By IAN MORRISON

I have been studying American healthcare for more than 40 years and I have assembled a large number of one-liners over the years. As we enter 2022, I thought I’d share my 22 oldest jokes and why they still matter. 

Coming to America 

1. I grew up in Glasgow, Scotland.  In Glasgow, healthcare is a right, carrying a machine gun is a privilege. America got it the wrong way round. 

Gun violence continues to ravage the United States. We have more guns than people. Kids get gunned down in school playgrounds and classrooms routinely. It happened once in Dunblane, Scotland in 1996 when a local shopkeeper walked into Dunblane Primary School and opened fire, killing 16 5- and 6-year-olds and their 45-year-old teacher.  It so galvanized public opinion, according to Smithsonian Magazine:  “By the end of 1997, Parliament had?banned private ownership?of most handguns, including a?semi-automatic weapons ban?and required mandatory registration?for shotgun owners”. 

Last time I looked, gun violence was the second leading cause of death in children in the US.  In America when we have mass shootings all we get are thoughts and prayers. 

And when it comes to healthcare as a right, even if we Build Back Better, it won’t be a right for millions of American residents, especially those who are undocumented. 

2. I am a Scottish Canadian Californian which gives me a unique perspective on healthcare (and all things to do with healthcare, including death and dying) because the Scots see death as imminent, Canadians see death as inevitable, and Californians see death as optional. 

This is one of my oldest jokes and it remains true.  In Silicon Valley, where I live, my affluent VC friends want to live forever and are working out and taking supplements to achieve that. In contrast, my British friend Dr. Richard Smith (former Editor of the BMJ) is sitting on the Lancet Commission on the Value of Death.  Enough said. (https://commissiononthevalueofdeath.wordpress.com/category/about-us/) 

3. Canada could have been the best country in the world: it could have combined American know how, British ethics, and French culture. Unfortunately, it got American culture, British know how and French ethics, a particularly nasty combination. 

Canada is still a great place, especially in contrast to a Trumpian America, but they have had their own issues with competence and corruption in recent years. 

4. As to why Americans can’t do Canadian-style healthcare: “I lived in Canada, I trained in health economics and health policy in Canada, my wife is Canadian, and most of my extended family live in Canada.  So the short answer is “You are not Canadian:  Canadians are different from Americans, they describe themselves as Unarmed Americans with Health Insurance.” (The latter part is borrowed).  

Despite all their troubles, including waiting times for MRIs and elective surgery, Canadians remain fiercely loyal to their healthcare system and view it more positively than their American counterparts do their own system.  https://leger360.com/surveys/legers-north-american-tracker-july-13-2021/ 

For Canadians their health care system is a proud point of cultural differentiation from Americans. 

5. Why do the French have the highest rated health system in the world? It has very little to do with their health system. The real reason is that the French walk, they drink red wine, and they get naked in the summer. Nothing will keep your BMI down better than getting naked in the summer. 

The French still smoke at higher rates than the US and consume more alcohol, and in recent years their diet has increasingly been Americanized by fast food, hypermarkets, and industrialization of cafes and restaurants.  Even though they had their own challenges with Covid, they have life expectancy above comparable countries, whereas America is far below that metric and going in the wrong direction. https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/ 

On Being a Health Consumer or a Patient 

6. (Healthcare) Quality is being in a waiting room with people who earn more money than you do. 

Despite enormous investments in what I call the quality police (the health industry agencies and actors who measure, manage, accredit, approve and regulate healthcare quality), the public still has a great deal of difficulty in judging health quality.   Consumers confuse choice with quality.  Patients are frightened and usually defer to their doctors when the chips are down.   Having gone through a serious healthcare surgery recently at Stanford, I would say a pretty good surrogate for quality is being in a waiting room with the affluent crowd.  

By the way, I used this line in a talk to venture capitalists a few years ago.  They looked at me with incredulity and nobody laughed, because nobody makes more money than they do. 

7. Good Health is a state of incomplete diagnosis (Borrowed).  

I credit my friend Bill Rosenburg, formerly of KPMG and Met Life with this line.  It was also widely circulated by my old mentor Bob Evans at UBC.  No matter the ultimate provenance of the joke, it is one of the best descriptors of modern medicine.   

If you look hard enough, everyone has something wrong.  Most cultures don’t bother finding out and it either resolves itself or it doesn’t. 

8. The Quantified Self movement is going to lead to a Frenzy of Cyberchondria, overwhelmed with false positives and the hyper worried well  

Do you really want to know your blood pressure in real time, all day long from your smart watch?  Does your doctor want 15 terabytes of data from your Peloton? Let me tell you: she does not.  

This technology can be incredibly helpful if we develop the right use cases, particularly in managing vulnerable folk.  Continuous monitoring of the buff seems like a waste of resources. 

9. It’s tough to be cost conscious when you’re unconscious. 

I used to tease the great Alain Enthoven with this line.  I’m all for more cost consciousness by consumers, but as Mike Tyson famously said: “Everyone has a plan until they are punched in the mouth.”  

10. How to pick a health plan  

Step 1.  Decide on the diseases you and your family are going to have in the coming year 

Step 2.  Find the best doctors and hospitals for those diseases 

Step 3. Identify which plans offer those doctors and hospitals 

Step 4.  Select the cheapest plan 

Step 5.  If there are no affordable plans with all the doctors and hospitals you want, go back to Step 1 and pick some new diseases 

This accurately describes how many Americans are asked to select health plan options whether in Exchanges, Medicare, employer sponsored coverage or even Medicaid. The joke tries to point to the absurdity of selecting a plan that meets your needs when by definition no one has perfect vision of their future health and disease.  (See Mike Tyson).  Maybe we should figure out a system to pay for care for people who need it, rather than paying for coverage that doesn’t cover what patients may need when they get sick. 

On the Role of Employers 

11. When it comes to healthcare employers are Cranky, Confused, Aimless and Spineless. 

The genesis of this line was a meeting in the early 1990s with the CEO of Baxter Vern Loucks and his leadership team.  My colleague Bob Leitman of the Harris Poll and I were presenting the results form our annual Healthcare Outlook surveys of consumers, physicians and employers.  We had too many slides and generated great discussion and so of course, we ran out of time.  As the meeting closed Loucks turned to me and asked what does the employer survey show in a nutshell: “When it comes to healthcare Employers are cranky, confused, aimless (I said)…..and spineless (Bob added)”.   

“Exactly” Loucks responded “you two are going to come with me next month to tell some other CEOs exactly that”.  Loucks was an ex-marine and a central casting CEO you would follow him anywhere.  

Loucks office called the next day and we were asked to appear in St. Louis at Emerson Electric in a couple of weeks time.  We waited in the board room and in walked Loucks with fellow CEOs Chuck Knight of Emerson Electric and Auggie Busch of Anheuser Busch. 

“Tell them what you told me” Loucks said.  “Employers are cranky, confused, aimless and spineless,” we said. 

Not missing a beat Auggie Busch said: “Yeah but we are not stupid.  Labor costs are a small part of our business, (we spend more on advertising) and healthcare costs are just 10% of labor costs”. We had a great discussion about healthcare.  Oh, and they did fire the benefit manager some months later, sorry. 

I am a long-time advisor to PBGH (Purchaser Business Group Health) which represents industry giants like Wal-Mart, Disney, Boeing and Apple and more than 40 others household names.  They are becoming much more activated in both purchasing and policy making as they deal with the consquences of Covid, and the reality that the healthcare provider “game” is completely dependent on self insured employers for their financial sustainability.  https://thehealthcareblog.com/blog/2020/05/19/the-end-of-the-game/ 

Stay tuned for more employer activation in 2022. 

On Obamacare and Replacing It 

12. On Republican Plans to Repeal and Replace Obamacare: “It’s like breaking up the Beatles where you just keep George and Ringo and expect it to sound good.” 

Mercifully, John McCain gave Repeal and Replace a thumbs down, but Republicans were close to repealing Obamacare and ripping out the essence of the program (the John and Paul) of raising taxes and subsidizing exchanges and Medicaid expansion. 

13. Republican policies are ideologically coherent, they’re just not actuarially coherent 

All of the Republican proposals to replace Obamacare were consistent with smaller government principles but they all fell short on affordability for consumers, reduction in the uninsured, and the resulting positive effects on health and financial security of the newly covered. 

On Medicaid 

14. Medicaid is bigger than France, It’s bigger than Wal-Mart 

Medicaid expansion has occurred over the last ten years in 38 states and more recent government action to fight Covid has further expanded Medicaid rolls in every state.  Build Back Better provisions, if enacted, would further expand eligibility for the program.  Even if BBB doesn’t pass, Medicaid will still be bigger than France in terms of number of enrollees and bigger than Wal-Mart in total revenue.  Massive Medicaid is the default program for an increasing number of poor, elderly and vulnerable populations, yet payment rates to providers are inadequate, this will be a central challenge for the future. 

15. It’s easier to get into Princeton than to get a Medicaid card in Texas. 

This is a true statement for childless adults, because like many other Southern states childless adults are not eligible for Medicaid.  And even worse, if you are in a category eligible for Medicaid but you earn more than $3,733 per year for a family of 3 (17% of the Federal Poverty Level), you are too rich to qualify for Medicaid in Texas.  Princeton has got to be easier to get into. 

On Business Models 

16. The prevailing metaphor for American healthcare is “Pimp my Ride” 

As I wrote back in 2005: 

“If you have teenage kids, you end up watching a lot of MTV or you have nothing to talk to your children about.  My kids are both in college now, but I have watched a lot of MTV in my time.  My favorite show of the moment is “Pimp My Ride”.  The show is in the genre of all makeover reality shows.  In this case a rapper host introduces a poor kid and their beaten up old car (the ride).   The car is taken from the young adult and transformed by a team from West Coast Custom (a body shop and customization company in LA).   

Each episode shows a different kid and a different car:  clapped out Pintos, beaten up Suburbans, and a plethora of ugly, weird, old and dilapidated camper/truck hybrids.  The process is always the same: they strip the car’s interior and install an unbelievable array of stereo equipment (woofers and sub-woofers included), video displays (even laptops) and the whole thing is topped off with an amazing paint job in vibrant blue or dazzling yellow, topped up with custom painted flames on the side.  They never seem to do anything to the engine, drive train, or chassis of any of these vehicles.    At the close of each episode the youngster is shown the transformed vehicle that has been “pimped” and they can never contain their excitement.  They are deeply grateful. 

The prevailing vision of quality in American healthcare is “Pimp My Ride”. 

We take a really bad chassis and engine and bolt on unbelievable amounts of high technology on a frame that is tired, old and ineffective.  We spend extravagantly on buildings, machines, drugs, devices, and people at West Coast Custom Healthcare.  The people who own the rides are very grateful because they don’t have to pay for it in a high deductible catastrophic coverage world, once you are over your deductible and ensconced in an American hospital the sky’s the limit.  It all looks great, has a fantastic sound system, and nice seats but it will break down if you try and drive it anywhere”. 

I rest my case. 

17. Really rich people don’t pay taxes, unless they have bad accountants 

I actually got this joke from my accountant.  He was correctly pointing out to me the fact that the ultra-rich have a wide variety of offshore and other tax avoidance schemes that are unavailable to even the ordinary affluent. 

18. One man’s waste is another man’s income.  Modern variant:  One man’s surprise bill is another man’s lucrative business model 

The whole surprise billing policy shenanigans has underscored the fact that many providers such as ER doctors and anesthesiologist (especially if they are private equity backed), air ambulance services and many others are completely dependent on surprises as their business model. Hospitals and health systems are often complicit in these models and it is why they are resisting the rules of adjudication of surprise bills which will inevitably reduce the economic yield from out of network activity. 

19. Managed Care Definition: An organized system of healthcare financing and delivery that takes the excess profits of hospitals, specialists, and drug companies and gives them to consultants 

Managed care been “berry, berry” good to me.  Managed care unleashed a gravy train for consultants that has continued for 30 plus years (with only minor perturbation by Covid).  The current managed care variants of value-based purchasing and population health still haven’t dealt with the fundamental question if managed care is so great why have American healthcare costs continued to rise faster and higher than anywhere in the world over the last 30 years and life expectancy and other indicators have gotten worse relative to our advanced country peers.   

20. At some point in the next five years the revenue from the Revenue Cycle Industry will exceed the revenue of the hospitals they serve in the financial management equivalent of the Rapture. 

We have armies of people faxing things to each other and in the modern version we have dueling robots where automatic upcoding by hospitals meets automated denials by health plans.  At some point the robots will explode and the health system will meltdown. 

On Disruption 

21. When smart Alec start up CEOs call me with a plan to disrupt American healthcare I give the same speech.  The American healthcare system is larger than the entire Italian economy and about as well organized.  So if you think you are going to disrupt healthcare it’s a bit like saying you are going to disrupt Italy. Good luck with that. 

US healthcare just edged out the German economy as the fourth largest economy in the world (it is actually twice the size of the Italian economy).  Such massive incumbency is not easily moved. The new disruptors with the massive resources thrown at them in 2021, also have massive burn rates which will be challenged in the next 24 months to deliver on the lofty promises.  I wish them well, we need the innovation. Ciao. 

On Being a Futurist 

22.  My definition of a futurist is an economist who couldn’t handle the calculus. 

I have been in the sweeping generalization business for more than forty years.  I like data and arithmetic, calculus not so much.  But I believe that if something is going to be a big deal in the future it has to start some time and be detectable to human beings without fancy mathematics.  Jokes can help tell those fundamental truths.   

Ian Morrison, PhD is an author, consultant and futurist in Menlo Park, California