Since World War II, the health care debate has been a struggle of left versus right. The left has tended to favor federal solutions, plus increased public provision of care and coverage. The right has favored state-level solutions, plus private provision of care and coverage. The left employs more pro-regulation rhetoric, while the right professes to favor freer markets. (The latter distinction is largely illusory. Both sides favor powerful regulation and merely disagree on who regulates what and through which means.) A more meaningful distinction is between worldviews we can call the Fortress and the Frontier.
The Fortress has two goals. The first is to imagine every terrible thing that might happen to someone receiving health care and then to focus public policy on preventing any of those things from happening. The second is to protect health care insiders — doctors, hospitals, insurers, drug and device manufacturers — from outside competitors who might threaten their turf.
The Frontier focuses on innovation. It understands that we cannot obtain great quality improvements and massively reduced costs without allowing consumers and producers to take calculated risks. The Frontier also understands that innovation requires constant, uninvited input from unknown dreamers. The IT revolution did not emerge from credentialed insiders anointed by public officials or titans of industry. It came from obscure figures in garages who were allowed to challenge and defeat multinationals in skyscrapers.
From his garage, Steve Jobs challenged IBM. Jeff Bezos sold books from his garage and his business — Amazon.com — changed the way the world purchases just about everything. Smartphones did not originate with telephone industry giants like Western Electric; the BlackBerry came from a couple of engineering students with some venture capital.
In less than a generation, home computers and smartphones went from dreams to toys of the rich to everyday possessions of Third World village children. America’s population now has near-universal access to information technology that is blindingly more powerful than anything the Central Intelligence Agency owned a generation ago. To get there, we accepted costs and risks, and we allowed serendipitous genius to arise in the unlikeliest of places.
We didn’t need vicious Congressional debates, invasive mandates, or a massive bureaucracy to oversee the diffusion of the new technologies. No one had to beg innovators to innovate. And innovators didn’t have to beg bureaucrats for permission to create.
Just the opposite. The IT revolution really began around 1989, when the federal government stepped away from ARPAnet — the embryonic Internet — and announced that the world was free to use it with few restrictions and little oversight.
One of the stunning questions for future political scientists to ponder is, “Why did we develop a bipartisan consensus that health care should be locked in the Fortress while information technology would be free to roam the Frontier?”
One traditional Fortress approach — federal grants for innovation — is likely to push innovation in less-than-ideal directions. In the early 1970s, an innovation grant would probably have gone to IBM to build a bigger mainframe, not to Steve Jobs to produce a tiny desktop computer. And enough innovation grants to IBM might have made it impossible for Steve Jobs to compete.
Shifting health care to the Frontier opens the possibility of real progress — of better health for more people at lower cost, year after year. This approach also offers alternatives to the all-encompassing ACA and its earth-shattering repeal-and-replace alternatives. My paper suggests a few dozen small initiatives to begin the transition. There are hundreds more waiting just behind. If we so choose.