If you ever retweet something of mine, please make it from this thread. 1/

Background: before I became a doctor, I used to work in and around the “payor” side of the health care world, both inside and as a consultant.

Payor is a euphemism for insurers.

It’s a term of art designed to make you forget that WE are all the “payors” for heath care. 2/

This thread is not about me; I just needed to establish context.

The insurance world is huge, complex, inefficient, and wildly profitable

If health care dollars were water, we’d willingly be sending it though a Byzantine aqueduct that has high evaporation and moves water uphill

So we lose a lot of health care dollars to inefficiency and to corporate profit.

I once did an analysis that showed that with all of the administrative waste in health care, we could have paid for an ACA “gold” level plan for every uninsured person in the US (2014).

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Corporatism has invaded the provision of health care, too.

Private, for-profit hospitals (not that it’s anything more than a tax term, but still), private equity firms buying up physician groups and imaging centers.

These entities answer to only one master: profit.

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I was working in a county hospital this summer. This is in Southern California. There was a wildfire feet from the hospital — and not a small one. I was urgently making my way through police and fire cordon checkpoints with my hospital badge to get to the building.

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I could see the wall of flame from the anesthesiology office. Still I was not afraid. “They’ll never let the hospital burn”, I told myself.

Hours later, an announcement: the fire hydrants had run dry. The hospital was sheltering in place.

I was scared.

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But do you know what happened? Over the next hour, fire trucks POURED in and surrounded the hospital. City, county, parks service, forest service, BLM, new trucks, old
Trucks, unmarked trucks. They arrived to protect the hospital so quickly and so effectively.

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As I drove home later that day, through the protective ring of equipment, I realized a fundamental difference between public safety and healthcare.

Public safety is BUILT on latent capacity. We pay for people and equipment to stand idle, over-prepared for emergencies.

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in contrast, health care has been monetized, and the incentive for profit has led to the pursuit of “efficiency” at every level.

Well, every level where *people* can have more squeezed out of them.

Harder work, more patients to care for, more paperwork, more complexity.

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We’ve left no latent capacity in health care. Everyone was working at their maximum. Forget burn-out. People were just holding on. Some stayed for what personal and professional gratification they found. Many stayed because of the financial realities of families and student loans

You know who wasn’t hurting? Working ever/longer hours with ever more complex patients and systems? Administrators. Executives.

But the front-line people and systems were already holding nothing in reserve in this county.

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And some part of the tragedy that’s now unfolding in this country is because of that. Because we let health care become a business. And businesses don’t keep 100 extra fire trucks around, their crews trained and ready, “just in case”.

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This — latent capacity — is the role of a functioning societal safety net.

And we sold ours to the highest bidder.

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