Healthcare Kludgeocracy
March 24, 2022
John McCracken, Ph.D.
Physicians aren’t “burning out;” they’re suffering from moral injury. Moral injury—being forced into behaving in ways that go against an individual’s moral values and beliefs—is the proper explanation for what is frequently characterized as burnout in physicians and post-traumatic stress in soldiers. In war, soldiers either perpetrate or witness events that contradict deeply held values and moral beliefs. The anger, exhaustion and depression that result are similar to the reactions physicians are exhibiting today.
Physicians are trained and deeply committed to giving primacy to the welfare of the patient. But today they are subject to an increasingly complex web of conflicting allegiances—to hospitals, health systems, employers, insurers and regulatory agencies, requiring them to consider a multitude of factors other than their patients’ best interests when deciding on treatment. Navigating an ethical path through such intensely competing interests is emotionally and morally exhausting. The moral injury that results from providers being forced to act in ways that conflict with their deeply held beliefs is what’s causing a loss of resilience and driving them to a tipping point.
The root cause of this condition is healthcare kludgeocracy. A “kludge” is defined by the Oxford English Dictionary as “an ill assorted collection of parts assembled to fulfill a particular purpose…a clumsy but temporarily effective solution to a particular fault or problem.” A kludgeocracy is a government or society built and run on quick fixes. It’s one in which the government tries to solve complex problems in haphazard ways, with patches and quick fixes as opposed to creating a fundamentally new policy approach to the problem. The end result is a policy mechanism that is substantially more complicated than is warranted by the problem it’s trying to solve, e.g., the Internal Revenue Code, which is now so complex and fluid that it’s almost impossible to determine even how long it is.
There are two principal reasons why healthcare has become a kludgeocracy. The first is a political culture that combines the long-standing American preference for market-based solutions and myth of small government with a public that simultaneously thinks that many important issues are legitimate subjects of government action and oversight. The attempt to preserve America’s market orientation and at the same time be a kind of social welfare state results in policy disfunction. Government can run a program, or privatization can take over, but when something is privatized and yet the government still wants a significant measure of control, it becomes unwieldy.
A textbook example is the Affordable Care Act. On the one hand, the ACA preserves many aspects of the status quo ante by continuing to allow employers to provide insurance for their employees and permitting individuals without employer-based coverage to independently purchase it in a marketplace. At the same time, 2700 pages of legislative language and over 11,000 pages of regulations create a mind-numbing level of overarching complexity. The law attempts to reap the benefits of both free-market principles and powerful government oversight. But in combining them, the result has been to exacerbate administrative bloat, cost inflation and physician time and resources required to deal with the labyrinthine processes of billing and reporting, all overseen by an increasingly overwhelmed CMS.
A second cause of healthcare kludgeocracy is a myriad of special interests that all fight to extract economic rents from public and private payers. During the past two decades, healthcare organizations have spent more than $10 billion on professional lobbying, more than three times any other American industry and more than the defense, education, automotive, securities and oil & gas industries combined. In 2021, there were 3,100 registered state and federal healthcare lobbyists, 48% of whom were former Government employees.
The result is the accumulation of multiple layers of legislative and regulatory rules, subsidies, patches and quick fixes, each responding to the most compelling voice at the moment. It has produced a complex set of healthcare policies and programs with little coherence or overall ideological justification.
Over the past four decades the scale of healthcare kludgeocracy has steadily increased, a principal contributor to healthcare’s share of GDP more than doubling, from less than 9% in 1980 to almost 20% in 2021. Going forward, there are likely to be more technocratic reforms that attempt to respond, but which will serve primarily to increase complexity. The one universal that all can agree on is that the current trajectory is unsustainable. In the memorable words of Herbert Stein, former Chairman of the Council of Economic Advisers under presidents Nixon and Ford, “If something cannot go on forever, it will stop.”
Healthcare kludgeocracy will indeed eventually be brought under control, but it’s unlikely to be the result of creative new CMS pilot programs or enlightened reforms led by the nation’s provider or managed care organizations, i.e., a “soft landing.” Instead, it’s more likely to have its origin in a seismic shift in public attitudes and demands resulting from the culmination of powerful economic forces much larger than just healthcare. How that might possibly play out will be the subject of a forthcoming blog post.
John McCracken is a Clinical Professor of Healthcare Leadership and Management in the Jindal School of Management, The University of Texas at Dallas.