Dr. Oz, We Have a Problem
Fifth in a Series of 21st Century Moonshots
When you go to work for Volvo in Gothenburg, Airbus in Toulouse, or Honda in Japan, nobody hands you a little white card indicating that you’re enrolled in the company’s health plan. A mechanic in Gothenburg, an avionics technician in Toulouse, and a machinist in Yokohama have health coverage that has nothing to do with their employment status.
When you go to work for General Motors in Michigan it does. Oh, and if you belong to the UAW and work for General Motors in Michigan you get a different white card than the folks who work in accounting.
Why?
The answer has nothing to do with healthcare.
It’s an accident of history that traces its roots to a federal wage freeze enacted in 1942 that brought Rosie the Riveter into the job market to make planes, tanks, and uniforms for American forces.
Nearly eighty-five years later, a significant portion of America’s $5 trillion healthcare system remains organized around an 84 year old workaround created for a wartime labor shortage.
Soldiers came back from the war, went to work for one company for their entire career and were handed a gold watch on their last morning. That world no longer exists. We change careers, change companies, and no one is waiting for the gold watch and the pension.
Today, more than 70 million Americans, 36 percent of the workforce, freelance, consult, contract, or drive for a platform. By 2027, that number will cross 50 percent. One in six workers is staying in a job they want to leave because they cannot afford to lose their health insurance.
Researchers have a name for it. They call it job lock. There is a companion phenomenon called entrepreneurship lock, the business that never launched, the risk that was never taken, the idea that died in a cubicle because the founder could not afford to walk away from their benefits because of a family member’s pre-existing condition.
A traveling nurse is equally valuable as their hospital based peer. The hospital based nurse gets employer provided care for themselves and their family. The traveling nurse is on their own.
We built it for Rosie the Riveter, sustained it for the organization man. We reward and subsidize the corporate worker and ignore the uber driver, the IT contractor, and the waitress because of an eighty year old workaround.
The clock is ticking. Gig work is overtaking traditional employment and neither the healthcare nor employee benefits market is structured to deal with this evolution.
Every debate about healthcare eventually becomes a fight over insurance companies, pharmaceutical companies, physicians, hospitals, unions, employers, or government. We argue endlessly about the participants. We rarely question the architecture connecting them. Yet architecture determines incentives, incentives determine behavior, and behavior determines outcomes.
The solution isn’t clinical. The solution isn’t political. The solution is architectural. The same architecture we applied to education and to housing. North Star, Hub, Scoreboard, Clock, and Throttle.
The North Star for a developed economy is, or should be, access to healthcare regardless of how or if a person earns a living.
Employers are the hub of the system today. It’s an administrative and economic burden that our global competitors do not face. It’s a tax on business that creates a structural disadvantage for American manufacturers competing in a global marketplace. It holds down wages. Every dollar an employer spends on spiraling health insurance premiums is a dollar that never shows up in a paycheck.
The hub should be a free market where the individual is empowered to make their own decisions about providers and where decisions are made by providers and not by clerks from payors.
The problem is not employers. The problem is that healthcare is attached to the employer instead of the individual.
A passport belongs to the individual. A Social Security number belongs to the individual. A driver’s license belongs to the individual. Healthcare should belong to the individual as well. It should travel with the individual from job to job, company to company, and through every stage of life. A temporary employment setback shouldn’t burden the individual with outrageous COBRA premium because their company downsized or sold a division to private equity.
The scoreboard for our health system should not be activity. Physicians should be compensated on outcome not on the volume of procedures completed. Every procedure, visit, and service a doctor performs is assigned an RVU value by the American Medical Association. Medicare uses those values to set reimbursement rates. Private insurers largely follow Medicare’s lead. The more RVUs a physician generates, the more they get paid.
It’s not working. America’s maternal mortality rate of 22 deaths per 100,000 births trails Albania, Croatia, Finland, Denmark, and Singapore. Our rate of chronic preventable disease reveals the same problem. $5 trillion, almost $15,000 per person isn’t working.
The throttle is investment in outcome based care that redirects the $5 trillion into care that works. To care that reduces our maternal mortality rate and the epidemic of chronic preventable diseases.
I’m not suggesting the system pay for facelifts. I’m saying that we pay for treatments that work and that those decisions should be made by providers and not by procurement managers who negotiated a good deal with a PBM. If a treatment works, fund it. If it doesn’t kill it.
All moonshots are audacious. Starting a business is audacious. Changing careers at fifty is audacious. Leaving a company to build something new is audacious. Caring for a sick spouse while working part time is audacious.
Why are we allowing healthcare portability to stand in the way of those choices?
We built this architecture for Rosie the Riveter and sustained it for the organization man. Both served America well. But the labor market they inhabited is disappearing.
We don’t tell people where they can bank based on where they work. We don’t tell people where they can buy groceries based on where they work. We don’t tell people where they can buy a car based on where they work. Yet somehow we’ve accepted the idea that an employer should determine which physicians, hospitals, pharmacies, and specialists we can access.
The architecture no longer matches the world it serves. It’s time to build one that does.