Solving any problem or improving conditions in the face of various predicaments (structural challenges created by and inherent in complex systems) first requires accurately recognizing whether you are dealing with a problem or a predicament. Problems are discrete/finite and have recognizable solutions that are objectively correct, such as “How do we treat wastewater from urban areas so that we prevent cholera outbreaks?” Etc. Predicaments are situations where many people in many different circumstances and with vastly different goals and resources interact such that each player gets a different outcome from one system perturbation - one action may be wonderful for some, but toxic for others in other words.
Problems have solutions in fundamental sciences in other words, whereas predicaments have no solutions, and have to be dealt with and managed through the political realm.
Just as with the housing shortage, understanding the predicament we find ourselves in vis a vis the medical industrial complex first requires that we recognize that in health care, we don’t have a problem on our hands — we have a full-blown predicament that results from the complex nature of the structural challenges we face. Everyone in society is a participant in the health care predicament — even the houseless person who has no formal access to health care is a participant and can impose a great cost on everyone else as a result of this absence of care.
And the greatest challenge is at the root: recognition that we don’t have a health care system any more than we have a housing system. What we have instead are a set of individual agents acting to maximize their own goals and well-being, and we hope that as a result, “as if by an invisible hand,” we will all be made better off (housed, or healed, as the case may be). (Systems are arrangements of interacting elements so arranged as to achieve a goal.)
We can conduct a mental experiment — we can hypothesize that, if the purpose of a system is what it does (true), then in both housing and health care, what we should expect to see the overall system to operate at the most economically efficient frontier, the curve on the graph of supply and demand that maximizes the profits to be reaped by investors.
And that is exactly what we have — we have a housing system that is exquisitely balanced to find and exploit opportunities to make money, but which is also therefore exquisitely sensitive to opportunity cost and which will only build housing that clears the minimum profitability bar that the investor’s alternative investment options set. As a result, we get and we only get whatever housing can be built with high margins, and not one room more. Those of us who are well-housed use a comprehensive package of laws and regulations to ensure that our particular housing investments are protected and constantly become more valuable, even at the cost of preventing enough housing for even the people already here, much less for those to come.
So too in medicine — the system configures itself to maximize net revenue, not net health. There is not a single actor in the medical industrial complex whose financial return is tied to actual health outcomes in the sense of compensation for results (pay for outcomes rather than process).
In medicine, we have allowed the private equity investors and insurance companies to configure the system and to restrict the number of providers to stay on the curve of maximum profitability, and we get whatever health outcomes result from that, just as we get only what housing the developers and land speculators can make a profit off.
A free-market, for profit system for essential goods and services like housing and health care works great — as long as you understand that “works great” means is that all the creativity and innovation in the system is focused on progress towards the system goal (financial yield), and that anything that interferes with the system goal is considered an obstacle and routed around.
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