They may only invite me because I occasionally swear, but I’m still flattered and I always say yes.
Last night, I gave a guest-lecture at Cal Berkeley– a class of grad students from the School of Public Health, and it was a ton of fun. (Thank you shout-out to PH 116! Student-driven and amazing).
The class coordinators invited me to speak last year in my role as executive director of the Chronic Disease Coalition. My previous City of Berkeley employment[i] and public health experience was all just a happy accident. This year, they invited me to speak beyond “just” chronic disease patients to take on all of “healthcare policy.”
If you know me and your job is healthcare policy, you are dying inside right now. It’s not imposter syndrome or professional modesty for me to say: I don’t really do policy at all.
Advocacy, sure. I advocate for patients constantly. I also have worked for care providers, including hospitals, physicians and kidney centers on issues of access to affordable, high-quality healthcare. I also educate and explain about policy, so policy and I are friends. But policy is really about law and regulation, it can be extremely tehcnical, and I am not a policy expert in that way. You’ve just got to know your lane. And in more disclosure that is nearly TMI, I have healthcare clients[ii], I have multiple health care providers, I am completely and happily shot full of vaccines, I take medication every day, and I believe health insurance is essential.
So thank you to all the providers who keep me healthy, the insurers who help me manage costs, and the scientists working away on the next generation of life-saving drugs. We have great individuals and organizations working in a deeply flawed system that is complex and interrelated and hard to change.
With less than an hour, here are three things I set out to tell the PH116 class, and fourth thing that I just yelled at them about:
If you want to improve healthcare, look at it differently: We don’t have a healthcare system, we have a healthcare marketplace.
Before the real policy people yell at me, a disclosure: part of my job is to explain complex systems, and one way to do that is to start by oversimplifying things. Broad brush first, then detail and nuance.
There are different ways of setting up a healthcare system. I’m not remotely qualified to compare them, but a smart friend of mine put it this way: In the U.S., we have not decided whether we think healthcare is a utility (services available to everyone) or a marketplace (individuals buy what they need and can afford).
Emotionally, we want it to be available to everyone. Practically, the healthcare system makes a ton more sense if you look at it through a marketplace-economic lens. Use Planet Money framing like buyers, sellers, middlemen, incentives, margins, loss-leaders and costs such as sunk, shifted, fixed, direct, indirect and variable.
To be clear: I’m not saying this is ideal. I am saying that every “person” in the healthcare marketplace has a 100 percent reasonable financial problem to solve, and you can’t change health outcomes without understanding that financial problem. So here’s a sample of marketplace-like dynamics:
- Patients like you and me need medical care, and no one wants to spend too much or more money than they have. Also, our need for those services is unpredictable;
- Patients need more care as we get older;
- Most healthcare costs are personnel, so big cuts = less staff and big raises = higher costs. We want well-trained providers to be paid fairly and well, but also we don’t want things to be expensive. It’s a sticky wicket for sure.
- Facilities like hospitals and clinics cost a lot of money to keep staffed, open, well-lit, clean, safe, and equipped. If they can’t pay bills, they can’t stay open;
- Society requires that some providers give healthcare to people who can’t pay for it, and that cost is shifted on to people who do pay for it;
- Insurance is the mechanism patients rely on to help them manage costs, and that providers need to pay them. So they’re very much caught in the middle;
- Preparation is expensive: Healthcare providers and facilities must have extra staff, training, space and stuff to respond to the unexpected. This costs money. Not spending the money costs lives;
- The federal government isn’t in the drug-development business. Whether you have a common or a rare disease, you’re relying on private-sector innovation for treatments and cures.
Phew!
The glaring issue is that we (the public) probably need more healthcare services than we can afford, and it’s a fantastically complex system that makes that possible. Costs and services are intertwined, so it’s pretty hard to cut costs without hurting someone’s services.
There are also a lot of health issues that the healthcare system doesn’t manage very well—often because our health problems have root causes outside what a doctor or nurse can do for us.
- Equity: There are huge disparities in access to treatment and outcomes.
- Behavioral and cultural change: Smoking, drinking, and poor diets are hard problems for individuals to solve.
- Stress: Draining all of us of life, daily.
- Misinformation: Oy.
- The Last Mile problem: Not just for transportation and utilities—some people are difficult and expensive to reach. And then there’s that expensive last mile of life that no one likes to talk about.
The Washington Post’s package about the decline in U.S. life expectancy is a must-read.
“Policy”= The rules of the marketplace as set by democratic institutions.
I think of policy as the rules of the road. While marketplaces are driven by financial incentives, elected bodies are run by political incentives—that is, the desire to give voters what they want and retain popularity. And so our democratic government sets the rules of the healthcare marketplace, including:
- Cost
- Access to services
- Quality
- Development, testing and approval of new treatments
- Patient privacy and data collection
- Professional standards
- Transparency
If you make the rules too hard, some parts of the system can break down.
One of the reasons I look at healthcare as a marketplace is because sellers can, quite literally, walk out.
Like any other business, if the government makes it too expensive or complex to run a hospital or a clinic, it can just close. (This is how some Southern states managed abortion services under Roe: abortion was technically legal, but onerous clinic regulations kept them from operating).
So one of the real challenges of healthcare policy is having the right amount of regulation and price controls to ensure doctors, nurses, hospitals and clinics can stay open for the people who need them. Policy is careful trade-offs, and it relies on good analysis, good listening, good compromise and patient-centered decision-making.
Don’t believe me? Ask NPR: They named their healthcare policy podcast “Tradeoffs.” It’s real good!
Public service announcement:
If you want to affect policy or health care or human behavior, you must stop talking like an expert!
Being an expert = Awesome.
Talking like an expert = Annoying.
The class was nice enough to let me vent and even laughed at me, and that’s great. Hopefully they laughed because they’ve seen for themselves that too many health and policy experts talk like experts, implying that we’re all supposed to just fall in line because they’re so smart.
That’s not what works. If you want to change law and policy, that means influencing elected officials, which means being straightforward, understandable, and person-focused. If you meet a fellow expert, by all means, go down the jargon rabbit hole and have a great time. But if you want to inform or persuade any other human, you must make yourself understood without being condescending.
FINALLY, THE CONCLUSION
I firmly believe that every player in the healthcare system is trying to do the right thing for patients. I have met really extraordinary people who are working tirelessly behind the scenes to improve the lives of patients.
- Insurance helps us smooth out costs and reduce the risk of bankruptcy—awesome.
- Doctors and nurses and radiology techs and PAs and cleaning crews—all obviously awesome.
- Scientists developing new vaccines and new treatments for shitty diseases—awesome.
- Accountants and CFOs who work to keep the doors open for when we need them—awesome.
- Elected officials, staff, regulators, patients and advocates who work extremely hard to improve the system—awesome.
Are there bad players and bad ideas? Of course. But we can make better, lasting improvements when we understand the problem that “the other guy” is trying to solve, communicate clearly, and collaborate for progress.
Good luck, PH116!
[i] 5.7 years as the spokesperson for the City of Berkeley. Cal Berkeley is where Nobel Laureates go to solve the planet’s most complex problems. Berkeley City Hall is where they go to complain that the neighbor’s ADU is casting shade on their tomatoes. I was also occasionally the PIO for the public health department. Berkeley is one of three cities in California that has it’s own public health department. Badass.
[ii] Hopefully it is clear that all this is just my opinion, and not that of my clients, who have their own opinions! It’s also not the opinion of the Chronic Disease Coalition or any of its members. It’s really just me, whistling in the dark, trying to make sense of the world. And FWIW, I reserve the right to change my opinion based on new information, better analysis, more useful analogies, or just a good night sleep.