Health, Education & Productivity

A recent email brought notice of four impressive National Academy reports.  Two were 2021 reports on High Quality Primary Care and The Future of Nursing.  One was a 2017 report on Pathways to Health Equity and the other was a 2012 report on Primary Care and Public Health.  These are all impressive pieces of work.

The findings and recommendations of these efforts are well reasoned and likely, if implemented, to lead to improvements.  However, the greatest constraints on health and wellness outcomes, as well as the costs of these outcomes, are not due to medicine, drugs, or reimbursement practices.  Fragmentation of the US health and wellness ecosystem greatly constrains what improvements can be entertained and adopted.

There is a central faith in the US that the free-market system will result in better outcomes.  Your health and wellness provider wants to maximize what they charge you.  Your health and wellness payer wants to minimize what costs they will reimburse.  Pharma wants to charge you as much as possible.  Everyone is trying to maximize their profits and provide you the minimal quality of services you will accept.

Doctors are often limited to 20 minutes per patient to sustain provider cash flows.  Payers may, in my experience, deny every claim, hoping you will not figure out how to protest.  Pharma will charge you enormous sums for drugs for which there is no evidence of helping you, but you are convinced are your only choice.  Patients are cash cows being milked whenever possible and, if not inconvenient, legally.

Health and wellness used to be the poster child for predatory financial practices, but this sector has given way to higher education.  The increases in the costs of higher education have far exceeded the increases in health and wellness.  Now, students have become cash cows, accumulating student debts far in excess of total US credit card debts.  We will soon get to the point that former students are still paying off loans when their children are in college, accumulating their own debts.

The government-backed student loan program gave universities license to steadily raise prices to fund out-of-control administrative and staff costs while moving to part-time faculty to reduce the costs of delivering education.  The fact that 25% of these faculty members are on welfare – mainly Medicaid and food stamps – did not give pause to university executives.  They are just trying to balance their bloated budgets.

To be fair, a significant percentage of budget increases are due to having to provide remedial tutoring to students whose K-12 experiences did not prepare them for college, as well as mental health services for a large percentage of students stressed out by the whole experience.  A large percentage of K-12 programs do not prepare students for college, or really for anything.  For example, only 37% of US high school graduates are proficient in reading.

Consequently, colleges in striving to accommodate increasingly ill-prepared K-12 graduates have to fund remedial services.  An alternative would be national standards for high school graduation, but local control of K-12 education works against this.  Local taxpayers are unwilling to fund the K-12 programs that would yield college-ready high school graduates.  Thus, a large proportion of US high school graduates are not prepared to compete with graduates from Asia and Europe. 

My recent analyses show that students graduating from high school with GPAs of 4.0 and math SATs of 800 will do quite well in college.  For the most part, parents invested in these students in terms of attention, time and money.  A large proportion of students did not experience such investments.  Here is a likely indicator of the problem – if you do not achieve a 3rd grade reading level by the end of 3rd grade, chances are you will never go to college.  Thus, the die is cast for 9-year-olds!

We would also like our healthy and educated population to be productive and competitive in the global marketplace.  Focusing on productivity is a mixed blessing.  On the one hand, it causes employers to invest in technologies to enhance human productivity.  On the other hand, they may invest in automation to eliminate human labor. 

Employers want the lowest cost means to secure revenues.  Thus, home healthcare workers, one of the fastest growing segments of employment, are inadequately trained and very poorly paid.  Nursing is poorly paid and older nurses are encouraged to retire to make room for younger nurses who earn less.

Higher education has rapidly moved to low-cost part-time faculty members.  Increasingly high-quality online offerings may eliminate the need for faculty members.  Everyone will learn physics from Richard Feynman and economics from Paul Samuelson, even though they are no longer with us. 

The overarching goals are maximizing revenues, minimizing costs, and optimizing profits.  Cash cows are zealously sought.  Exploitation of consumers and workers is all too common.  The free-market economy has benefits, for example, in terms of innovation.  However, these benefits are not widely shared.  The winners gain enormously.  Everybody else joins the herd of cash cows.

The fragmentation of our economic and social system enables everyone to focus on their personal success in terms of income, education, and health – and automobiles, bank accounts, and housing.  The theory is that everyone doing this will lead to all of society being better off.  For those pundits arguing this, I would like to see hard data that supports these assertions.  Absent such data, they should be immediately fired or flogged.

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