Stratego

Why is medical care a mess? Because we keep backing into systems instead of creating them purposefully and with foresight. Medicare, for all the congress likes to scream it isn't, is socialized medicine. It just has a capitalist overlay. When the government tells you how much you may be paid for medical care and supervises their perception of the adequacy of that care, that isn't exactly a free market scenario.

How'd it happen? You have to go back about 100 years to the Flexner Report. Medical schools then were largely local hospitals with doctors who doubled as teachers of basic science. There was no guarantee that what you were being taught was correct or useful. Students were apprenticed to a practicing MD, and after two or three years, if the MD thought them worthy, they were admitted to medical school and taught some scientific principles. Quacks abounded.

The AMA wanted to establish some standards for what a medical education should be, but lacked the money to do so. Not so the Carnegie Foundation. Run by Abraham Flexner's brother Simon, one of it's mandates was to promote quality education. So Flexner was hired to survey the medical schools in the US and Canada.

His background was that of an educational theorist and administrator, and he'd raised the hackles of American universities in a book he'd done a few years before, criticizing the teaching methods of most institutions. His ideal was the German university with its strict curriculum and rigid requirements.

In 18 months he surveyed 184 medical schools and, to make a long story short, in five years there were 32 left, all asociated with univerities. Hopkins was his ideal, as it was already unusual in that their basic science faculty were not MD's but salaried professors of individual subjects. Shortly thereafter, the Rockefeller foundation (now headed by Abe's brother Simon) offered to help Hopkins go one step further, and salary its medical professors, with their generated fees going to the school.

They turned to Abe to set up the adminstrative system to do this. Mr. Flexner had long said that medical schools were essentially pulic service institutions which had to be monitored to make sure they were doing the job correctly. Within 25 years, every medical school in the US ran on Flexner's system with its built in methods of allowing outsiders to decide who was doing what well or poorly.

So when 1965 and the Mill's bill came along, the ability to have governmental intervention in medical schools and MD's was ready to go.

But they backed into it. Instead of having, for instance, a department of medical administration for medicare, they outsourced the admnstration of it to 32 Blue Cross/ Blue Shield orgainzations, 16 commercial insurers, and one private insurer. That's the way it is today.

So with no direct governmental administration of medicare, the congress had to do something to make people think they were on the job, monitoring it. And the agencies and laws began to pop up (COBRA, EMTALA, JCAHO, on and on) each with it's narrow set of criteria, unrelated to any other agency's agenda. And every care delivery system in the US has to prove to these beureaucrats NOT that they are doing a good job for patients, but that they are delivering care in keeping with each agency's requirements. If you don't, you get fined, and in doctor's cases, jailed.

I don't think it can be fixed now. There are too many layers of obfuscatory agencies you'd have to trim away to cut the cost of running a national health system down to a manageable level. And, referring back to my last post. all those agencies want to do is survive. Even if we don't.