That's a question people rarely ask. They hear my point of view and my criticism, and they listen politely. But they don't say, "How would you fix health care in America, smart guy?"
So I'm about to answer the question that no one's asking.
What follows is going to gloss over a lot of issues and it's going to paint a lot of others with a fairly broad brush. That's necessary.
Let's start with a definition, then three assertions.
First of all: "health care" is a crummy term, because it includes different things. For the purpose of this document, I intend it to include two things that really have almost nothing to do with each other: a) preservation of good health in those who enjoy it, and b) diagnosis and treatment of diseases.
Now the assertions:
1) America needs universal health care. In other words, all American citizens as well as other people present in America need to be able to receive health care.
2) The government needs to accomplish this.
3) The government needs to pay for it - the lone, single payor - and pay efficiently for it, eliminating waste.
I believe all of the above. Here's why:
If Americans can't get healthy and stay healthy, they can't work. They can't go to school and learn. They can't move on to all the other functions we expect of fellow-citizens. They can't participate in the economy. They can't take care of their kids. The specter of their illness is bad for even those who are spared - it's the worst sort of terror. And a lot of diseases are contagious.
Only the U.S. government is big enough to guarantee health care for its citizens. No other entity could accomplish it. Private industry has only succeeded in siphoning dollars from employers and their healthy employees, dollars that should have gone to caring for sick people and instead went into the pockets of middlemen.
We have the ability to deliver the best health care in the world, here in the USA. Good health care isn't cheap, and, ceteris paribus, you do get what you pay for. Only the US Government can foot that tab. And the tab is so monumental that even the US government can't afford it, if it's delivered wastefully or inefficiently.
The US Government has to get into the business of managing health care because no one else is big enough to do it right, powerful enough to enforce it right, and no one else has so vested an interest in keeping the costs appropriate.
Now. How to accomplish it:
We must have a universal, single-source electronic medical record. Sounds like a monumental task. Doctors won't use it. Patients will worry about their privacy. Big Pharma and Big Healthcare will use it to control and ration care. Lawyers will use it to run rampant with their malpractice suits.
Flush all the objections aside. We must have this, or nothing else works. Both Amazon and Google are loudly bruiting about that they're ready to take this on. Pick one - for the rest of this article, I'm saying Google, for brevity - give them $20 billion, and make it happen. (Maybe it's not Google, maybe it's a GSE. Whatever.) Non-participants don't get paid or don't get cared for. Period. It makes everything possible. Here's how:
1) Cut waste from repeated tests. Like this: Joe Smith shows up at E/R A. Just last week he was in Hospital B, where he received an MRI scan of the brain. I don't know this - or maybe I do, but I can't get hospital A to show me the images at midnight - so I order another MRI scan, because I'm afraid that I'll miss something if I don't. Cost to society: $7500.
*Or*, I look up Joe Smith's record on Google and quickly flip through last week's MRI scan and the official report.
The unnecessary costs eliminated would pay for the cost of starting the system up, in one year.
2) Side benefit: the benefit of having medications, drugs, problem lists, diagnoses, prior surgeries, lab work, and test results always available, on every patient, at the point of care, no matter where that point of care was, will enable a whole new way of taking care of sick people. It would be so much easier. Chip people with their SSN at birth if you have to. Non participators can pay for their own care, if they can find a doc willing to bother.
3) Pay Google to figure out how to let doctors call a number and dictate straight into this medical record - to make entries from their cell phone, from the internet, from any phone or terminal. "Oh no," you say, "the average doc spends $40,000 a year on records, charting, and dictation fees." Right. Shift that burden to the government. Shift it to Google, frankly. I bet they'd find a way to let every doc dictate and get it transcribed, either electronically or crowd-sourced, for nearly free. Doctor satisfaction: through the roof. Patient care: improved boundlessly. Cost to society: more than paid for.
4) Measure outcomes. There are three core metrics here:
a) Patient satisfaction. Easy enough. Devise standard questionnaires for common diagnoses and one-size-fits-all questionnaires for other diagnoses. Administer them over the internet. Hospitals already routinely do this for all admissions. Make it a national guideline. Link it to the doctors and hospitals responsible. Give the top providers monetary bonuses. Administer fines to the bottom of the barrel, or delicense them.
b) Patient outcome. You can measure this a number of ways. Caveat: this is a hard thing that looks easy. But it's not impossible. Every disease that's studied, and that's most of them, has a constantly evolving outcome metric agreed upon by major researchers. Pay these leaders in their field to come up with outcome metrics that will be fair, objective, and easily measured. Then make our central info repository measure them.
c) Cost of care delivery. Measure docs, patients, dollars and outcomes. Again, a hard thing that looks easy. Patients aren't all the same. A doc whose cost of care per patient is much higher may simply be comfortable/happier managing sicker, more difficult patients. That doctor gets a gold star. Then again, he may be self-referring many unnecessary tests on basically healthy people. That doc gets a slap on the wrist. Outlier analysis, people. We have medical statisticians languishing forgotten in biostats research departments who'd find this a cakewalk compared to the crazy calculations they do all day. Put 'em to work SAVING AMERICA. No really.
I really believe most docs want to do right by their patients. Most docs want to be compensated for their skills, too. These things aren't incompatible. The savings possible here could be used to make sure that ethical docs providing quality care could make what they think they ought to be making. Heck, pay those docs even more, so they can hire more staff to make them even more efficient and expand their reach even further.
Docs will try to game the system. People try to hack into Google's servers, too. You think Google doesn't know how to put up a countermeasure? When everything goes onto one medical record, there will always be a trail.
There are a lot of problems with this. Probably the biggest is that it's a transformational idea that uses technology to provide a magic bullet. There's a lot of resistance to those kinds of ideas. Implementing them is fraught. It's so easy to say "It'd never work." Politically, it's probably impossible.
But I think it's also inevitable. And it would solve so many problems to start it off right from the beginning, rather than try to rely on the capital markets to somehow birth this thing when they've had 45 years to try (45 years A.M. - Anno Medicare) and a track record marked only by catastrophic, death-spiral failure.