There are numerous systems in the U.S. that were designed to serve people according to their needs. Many of these systems have been overloaded, stretched beyond reasonable expectations and are dysfunctional to the point of being, for many consumers, a negative experience. The three that I will mention are among those where many of us have years of experience, some of it quite positive and productive, and in the past several years, not measuring up to adequate.
The first system is health care and medical practices that have become driven by a bottom line, for profit, corporate mentality. Many of them are held captive by the insurance companies, another system that is also motivated by bottom line. Corporate organizations are important in our culture as they are the drivers of the economy. However, when profit for stockholders becomes a priority over serving people, we see conflicts arise. Exhibit one is United Health Care’s profits in 2021 at 24 billion dollars. The CEO’s salary, including stock awards and other forms of compensation for 2022 was over 18 million dollars. Insurance companies tell doctors and hospitals what they will pay, the docs and hospitals charge more than that and then they negotiate to reach an agreed upon price.
Physicians dealing with insurance companies often hire full-time staff, beyond nurses and front office managers, to complete all the paperwork to collect money from the insurance companies and that adds to their overhead expenses. In addition, many large practices have a contracted third-party finance company to track and follow billing procedures.
Another challenge for physicians is how many patients they can see and deal with on an average day whether it’s an office visit or a surgical procedure in a hospital or clinic. That number in an office may be as high as 40+ and in surgery 6, 7 or more depending on the nature of the procedure. A VA hospital may limit the number of patients on one day for one physician to as few as 8 so that 45 minutes is scheduled for the visit and 15 minutes for the follow up notes for the paperwork. That is one of the big differences between a hospital and practice that is for profit as opposed to a government sponsored, not for profit operation. Doctors who would like to spend more time with patients are frustrated by externally imposed limits of payments for office visits, procedures and days in a hospital.
Many hospitals had their origins in non-profit religious groups that over time could not keep up with the changes and gave up control to the corporate entities. The U.S. is unlikely to consider a national health service because we are captive to a capitalist, corporate controlled market. Nashville, Tenn.-based HCA Healthcare, a 182-hospital system, posted a net income of $7.7 billion in 2021, including investment gains and operating profits. HCA also had the highest net patient revenue among the top 10 hospital corporations at nearly $44 billion dollars.
A second dysfunctional system is made up currently of two divided political parties and a serious lack of collaboration and cooperation. They oppose each other vociferously in campaigns to get elected and then continue to voice their differences and conflicts openly and often through personal attacks, opposition and objection that lead to further separation and division. What we have witnessed in the past six years is the culmination of years of growing apart rather than together and it’s likely to get worse before it gets better. While many continue to call for a government that was signaled by Abraham Lincoln, spoken at Gettysburg, to honor the soldiers that sacrificed their lives in order “that government of the people, by the people, for the people, shall not perish from the earth.” These words apply as well to the countless soldiers that died for the cause of democracy in the following 150 years. Democracy is a living system of government that can only prosper by being reinvented again and again. It can be strengthened by a referendum if a question can be answered by a simple yes or no. But it is not that simple.
Elizabeth Powel of Philadelphia, friend of George Washington asked Ben Franklin. n 1787, “Well Doctor what have we got a republic or a monarchy ?” – “A republic, madam,” replied Franklin, “if you can keep it.” What we have today that is a threat to our democracy is not some outside enemy but rather the uneducated, misinformed and misled percentage of the population who believe what is said without any regard for whether or not it is fact as opposed to fiction. That and so-called leaders who are not leading but falling in step behind a failed presidency that spawned an insurrection.
A third system is education, both public and private, preK-16 and beyond. Teachers, who are expected to help students become excited, motivated, creative learners and doers, are woefully overworked and underpaid. While many recognize and acknowledge the important role of teachers, they have been weighed down by bureaucratic expectations of measuring success by standardized test scores and not by how students become productive, contributing members of their schools and communities. We have also witnessed a recent spate of parents wanting control of the curriculum which will put many teachers at odds with the parents of their students. The elephant in the room is what is referred to as CRT or critical race theory and whether or not history as it stands will be a staple in schools’ offerings.
While there are many notable exceptions such as STEM and STEAM, we have not moved that far from standard classrooms with students in rows or around tables, teachers by grade levels and subjects and in buildings that resemble prisons. The way that learning is catalogued and teaching is categorized has done little to move education to the forefront of exploration, discovery and the application of ideas that make up a transformative experience.
Just because students spend however many years in school does not mean they receive an adequate education and when you examine today’s population you find noticeable gaps in their understanding of the basics of language, history, science and the arts. In the U.S., public elementary and secondary schools are spending $11,070 per pupil for a total over 10 billion dollars annually. Expenditures are equivalent to 2.84% of taxpayer income. In 2019–20, U.S. degree-granting postsecondary institutions spent $671 billion (in constant 2020–21 dollars). Total expenses were $430 billion at public institutions, $228 billion at private nonprofit institutions, and $13 billion at private for-profit institutions. People need to ask what the results are for both personal and public spending. We are capable of doing better in all of these systems. In the next post, we’ll look at some options for improvements in all three systems.
It’s partly about how much these systems cost and how much is spent. It is also about the quality of the service as well as the outcomes.