Adjustable Space Shuttle Components - Packing for Mars - Mary Roach - 99 Percent Invisible

Adjustable Space Shuttle Components

Imagine driving your car without an adjustable seat. Imagine if every component of your vehicle was designed for an “average” sized person. Your seat probably wouldn’t fit you right, your legs may not reach the pedals well, or your head might be bumping up against the roof of the car. Standardized sizes that can’t be adjusted and that are based on an average for each person end up failing to actually fit anyone.
But super adjustable seats are not always a great thing either. In her book Packing for Mars, Mary Roach writes about the costs and engineering challenges that adjustable components on space stations present. “As things stand,” she writes, “NASA has to spend millions of dollars and man-hours making seats lavishly adjustable. And the more adjustable the seat, generally speaking, the weaker and heavier it is.”
When quoting NASA Crew Survivability Expert Dustin Gohmert, Roach includes, “The Russians have a much narrower range of crew sizes,” which means that they don’t have to adjust their seats, space suits, and various technology to the same extent as NASA which recruits astronauts with more varied bodies. Roach continues, “This wasn’t always the case. Apollo astronauts had to be between 5’5″ and 5’10”.” Today, however, we don’t want to limit someone’s opportunity to contribute their talents to space exploration and missions, even if they are a tad short or a bit taller than typical. We want the best people on our missions, and that means engineering expensive adjustable components with multiple potential fail points.
Adjustability is important in almost anything we design. Human bodies all come in different shapes and sizes and One-Size-Fits-All garments, seats, and utensils can normally do a good job for most, but not all of our bodies. Making the world more adjustable is definitely a slower and more expensive process, but it generally leads to better inclusion and better results for everyone. This isn’t necessarily the case for the space program, where designing ever more flexibility into the components of the system can mean more failure points and risk for everyone involved. Space travel is full of trade offs, and the trade offs can be expensive, time consuming, and even pose safety risks. Roach explores these tradeoffs in her book and looks at the ways we have calculated these tradeoffs throughout our history to show how much society has changed in terms of inclusion, thinking about designing for the average versus individual flexibility, and what it means to be human in spaces our bodies didn’t evolve to fit.
Imagine driving your car without an adjustable seat. Imagine if every component of your vehicle was designed for an “average” sized person. Your seat probably wouldn’t fit you right, your legs may not reach the pedals well, or your head might be bumping up against the roof of the car. Standardized sizes that can’t be adjusted and that are based on an average for each person end up failing to actually fit anyone.
But super adjustable seats are not always a great thing either. In her book Packing for Mars, Mary Roach writes about the costs and engineering challenges that adjustable components on space stations present. “As things stand,” she writes, “NASA has to spend millions of dollars and man-hours making seats lavishly adjustable. And the more adjustable the seat, generally speaking, the weaker and heavier it is.”
When quoting NASA Crew Survivability Expert Dustin Gohmert, Roach includes, “The Russians have a much narrower range of crew sizes,” which means that they don’t have to adjust their seats, space suits, and various technology to the same extent as NASA which recruits astronauts with more varied bodies. Roach continues, “This wasn’t always the case. Apollo astronauts had to be between 5’5″ and 5’10”.” Today, however, we don’t want to limit someone’s opportunity to contribute their talents to space exploration and missions, even if they are a tad short or a bit taller than typical. We want the best people on our missions, and that means engineering expensive adjustable components with multiple potential fail points.
Adjustability is important in almost anything we design. Human bodies all come in different shapes and sizes and One-Size-Fits-All garments, seats, and utensils can normally do a good job for most, but not all of our bodies. Making the world more adjustable is definitely a slower and more expensive process, but it generally leads to better inclusion and better results for everyone. This isn’t necessarily the case for the space program, where designing ever more flexibility into the components of the system can mean more failure points and risk for everyone involved. Space travel is full of trade offs, and the trade offs can be expensive, time consuming, and even pose safety risks. Roach explores these tradeoffs in her book and looks at the ways we have calculated these tradeoffs throughout our history to show how much society has changed in terms of inclusion, thinking about designing for the average versus individual flexibility, and what it means to be human in spaces our bodies didn’t evolve to fit.
Homelessness, Temporary Assistance, and Social Costs

Homelessness, Temporary Support, and Social Costs

Support in the United States is typically only given to those who are viewed as deserving. People who lose their homes in unpredictable natural disasters, people who are targeted by criminals, and those who simply had bad luck but were otherwise hardworking are worthy of help and assistance. Those who seem to just be lazy, who made poor decisions, were gullible, or who used drugs are not seen as worthy of our time or charitable efforts. The consequences of this plays out in homeless shelters and on the streets of our country every day. Without society feeling a need to help people who are viewed as deviant and unworthy, the role of supporting these individuals falls to the altruists, some church groups, and the families still willing to provide second chances. Often, any aid provided by these groups is conditional and temporary.
“Just as some women are homeless because their families can no longer support them, other women have little or no family support because they are homeless,” writes Elliot Liebow in Tell Them Who I Am. People lose social and familial support and can end up homeless. However, homelessness itself is often a reason for why support is taken away from people. Whether we are trying to support people because they are family, because we feel altruistic, or for other reasons, at a certain point any aid or assistance that we provide begins to feel useless. At a certain point, we cut people off and demand that they help themselves before we help them any further. Homelessness begets homelessness in this scenario as aid and assistance is taken away from those who need it most.
It is fine to believe that homelessness is a cost to the individual who becomes homeless, that it is a consequence of their bad behaviors and poor decisions, and to imagine that we are not responsible for the homeless individual. It is fine to decide that we won’t help them if they won’t help themselves. It is fine to decide not to help people who use drugs, drink to excess, and refuse to take the necessary steps to work and live as a productive member of society. But in doing so, we should be aware that these individuals did not become derelict in a vacuum. They were part of a society that failed at some point to direct them in a more productive way, to help them feel connected, to help them find meaning in their lives. We should also note that refusing to help individuals still pushes a lot of costs back onto ourselves and our societies.
At a gut-level, I don’t like the idea of simply providing housing, cleaning and sanitary services, counselors, and whatever else is needed to homeless individuals and potential drug users without  requiring them to get their lives back on track. I don’t like thinking that developing a system that provided a comfortable life without any effort for everyone might encourage more people to drop out of society and become useless druggies wasting their time away on the social supports and services of others. But I also don’t like that we treat the homeless like a plague, that we simply wish they would vanish, that we force them into dangerous situations on the streets where they could freeze overnight, die from heat exhaustion during the summer, and could be victims of crimes simply because they were defenseless and existed. I also don’t like that we will spend millions on emergency room healthcare costs, on police and jail costs, and have blighted sections of our cities because we won’t help the homeless by paying the up front costs to provide people housing and jobs. When I consider all the alternatives, giving the homeless a place to live, a care taker to watch over them, and helping provide basic sanitary services for them seems better than allowing the homeless to rot in the streets. I can’t imagine how anyone could ever come back from the streets, but perhaps more people could come back from a life where they are provided safe and sanitary spaces, even if we don’t think they deserve the effort it would take to provide such a life. I think we should at least try to treat them with dignity and give them a place where they can find dignity within themselves if they ever want to turn things around. Either way, we all live on this planet together, and we all create society together, so we cannot escape the costs of the homeless or wish the homeless away.
Homelessness and Health

Homelessness and Health

When I was completing an MPA I took a couple of classes out of the MPH (Public Health) program. In one of the classes our professor assigned a group of us to a project focused on ways in which public agencies can access Medicaid funding for housing assistance programs for homeless individuals. The basic idea was that homeless individuals utilize healthcare resources and are unable to pay for any services they receive. The government, usually the local city or state government, ends up covering the cost of care provided to homeless individuals. The alternative would be that homeless individuals cannot access healthcare, and that they become more likely to spread communicable diseases or to die from preventable causes wherever they manage to find shelter.
This means that local governments end up paying a lot for the healthcare needs of their homeless (Malcolm Gladwell once wrote a story about “Million Dollar Murray” who happened to live in my hometown of Reno). Our project was to see what was permissible under Medicaid guidelines to allow hospitals and local public health entities to access Medicaid funding to provide housing for individuals who would otherwise drive huge healthcare costs. Accessing Medicaid funding would shift part of the costs to the federal government and bring in more federal funding to allow more individuals in the area to receive support. The ultimate goal was to get people established with basic housing and in the long run cut down on the number of emergency room visits and medical services that people would need.
Being homeless can drive up healthcare costs by driving people into worse health states. This is something that is often overlooked when we think about the homeless. As Elliot Liebow wrote in Tell Them Who I Am, “In many cases, the very conditions of homelessness produced poor health care as well as poor health. On the one hand, the women sometimes failed to tell the doctor that they were homeless; on the other hand, even when doctors knew their patients were homeless, they often failed to appreciate the significance of that fact.”
As my small team of fellow graduate students completed our project, we focused a lot of thought on housing individuals with diabetes or asthma. If you are homeless and have either condition, managing your health becomes dramatically more challenging. Doctors have to spend additional time with homeless individuals to help ensure they know how to use their medications and have secure and temperature controlled places for them. But as Liebow’s quote notes, this doesn’t always happen, even if a doctor knows the patient is homeless. A person without a fridge may not have a place to store insulin without it going bad. They may not then be able to access insulin when needed, and may end up in the ER for an emergency that would never happen if we had simply ensured they had a place to live and keep their medicine. Homeless individuals with asthma may find themselves sleeping in a car in a parking lot, or under a freeway overpass. This means they are in a place where they are exposed to more car exhaust and dust, potentially triggering a severe asthma attack and necessitating another entirely preventable ER visit. In both cases if the had been given a place to live that wasn’t densely inundated with vehicle pollution or had a way to safely store their medication, they wouldn’t have had to go to an ER. Society could have have paid the cost of their housing, but instead we chose to let them be homeless and pay for thousands of dollars in medical costs after they had a problem.
The question our team looked at is how many ER visits does it take to offset the costs of simply providing a house first? And what types of services will Medicaid allow to be billed that help secure and individual in the housing they are provided? As it turns out, Medicaid does offer assistance for housing search, coaching on how to be a successful tenant, and other basic services to help ensure someone can live within any housing they are provided. It doesn’t, however, allow any reimbursement for rent or direct housing costs. Nevertheless some hospitals and some local governments are beginning to invest in housing first strategies. Any efforts that keep people out of the ER will save money in the long term, even if it is more expensive up front to provide someone with a place to live. The returns and benefits to a persons health ultimately outweigh the costs of providing housing as fewer healthcare services are needed.
The Costs of Work

The Costs of Work

One argument that is popular against welfare and social support programs is that they discourage work by encouraging people to sit at home collecting a welfare/disability/unemployment check rather than being a productive member of society. This is an argument that is picking up steam as we start to move away from the COVID-19 pandemic, as enhanced unemployment benefits run out, and as companies have trouble hiring back employees who seemingly don’t want to return to work.
To me, as I have heard people make this argument, I think that people make a mistake in who they think are the primary beneficiaries of welfare/disability/unemployment benefits and I think they make a mistake in how they imagine people receiving such benefits actually live. I think people imagine their own lives and living standards, and transpose those onto benefits recipients, except with money coming from the government and not from a job. They see people who are just like them, enjoy the same living standards, but choosing to be lazy instead of making the sacrifices that work requires. With this vision it is understandable that people get angry and want to tear down such social support systems.
I recognize that fraud, waste, and abuse of social support systems occurs. I know there are people cheating the system to get disability insurance and that they would find a way to go back to work if their checks ran out. I also know there are people abusing food stamps programs, and I generally believe it is better for people to be working productively than watching the price is right and not trying to do something valuable for themselves and others. However, I think these arguments are often more anecdotal than factual, and I think tearing down the whole system because a few people cheat is dangerous and misguided. I think the statistics demonstrate that the programs are necessary, and I think that additional considerations regarding the cost of work should also be made to help us better understand why there are “lazy cheats” out there.
Kathryn Edin and H. Luke Shaefer do a good job examining the real costs of work and the pressures these costs place on families and individuals to rely on social support systems rather than their own industriousness. Regarding welfare in 1996, the year it effectively died to be replaced by a new system, the authors write, “Work paid only a little more than welfare but cost a lot more in terms of added expenses for transportation, child care, health care, and the like. It was more expensive to go to work than stay on the welfare rolls.”
20 years later we still have this problem, especially in large cities where economic opportunities seem to be located. The costs that people face when trying to work rather than when accepting social support program benefits add up and are impacted by many factors beyond the wage than an individual can earn. Many cities are too expensive to live in, and as a result people have to commute very long distances to get to work, and that commuting adds up in terms of time, vehicle maintenance, or transportation fares. While working and commuting, children need to be watched by someone, adding child care costs into the equation. Time spent in a car or sitting on a bus also takes away from any chance to be physically active to help ones health, potentially increasing health care costs because an individual doesn’t have time to cook a healthy meal and doesn’t have time to go to a gym or get out on a walk.
Individuals who might be prone to laziness don’t have a hard decision to make when faced with these calculations. They can lose all their time, have to pay for child care, and end up with poor health and few extra dollars to spend if they pursue work. The alternative is to accept poverty, accept government aid, and at least reduce the costs, time demands, and stress that work adds to their lives. However, I don’t think most people enjoy or want this life, and I don’t think it is anything to be jealous of.
I don’t think the answer here is simply that employers need to pay more and that the minimum wage needs to be raised. I think that can certainly be part of the equation, but we clearly also need to help people live closer to their jobs, have better affordable access to healthcare, and afford quality child care that will help their kids and keep them safe. This is an idealistic and possibly unrealistic set of policy desires, but I think that is because we have misperceptions about who uses aid, and about our roles and responsibilities as individuals within society. I think that years of focusing on ourselves as individuals has in part contributed to the erosion or lack of development of social supports that would help tip the balance for those prone toward laziness away from staying home and toward working. As it is now, we accept the high costs of work and then criticize those who opt out.
Paying with Time - $2.00 A Day - Edin & Shaefer - Joe Abittan

Paying with Time

“One way the poor pay for government aid is with their time,” write Kathryn Edin and H. Luke Shaefer in their book $2.00 A Day.  In the United States we are wary of people getting things for nothing. We have a social support system that ensures people are worthy of government aid before they receive any support. We often tie work requirements, job search requirements, and drug screens to government aid, ensuring that people who accept aid are still making efforts to contribute to society. Still, even with these requirements people who don’t receive any government aid (at least not in the form of direct cash or in-kind welfare benefits) dislike the idea that so many people can access government aid for nothing.
 
 
However, as the quote from Edin and Shaefer shows, government aid is not really free, and the costs can be significant and even counter productive. On one hand it is understandable that locations to access government aid for things such as food, housing support, or direct cash transfers, would not be located on every street block. It makes sense that service centers would be relatively limited to reduce the government costs for administering programs. However, while this can make fiscal sense for government, it can also be a deliberate strategy to limit the number of people who access welfare benefits and receive services that are available to them on paper. Having a single location that operates standard business hours will necessarily mean that some individuals and families are incapable of accessing aid that is only distributed from that one location. A failure to co-locate aid offices also means that individuals and families may be strained in trying to access the aid that they need. Time can be a limiting factor that prevents people from accessing the aid and services which should help them get to a more stable economic position.
 
 
If people are able to make it to the location, aid often comes after lengthy applications, long lines and wait times, and lengthy commutes. Politicians may deliberately design aid programs to have these time costs as a way to reduce fraud and reduce the appeal and dependence on government aid, but for those who need it, it may mean forgoing necessary aid to help get one’s life back on track or to help put food on the table for a hungry family.
 
 
Often, the programs that provide aid are intended to temporarily support people until they can provide for themselves. However, if short-term aid is truly needed, to the point where the time costs are necessary to go through, then individuals may not be spending time looking for jobs, addressing child behavior issues, or otherwise using their time in a productive manner. These time costs are real, and can limit people’s opportunities in ways that actually make them more dependent on the governmental aid, and less capable of providing for themselves. The aid that people receive may seem as though it is free, but the time costs need to be considered, especially if programs are unwieldly and actually prevent people who do access them from taking steps to no longer need government aid.

Framing Costs and Losses - Joe Abittan

Framing Costs and Losses

Losses evokes stronger negative feelings than costs. Choices are not reality-bound because System 1 is not reality-bound,” writes Daniel Kahneman in Thinking Fast and Slow.

 

We do not like losses. The idea of a loss, of having the status quo changed in a negative way without it being our deliberate choice, is hard for us to accept or justify. Costs, on the other hand, we can accept much more readily, even if the only difference between a cost and a loss is the way we chose to describe it.

 

Kahneman shares an example in his book where he an Amos Tversky did just that, changing the structure of a gamble so that the contestant faced the possible outcome of a $5 loss or where they paid a $5 cost with a possibility of gaining nothing. The potential outcomes of the two gambles is exactly the same, but people interpret the gambles differently based on how the cost/loss is displayed. People are more likely to take a bet when it is posed as a cost and not as a possible loss. System 1, the quick thinking part of the brain, scans the two gambles and has an immediate emotional reaction to the idea of a loss, and that influences the ultimate decision and feeling regarding the two gambles. System 1 is not rationally calculating the two options to see that they are equivalent, it is just acting on the intuition that it experiences.

 

“People will more readily forgo a discount than pay a surcharge. The two may be economically equivalent, but they are not emotionally equivalent.”

 

Kahneman continues to describe research from Richard Thaler who had studied credit-card lobbying efforts to prevent gas stations from charging different rates for cash versus credit. When you pay with a card, there is a transaction processing fee that the vendor pays to the credit card company. Gas stations charge more for credit card purchases because they have to pay a portion on the back end of the all credit transactions that take place. Credit card companies didn’t want gas stations to charge a credit card surcharge, effectively making it more expensive to buy gas with a card than with cash. Ultimately they couldn’t stop gas stations from charging different rates, but they did succeed in changing the framing around the different prices. Cash prices are listed as discounts, shifting the base rate to the credit price. As Kahneman writes, people will skip the extra effort that would garner the cash discount and pay with their cards. However, if people were directly told that there was a credit surcharge, that they had to pay more for the convenience of using their card, it is possible that more individuals would make the extra effort to pay with cash. How we frame a cost or a loss matters, especially because it can shift the baseline for consideration, making us see things as either costs or losses depending on the context, and potentially altering our behavior.
Value in Healthcare

Value in Healthcare

A common complaint about healthcare in the United States is that it has traditionally operated on a fee for service (FFS) based model. It is a natural and easy to understand system, and generally the type of system that both patients and providers prefer. The idea is that you pay for the services you receive from a healthcare provider. So if you need a tooth extracted, you go and have the tooth extracted and pay for the extraction. If you need a skin check, you go and get a skin check and pay for it. However, this FFS model can encourage a lot of waste through unnecessary medical procedures, and the value in healthcare is sometimes lost when we wait until someone has a problem before we help them with their health.

 

A lot of government programs, employers, and insurance companies are making efforts to push against FFS in an effort to provide greater value in the healthcare services we pay for, but it is worth asking, what is value and how can healthcare systems provide it? Is value just better health? Is it services that a patient said they were happy about? Is it care that saves a life or can it just be care that makes a life somewhat more comfortable? Dave Chase helps explain one aspect of value in healthcare in his book The Opioid Crisis Wake-Up Call, “Value is defined as the ratio of quality to cost. Value increases as the quality of the care increases or the cost of care decreases.”

 

FFS encourages short appointments where doctors cram as much as they can bill for into the shortest possible time before moving on to the next patient to do the same. Value based models, on the other hand, seek to improve the quality of the care provided without adding more costs to the patient and their insurer. As opposed to simply cramming in more tests, treatments, and procedures to get more money, value based systems that increase quality focus on improving health outcomes while keeping costs stable.

 

Alternatively, value based models might seek to keep quality the same, but reduce overall costs. This can wade into territory we don’t necessarily want to support, such as cutting nurse management staff to keep overhead low, but it could also look like more comprehensive care to reduce costly re-admissions after a procedure. When we think about value and try to build systems around value, we ultimately have to think about quality and cost, and how those are related. We can cut pieces out of the system that are just meant for signaling and cut pieces out that might be unnecessary without diminishing quality. But at the same time, we really need to examine whether the pieces we want to cut really do help with the quality of the care, especially over the long run.

 

Thinking about value in healthcare isn’t entirely new, but it is receiving increased focus, which is important if we want to have a healthcare system that people actually trust and are willing to engage with when necessary.
Fiduciary Healthcare Responsibilities

More on Fiduciary Healthcare Responsibilities

Yesterday I wrote a little bit about the fiduciary healthcare responsibilities that employers hold given that companies invest our healthcare dollars in plans and structures that can be quite costly. In his book The Opioid Crisis Wake-Up Call, Dave Chase writes, “Given the wide cost differentials, CFOs and CEOs are failing in their fiduciary responsibility if they do not move to modern health care delivery models that are proven to save money while maintaining or improving health outcomes and patient satisfaction.”

 

Chase’s book is all about current structures and systems for healthcare coverage, delivery, and access that are within the control of employers. Healthcare is a complex field, and for years, employers have not had a hands-on role in shaping and creating the models they work through to provide health insurance to their employees. Chase argues that the result has been increasing costs without pressure on providers or insurers to make sure that the quality of care matched the costs.

 

Innovative and truly caring companies have shifted the status quo and shown that quality healthcare can be affordable. They have shown that preventative medicine can be supported and promoted by thoughtful employers, saving healthcare dollars and improving employee health in the long-term. Companies that ignore these models will effectively be wasting healthcare dollars and hindering the health of their workforce. This exposes companies to liability for not fulfilling their fiduciary healthcare responsibility.

 

When we talk about health policy and improving the healthcare system in the United States, we usually talk about government policy, about hospital charges, and about minimum standards for insurance and rising insurance premiums. Chase thinks we need to spend more time talking about our employers, and about what they can do to help improve the system, without requiring laws to be passed or companies to make policies that go against their own best interest. Employers have a lot of leverage if they take their fiduciary healthcare responsibility seriously.
Self-Insured Health Plans

Self-Insured Health Plans

“A self-insured health plan,” writes Dave Chase in The Opioid Crisis Wake-Up Call, “is established when an employer sets aside some of its funds to pay for employees’ medical expenses. Employees then contribute to the plan rather than pay traditional premiums.”

 

In the United States, it is not uncommon for large employers to chose to be self-insured rather than to offer health insurance provided directly through an insurance carrier such as Cigna or Anthem. Chase explains that self-insured plans shift risk from the insurance carrier to the employer, with the benefit of reduced administrative costs and changed financial incentives. Large carriers are often still contracted with in a self-insured system for some administration and bill paying functions. In a traditional relationship, as Chase explains, employees pay premiums and “if the premiums exceed the medical expenses, the carrier wins.” Self-insuring eliminates this aspect of health insurance, reducing the total amount that employees should need to contribute by eliminating a profit motive for the carrier.

 

Chase highlights another benefit of choosing to self-insure, lower taxes and fewer regulations to abide by. In the United States, each state has an insurance commission that sets its own standards and requirements for insurance (auto, home, medical, etc…). The benefit according to Chase is that, “the Employee Retirement Income Security Act of 1974 [ERISA] states that a private, self-insured health plan is administered in accordance with its [ERISA’s] terms and federal rules. So, these plans aren’t subject to conflicting state health insurance regulations or benefit mandates.”

 

This is an important point that I have been thinking about in Nevada. My state requires that health insurance cover ABA treatment for children with Autism until they turn 21. However, not all of the plans that Nevadan’s have through their employers actually cover ABA treatment and some only cover ABA treatment until a child is 7 years old. While selling insurance across state lines (as in buying an insurance plan sold in California and according to California statutes and regulations) is not legal, offering a plan from a self-insured employer based in another state is legal. Some employers in Nevada are very large, are self-insured, and have headquarters based outside the state. These plans are not subject to the changing health insurance demands of every state since they are regulated by ERISA. So many Nevadans, despite state law, do not have coverage for their child’s ABA therapy.

 

It is important to note that self-insuring can reduce costs for employers, give them more control over the plan they design for employees, and can offer tax advantages along with easier implementation by reducing regulations and applicable laws. Employers should move in this direction to create better health plans that give them better access to their own data and needs. At the same time, we should recognize that these types of plans can be hard to regulate and present challenges to patients, employees, and lawmakers who want to see specific changes or policies. Employers should strongly consider self-insuring to get away from the profit motive of health insurance carriers, but should recognize that avoiding individual state health insurance requirements by self-insuring could lead to a backlash against self-insured health plans.
The Cost of Outliers

The Cost of Outliers

Malcolm Gladwell is well known for his book Outliers, about people who become extremely successful thanks to intense practice, good luck, and supportive situations that enable their early practice and skill development. If you have read his book, you probably have at least a little exposure to the idea that some people are unique and can have a surprising influence on the world. But one area you probably haven’t considered with the impact of outliers, unless you study healthcare economics, is in medical spending.

 

In his book The Opioid Crisis Wake-Up Call, Dave Chase explains the issues with outliers in our system. “Six to eight percent of plan members are spending 80 percent of the plan dollars,” Chase writes.

 

We probably imagine that our healthcare costs are so expensive because so many American’s don’t eat well and don’t exercise. I have argued in the past that we don’t support a universal healthcare system in our country because many people think the problem is that others are not taking responsibility for themselves and are simply fat and lazy, costing more for the rest of us. The reality is that a huge amount of our total healthcare spending, as much as 80% according to Chase, is from a tiny percent of the population. Our outliers are driving the cost of healthcare up at an alarming rate, and it is not simply because these outliers are fat and lazy.

 

The people who spend the most on healthcare mostly have rare diseases, congenital conditions, or need extreme emergency acute care. Chase writes, “They tend to have complex health problems, usually with multiple comorbidities.” Because we don’t recognize that most of our spending goes toward outliers, and because we are biased against a vision of fat and lazy people, we adopt policies that bankrupt these outliers who often were simply born with bad luck when it comes to health.

 

What is really detrimental to our system is that these outliers are often misdiagnosed. Chase writes, “In any given year, about 20 percent of the outlier group is completely misdiagnosed. This means that about 16 percent of plan dollars each year are being wasted on treatments for diseases the patients don’t have.” It will always be difficult to treat outliers. They are not typical patients, and have multiple health issues that interact in complex ways. But because we don’t make their care easy and because healthcare in the United States has so many barriers, we end up failing this population, and the errors and failures mean that we waste a huge amount of money and resources in their care. It doesn’t just cost the individual, but everyone on the healthcare plan.