Comments on “Post-apocalyptic life in American health care”



Marshall's picture

From Eliezer’s new book:

“For our central example, we’ll be using the United States medical system, which is, so far as I know, the most broken system that still works ever recorded in human history. If you were reading about something in 19th-century France which was as broken as US healthcare, you wouldn’t expect to find that it went on working when overloaded with a sufficiently vast amount of money. You would expect it to just not work at all.”

I can empathize

Ian's picture

Sounds similar, but even worse, than my grandmother’s situation about 10 years ago. Blessedly, she did not have to deal with cancer on top of dementia. But she was transferred to an SNF without any notification to family members, or management of her residence! It is both fascinating and depressing that a new class of professionals has arisen, simply to be one’s “agent” within the system.

I'm sorry to hear

James's picture

My family recently went through a similar sort of situation. It’s really tough and I’m sorry to hear that you have to deal with this. Best wishes to your mother, you, and the rest of your family.

Medical systems

Caleb's picture

I’m sorry to hear of your mother’s situation and your difficulties. I wish you both well. While I realize the post was epistemological and ontological commentary rather than political, and knowing that in the US healthcare is a political football, I say the following in the hope that it can be seen as something other than a political comment. There is a context to these systems that you describe. There are assumptions embedded in both the description and the speculation. Some of the assumptions are ‘political’ in nature. Maybe I agree with them, maybe not. But let me make the following empirical point - we know that despite spending massively more both in absolute terms and on a per capita basis, the US healthcare outcomes rank well down the pack, so why use the US as the paradigm of what is possible or likely for the future? That’s a narrow perspective at best, and it’s the kind of narrowness that becomes self-fulfilling. Anyhoo, I used to live in Japan. No lack of medical technology or capabilities there. Significantly better outcomes. Much less work expected of patients, and much less stressful to deal with than the US system. And the really big difference is that the Japanese don’t think of their medical system as a “trillion dollar free market” or whatever. They think of it as a social good and design structures, processes and incentives accordingly. You see where I’m headed, obviously; the reason that a return to primitive modes of engagement is a subject of this post might have something to do with limitations in the set of assumptions embedded within both the system and the way the writer thinks.

A more conservative estimate

Adrian Wilkins's picture

A more conservative estimate of the costs of admin is around 27% ; this is the percentage of staff employed in the American healthcare system solely for billing administration [1].

The UK NHS by comparison is simpler - noted for it’s efficiency yet still primitive in terms of technology (fax!), plenty of room to improve - and manages to provide universal healthcare to the UK for less than half the cost per head of the US. You actually pay around 30% more per head in taxes spent on healthcare than we do. The fact that the majority of you get no healthcare at all for that should be causing riots all up and down every state.



James X. Kennedy, MS, LMSW's picture

Your so-apt comment that healthcare offices are like a pre-modern town had me and kept me. I am still in health care administration (nonprofit, upstate NY) and was previously (in the 1980s) and SNF administrator. Thank you and I am sharing this post widely.

Jim, Geneva NY

Here's your consulting business

R C's picture

“Maybe an ethnomethodological understanding of how health care organizations operate in practice could make the systems work incrementally better.”

Very hard work, to be sure, but deeply insightful.

System is broken forever and we keep breaking it more

Deepa Shiva's picture

I had been advocating for Integrated Health Care Platform - even tried building one in India, a country with less regulations and more private hospitals. I have worked in United States with Kaiser Pharmacy division and Blue Shield of California. Lot of people have right intentions to fix the system, but no where to begin. With the on-going changes in the political system makes it more difficult.

With the electronic medical records, EPIC ( is almost the monopoly and between their systems they can exchange records (Stanford and Kaiser did this for me), but when it came to Sutter Health they couldn’t, so all my records had to be faxed from Stanford to Sutter (this is because of change of my Insurance). Beginning with two major players as like you proposed Insurance and Hospitals, we do have systems (for ex:, but not exposed to patients. The biggest challenge apart from fragmentation of the data and information, I notice is lack of transparency to patients.

The UCLA health network has

Anonymous's picture

The UCLA health network has bought up so many private practices in and around LA that it carries at least some of the benefits of an integrated system. However, it also seems to cause a 300% price increase. It’s all somewhat reminiscent of the Mythical Man Month, but at least the doctors all have access to the same body of records …

I know MMM is an old book with antiquated prescriptions, but the problems of communication overhead remain very prescient. It seems to me that once systems scale beyond practical boundaries of communicating they decay into a chaotic background noise that seems to naturally invoke tribalist stylings

Health Care Reform: Dynamics Without Change

Sound familiar? It was written in 1972. The core of the problem is trust and incentives. When you contact Fedex to ship that envelope to an island in Lapland, you KNOW where you want it to go and you know what you want to send. FedEx would not look so great if you had to show up at Fedex and the worker there got to recommend (or demand) where the envelope would go and what was in it.

We can’t know as much as the doctors and nurses. So we have to trust them. You could trust the counter worker at FedEx. But would you still trust that worker if her income depended on where she told you to send your package? (Fee for service). Nor could you trust them if she got a bonus for only sending your package across the street? (Managed care). And if the envelope or packing supply companies could pay her on the side, it would get even crazier. (Drug companies and medical device companies.)

The instant these financial incentives spring up you get (if you’re lucky) the 1,600 pages of regulations necessary to keep them in check.


tooearly's picture

You wrote:”Back-of-envelope calculations say a working health care system would deliver dramatically better quality at 10-20% of the current cost.”
Surely you don’t mean we really could save 80-90% of current cots?

80-90% off!

Yes, that’s my best guess. I do the analysis by considering a particular medical service, finding out roughly how much a person providing it gets paid per year, and dividing by how long it takes to do to get the direct labor cost; finding out the cost of the equipment used and amortizing it; and adding in an estimate of the overhead (cost of the building and a reasonable level of administrative work). I’m reasonably skilled at this sort of analysis as a consequence of having run small businesses.

Estimates may vary, but everyone seems to agree that heath care is way more expensive than what you’d expect based on this sort of analysis. No one seems to know why; or, put a different way, where the money all goes. Everyone who has studied the problem agrees that it’s highly mysterious. It’s clear that administrative costs are needlessly much higher in health care than elsewhere, but that’s probably not the only source of the discrepancy.

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