fantastic arts and, above all, the civil rights movement. But also, the standards developed during times of deprivation that preserved family units, distributed labor, and inspired thrift and perseverance were no longer relevant.
Their new normal, of course, needed to be enforced and so it has for over 50 years.
It has become nearly impossible to talk about the Medicaid program, that largely serves the twin beasts of hospitals and nursing facilities, without being accused of killing babies and pregnant women. Any suggestion that Medicare could use an update brings down a rain of criticism of abandoning seniors. Of course, during COVID, the mere suggestions that schools remain open or jogging outside without a mask was OK, meant you wanted grandma to die.
Federal health policy has stopped being about health and more of a way to demonstrated conformity, an act of sorts.
That too is coming to an end. The Millennial generation does not line up for jobs on Capitol Hill as they once did, shutting off the flow of highly qualified people to K Street. Lobbyists continue to age. The endless possibilities that Washington’s power typically confers do not seem to excite anyone any longer. It doesn’t help that most of Washington’s work has seemed more designed to make someone rich than to solve an actual problem.
In the power struggle to define the next stage of health policy. Washington is poorly equipped to prevail.
Have a great rest of your weekend.
Emily Evans
Managing Director – Health Policy
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