Change the System, Stupid (Part 1 of 3)

When Bill Clinton was active for President in 1989, his attack administrator James Carville had three abbreviate but able letters printed on affiche lath and displayed in the wings so that Clinton couldn’t absence them as he went on date to speak. They were the following.

1. “Change against more-of-the-same,

2. The economy, stupid,

3. Don’t overlook bloom care.”

It formed for Clinton. Maybe it will plan for our torn bloom affliction arrangement with slight revisions and in about-face order.

1. Don’t avoid (healthcare) causes.

2. It’s the system, stupid.

3. Change against more-of-the-same.

The afterward alternation of three online writing – one for anniversary of Carville’s slogans – discusses what is absolutely amiss with healthcare and how to cure it, not just accomplish things briefly assume or complete better. The aboriginal (below) will alarm some causes of healthcare dysfunction: amiss measurements; budgetary fantasyland; as able-bodied as cultural abashing and conflict. The additional will appearance why the arrangement is at fault, not its parts: centralized contradictions; medical malprocess; and abortive decision-making.

The aboriginal two online writing are descriptive: they alarm what is wrong. The third is prescriptive: it suggests what we charge to do to cure the patient. Details on all of these issues can be begin in the accessible book Medical Malprocess, and at, which is aswell area the recommended civic chat could start.


When anecdotic our ailing healthcare system, a lot of humans abash what doctors alarm signs and affection with causes. Rising costs; diff and abbreviating access; errors and bad outcomes (not necessarily the same); and shortages, abnormally of nurses and doctors: these are all symptoms. If we amusement Them, we will affectation the absolute problems and not cure the patient. Therefore, the aboriginal footfall in accurate healing is analysis of why, the causes of the affection in our healthcare system.


Experts in business and administration consistently admonish us that you get what you measure. This agency that what you pay absorption and admeasurement is what the workers will do bigger and added of. The outcomes abstinent in healthcare are: deaths; complications; errors; costs; and lawsuits. Is that what we want? That is what we get.

Healthcare advance deaths, errors and costs because barometer them is simple: they are all concise and simple to quantify. The outcomes we absolutely wish are harder to admeasurement and long-term: long, advantageous life; beneath money spent; continuously bigger and bigger care. If we alpha barometer the outcomes we seek, abounding of the inconsistencies, abashing and affection in healthcare would vanish.


The chat “cost” does not accept the aforementioned acceptation in healthcare as it does in accepted usage. When you go to the cleaner to aces up your skirt, you pay a bill that is according to the cleaner’s absolute amount additional some profit. In healthcare, no one knows the accurate amount of anything. That is no exaggeration and bears repeating: no one how abundant your breach adjustment or affection anaplasty in fact cost! In healthcare, alleged amount is an allocated amount and has annihilation to do with what gets paid. That account too bears repetition: what gets paid in healthcare is about a actual baby atom of what is billed.

For all healthcare casework and products, there are transaction schedules adapted by the government and the allowance companies chase suit. So, transaction or supply (of money), alleged acceptable reimbursement, is fixed. Demand (for services) is variable. Anyone who accept anytime counterbalanced a checkbook, abundant beneath a accomplished economist, will acquaint you that a arrangement with anchored accumulation and capricious appeal cannot be stable. This is a compound for disaster. Welcome to healthcare budgetary fantasyland area words do not beggarly what they usually beggarly and area humans active for top appointment affiance bigger and cheaper and quicker. They cannot deliver, not with the arrangement we currently have.


The ability of healthcare is a third antecedent of dysfunction. It is complicated by abashing and conflict.

Confusion is ubiquitous. Providers – nurses, doctors, amusing workers, affiliated bloom cadre – are consistently told to put the accommodating first: in school, by their mentors, and according to the assurance at the foreground aperture of every hospital, dispensary and office. Then absoluteness sets in. Talk to the patients, sure, but we do not accept abundant translators: the account does not allow. Be caring of course, but do the history, physical, think, accomplish decisions and address out the prescriptions in 14 minutes: doctors accept to be efficient. Sorry, but that catheter or accurate biologic or assertive specialist is too expensive, not covered in the plan, and accordingly you cannot use it or argue her. Yes, it is actual harder to get to the hospital from the parking structure, but that is the cheapest way to body the structures. Etc. Etc. The provider is absorbed with a cultural amount that the abundance of the accommodating comes first, but the account is king.

Those who bear the care, alleged the white coats, accept a altered ability than those who ascendancy the assets bare to bear that care, alleged the dejected apparel or suits for short. Even admitting they plan in the aforementioned abode and allotment (unknowingly) amount values, they anticipate differently, were socialized to altered standards and access problems in fundamentally altered ways. Worst of all, anniversary sees the added as the enemy. This conflict, accompanying with bound resources, backbreaking rules, and a abundance of adverse regulations assures that collaborative botheration analytic will not happen.


In adjustment to cure anything, from your golf allotment to our healthcare system, we accept to amusement the affidavit for affliction not just the symptoms. Some of the aloft causes accept been discussed above. You can accede these and others in greater detail at In Part 2 of this series, it will become bright that the arrangement as a whole, not individuals or locations of the healthcare system, is at the basis of our problems. Part 3 will appearance what we can and accept to do to fix healthcare.

Note: Every account fabricated herein can be accurate by evidence: they are not artlessly the author’s assessment or bias. For assay of these references, feel chargeless to acquaintance the author.

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