There’s a lot of talk about there about “economic stimulus” and “infrastructure”, but what is “infrastructure”? Traditionally, it’s the basic physical and social structure needed for a society to operate. Roads, sewers, utilities, schools—these are the “guts” of our nation. Without these things, and the pooling of resources they require, we are nothing more than an anarchic collective coexisting on a shared continent. Much of what is defined as infrastructure is about the basics of life—food and its distribution, public health, safety. How is health care not a part of that?
When we talk of investing in infrastructure, we cannot leave out health care. There are basic changes that need to be made to insure the continuation and improvement of a civilized nation.
By whatever means, health care must be available to everyone physically living within our borders. Anything other than universal access is nonsensical. We currently “cover” the uninsured, but in expensive and irrational ways—by forcing them to only seek catastrophic care, burdening us all. Any rational nation must provide basic preventative care (not that we can make everyone use it). This care must be based on the best standards of evidence, and allow patients and providers sufficient freedom to interact, but with some less chaotic form of rationing—one that is explicit and ethical, rather than implicit and punitive.
We know a great deal about what does and does not work in medicine. We are also learning that a fractured and fractious health care system does not operate safely. We must make it easier for physicians to practice safely and rationally. This may mean having universal standards for compatibility for electronic health records, so that a patient’s health information is portable. If I receive a transfer from another hospital or doctor, I shouldn’t have to wait days to receive poor-quality photocopies of records. This leads to medical errors and duplicated efforts.
It also means giving physicians easy access to tools such as performance standards, without punishing them for their patients’ failures. I would love to have easy and portable tools for monitoring the progress of my hypertensives and diabetics, and to be able to see how I measure up against evidence-based goals. This has to be done in such a way that I am not punished when a patient doesn’t follow my advice. It also has to allow me to track information in a way that is compatible with my practice. Currently, I report diabetic data to two separate entities, on two separate forms, both of which are crappy. It’s possible to engineer out “crappy”.
Rational supply of providers
Right now, 2% of American medical grads chose primary care specialties. There are many reasons for this, among them crushing medical school debt and relatively poor reimbursement in primary care. If we want an adequate supply of primary care docs, then we have to supply them, either by changing the market forces by paying them better, or by explicitly recruiting them via strong incentives.
This is just a starting point, but if we are going to pour a trillion dollars into the economy, much of it on “infrastructure”, we would be insane to leave out the biggest ongoing infrastructure cost in the U.S.—our health care system.