Health Care Divide and Conquer

Put simply, health care isn't just one thing. It's at least three.

Health Care Divide and Conquer
See the Commonwealth Fund report for full notes, data source, and credits.

Every time I read an article that's trying to unravel our disaster of a health care system (like this investigative report), it makes me want to advocate a divide and conquer approach. Put simply, health care isn't just one thing. It's at least three.

Well Care

The most basic kind of health care is well care and minimal intervention care like your annual physical, routine lab work, medicine for your daughter's ear infection, even a non-surgical bone set and cast for a broken arm, plus follow-up and some physical therapy.

This kind of health care is routine, lifelong, can mostly be provided by a primary care physician or physician's assistant or nurse practitioner on an out-patient basis. Everybody needs it. It shouldn't be outrageously expensive, and for the most part, everybody should pay for his or her own, just like we have to pay for food, housing, transportation, and all other regular living expenses.

For people who neglect routine medical care for themselves or their families, thereby pushing themselves up into higher tier needs, one could imagine imposing some fairly strict penalties. I'm not talking about forcing people to buy mandatory health insurance. I'm talking about people taking responsibility for their everyday lives, including routine health care. If financial assistance is needed, it would be on a par with food stamps or subsidized housing.

True Insurance

The second kind of health care is a true insurance problem. It has to do with risk and rarity. It’s based on probabilities where a large potentially-at-risk crowd pays to cover the small percentage of people who are actually affected.

We buy fire insurance because IF our house burns down, we'll need help with replacement costs. The risk is low, the event is rare, but for the few people whose house does burn down, the negative impact is incredibly high. So we're willing to group together with others, pay a small fee to cover the risk, and pay out to the unfortunate few who draw the short end of the stick – because we would want them to do the same for us. Medically, this means we need true health insurance to cover treatment required after a car accident or a fall, or if we get cancer.

Whether true health insurance should cover metabolic disease (diabetes, heart disease, lung cancer in smokers), where risks are closely related to predictable, controllable, and known behavioral or environmental factors is something I'm not competent to judge, and we can admit there are issues here. On the other hand, insurance analysts specialize in determining the cost of providing car insurance to male drivers under the age of 25 who drive expensive sports cars. I'm sure it can be figured out.

In any case, a true insurance problem is an entirely different class of medical care from well care, with a dramatically different kind and level of funding required. Importantly, it's a need that deserves to be met by a genuine health insurance system.

Life Stage Care

The third kind of health care is like neither of the other two in the sense that it's neither routine nor lifelong, yet it's potentially major – but it's also predictable and a different kind of risk, if it even really classifies as risk. This is health care related to life stage, whether maternity care, neonatal care, the challenges of aging, or end of life care. Healthcare related to certain vocations might be similar, such as the sports medicine required by athletes.

This is a partial list – perhaps menopause, or puberty, or divorce-death of spouse, or other life stage events would qualify similarly. Everyone goes through a set of predictable life stages, and their needs vary along the way. To be sure, only women require maternity care, and today few enough women even have children... but it's still a demographically-based category and applies to most people in the category.

Exact health care needs for individuals in a given stage or vocational group could range widely. That's okay. Most babies are born healthy, most pregnancies are normal, some (few) old people age gracefully and die peacefully at home in their sleep, but most don't. Specialists are required who can handle not only medical concerns but other related emotional, family, social, and job-related challenges. Life stage health care impacts the whole of life.

Again, there are plenty of issues to be sorted out here, but life-stage or vocational health care requires yet another and different sort of system to provide and pay for it. It is more on a par with saving up for children's college education, or dealing with retirement. Most people should be responsible for their own care – possibly with some risk-based insurance type options built in if that makes sense.

Financial assistance, where provided, might be comparable to helping people take responsibility for long term financial planning. Education, incentivizing, and applications of nudge theory could work. Or, maybe we do need special programming, whether provided by private or public institutions, by businesses, non-profits, or local community centers, with funding secured and expended as makes the most sense for each life stage or demographic. In any case, again we're talking about a very different kind of health care challenge compared with well care or risk-based medical insurance.


I'd like to see our thinking about health care divided out completely into separate departments, with appropriate solutions developed for each of them independently. Bundling together creates a dysfunctional health care behemoth where doctors and patients get taken advantage of by "the system," costs keep on rising, quality of care keeps falling, and human health statistics such as infant mortality rates, rates of chronic disease, and longevity compare negatively to the rest of the developed world. A recent report from the Commonwealth Fund provides damning evidence.

Given vested interests and entrenched institutions and infrastructure, I don't have much confidence that a mere conceptual shift could help, but I feel compelled to at least throw it out there.