🏗️ "It's time to build," — but what about healthcare?

Plumbing Marc Andreessen's new essay for lessons

Marc Andreessen — venture capitalist, thought leader, legendary designer of the Mosaic web browser, author of the era-defining 2011 essay "Why Software Is Eating the World” — is out with a new treatise.

His prescription for the post-coronavirus world? “It’s time to build.”

The entire piece is highly recommended. Andreessen implores us to build across the board, in every industry. He means new schools, new housing, new cities even. In manufacturing, he suggests Elon Musk’s alien dreadnoughts, — “giant gleaming state of the art factories producing every conceivable kind of product, at the highest possible quality and lowest possible cost.” In transportation he means high speed rail and soaring monorails. As for climate change, he notes that “all carbon-based electrical power generation on the planet could be replaced by a few thousand new zero-emission nuclear reactors, so let’s build those.”

And yet healthcare is perhaps the one industry Andreessen mentions which defies easy calls to build. Some things should be simple, such as the cotton swabs and common reagents that are currently bottlenecking coronavirus tests, and the surgical masks, face shields, and medical gowns for which there really is no excuse for a country like ours to be short on.

But after that, healthcare gets difficult. For decades, it’s been the one industry that continually defies attempts at structural and regulatory reform. Developing vaccines and new therapies for a disease we’ve never seen before really is hard, but so is everything else, from building new hospitals to innovating new delivery models to developing new medical devices.

One doctor I worked with had developed a simple all-in-one device to drain abscesses called a Quickloop. Materially, it consisted of little more than a curved needle and plastic tubing, but as the physician inventor recounted to me, the approval process for the device would easily take years, with thousands of pages of multiple submissions to regulatory agencies, including studies proving the device’s effectiveness in draining abscesses more effectively than previous techniques. And even then, he told me, prospects for bringing the device to market amounted to breaking into a space guarded by a cabal of oligarchic industry giants.

Clearly this is not the path to a better healthcare system.

A huge part of the problem is regulatory capture, as Andreessen notes: “We need to want new companies to build these things, even if incumbents don’t like it, even if only to force the incumbents to build these things.” In healthcare, incumbents from insurance providers to large health systems have not just captured the regulatory machinery of the country, they’ve perpetuated an industry structure in which the only way to survive is to grow as big as possible as fast as possible. As I’ve written previously, healthcare is more or less a Game of Thrones-style power struggle between warring kingdoms.

What then is the answer to Andreessen’s call to build, if you work in healthcare? The answers aren’t easy. If they were easy than healthcare wouldn’t be one of the only sectors with few, if any, truly pioneering business leaders. There is no Steve Jobs or Elon Musk of healthcare. Until CRISPR — which is likely to go down as one of the most important discoveries of the past half century (and potentially all of human history) — the most famous recent innovation in healthcare delivery was arguably Atul Gawande’s checklist manifesto, which introduced hospitals to the stunning insight that if they washed their hands more thoroughly, fewer people would die from hospital-acquired infections.

The thing is, healthcare is chock full of highly intelligent, entrepreneurially-minded, educated people with the funding, the ambition, and the connections to make things happen. So why do so few things happen?

Another physician who I spoke to three weeks ago told me that his company had direct relationships with mask manufacturers in China and could ship N95s to hospitals tomorrow, if only the hospitals would buy. He told me he suspected that “hospitals would rather ‘run out,’ and claim shortage and allow people to become exposed as it is cheaper for them — no joke.”

Meanwhile, for the past decade, hospitals throughout the country have routinely been short on the most basic medications, even saline solution. Yes, the so-called greatest country in the world (not accurate by almost any metric you choose) can’t keep its hospitals adequately stocked with properly mixed and sanitized salt water.

At least the coronavirus has begun to shake loose the regulatory stranglehold on innovation and experimentation, if just a little. States are relaxing their ridiculous restrictions on recognizing the medical licensing of other states. Any potential HIPPA violations from conducting a telehealth consultation via Skype, FaceTime, or the like are being waived. Politico published a list of every law and regulation New York Gov. Andrew Cuomo has waived to combat coronavirus, and to read through it is to be made meticulously aware of the astonishing oppressiveness of the American regulatory regime.

And yet simply reducing regulation is not the answer Andreessen has in mind, at least not entirely. As for politics, Andreessen writes that both sides have work to do:

The right is generally pro production, but is too often corrupted by forces that hold back market-based competition and the building of things. The right must fight hard against crony capitalism, regulatory capture, ossified oligopolies, risk-inducing offshoring, and investor-friendly buybacks…

It’s time for full-throated, unapologetic, uncompromised political support from the right for aggressive investment in new products, in new industries, in new factories, in new science, in big leaps forward.

The left starts out with a stronger bias toward the public sector in many of these areas. To which I say, prove the superior model! Demonstrate that the public sector can build better hospitals, better schools, better transportation, better cities, better housing. Stop trying to protect the old, the entrenched, the irrelevant; commit the public sector fully to the future.

Andreessen suggests that the left start with the Veterans Health Administration. If public healthcare works so well, let’s see the results! The model is right there, waiting for the superior public official, manager, leader, innovator to come along and make it a shining example of superior healthcare delivery. Or take Kaiser, the single-payer, integrated private counterpoint to visions of a Medicare-for-All future. Scale it across the country! Let’s see how it performs in rural areas outside the wealthy, urban markets it currently dominates. If it doesn’t work, then we know we’ll need something different. Or, perhaps the fact that Kaiser hasn’t expanded already tells us what we need to know.

If so much innovation in healthcare is hampered by entrenched powers protected by regulatory capture, perhaps two interesting examples of disruption to look toward are Uber and Airbnb. Both companies went up against entrenched industries protected by a dense thicket of regulation, and both flaunted city and state rules — the faked it until they made it. Uber (and Lyft) insisted it wasn’t a taxi service at all, but a ride-sharing app, so its drivers didn’t need to purchase things like taxi medallions or abide by any of the same rules that taxi drivers did. Meanwhile, Airbnb insisted it was fundamentally different from a hotel, so its hosts (until recently) didn’t need to pay lodgers’ taxes or follow any of the same rules that hotels had to.

In the early days of the coronavirus pandemic, it was a group of doctors in Washington State who bravely ignored FDA directives prohibiting them from using an academic study to begin testing for coronavirus, and thank God they did. Elsewhere, new healthcare startups like One Medical and Dedication Health have innovated essentially be performing an end-run around the entire insurance-dominated, reimbursement-driven payment structure. Or, as it is also known: returning to medicine’s roots, when doctors delivered a service and their patients paid them for that service.

We can only hope that, in the wake of coronavirus, the good people of healthcare figure out how to perform more end-runs. We can hope that politicians of both parties realize that sometimes they need to get out of the way, and other times they need to actively speed the way. We can hope the American people remember how to take responsibility for their own health, from eating healthy to exercising to looking after their mental well-being.

“Building isn’t easy,” Andreessen wrote, “or we’d already be doing all this. We need to demand more of our political leaders, of our CEOs, our entrepreneurs, our investors. We need to demand more of our culture, of our society. And we need to demand more from one another.”

Amen to that.