But there is a world of innovation out there that is still yet to be done.

Ok, having slept on this, I think I can explain myself.

The American health care system is a work place. In that way it’s like any other real estate brokerage, factory, software shop, or retail store. It’s a system that does work and makes some money and spends some money.

The thing about most workplaces, and this is world wide, is most are completely broken with regard to quality of work produced. They are 19th century in terms of efficiency at best. That’s true worldwide, even Japan. Japan has world famous pockets of quality but they are poorly understood and from what I’ve seen they don’t represent the state of the nation.

Focusing specifically on America, what I’ve seen is management recognizes that there are problems with quality, and things cost too much, but they hold tight to the reins of power and behave in a lot of incompetent ways. They encourage everyone to “do their best” and motivate and set up processes which need to be complied with, blah blah.

And here it sounds like I agree with you, but I think this is just a symptom and not the root cause.

Most people in the whole world have never even seen a workplace that understands how to build quality into whatever they do. Even fewer have worked in one and could actually understand what they see in a quality minded workplace.

Quality, when you sit down to study it, is beautifully counter-intuitive, highly experimental, rigorous, and respects the humanity of all it’s participants.

What’s even more pertinent here, is that quality provides a back door where management begins to gracefully relinquish power.

So the root cause, as I see it, is that Americans’ view of quality is distorted from reality. A few anecdotes from clueless business press writers about “the Japanese” is about where most of us stand.

There are a few pockets in the Medical industry where people are discovering that they can push costs lower than they thought and reduce medical errors and of course deaths a lot lower than they thought at the same time.

Finding and promoting those stories seems like something that can be done to address the true root cause of the American paradox.

And what if Americans just spent less on medical care and nothing else changed? Wouldn’t we just be as bad as anyone else, unremarkable? Sounds like there’s a ton of waste to be eliminated.

*There is a growing appreciation of small homes/living spaces. Affordability and sustainability are motivating factors, but some of these homes are just plain cool. No reason small can’t be stylish.

*Scroll through the shackitecture page at http://www.dinosaursandrobots.com/search/label/shackitecture or try gorilla designs post Katrina work at http://gorilladesign.org/. For the uber trendy there is the luxury steel cabin on stilts http://www.oskaarchitects.com/Projects/38/Delta-Shelter.

-Adam

I think there are a number of things that cause our “high spending” “relatively poor health” paradox.

Much our our relatively poor health relates to lifestyle factors more than health system or healthcare problems - poor diet, and lack of exercise being the leading contributors. You suggest that we’d be doing more about these problems if we were a less unequal society - it’s an interesting hypothesis. I don’t believe though that the more equal societies in Europe have been much more active or successful than we have in this arena. It’s turning out to be very hard to change peoples’ behavior in desirable way.

On your point about the narrow range of criteria for allocation of research funding you see in the US - I’m sure you are right, that it is too narrow. From talking to researchers who have sought funding in the US and in Europe though (again, more equal societies) - I have heard only that research funding there is even more conservative…tending to fund research that looks at the same range of questions, uses the same methodologies over and over. Outside of the box researchers often move over here for this reason.

On innovation - my sense is that the very pluralistic, and decentralized, US health system probably generates significantly more innovation than other OECD countries. Unfortunately because of our funding system, almost all innovation is focused on new drug or treatments or new ways of delivering care that can generate higher revenue for the provider/ innovators, not save anyone money. India, as you’ve mentioned, is an engine for generating innovations to bring costs down precisely because 85-90% of payment is out of pocket. When patients pay out of pocket, they tend to do more research on prices - when able. So, bringing down costs is a real market advantage.

Jacobs really did say what I have her saying. Look on pp. 248-9.

When you criticize the American health care system it’s like you are criticizing California. It’s epically gigantic and you come to conclusions like “inequality is the root problem.” Nobody is going to fix health care any more than they are going to fix the state of Florida.

I have three kids with autism and I had a pediatrician who was completely bought into mainstream dogma. All she could do for us was miss the initial diagnosis (by years, tragic), prescribe antibiotics like candy, and berate us for not wanting to vaccinate our kids who were constantly suffering cold symptoms.

We left her for a very pragmatic doctor with extensive autism experience. Our kids have improved a great deal in both language and behavior with her help. One is reading even. No clue about the story mind you, but he likes the words.

There are pockets of innovation within the monster that is the whole of health care. It’s not a whole and can’t be addressed as a whole. Those pockets are separate entities and need to be understood as separate. That leads to far more actionable stuff like promoting self-experimentation and pragmatism.

Another pocket of innovation you might care about… You might add to your catalog of current events, that a few doctors are discovering the “lean” quality movement. There is a lot of literature coming out and the results of of applying it are often positive in terms of cost and mortality. If that idea manages to spread it could take out a big part of “inequality” in it’s wake.

Anyway, all my blathering to say, I think you missed the root cause, and this inequality you speak of is a false dichotomy.

“Was the current financial crisis due to reckless lending? Not really. That was an opportunistic infection. It was due to a problem building up unsolved: lack of affordable housing, which was due to lack of innovation in the housing industry. Lack of real solutions made room for a phony solution that, funny coincidence, benefited the powerful: rip off poor people by lending them too much money.”

IMO the housing bubble was basically a transformation of the NASDAQ (tech) bubble into the housing market. Easy borrowing was mostly engineered by the Federal Reserve in an attempt to prevent a recession (encourage economic growth). I.e., it was *innovation* on the part of the ruling class aimed at solving their own problems that caused the problem.

To the extent it was specifically about housing, you’re right that it was abetted by government policies aimed at increasing “affordability”, but these in turn were innovations to again solve the same problem: how to maintain or increase their own power by ingratiating themselves with certain constituents and so on.

That is to say, lots of problems are caused by *too much* innovation to solve problems (problems such as “How do I increase short-term profit?” or “How do I get elected again?”) by people who will stand to benefit against an often larger group who will stand to lose, where the second group’s losses are too diffuse or obscured to adequately motivate sufficient counter-actions.