On a Tuesday morning, you can witness the same scene unfolding in practically every American clinic. A woman in her late fifties is picking up her third blood pressure prescription this year. As a nurse describes his new statin, a man with prediabetes nods courteously. His grocery budget is never questioned. No one inquires as to whether he sleeps. The co-pay is cleared, the visit is over, and the door shuts behind him. In ninety days, he will return.
In a peculiar way, this is how American medicine has come to operate. Transactional, reactive, and incredibly costly. The United States has the lowest life expectancy in its peer group despite spending more on healthcare than any other wealthy nation—nearly 18% of GDP, with estimates indicating that by 2031, it will account for one-fifth of the total economy. It’s a fact that ought to make people angry, but for some reason it doesn’t. It no longer shocks people.
Other developed nations had already discovered something. Decades ago, the focus shifted from treating illness to preventing it in France, Germany, the UK, and Australia. There, primary care is not viewed as an afterthought in terms of budget. In Berlin or Lyon, a general practitioner is the focal point of a patient’s medical life and is compensated and trained appropriately. They are not merely a stopover on the way to a specialist. Food, housing, mental health, and social support are all regarded as medical problems because, well, they are.
America went in a different direction. Procedures and the things you can bill for in fifteen-minute increments are the foundation of this system. Talking to a patient about their recurring visits does not result in a CPT code. Inquiring about their loneliness, job, or neighborhood doesn’t appear neatly on a hospital’s quarterly statement. Thus, it disappears. All that remains is a machine that has been tuned to measure symptoms.
The trickle-down effect of this is difficult to ignore. Insulin is rationed by families. Because the deductible hasn’t been paid, people put off getting mammograms. Conditions that ought to have been discovered in someone’s living room three years ago are common in emergency rooms. When the bills do arrive, they do so with the casual cruelty of a parking ticket. There is a growing perception that the nation has come to accept this as a necessary expense of conducting business.
Some states have begun to retaliate. In an effort to impose some semblance of discipline on payers and providers, Massachusetts was the first state to establish an annual benchmark for healthcare cost growth. Similar initiatives, such as gathering spending data, identifying cost drivers, and linking growth to local GDP or wages rather than letting it float free, have been carried out by the Peterson Center on Healthcare and the Peterson-Milbank Program in collaboration with other states. These efforts are very unglamorous, quiet, and technical. They may also be the most significant policy initiatives currently underway in American health.
It remains to be seen if any of it scales. The federal picture is still unclear. While hospital systems and specialty medicine merge, primary care continues to deteriorate. There are still gaps in insurance. Out-of-pocket expenses continue to rise. Furthermore, as soon as lobbyists enter the room, the political desire for structural reform usually disappears.
Watching states attempt, however, has an almost hopeful quality. States like Vermont, Connecticut, Rhode Island, and Oregon are experimenting with managing healthcare as a public good rather than a private commodity. They’re not holding out for Washington. They’re not holding out for a flawless strategy.
Perhaps that’s the only way things change in this place. State by state, gradually, until one day the nation realizes it has, almost unintentionally, begun treating causes rather than symptoms. Whether that day arrives is still up in the air. At least the work has started, though.
