Preparing for the Worst in Healthcare
What do we need to consider as we plan for the future?
Ideas for my ‘Office of Medical Net Assessment.’ If it existed.
In addition to following quite a few writers on Substack, I tend to listen to podcasts when I drive or run. There’s always something to learn so I try to use my time well. Frankly, it’s an amazing time to be intellectually curious. There are so many options, so many topics, so many ways to access information that you almost have to try not to learn on a daily basis.
My interests are pretty wide ranging. I enjoy listening to Matt Fradd’s Pints with Aquinus, Louise Perry’s incredible podcast Maiden, Mother, Matriarch, Dr.Jeannie Constantinou’s Search the Scriptures, and various others podcasts touching on a number of topics.
Another of the podcasts I follow is School of War, by Aaron MacLean.
I have long had an interest in military history. Mr. MacLean has engaging, informative guests. I highly recommend listening.
Most recently I enjoyed his segment with Thomas Mahnken, of the ‘Office of Net Assessment.’ Basically, and I’ll summarize this poorly, Mr. Mahnken’s work has to do with helping our defense establishment use every bit of information possible to prepare for future conflicts. And if you listen to this podcast you can see what a daunting thing that really is.
Now as much as I enjoyed it, that sort of thing is WAY out of my area of expertise. But it did set my doctor wheels turning. And I started to wonder what factors would be important, in the house of medicine, if we had our own equivalent ‘Office of Net Assessment.’
Of course, somewhere in the Department of Health and Human Services, such an animal may exist. (If you know of it, please inform me.) However I fear that it is far removed from what’s happening on the ground in healthcare.
My concern, having practiced over thirty years and through things like the original SARS, H1N1 and the madness of COVID, is that we really aren’t preparing for much of anything. But trust me, as I have written before, healthcare in America is in a downward spiral. Or as pilots might have said in older times, the system seems about to ‘auger in.’
This podcast made me wonder about the things going wrong in healthcare, or about to go wrong. Not that I have all of the solutions. There are amazing physicians who are engaged at many levels in policy; I know some of them. If anybody can fix them, these folks can. However, I see myself as less of a policy maker and more of a reporter. And I’m here to say that there are problems and signs of problems. And we’re nowhere near being ready to handle them.
By way of example, the grand mess of COVID (so fresh in our minds) has yet to be fully explored . It doesn’t seem as if anyone who was the loudest and most insistent about lock-downs, origins of the pandemic, etc. is willing to admit that there were problems. Much less are they willing to say something like ‘hey, we got that wrong. Maybe we should have a commission and figure out where we messed up.’
People in government, and in healthcare, are often loathe to admit their mistakes. Fair enough. None of us like to be wrong, or have our mistakes aired out for all to see. But maybe the future health and safety of the nation would be sufficient reasons to revisit the problems.
After all, other pandemics will come. Have we begun to stockpile? Have we considered the many diseases that can cross from animals to humans or can change locations with mass migration of people groups like we see daily at the border? Does anyone remember Cholera? The Haitians sure do. Of course, they have serious issues with clean water.
https://www.cdc.gov/cholera/haiti/index.html
But the source of the outbreak? UN Peacekeepers.
https://www.bbc.com/news/world-latin-america-37126747
Have we contemplated the idea that non-state, or state, actors might still use biological weapons in the future? Especially given the pace of bio-tech? An ‘office of medical net assessment’ would consider these possibilities. And it would start buying a lot of protective gear and educating people in its use.
(My personal fear is that we’ll one day have a gastrointestinal pandemic like cholera and be utterly unable to respond with sufficient gear, decontamination equipment and IV fluids…focused as we were on respiratory illnesses like COVID and influenza.)
What else do we need to consider? Here are a few other issues that I see on the horizon.
Hospitals and physicians are increasingly owned, managed, mismanaged and wrecked by the private equity system which pervades American healthcare. As such we have medical professionals of every variety looking for the quickest exit possible from the misery of their work. This may enrich many CEOs of healthcare systems, but it also means that as time progresses and money changes hands, human beings will have fewer and fewer options for care. Not to mention the incredible ‘brain drain’ as those who are young and well educated are always looking for a way out, and those with decades of experience (grey beards like me), and the option to leave healthcare (which I don’t have yet), do so quickly and without looking back.
Which means, and I’ll get ‘technical’ for a minute, lots of people will suffer and die who needn’t suffer and die. Now I’m not a fan of single payer (I’ll explain why sometime), but I’m also not a fan of unregulated profiteering in an endeavor as essential to human thriving and national security as healthcare. I will say, and with some hope, that there is movement here as the government is looking at the effect of private equity on emergency care.
Another devastating issue we face is that mental health services are few and far between, so patients with severe mental illness often end up homeless and cycle through the ER (or jail) over and over. For a variety of reasons , this now starts somewhere around age five from what I’ve seen. You may think I’m joking, but I’m not.
We have epidemic psychosis, depression and anxiety in adults and kids. Until we address this, families will still be devastated, hospitals will be more and more overwhelmed, homelessness will expand further and human beings will suffer in prisons of their own minds. This renders them unable to provide for themselves or their families, unable to contribute to the wellbeing of the nation, and it means that their children will need the support of elderly family members and/or the state. And the healthcare system. Which is not prepared to do so to the degree necessary.
Ditto for the drug epidemic, particularly fentanyl and methamphetamine, which leave humans wandering the streets as all but zombies, and causing all of the same things listed above. These people have terrible infections and need complicated surgeries like replacement of infected heart valves, long term antibioitcs, amputations, trauma from car crashes and violence; the list is long. And of course, all of it is intertwined as drugs cause mental illness and the mentally ill sometimes self-medicate with drugs. Addressing the border would help to reduce the flow of some drugs would help. But I don’t see that happening anytime soon.
Medical marijuana? Legalized marijuana? Marijuana for anxiety, etc.? Disastrous. And only making people more psychotic, more anxious and less productive. Sorry disciples of cannabis, it’s not working out. And all of it is leading to more of the above.
Has our federal system looked at ways to mitigate these issues? No, mainly they remind my colleagues and I to be careful not to prescribe too many pain pills to those with painful conditions. And force us to take meaningless class after meaningless class to demonstrate that we understand the problem they aren’t fixing.
An ‘office of medical net assessment’ would also consider the very real problem of an aging population. People are living longer, and surviving illnesses and injuries unimaginable in the past. Wonderful as that is, we don’t have enough nursing homes and we certainly don’t have enough people willing or able to work in them effectively… or safely. We don’t have enough social workers or individuals to go to the homes of the elderly to keep them in their own places as they age. And as so many have pitifully small retirement accounts, they will truly be in danger of homelessness. This is a national crisis. But not quite as disastrous as the other population issue, which is depopulation.
Humans aren’t reproducing enough. Which, we have been told, is good for the earth. (I actually doubt that.) But it also is very bad for other humans. Because humans produce innovation which benefits others. They also do silly, annoying things like make food and energy, build homes and business, create the Internet, make cat videos and provide healthcare for other humans.
We aren’t quite up to the ‘rise of the machines’ yet so we need other warm-blooded humans to do things and make things. While pandemics and ongoing wars are effective at reducing human populations, equally effective are endless lectures about how marriage and the raising of children are dangerous wastes of time that could be spent having fun. Some governments in the world understand this and encourage families with tax incentives. Ours seems tone-deaf to the issue. FYI: no babies, no doctors. No nurses. No people to make drugs or build hospitals. No people to fix the Xray machine. And ultimately, no people to run sewer lines or provide clean water.
For a nice discussion of this see this Maiden, Mother, Matriarch podcast:
What about hospital closures? They’re happening. Due to the financial motivations of private equity, due to unregulated costs, due to uncompensated care, due to lack of staffing, hospitals large and small close all the time. But they need to be open. And they need to do things that don’t always pay corporations well, like deliver babies and care for pregnant women. (Lots of labor and delivery units in rural hospitals have closed…it’s a national embarrassment as young mothers in labor or with complications have to go hours from home for care.)
A rational strategy for our healthcare would involve more hospitals, and in my opinion many smaller facilities outside urban areas to serve as strategic assets in time of disaster or war. Urban teaching centers can only handle so much, and we need other options if we are to survive as a nation. (These should also serve as stockpile centers for equipment and medication in time of national crisis. I would see the building and staffing of these as a ‘medical Manhattan project.’)
Furthermore, whatever one feels about unfettered immigration, those people need medical professionals and facilities to be seen. We can’t allow them in then pretend that we don’t need more surge capacity to care for them. We have insufficient facilities for those people who already live here. And we certainly can’t just assume that ‘the ER will take care of them.’ We don’t have enough ERs, or rooms in the ERs, or staff, or specialists, or local primary care providers, nor any real incentives for a person to work in primary care, or anything else in place to cope with what seems to me a clearly politically motivated explosion in immigration.
We are also dangerously dependent on other countries for our medications. In fact, if you know an insulin dependent diabetic, that person is about one week to one month from devastating illness or death if the supply chain shuts down. My own son is diabetic and we can get one, maybe two vials of insulin at a time (and at a ridiculous cost for something so essential).
Without a readjustment of our priorities, a loss of the web, a financial crisis with lack of access to online funds, a loss of manufacturing from pandemic or a large-scale war would render millions on the brink of death from an easily treated disease. We got a hint of this recently when Change Healthcare, a financial division of United Healthcare, suffered a ransomware attack and couldn’t process payments. It seems that our electronic medical records systems and payment processing systems aren’t as secure as we’re led to believe.
But this is only one disease. Many of our citizens are fragile; due to their need for oxygen, antibiotics, chemotherapy drugs, procedures like dialysis or the many other things they need on a daily basis.
Something as simple as the inability to ship medications would cause enormous suffering. I recently saw that the UK is trying to make a move to electric powered ambulances. My jaw dropped open. But rest assured, someone here will suggest it. In my own ‘office of healthcare assessment,’ that would be a no-go. Redlined right off the top. Too unreliable, especially for long transfers.
These are just scratching the surface. I’m about to go to bed. So I’ll leave this here. I’d love to have your insights into areas where we need to plan for the future of healthcare! Please leave them in the comments.
Thanks, and sorry I’ve been out of the loop. Busy week.
Edwin
I'm a Canadian and one of the things I do is install/support EMRs for physicians. The Canadian 'free' healthcare model is broken. I see it first hand, as both a patient and IT worker, the mess that the government has made. The long waiting lists, overloaded emergency rooms, overloaded bureaucracy and lack of family physicians all demonstrate different issues. The government controls where physicians can work (see Quebec PREM), how many can graduate and what they get paid. They try to patch problems with incentives that have worse consequences.
Here in Canada, the government can only make the situation worse. They have no incentive to do a "better" job... Their motivations are expanding their bureaucracy and getting re-elected.
As long as government is in charge of the decision-making, I am not optimistic about the future of health-care in Canada.
You’ve hit all the reasons our healthcare is disintegrating, but the big one is the mismanagement of healthcare by private equity big business. The only way to fix this is for independent physicians to establish small, physician-owned hospitals (yes, need to undo that 1996 law preventing physicians from owning hospitals), and have physicians making medical decisions, not those trying to make a profit off of patient illness. Direct Primary Care is a start. I suspect in time we will wind up with a dual healthcare system, one which owns physicians and one which does not. I am tired of committees wringing their hands and doing nothing to fix the very obvious problems with private equity healthcare..