How to Fix US Healthcare

and why I should work on the Trust Assembly instead of getting mad at Taylor Lorenz

Would you rather do good for someone, or have someone feel like you did good for them? It is one of the most painful facts of the universe that those are not always perfectly overlapping circles in the Venn diagram of life. When these two circles diverge, in the first case the person typically hates you at least for some period of time. Maybe even forever. In the second case, you end up in some kind of codependent doom spiral. Your drug addict cousin will really love bomb you for giving him fifty dollars, and he’ll probably say some really nasty stuff if you force him to go to rehab.

Here’s the same question at a larger scale:

Would you rather contribute to the success of an organization or have everyone feel like you contributed to the success of the organization?

Say you work somewhere as the boss. The numbers just aren’t adding up anymore. The market has shifted. Technology has changed and everyone else is doing more with less. The old way of doing business no longer works. You’re losing money. The finance guy comes to you and reports that you can stay this way for about two more years and then you’ll be bankrupt. Every day that ticks by gives you less maneuverability to get out of it. The choices are limited. You can stay the same and lay everyone off in two years when you go bankrupt, or you can make the cuts right now and potentially keep a smaller number of people in steady employment indefinitely.

In your deepest heart, which one do you know to be the right choice? At the same time, how easy is it going to be to push that hard and be hated that much?

People fail this test all the time. I fail it all the time. And even knowing that, I know I will continue to fail it all the time.

So, let’s talk about economics.

There’s a story everyone at the sawmill used to tell about the company negotiators informing my uncle Bruce, who was the union lead, that the wages requested in that year’s contract weren’t competitive. In economic terms, what that man meant by “competitive” was that if you looked across the region at everyone who worked in a sawmill that the figure being requested in the union contract was much, much higher. In my dad’s mind, the negotiator was telling him that he was a loser who would just give up rather than try to win. My dad thought “competitive” meant the kind of fighting spirit you brought to the field to win football games.

So, my dad stood up and told the union negotiators that he would show them what it meant to be competitive. He would be waiting outside the conference room and they were all welcome to come out, one at a time, and he’d beat the shit out of each and every one of them. Then, when he was the only man left standing, they would be able to see how f—ing competitive he was. But with a lot more cursing and probably having some other men hold him back. I’ve heard multiple people say that my dad spit in someone’s face, but he denies it.

This was not a show. When my dad tells this story now, over thirty years later, he still gets red in the face and fired up. My dad would definitely have beat the shit out of all of those guys. In this particular respect, my dad is nuts.

This is just how my dad is, though. My uncle Bruce knew that, and the whole reason my dad was there —although my dad still doesn’t realize this— was to be the guy who freaked out and threatened to fight the company negotiators. The first proposed amount was never going to be the real amount, which my uncle Bruce also knew, but he did get a higher number than he expected because the negotiators were so thrown off by my dad that it ruined their strategy. That made anything my uncle Bruce said after my dad was kicked out sound incredibly reasonable. My dad not understanding economics turned out to be a really good negotiation strategy.

Now, here’s a twist. My dad was fired for this. He literally threatened a whole bunch of guys who worked at his company in a room full of witnesses. Of course they had to fire him!

I would have fired him.

And then they had to un-fire him.

My dad was fired and then immediately re-hired something like seven times in thirty-five years.

Why?

Supply and demand.

Oh, the union played a roll but the reason they had leverage to do it was basic economics. I grew up in a town with a population of around 16,000 people. About one-thousand of those people are homeless drug addicts. Probably about another 4,000 to 5,000 of those people are disabled or otherwise suffering with an untreatable mental illness that makes them unable to work. By the time you account for age, gender, and physical ability my dad was the only game in town to do his job. The labor supply was too shallow to replace him and the mill always struggled to stay staffed to meet production demand. My dad had a temper, but he was a good and reliable worker. They couldn’t afford to keep him fired.

My dad always told me that economics was evil. It turned out, economics is a saw that cuts both ways.

Very few things make me as frustrated as a total refusal to engage with economic realities or to learn anything on the subject. It’s frustrating as hell because at the same time I write those words down, I can emotionally recall my own reluctance. When I first read an economics book in high school, it felt like opening the Necronomicon and learning the secrets of hell. It seemed like stuff that only the rich republicans who lived on the hill where it never flooded were supposed to know about. Buying stock? Diversification? Risk management? Why not just go make a deal with the Devil?

What that book told me, though, is that the reasons I thought we were struggling were not the actual reasons we were struggling. And unfortunately it was undeniable because the concepts were so clear that it was like watching a bunch of puzzle pieces snap together. The problem is that so much of it is counterintuitive. You want low rents? Economics says don’t pass laws that say the rent has to be low. You want wages to be high? Economics says don’t enforce a minimum wage. None of that feels like it should be true. Economics is like learning to drive into the skid when your car hydroplanes. Every part of your body tells you to turn your wheel away from the direction of the skid, but the only thing that will actually save you is doing the thing that your every instinct tells you is more dangerous.

I used to think economics was a game that was made up by rich people to justify screwing people over, but that’s not the case. Economics is just part of the universe. Economics is just what happens when there’s limited stuff to go around and more people want it than can have it. Whether you choose to give it a name or not, it’s what happens. There are patterns that repeat over and over again, across time and cultures.

People talk about it like it’s a saw that only cuts one way, poor against rich. But it works for poor people too! It frustrates me that poor people don’t know this! When people who know a lot about economics on the wealthy side say things like “wages are too high” I want to laugh, because in a free market there is no such thing as a “wage that is too high.” People should laugh at them for saying that! Your wage is as high as allowed by the demand for your work. That’s something that’s as true for the hourly retail worker as it is for the CEO. Limited labor supply? That’s another way of saying higher wages. If you know how the patterns work, you can make sure you live in a pattern where the common person has a good wage. If you don’t, you’ll only ever end up in that position by luck.

If you want to “get even” with rich people, read a book on economics. If you want to help the underclass, read a book on economics. If you want to fight for the downtrodden and the oppressed, read a book on economics. This is by far the greatest knowledge you can give yourself to provide actual, durable improvements to the lives of other people.

Why doesn’t this happen? Well, the trade off is that unless the people you’re going to help have also read books on economics, they’re going to think you’re being a huge dick and that you showed up to make their lives terrible. You’re the guy showing up to remove the rent protection laws, the minimum wage laws, or whatever law intuitively feels like it’s saving everybody. They’ll call you a class traitor and friend of the rich, etc. People in my own family have done it to me because I literally just tried to help them open a 401k account. Even when I offered to put money into their account just to get them going! I might as well have gone into a Puritan village a couple hundred years ago and proposed worshipping Baphomet.

Which brings me to the topic of health insurance.

Your intuition is that all of this would be better if it was free. In health insurance, let’s say you run the business for no profit. “Free” here means it’s all paid for from taxes. No investment, no growth. You push all the money you get back into paying for care. Good right? Surely, that would save a ton of money! Right?

Now let’s do the counter example where you run the company to make some money. Insurance companies have very low rates of return. Something like 3.3%. So when people say “Why didn’t the insurance company only pay $100 dollars for my grandma’s medicine when they had $103! That $3 would have made all the difference!” they’re usually leaving out the numbers because that doesn’t sound right to you, does it? You know that the $3 doesn’t mean that much to the treatment, but that $3 is the difference between an expanding enterprise that can attract investment and make improvements, versus a stagnant enterprise that will never improve. If you found out an insurance company denied 30% of claims, but only had a 3% profit margin, you start out right away knowing that it wasn’t ever possible for them to approve all those claims. There was never enough money to do so. It takes the wind out of your sails on finding an easy fix.

I’m going to explain to you in a minute why this is still wrong and insurance really is a bad model for healthcare, but it’s differently wrong than you probably think that it is.

The fact remains, however, that if you choose not to think about this stuff that you will probably feel great for some period of time. A feeling like you really stuck it to the man. People will call you a hero for saying things like, “there should be more goodness and less badness in the world” and they’ll never actually try to understand how you’re going to bring that about. You’ll demand everything be free while people throw rose petals before you. Your intent will be all that matters to them. Then you’ll end up killing an almost unfathomable number of people.

This is the other reason I get frustrated. Not at kids, or lay people who spout this nonsense, but professionals who should clearly know better and must have been told better in their career. This has played out in history, again and again. If you went to a good school and paid attention, you can’t just pretend this isn’t real. Unless you’re pretending to yourself to make people like you instead of doing your duty to be honest. Ignoring economic realities gets people killed. It gets them killed in enormous numbers. And because of that, I honestly have no idea why saying you are “anti-capitalist” isn’t something socially akin to declaring full-throated support for Nazism.

It’s a different way of saying, “I am willing to bring unimaginable suffering and death upon the world so that people will tell me that I’m great.”

Okay, so why does everything suck then?

Suck is a relative term. You live a life that in some ways a king from two hundred years ago couldn’t even imagine. You can take a hot shower. You can make ice in your home. The temperature can be whatever you want. I won’t go so far as to say that the king would trade places with you. That king had more prestige and respect and other things that might be more valuable than creature comforts, but tangibly? You have better healthcare than that king could imagine and it isn’t even close.

Most people “on my side” stop here. If you’ve encountered this argument before and someone said “be grateful that at least your mom was high on morphine while she died” I’m sorry. I’m not actually on that side.

My real side is that this is the United States of America and we should enjoy such incredible prosperity and efficiency that it’s almost embarrassing. People should feel a social stigma about asking an American how old they are because we age like elves in Tolkien. American medicine should be so good that it feels like you drank from the Holy Grail ten seconds after you got into the hospital.

Your great grandmother should have a 150 year birthday party and then be in such great physical health that she takes a long and unassisted after dinner walk with the whole family. Her hair should be only a little gray.

Things should be better and we should work to make them better.

So, how can we do that?

Step 0: Recognize that the Whole Concept of Health Insurance as Currently Legally Mandated No Longer Makes Sense

Health insurance used to be dirt cheap. Some of you are snidely smiling and retorting, “yeah, but look what it covered.” Those snide smilers have a point. Health insurance used to be dirt cheap because it only covered horrific catastrophic things that almost never happen to anyone. Weird accidents and freak diseases. Or at least, things that happen very infrequently compared to how frequently you pay your premium, so that by the time it happens to you, on average you’ve basically paid in the whole cost of the treatment over time. That is, health insurance used to be cheap because it was actually insurance. What we have now is not insurance.

Insurance is when everyone pays a small amount of money into a giant pool that is then used to pay out for very expensive but infrequent events that everyone is trying to avoid. That giant pool of money can exist and be cheap because the risk everyone is trying to avoid doesn’t happen a lot. Car insurance works this way. You don’t want to get into an accident. You mostly don’t ever get into an accident. But you pay a little bit of money “in case” you get into an accident, and everyone else does to, so whoever gets unlucky doesn’t have to pay for a whole new car by themselves. To be clear, your money is consumed in this process. The insurance company uses your money to pay for their operating expenses and to cover the cost of the new car for the unfortunate person who got in the wreck. They are legally mandated to pay out a certain portion of their premiums as claims. They must do this. Insurance companies post very low profits because of these requirements.

Healthcare doesn’t follow this model. You will use the doctor. You will need routine care.

What we have now with “health insurance” is a weird mandatory subscription and couponing service that annealed out of a bunch of independent steps that made sense to the people taking them, but when assembled together became Frankenstein’s monster. No single person invented this system. Some of this stuff goes back to weird price controls that happened after soldiers returned from WWII, and from that one event we still have your health insurance tied to your employment. Then it became a game of “add this one more thing to insurance coverage, because this terrible thing happened” until the whole thing became bloated. It has perks, yeah. We get faster and better quality care than people in other countries, but it is also massively more expensive and we get worse overall outcomes. It could be better in so many ways.

You will be going to the doctor. You will need medicine. That is not a situation where insurance is the appropriate mechanism.

Step 1: Make Insurance Insurance Again

Health insurance didn’t cover your regular all around medical expenses several decades ago. It covered things like you needing to be flown to a trauma center in a helicopter because you got into a car accident on a mountain in the middle of nowhere, or your kid having a weird bone cancer.

Health insurance needs to return to that model. It should be nowhere near regular everyday, routine care. If you’re not going to an emergency room for an extended stay, or fighting to keep yourself out of an emergency room, whatever you have should not be covered by insurance. Why? Because that 3% profit margin I mentioned above for the insurance company is a lie. Well, not quite a lie but it’s missing all the context you’d need to reach a good understanding, which I still classify as deceptive. Your health insurance company is also going to take another 12-13% of your premium to pay salaries and other operating costs. So it’s more like 15-16% consumed by the insurance company from the amount of money you paid in through your premiums.

In an insurance context this is fine because the events they are planning against are infrequent. This sounds horrible, but it’s actually really good that you don’t call your disaster insurance company up all the time because if you did disaster insurance would be much more expensive. Their overhead costs would blow up. In the context of something you will be using, it’s… well insofar as it functions like insurance because your kid got leukemia, which almost never happens, it’s great. You drew the unlucky straw and insurance was there to protect you. Insofar as you are going for regular check-ups, a broken arm, etc, it’s a scam. It can’t not be a scam.

Having another person standing in the middle of your every single medical expenditure means you have to pay both for your medical care plus the cost of that person standing there keeping track of it all. But still, that’s not all. Who else has to get paid to deal with your insurance? The care provider. Your doctor has to deal with all that crap, too. They’re going to spend 10% of the total revenue they bring in just trying to settle with your insurance company. That means the cost of your care was inflated by another 10% to cover those expenses.

We’re now up to 25% of the total costs of your care being inflated because of the insurance model. But it’s worse than that, even. This billing model creates opacity. Nobody can see how much something is going to cost even if they want to. A dynamic dance between your healthcare provider and the insurance company has to take place first. Most health care companies can’t give you a transparent list of prices for what their care will cost. Imagine you went to go buy a coat and you were only allowed to pay with coat coupons. And the coat might be entirely free or you might have to pay for the whole thing. Or only part of the coat. You don’t know. Also, no one is sure how much the coat itself costs. This should be illegal. In fact, I’d argue it’s extortion. It’s terrible that we are in the position.

What that means, though, is that hospitals and doctors don’t have to compete for your business. They don’t have to lower their prices to match the costs of other hospitals because you never got told the price. You can’t even ask for the price a lot of times. Right now, there’s a predator-prey relationship between hospitals and insurance companies to inflate the costs of care so that payouts are bigger and premiums can be higher. Nobody has to try to make this happen. Nobody even tried to make this happen. It just did and then nobody tried to fix it. Costs keep going up on each side, and both businesses fight tooth and nail to stay afloat. This is what I mean by being frustrated about economics education. If all the incentives point in the right direction, what is incentivized to happen is just what does happen.

This is very easy to see if you ask the right question. Next time you get a medical scan on an expensive piece of equipment, ask what the cost is to use the same piece of equipment to perform the same scan on an animal. Your technician won’t know, but just call a veterinarian and ask. Pretend your dog is sick. Veterinarians use the same equipment, albeit in different settings. But most animals don’t have insurance and veterinarians have to compete for business. If someone quotes you a higher price, ask them to subtract the cost of anesthesia for the animal unless a human would have to get the same anesthesia. You’re usually looking at something like a 50% reduction minimum. For the same equipment and the same level of technical training.

How much do you think it costs to give a round of antibiotics to a cow?

My wife worked at a hospital and my sister is a nurse. A lot of what you think the hospital spends money on is wrong. A lot of it is trying to get money for care they already provided, increasing prices to cover the times they were shafted, and administrative bloat. Even so, hospitals post profit margins less than 1%.

This is what I mean by supply and demand being a saw that cuts both ways. Because you don’t know about it, you don’t know how to make it work for you.

So what do we do?

Blow this shit up. Throw a stick of dynamite upon it. Make insurance be insurance again. Get rid of the middle man for your everyday care. Run for cover.

Step Number 2: Align Incentives for Regular Care under a Subscription Model

When a bunch of doctors and nurses and specialists come out of the rubble of the substantially reduced insurance industry, they are going to rightly say, “hey this won’t work because we can’t handle the volatility of payments to services and people not coming in for care will reduce overall health outcomes.”

As a quick note of apology, in a perfect world it’s better if you just save money and go pay places one-off for each piece of care you need. That is maximum market efficiency. However, in a world of friction and limited foresight, most people would fail at that and it would be politically and socially non viable. The thing people can’t handle about medical expenses is that they are extremely volatile, where you don’t pay anything for years and then suddenly you owe half of a year’s wages all at once.

The problem is budgeting. Have you ever tried to make a budget work? That single question separates “who cares” from “I just came to this rally to try to score chicks” really quickly. Budgeting sucks. Projecting costs sucks. If you ever want to have career immortality at a business, drink the blood of learning how to do budgeting because it totally sucks and is like having your skin peeled off and laid out under the sun for a thousand years. Nobody wants to be responsible for it, including me. I like product development. Still, someone has to do it. Your hospital probably frets a lot about things like cash flows and pay periods and all kinds of other junk. It’s a headache. It also drives up costs because you have to account for periods where no money is coming in.

But it shouldn’t be a headache.

Remember, you are going to go to the doctor. It is going to happen. And you don’t want to get one single massive expensive bill when you go. Most people don’t break their arm every weekend. Nobody wants to do that stuff.

For your everyday care, grab that shellshocked doctor and say, “we are replacing the insurance model with a subscription model. I am going to need care and I will be paying you something like a retainer to be ready to provide that care. We are creating a legal framework for healthcare providers to create networks for care and people will pay you some amount of money each month directly to you. There is no middle man in this and cash flow will be steady and easily predictable. You will be able to balance your material and staffing costs against the population you are servicing to come up with an easy number. This framework will include incentives to make sure you are doing the right thing. You will be able to buy reinsurance in case you have cost overruns.”

What do you think your doctor would say to you that would be different if their paycheck depended on you getting good and affordable healthcare? Most of my time with my doctor is them checking boxes to be able to bill the insurance correctly. I talk to them for maybe five minutes. Under a subscription model, the total cost to the hospital network you subscribe to is going to be the sum of all the subscription revenue minus the cost of your care. That means my doctor has a stake in me being healthy all the time and me not being a drain on the system. My doctor becomes maximally incentivized to provide me with good preventative care at a low cost.

Hold on. Did fat positivity just vanish? Poof! Just like that? Right into thin air?

Wait, your subscription to the hospital network comes with a gym? They will haul gym equipment to your house? And they offer some kind of discount meal service? Why would they do that? Because the cost of making sure you have a healthy heart is a lot less than paying for you to manage a heart condition. They’ll do it out of economic necessity. Hell, what if a guy with an Ozempic blow dart gun just hung around the entrance to a Sizzlers?

But more than this, if hospitals have skin in the game this way it creates a powerful lobbying interest to make sure what you eat is healthy and drugs are cheap. There’s an industry that has skin in the game to keep you strong and fit. It makes them very interested in the quality of care you receive and the efficacy and cost of drugs. Did you know most people with high cholesterol can just reduce that with red rice yeast you can buy at Costco? The care providers themselves, right there, with boots on the ground with real time feedback can make decisions. You could have all your drugs in a paper bag waiting for you at checkout. And because they hold the money it also makes them a natural enemy of the drug companies driving up prices.

No more shoving a pill in your mouth at the drop of a hat. No more pharmaceutical company salesmen coming into the office to sell your doctor on only providing an expensive pill when there’s a cheap generic. The doctor will want you to get the cheapest medicine possible, too! No more weird Byzantine rules about medical testing. If your doctor thinks you need it, they order it. People start to do super obvious things, like run the medical diagnostic equipment around the clock, which only makes sense, so while you have someone using an MRI at 2am, the whole thing runs at like a third or a fourth of the cost. Probably some of these care networks will even offer the cheap concierge service like those available in other counties there every few years they just give you every test. Just in case. There’s no reason this couldn’t happen.

Every network should have surgeons, internists, GI’s, dentists, etc. They all get paid some consistent amount of money for being part of the network. They get financial security. You get to have someone waiting there when you need care and no giant, unexpected bill at the end. There aren’t really “referrals” as such, in the sense nobody has to approve you going to see a specialist. Your doctor just has a relationship with you and says “Oh yeah, let me set you up with an appointment to talk to Bob in the app.”

Now, on top of this, you have to layer in some mandatory legal framework to make sure the hospital doesn’t just deny you all the care. Something like, “improve this metric by this much or you can’t pay bonuses, etc.” There needs to be a board of non doctors who don’t make money from this system providing oversight with checks and balances. That part gets complicated but mostly just giving people freedom of movement and choice solves this problem.

Get hurt while traveling? That’s okay. Your care network itself can have an insurance policy to keep you covered. The hospital network had a really bad event and overspent? That’s not great but it’s okay. The network has insurance.

Step 3. Make it Default Easy to Save for End of Life Care and Create Cheap Medical Credit

I don’t like this part, but it’s true.

You’re going to die. It happens to everyone. And you should be able to die, at home, on a mattress, high on morphine. When it happens, it shouldn’t take all the money you have ever made in your entire life to do it but facts are facts. Multiple years of your earned income are going to be consumed in those last few years of your life. To account for that, some portion of your paycheck should just go into a tax free low-risk investment account that is a major headache to make withdrawals from for anything other than medical costs. Every incentive should point to you contributing to this for your entire life.

I do think you should be able to opt out of this, but by default you should be opted in, and it should be a big headache to opt out.

If you do opt out… well, I mean, okay. Go hang yourself if you want. It should be hard enough to opt out of this that people will feel okay about saying that to you if you get hurt and buried under a mountain of debt. Feel free to mess up your life, I guess.

If you opt in and the pay the minimum, then something like overdraft credit can kick in. Just keep making the payments you were making, and it will all balance out based on the bond rate, and people dying without using the whole amount.

This is inflationary by the way, but you’re going to have balloon costs for end of life care and you are going to end up paying for them one way or another. In my ideal future, a self-driving car takes you to and from medical facilities, and robots help you go to the bathroom give you pills. That’s affordable because you’re only going to use them for a few years before they go to the next person in the line to die of old age.

This can also only exist in the context of price transparency, where you have a medical care subscription and major disaster insurance covering all your expenses up until this point. Because you have money when this happens, a market will be created to provide at home care for you because it will benefit from network effects of other people making the same kind of choices. Think of it like a distributed nursing home.

Step 4. Create a Treatment-Based Bounty System

Medicare will still exist because we can’t get rid of it, even though I think we would probably be better off without it. Government funds inflate costs for everyone. That’s true for college tuition and it’s true for the health system. As soon as dollars become infinite so do prices. That’s another one of those counterintuitive things, where you go in with good intentions to solve a problem and then made it way worse by giving everyone free money. That said, we won’t ever be able to go through the bloodbath to get off it and I’m not heartless enough to try. I’m also not going to watch your grandmother die because in ten years it will be so much cheaper to treat other people’s grandmother.

How do we save money on this? Think of a “Wanted” poster in the old west, except for disease.

Take the top ten or however many medical concerns that are draining the most funds from Medicare and create a bounty system for the creation of novel treatments. If you can create an Alzheimer’s treatment that can meet xyz milestones, improving outcomes and lowering costs, you get the bounty. This should be a lot of money, proportional to how much it costs for us to pay out for the costs of care. Way more than a researcher could ever get from selling to a pharmaceutical company. Maybe even the entire yearly cost to the system to pay for it. The research group gets to claim the bounty and get the money but the government keeps the patent. That amount of money should be instant billionaire status kind of money.

The way this works today is super screwed up.

Today, very often government grants are given to research labs, the research labs do work, and then they sell the patents to pharmaceutical companies. This isn’t always the case, but it happens enough to be irritating. The pharmaceutical company then has monopoly power over that drug and can charge whatever they want. They’ll say they have to do this because they need to cover the costs of development for other drugs, and that’s sort of true but is only half the picture. The approval process takes years upon years and everyone involved has every incentive to lie and overstate efficacy along the way, because the alternative is saying they wasted twenty years of their life. The government spends the money and doesn’t even get any reward!

A bounty system aligns incentives. It makes economic incentive for curative treatment instead of palliative treatment. The picture is simple and clear. We are spending money every year. We are willing to spend a lot of money upfront to spend less money over time. That’s basic economics and it cuts out insurance companies and pharmaceutical companies as middle men and removes monopoly power. It lets us keep the benefit of stuff we are already largely paying for. And it gives the incentive directly to the research scientist, who I assure you can be kinda… lazy? Maybe it was because I was in a lazy lab but when I worked in a research lab it was just kind of… very grab ass.

If you put this much money on the table you get driven people to enter into the research field. Say goodbye to being an MBA with a 150 IQ. Start looking at molecules. Money is in molecules and we can have a streamlined approval process. This isn’t to replace the private market for doing this, and I think we will have some great companies using AI, but if the government is paying for research grants, then people who fund the government should see the reward. Namely us, the citizens.

This creates an economic winch that drives down prices even more consistently, for as long as people get sick. Pharmaceutical companies lose monopoly power. They have to compete on manufacturing prices. That means every drug is manufactured as cheaply as possible, approaching the cost of the chemical components. The cost of development is shared across the entire population.

The big money is purely on the research side. Create a legal framework for college support and profit sharing but which forbids pharmaceutical companies from participating. Government money should never be used to create a monopoly. Giving the participating scientists the right to admit or not admit members into the group keeps the researcher quality high. The successful researcher can take home the biggest payday but this way not everyone gets screwed because they chased the wrong treatment. The losers can still get some of the value. You want people who have spent decades acquiring the needed knowledge to actually try to reach for the brass ring. Most of them are going to miss, but the one who catches it will lift up all of humanity and the ones who failed aren’t chumps. It’s hard to make medical treatments and you need many, many people trying to get the few people who succeed and redeem the system.

We can even have treaties with other countries to help pay for the bounties. They can either contribute to the bounty or pay us for the intellectual property when they use our drugs. No more of this shit where we pay for the development costs and don’t get the benefits anymore. No more of this scam where other countries take our drugs and drive down prices and shift costs back to the US.

Step 5. Give people with no hope the right to try, to speed up the research loop

If you’re going to imminently die of cancer, you should be able to inject anything into your body you want the second after someone put that chemical in a gorilla and the gorilla was okay. I like gorillas but I like people more.

A doctor literally did this recently when she got cancer and cured herself. But everyone was mad she didn’t follow bureaucracy. That’s… well, stupid. People should be able to make an informed choice with many treatments laid out and strong laws about what the doctors have to tell you. You should maybe even have to pass a test to be able to do it, but you should be able to fight for your own life.

If I ever get cancer that is resistant to other treatments, I am showing up at that lady’s office and slipping her a hollow book full of cash and I am making that happen.

Step 6. Standardize and AI Optimize Medical Data as a Public Good

AI requires a lot of training data to be good. So what if all of your data, pictures, blood labs, etc, were fed into a giant model along with everyone else’s and we built a really good medical AI assistant? One that kept improving because the medical records were all standardized for optimal training? You could have a phone app that tells you if your mole is something you need to worry about.

That would be so goddamn cheap.

Because AI requires giant data sets, likely more than a single hospital can produce, there is extreme value in coordinating the formatting of the records. This is something government could do well enough to make a huge difference.

Pass legislation requiring all medical record software to make data exportable in this fashion. Make the data anonymous apart from demographic data. Have money captured from this go back to the people who are contributing their data to the system.

This also makes it very easy for you to show up somewhere and have your records transferred in a way that another hospital can know your entire medical history.

Step Whatever, but Remember to Love People more than you Dislike the People with whom you Disagree, which in my case is Taylor Lorenz

I am writing this because a guy got shot in Manhattan and people thought it was awesome. I also wrote a little bit about it before but nobody read me back then. Joyful memes have been everywhere. That guy was the CEO of United Healthcare. I don’t really know that much about him other than that he was somebody’s baby at some point and there was an ongoing lawsuit, which the public at large has already judged and found him guilty.

I also know that he didn’t invent people getting sick or dying of old age or poverty but people spat on his grave and pretended like he did. People said stuff like he denied 30% of claims but never added the context that the company was running a profit margin of 3% and that there was never money to pay for all of those claims. Or that even if our healthcare system was ten times better you would still have plenty of stories of horror about what happens when someone was destroyed by illness and nobody could do anything about it. Do you think it will ever be perfect? Even if it was much better people will still show up at the hospital and find a doctor struggling to say, “I’m sorry, there’s nothing we can do.”

I get being upset if you don’t know better. Spout off by all means if you never put yourself in the position of trying to figure out how to make all of this work. If you do know better because you went to a good school where someone certainly taught you about economics, then I mean… well, I’m upset with you, but I bet it feels nice for everyone to tell you that you’re a great person. No, let me be honest. I gotta admit, I’m not proud of it, but I hate you a little bit for saying something that I’m sure you have to know is a lie because it makes people like you more when you lie to them.

You’ll have to forgive me if I roll my eyes when I see someone seeking applause for saying that they want more goodness and less badness but they don’t have a specific idea on how to make that happen. You want more goodness? AND you want less badness? Wow. Amazing. That’s really not a position or a moral argument or a statement about morality. Deep down, everyone knows that.

When I was young, Democrats were the party of the working class. They were the party of labor unions. The working man. On the entire Olympic peninsula, no one was even allowed to own a Husqvaarna chainsaw because they were coded as Republican. You had to own a Stihl, or you owned nothing. My dad is still a staunch Democrat, even as the party has moved away from him. He remembers striking and Democrats having his back. He’s still living in a world decades gone.

The Democratic Party from my youth no longer exists. This isn’t a tangent. I think the reason the Democrats are suffering right now is because of this shit.

There’s a meme on the left today that goes something like, “I am super loving and compassionate and I care about people so much (beat) that is why I want to slaughter thousands and make a pile of dead bodies and stick my enemy’s head on a pike as I bathe in a river of innocent blood.” I saw the same reactions on October 7th. I wish this was an exaggeration. I’m not saying it’s the entire Left, but it certainly isn’t no one and I’m not imagining it. You’re supposed to be human first and political second, but we live in era of extremism. Huge percentages of people contorts their actual selves, the person they are when they’re not putting in a show, into an avatar of online bullshit. We now have as many liberal tankies as we have weird conservative Illuminati uncles who think Bill Gates is sneaking microchips into his vaccines. You’ll have to forgive me if I’m more concerned with the former rather than the latter, although these things have seasons and shift like the weather.

You should really ask yourself, if you felt joy at a guy being shot in the street why you’ve never tried to think of a better system. I mean that specifically. Why do you only care about the sick and the dying when you get to witness a murder and say that violence is good? Where was your effort, otherwise? Where was your voice otherwise? The spirit of bloodlust and murder stirs in every heart. Societies that didn’t practice human sacrifice have been the exception, not the rule. That’s in you and me the same way it was in our ancestors. Let’s not pretend you’re feeling some special sanctified emotion because of the circumstances of this case.

It bugs me a lot when people give themselves a moral hall pass. If you’re going to do something wrong, at least know in your heart that it is wrong.

Don’t pretend to yourself that when you get off on death that it’s because of some super enlightened reason other people can’t understand. What you’re feeling is the same thing our ancestors felt in the caves when they decided someone random person was making the herds thin and the weather bad. The mob excitedly watching the priest tear out the heart of a human sacrifice to make the sun come back wasn’t unique to the Aztecs. Be honest with yourself. Life is hard. It’s hard to fix things. Work is hard. Most ways of doing things don’t work. Isn’t the reason you feel great about seeing someone die that it makes it so much easier for you to imagine that it makes the world better… somehow? Doesn’t it make it easier to imagine that you don’t have to do anything really hard to make the world better? It’s a psychic relief to imagine all you had to do was clap for the murder of one person!

I’m a human, too. I’ve been joyful someone died. I’ve been the person cheering in the Aztec mob. Even though it was because that person hurt me directly, I won’t pretend to myself it was some beautiful noble impulse or anything other than a shameful dereliction on my part. I am “cleaner” only in one tiny way. I have never shook hands with the Devil and then angrily demanded that my hands were clean.

I started writing this because I can’t stand Taylor Lorenz, who has been one of the biggest cheerleaders of this murder. She recently appeared on television to express the “joy” she felt watching that man get shot, only to immediately pretend she hadn’t said it at length for days. If she was just someone cheering it on, with no education or responsibility, I could almost forgive it but she has to simultaneously pretend she isn’t doing that. It’s so slimy I can’t help but be angry at it.

That emotion shouldn’t be what I finish this piece for, though. People like Taylor will always exist, and they’ll always act like a barbarian to eke out a living. I should also try to remember that she seems deeply unwell, her income depends on her being unwell, and she’s lost the ability to help herself dig out of the pit she’s in. Or even see it as a pit, for that matter.

I started this substack not to fix healthcare, but because I think the social institutions that allow us to fix problems are out of whack. The things that fix things are broken. People are struggling to figure out what and who to trust. People don’t know who to look to in order to fix problems. That needs to be addressed. I don’t think you can really fix anything else until is addressed. Or at least, not for very long.

If you want to know more about that, you can click here to learn more.

What are your ideas to make the world, not perfect, but better?