Mapping the US healthcare system’s financial flows
healthisotherpeople.substack.com126 points by brandonb 5 hours ago
126 points by brandonb 5 hours ago
It's a truism that America's system was never designed -- it's a patchwork of different pieces that each pay for some people in some situations.
But I've been reading about our system, since I fell down a rabbit hole a couple years ago. Things are bad, yes, but there are actually interesting ideas out there, and real efforts at reform that are being tried.
For example, did you know Maryland has a different way of funding hospitals than most other states? [0] And that other states are interested in copying it?
[0] https://www.vox.com/policy-and-politics/2020/1/22/21055118/m...
A system built as a mish-mash patchwork is likely to be solved by a similar "ground-up" framework.
Each state should be free to experiment (as Maryland has done here) and the federal levels should be restricted to providing funding and basic guidelines that have to be met.
Part of the problem is that as you begin to delve in and see where the outflows are, you start to realize that fixing the fundamental problem involves making the people healthier in general, which will rumble the very foundations of Wall Street.
One of the great powers of federalism is not having to duplicate efforts for every state. It also reduces cost by allowing 'one-size-fits-all' and economies of scale, rather than each state having its own bespoke whatever.
Many countries around the world enjoy the benefits of coordinated public health departments. Part of the United States' poor response to COVID was because there was no central public health department that could work closely with state agencies to e.g. provide data about what's going on, share best clinical practices, etc. Each state is an island.
So no, I don't agree that the only goal of the federal government should be piggy bank. States should have a lot of latitude with their policies, but generally standardizing things across the nation would be a net positive.
Many countries around the world are the size of US States. The UK and Germany are only twice the size of California, for example.
The problem in the US isn't that we can't do things, it's that nobody can agree on what to do. And to solve that problem, let states do their own thing as much as we can, and it'll become obvious where the good systems are.
Or in other words, an argument needs to be made why the EU "works" with individual "states" doing their own thing, but the US cannot "work" unless it's considered as one large country.
This analogy is quite misleading, because, in addition to California, there is also Wyoming, with a population of less than <600k.
> analogy is quite misleading, because, in addition to California, there is also Wyoming, with a population of less than <600k
Wyoming has the population of Malta [1][2] but the GDP/capita of the United States and Norway [3][4]. It should be expected we'd have a different optimal solution from California.
[1] https://en.wikipedia.org/wiki/Wyoming 588,000 in 2024
[2] https://www.worldometers.info/world-population/population-by... 545,000
[3] https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ... $90,000 in 2024
[4] https://en.wikipedia.org/wiki/List_of_countries_by_GDP_(nomi...
Sure, but fighting the impulse to solve problems at the Federal level that could/should be solved at the State level doesn’t preclude individual states from building multi-state solutions together.
More of these exist than people realize - and are a great way to "latch on" to the success of another program.
It's the general knee-jerk reaction that's brought out whenever people try and have modern ideas for the US, like modern healthcare or high-speed rail. "B-but, it's so big!"
Scalia was right in saying that the checks and balances slowing things down is a feature, not a bug. The Framers were right about protections against faction. I’m not sure they understood how badly malicious schemers could deliberately manipulate the system. Things just aren’t getting done, and it is killing people.
Half of the problem with American politics these days is people from blue and red states trying to force the entire country to become one giant blue state or one giant red state.
It's too big for one-size-fits-all answers. Every state should be able to largely do its own thing as long as it isn't violating the Bill of Rights.
If you look at some of the more controversial bills being passed in the states, they're also being more or less lifted out of national political action committees and think tanks. Extreme in-state gerrymandering (supported by national party organizations) has effectively nationalized big parts of state politics in those states.
I've spent the majority of my adult life in Washington State and I've witnessed this firsthand. This place used to have a unique vibe that was more purplish-blue "granola hippies with guns that just want to be left alone." Progressivism mixed with an Old West libertarian streak. There was a GOP minority, and the red east and blue west played off against each other and kept things reasonably center-left.
Now it's a one-party state, and the legislature might as well be the state Parliament, taking its marching orders straight from the DNC. The Governor is just as all-in on drinking the blue Kool-aid, and the state Supreme Court seems like it only exists to validate what the other two branches decide. And looking at places like Texas and Florida, seems like the same is happening on the other side of the aisle.
What's infuriating is there are conservatives in blue states and liberals in red states getting just steamrolled to the point of "why should I even vote or participate, when I'm just going to get told to sit down and shut up?" That's not healthy for democracy. The rights of the minority exist for a reason and you can't just vote things away because you have 50.01 percent of the vote.