10. The Future History of Health Care

Despite near-magical advances in the science of medicine and eye-popping investments across the care ecosystem, U.S. health care is on course to be even more crushingly expensive and piecemeal.

Private insurance will be prone to higher and higher deductibles, with continued inequity between haves and have-nots. Public debate on health will continue to be more about who pays for the care than about improving the care and lowering the cost.

It doesn’t have to be that way. In fact, we think it would be crazy not to have terrific health care available to everyone at an affordable cost by 2050, providing longer, more active lives.

In this week’s serialization of “A Brief History of a Perfect Future,” coauthored with Paul Carroll and Tim Andrews , we explain why we have the tools to build a better future. And, we outline ways we might—starting now— collectively work towards inventing a future that we would proudly leave our kids by 2050.

We hope you’ll take a read or a listen, and give us a “like” to help prompt the LinkedIn algorithmic overlords to spread our work.

CHAPTER 10 — The Future History of Health Care

Future History Scenario: No More Pandemics?, July 7, 2050

WASHINGTON, D.C. – The Department of Health and Human Services (HHS) announced today it had identified 27 cases of COVID-49, the disease caused by the novel coronavirus that first appeared three weeks ago. But, as has become the norm, HHS said it expects to extinguish the outbreak in less than a month.

The nationwide tracking system that lets HHS see where concentrations of illness are building found the 27 cases in three pockets, one at a Utah ski resort and two others on the Gulf Coast, one in Houston and one in New Orleans. Contact tracing has identified roughly 1,000 people who are most in danger of having been exposed to those who are infected, and all will be quarantined for the next week while the tiny sensors they’ll ingest every day are monitored for any evidence of the virus in their bodies.

The department said the genome of the virus makes it a near-perfect match for Vaccine #284-B in the HHS’ library of 2,122 “plug and play” vaccines it has developed for the viruses that are most likely to produce global outbreaks. All have been tested for safety and efficacy, so vaccines can be rolled out immediately.?

“The vaccine went into production this afternoon,” said HHS Secretary Dr. Zoe Jenkins in a two-minute holographic call. “We’ll have enough doses to cover the areas around the afflicted areas by the end of the week and will make enough so we can react immediately if the virus appears elsewhere. With this outbreak, we expect a total of about 100 cases nationwide, and, we hope, zero deaths. This outbreak should be fully behind us in three weeks.”

She added, “We almost shouldn’t talk about pandemics any more. ‘Pan-’ means ‘everywhere,’ and, while these viruses certainly have the same potential for devastation that COVID-19 had back in 2020 and 2021, viruses these days barely get a foothold before we stomp them out.”

How to Build that Future:

Without a serious change in course, health care in 2050 will still be better than it is today. That will be thanks, in particular, to the Law of Zero on genomics but will also be because of the sorts of improvements in drugs and treatments that Big Pharma and medical researchers and hospitals will deliver in any case. But the current course in the U.S. would likely lead to health care that would be even more crushingly expensive and still piecemeal, with a mishmash of public programs and group insurance covered by employers. Private insurance will be prone to higher and higher deductibles, with continued inequity between haves and have-nots, and with the public debate on health continuing to be more about who pays for the care than about improving the care and lowering the cost.

We think it’d be crazy not to have terrific health care available to everyone at an affordable cost by 2050, providing longer, more active lives.

The health care cost problem is especially thorny in the U.S., where historical anomalies have produced a system that costs twice as much per capita as in other major economies while providing average or below-average care. But the opportunities for improved care extend throughout the world — and they’re enormous. The Laws of Zero and a series of related breakthroughs in medical technology can produce two paradigm shifts by 2050.

The first shift will be from sick care to health care. At the moment, people tend to spend roughly seven minutes with a doctor during an annual checkup, and they otherwise encounter the health system only when they’re injured or sick. We’re the subjects — the patients — being treated by a system we struggle to figure out. By 2050, not only will we understand the system, we’ll largely control it. We’ll encounter the health system continually, mostly through feedback generated by AI,[1] but also through easy access to quick consultations with doctors, nurses, and other appropriate members of integrated care teams. The system will resemble a turbocharged FitBit or Apple Watch. We won’t just get information on step counts and heart rate, because the Law of Zero on information means that the sensors on our wrists will be greatly upgraded, that we’ll have contact lenses rimmed with sensors, and that we’ll have sensors the size of a grain of salt that we can ingest. (All these options will be at our choosing; no one will be force-fed technology or be otherwise wired up without their permission.) These sensors can then report on vital signs such as blood pressure and glucose and cholesterol levels, and they can even monitor for disease.[2] [3] We’ll also be able to analyze the profusion of data in real time and translate the results into actionable next steps for both provider and patient — something that isn’t possible today with the far more limited data available at our disposal.

While people today marvel about the Internet of Things, in the Future Perfect these sensors will give us access to an Internet of Me. The data stream from all the sensors on and in our bodies will be controlled by the person hosting them but will typically be shared with the computer systems of care teams. While people today try to get to 10,000 steps, people in the future will have access to a series of more sophisticated and important goals on blood pressure, blood sugar levels, etc., and they’ll be provided with advice on how to hit those goals. This advice will become increasingly personalized as the Law of Zero on genomics takes hold and we learn more about our individualized vulnerabilities, based on our unique genome and how it is being expressed via epigenetics.?

If we want, we can be coached toward our goals using the best behavioral science, too. Americans have been described as the worst patients in the world because of all our bad habits.[4] But think about how successful Facebook has been at tweaking its algorithms to capture ever more of your attention; now think of what could happen if that same sort of constant testing and tweaking could be done by medical professionals to help us overcome our bad habits by providing information and nudges that would continually improve our health.[5] Done right, behavioral science could drive as much change as just about any of the coming breakthroughs in medical science. A prominent doctor friend of ours says, “I can tell people exactly what to do to decrease their risk and, individually, how to do so with high efficacy. But that knowledge doesn’t get translated into action. Moving to action is where the gold is.”?

The second paradigm shift in health care will build on the same sorts of Laws of Zero capabilities to go beyond today’s focus on individual care and allow for an overlay that manages public health in ways far more powerful than are possible today. In the U.S., in particular, the devastation from COVID-19 occurred because of a failure in the public health system. The U.S. system is designed around, “Call your doctor,” and, “Work with your insurer to figure out how much you’ll pay out of pocket.” But that approach doesn’t work so well when you need to test whole populations (repeatedly) and need to institute contact-tracing programs. That “call your doctor” and “work with your insurer” approach also doesn’t address the social determinants of health — such as income, education, neighborhood conditions, and access to transportation — which are often related to racial inequities and which are increasingly understood as crucial. Besides, many of those who suffer based on these social determinants of health don’t even have insurance or a regular doctor to call.

Management guru Peter Drucker once wrote something commonly paraphrased as, “What gets measured gets managed.” Well, in the Future Perfect, almost everything will be measurable, so almost everything will be manageable, both for the individual and for the public at large. AI will be able to flag areas where, for instance, groups of people’s temperatures start rising and will alert public health authorities to investigate. AI will rapidly spot nascent pandemics[6] and other problems that affect a whole population, such as the epidemic of opioid use that was ignored for so long and the water problems that hit Flint, Michigan. AI already allows for early detection of heart attacks, influenza, and other conditions by examining the language used in tweets and in internet searches.

Health officials will be able to calibrate the value of tools that aren’t typically thought of as part of the medical arsenal, such as transportation. Public health officials could blunt the scourge of suicides,[7] which claim more than 40,000 lives each year in the U.S., by seeing patterns that represent warning signs of depression and by letting them test what interventions work.[8] In general, while clinical trials have been expensive and have taken ages to conduct, in the Future Perfect it’ll be possible to test and constantly learn about the effects of medicines and treatments. The whole world will be a natural experiment where researchers will be able to explore cause and effect and continually update the collective wisdom about best practices.

Becoming more wired-up and taking part in the public health monitoring will need to be voluntary. And we’ll need to be careful. Nobody wants to create an opening for Big Brother. But the benefits of the sorts of breakthroughs we expect should attract more than enough willing participants to allow for the two paradigm shifts.

Those shifts will let us finally tackle the two stats that have long bedeviled health care: that five percent of people account for 50 percent of health care spending every year, and that 70-80 percent of spending relates to chronic diseases.

The five percent figure has always seemed to be an easy target: You just identify the five percent and focus on them, right? The problem is that the five percent change from year to year, as many recover or, sad to say, die. New people move into that five percent, but it’s been difficult to predict who they’ll be. That prediction, however, will become much easier with a huge chunk of the population essentially wired to identify health issues, and spotting illnesses like cancer in their early stages will make them far less expensive to treat. Already, the Office of the National Coordinator for Health Information Technology has funded research to use AI for patients with chronic and end-stage renal disease and to match them with the best treatments based on each patient’s specifics and preferences.

The chronic disease issue will always be with us in at least some form. In some cases, the issue may expand because – happily – diseases like AIDS and many forms of cancer, once seen as death sentences, can now be managed as chronic conditions. But many chronic diseases, such as Type 2 diabetes, can be drastically reduced through new focus on prevention and population health and through the continual feedback that can help individuals manage their health better.?

The Laws of Zero will also accelerate breakthroughs in the chemistry and biology of medicine. For Exhibit A, just look at the historic development of safe and effective Covid-19 vaccines. The success of Operation Warp Speed in the U.S. and similar vaccine development efforts around the world would have seemed impossible in early 2020. Now such vaccine development will become the norm, and there will be a long list of such amazing accomplishments between now and 2050. For instance, as we described in the chapter on the Law of Zero on genomics, insights from AI should let scientists target the gene-editing tool CRISPR and turn it into a full-fledged way to treat many chronic diseases, such as sickle-cell anemia and certain cancers. AI also recently contributed to a breakthrough in modeling proteins that is expected to allow for other life-changing drugs and treatments to be developed in months — not years — and at far lower cost.[9]

The Laws of Zero will solve some health and sickness problems on their own. In addition to what driverless cars do to improve health indirectly, they will, as we’ve noted, greatly reduce the traffic accidents that kill some 1.4 million people worldwide each year. The World Health Organization says 3.4 million people die every year of water-related illnesses. Give them abundant clean water, and watch what happens. Providing everyone with all the energy they need creates the potential to wipe out a huge percentage of the illnesses and deaths that now occur because of poverty.

The two paradigm shifts – reorienting around the patient, rather than the health care system, and adding a digital overlay focused on public health issues – will make the world look very different for individuals, providers, and government:

Individuals: The key development will be the emergence of an integrated data model that captures all the information on the health of those who’ll choose to participate. Drawing on the Laws of Zero on computing, communication, and information, the single data base that will arise will always be up to date and available as the single source of truth when someone deals with the health care system. By contrast, doctors, hospitals, and insurers today each have their own snapshot of a patient’s data and exert rigid control over what they know. Until very recently, some information couldn’t even be sent directly to a patient; it had to go through a doctor first. The release in the U.S. in early 2021 of long-awaited rules against information hoarding is already making a difference but is just the beginning of what will be a long process.

Advances in the Internet of Me will let everyone monitor their health, based on research-based evaluation of vital signs and real-time monitoring of diet, exercise, and sleep. Sleep’s importance was always intuited but never really understood. We spend a third of our lives sleeping, and everyone always reports being tired. In the Future Perfect, we’ll have figured out how to help people sleep better and will be able to show people the long-term effects on their health. The new health data model will include a growing amount of information based on genomics but also on income,[10] education, and other demographics not normally viewed as health factors — researchers have recently learned your nine-digit ZIP code may say more about your life expectancy than your genome does.

Health measurements will be used to fine-tune actions for best results for each individual. It’s long been known that poverty correlates with poor health, and system administrators in the Future Perfect will understand the relationship. “Free” water and wide access to healthy food will enable administrators to direct resources to people in ways that could improve their diets and general health. “Free” transportation will be used by government agencies or doctors to send good food or other forms of help or to let people come in for any tests, consultations, or treatments.

Providers: Care providers will continually interact with individuals, drawing on the insights of behavioral economists and using methods that actually drive change — there will be no more reliance merely on annual suggestions about quitting smoking, losing weight, and exercising more. The interactions with care providers, most of them automated, will happen through texts, vibrations on the patient’s smartwatch, or other digital communications and will incorporate continual feedback from the patient. Primary care doctors will operate as highly sophisticated advisers, working in care teams with other professionals such as nutritionists, health coaches, community health workers, and mental health professionals. Care will be longitudinal, not episodic. In other words, you’ll feel like you’re dealing with the same team for years or decades, rather than just bopping into a clinic and dealing with whoever happens to be there when you have a problem. Care teams will help people manage their health in every way, not just through the medical system.

A future consultation won’t require you to sit in a doctor’s office, where you’ve been waiting for 45 minutes after filling out reams of paper forms. The new consultation will mostly be between you and your wrist, as you use whatever device you’ve chosen to track your health status and to see what the AI is steering you toward doing in terms of diet or exercise. A more elaborate consultation with your provider will usually require nothing more than a video connection so you can confer with a doctor or nurse. The health care professional on the other end of the line will have access to all your health information in real time and will be able to gather nonverbal cues thanks to high-resolution images — say a video of you walking and talking or perhaps via a picture you take of a rash or a mole.

The result of all these advancements might come to be known as lifestyle medicine, where the goal is just to keep people healthy. There will be plenty of hands-on care and access to miraculous drugs, but the focus will be on helping people be healthy through a better lifestyle. Gordon Bell, the developer of the first minicomputer back in the 1960s, used to say that “the most reliable part of the computer is the one you leave out,” and that sort of idea will become a health care mantra: “The most effective treatment is the one you don’t need.”

The lifestyle medicine approach will draw on genomics and the profusion of other data and will be able to classify people according to those who need prevention, those who need occasional treatment, and those who require chronic care.

More generally, lifestyle medicine will mark a shift away from today’s mindset of helping patients navigate the health care system. In the Future Perfect, everyone will be recognized simply as people, not as patients or prospective patients. People. People who want to live long and fulfilling lives. And why should people have to figure out the system? Why wouldn’t the system adapt to fit the people?[11]

The shift in thinking will look a lot like the change that’s occurred since the advent of personal computers 40 years ago. The techies kept telling everyone in the 1980s and 1990s that we all had to become computer-literate. Computer literacy was supposed to be a matter of national importance that would help us better compete with other countries. The real issue turned out to be that computers were way too hard to use. Once Steve Jobs came along and showed everyone what good computer design looked like, using one became almost intuitive and the need for books and courses on computer literacy went away. Well, we haven’t found the Steve Jobs of health care yet, but, regardless, in the next 30 years we’ll finally kill the idea that people need to adapt to the system. In the Future Perfect, we will make the system adapt to us people. ??

Recommendations on how to achieve a healthy lifestyle will be backed by an enormously sophisticated system of data analysis — none of this diagnosis-by-infomercial we’re encouraged to do today — and will be fine-tuned constantly, as we change and new insights are gained. Management guru Peter Drucker, in one of his crusty moments, once told us people don’t change. They eventually die and are replaced by people who have more current ideas and information. Even with doctors, who must stay abreast of the latest research, it can take time for the whole medical community to catch up with a change in science. But, in the Future Perfect, the newest research will get pushed out instantly into databases and will be incorporated via AI into the computer-driven recommendations made to doctors on possible treatments. Doctors can be monitored, too, to be sure they’re following the evidence, making something like the opioid epidemic of the 2010s much less likely to recur. Although some doctors may resist the monitoring part, we’re confident, based on extensive work with the American Medical Association and other medical organizations over the years, that they and other caregivers will welcome the Future Perfect. For one, thanks to the far more sophisticated computing, communication, and information capabilities, they’ll avoid much of the paperwork that bogs them down today. As a result, they’ll be able to spend far more time with the individuals they’re helping, and they’ll get to see the sort of improvements in health that likely got them interested in medicine in the first place.

The more sophisticated approach provided by behavioral economics will help build a virtuous cycle, with continual communication through smartphone apps. In the Future Perfect, people will see they’re becoming healthier, which could encourage them to continue on that trajectory, which would make them even healthier, which… you get the picture. Measures such as the Personal Activity Intelligence (PAI) will give those who want access to it a reasonably accurate real-time reading of their likely lifespan, which will motivate many to improve that number.

The new “hospital” will be your home, perhaps in the living room or a bedroom. In the vast majority of cases, the sort of equipment that’s used in a hospital room can be set up in a home and monitored remotely, with a nurse or doctor providing most care via a telemedicine connection and with someone visiting occasionally. People actually tend to recover better when they’re constantly around family or friends rather than when they’re in a sterile hospital room, feeling cut off from the world.

Hospitals will still exist, sure, but they’ll become more specialized. The key pieces of a hospital are the emergency care, the operating rooms, and perhaps the maternity department — though many women choose to give birth at home. But there’s no particular reason the three entities need to all be together, and there’s certainly no particular reason to have them in a huge building with every potential medical specialty, including psychiatry, physically present. Most elective surgeries, such as joint replacements, have much better results and are done far more cheaply in a facility that specializes in them, so more surgical procedures are moving out of the hospital and to ambulatory surgical centers. Even now, specialist facilities[12] known as “focused factories” draw patients from around the country. With the Law of Zero for transportation slashing transportation costs, elective surgeries will largely happen in specialist facilities because distance will be of no concern. Why rely on your local general surgeon, who last replaced a hip six months ago, when you can easily get to a doctor whose team has been doing three hip replacements a day for years??

Lots of health care organizations are already experimenting with ways to let people age in place as long as possible, which will reduce the number of elder care facilities in the Future Perfect. Much of the attraction for these facilities had been to help those who could no longer drive and wanted their needs for food, medical care, and companionship to be met within walking distance. But autonomous vehicles remove travel constraints, and most people would prefer to stay near their friends and family rather than pull up roots and surround themselves with other old folks. Medical equipment, when needed, could be set up in homes.

Robotic assistants will increasingly be able to take on the role of nurses; they’ll deliver medications, watch the patient take them, get people up and walking around, and let caregivers or relatives check in via video to see how the person is faring. Staffing with robots may seem impersonal, but their handling of mundane tasks will free the human caregivers to do the more meaningful and important work. And, as odd as it may sound, many elderly people form emotional connections with the robots. While a human caregiver can’t spend all day with a person, a robot can, and it can alleviate some of the loneliness that can come with aging.[13]

Doctors will evolve into a sort of cyborg, gradually absorbing all the benefits technology can provide. They — and other caregivers — will bring all the skill and empathy that humans can provide and will also have constant access to data and the latest research that computer systems can provide. Again, we believe doctors will generally welcome the change, because it will reduce their need to memorize so much material and will let them focus instead on diagnostics and care.

Business models will change, both for hospitals and the health insurers that pay them on people’s behalf. Many will likely resist, but the current models just aren’t sustainable. Everybody has a hard time dealing with insurance, and few are wild about a hospital system that won’t say in advance whether a common blood test will cost $10 or $10,000 and that may include a surprise bill in the tens of thousands of dollars because, even though the hospital is in-network, an out-of-network doctor briefly examined a patient. Bipartisan efforts to curb the excesses of “surprise billing” and to make drug and hospital pricing much more transparent are finally coming to fruition as of early 2021. So, in 30 years, you won’t have to guess what you’ll pay out of pocket, and you won’t spend weeks fighting with your insurer about what is or isn’t covered. We promise.

Government: Government policy will need to change to allow many of the benefits we’re sure will be possible by 2050. While we’re generally reluctant to prescribe policies, we think a few principles shouldn’t be controversial. First, as a baseline, everyone should have access to good care when sick. Second, governmental policies should encourage and facilitate good health.

On sick care: In the U.S., the richest country in the history of the world, there isn’t any excuse for not providing good care to everyone who is sick. Yet, at the moment, about 10 percent of Americans aren’t covered by insurance, and deductibles are so high on many forms of insurance that people won’t seek needed care. This needs to change. One possible model, prescribed by the late Uwe Reinhardt, a prominent health care economist, would work as much as possible within existing structures but would have the country define a base standard of care that would be covered through insurance with low deductibles. Anyone who could afford that insurance would pay for it (or any more expensive plan or care they wished to purchase). Anyone with no way to pay for the baseline insurance would have payments covered by the government. Those with modest means would be subsidized by the government on a sliding scale, with government support depending on their income that year. Germany roughly follows Reinhardt’s approach and spends less than half per person what the U.S. spends on health care and also beats the U.S. on key metrics such as life expectancy, which is 81 years in Germany versus 78.5 years in the U.S.?

On staying healthy: The role government should play in keeping its residents healthy is more politically sensitive. Few would argue government shouldn’t keep poisonous chemicals out of the water supply and hazardous pollutants out of the air. But how far should that principle stretch? What role should government play in directing individuals away from smoking too many cigarettes or chugging too many sugary drinks, for example, even when it’s scientifically proven that poor choices like these will dramatically increase the risk for cancer and diabetes? We don’t have a simple ideological answer, but we do have a simple economic one: Policy should tilt toward encouraging health because the cost of not doing so is overwhelmingly high for society, including for the taxpayers who foot the bill for programs to treat those who fall ill.

While a 30-year glide path to the Future Perfect should allow for plenty of time to define a rational policy and let all parties prepare, and while all the progress in prospect would seem to demand considerable rethinking to design a system that takes full advantage, we realize the history of health care redesign has mostly been a disaster in the U.S. More than seven decades ago, President Truman tried to institute a national plan. President Nixon tried major reform again five decades ago. President Clinton tried three decades ago. President Obama tried a decade ago. You get the idea. But, as Germany shows, better care at lower cost is eminently possible, even today, and the Future Perfect health care system will slash away at two huge tranches of costs, freeing trillions of dollars to be deployed more productively.

The first tranche is the money currently wasted through administrative complexity, diagnostic errors, delayed diagnoses, undertreatment, overtreatment, and fraud The complexity is actually a feature, not a bug, of the current system. Everybody pays a different price, negotiated by each provider with each payer, often with little connection to the actual cost — and providers and insurers profit mightily from the lack of transparency. (As of 2021, transparency into health care costs and charges became a reality, but a limited one with much more still to be done.) Electronic health records, often built onto platforms originally created to support medical billing, were conceived of as a way of standardizing and sharing information on those receiving care. Yet these records made it easier for providers to bill at higher levels for care delivered to patients. Even though providers benefit from the current system, when you add that complexity together with the errors and overtreatment, this tranche is an obvious target: It accounts for fully one-quarter to one-third of health care spending.[14] With U.S. health care spending headed toward $4 trillion a year, that means that $1 trillion to $1.33 trillion is wasted every year — which can cover a lot of cost in whatever new system is developed. ?

The waste and fraud ingrained in health care will be hard to identify and may be even harder to root out — after all, one person’s waste is another person’s revenue — but the Law of Zero related to information will give us access to (anonymous) information about every condition in every (participating) person in real time. The powerful network created by the Law of Zero on computing will monitor all this information and provide a feedback loop that will allow for constant learning about what works and what doesn’t. After a few hundred billion cycles, that feedback will drive out an awful lot of bad decisions, including unneeded treatment and errors that produce expensive complications. For instance, it took years to realize how much unhelpful back surgery was being done, contributing to a $100 billion-a-year back pain industry that has been called “mostly a hoax,”[15] but, in the Future Perfect, correlations between treatments and poor results will be spotted far sooner. Constant feedback will make the system ever smarter about spotting fraud. Administrative complexity? That’s easy. The computers will handle it all.

The second tranche is the money being spent to treat the late-stage manifestations of chronic diseases, like diabetes and cardiovascular disease. As we’ve noted, 70-80 percent of sick care dollars go to treat chronic diseases that often could have been better managed at earlier stages and that sometimes could even have prevented. For example, the CDC estimates that eliminating three risk factors—poor diet, inactivity, and smoking—would prevent 80 percent?of heart disease and stroke,?80 percent?of Type 2?diabetes, and?40 percent of cancer. The reduction in pain and suffering would be amazing; the cost savings would be spectacular.

Take diabetes, one of the fastest-growing diseases in the world. Thirty million adults in the U.S. suffer from it today. The American Diabetes Association estimates the total cost of diabetes in 2017 in the U.S. was $327 billion, made up of $237 billion in direct medical costs and $90 billion in decreased productivity. In the future, those costs could double or even triple. That’s because another 84 million people have a milder condition, prediabetes, that puts them at high risk for developing Type 2 diabetes, and medical expenditures for people with diabetes are 2.3 times higher than for people without it – it is the leading cause of blindness and kidney failure, often leads to the loss of a leg or foot, significantly increases the risk of heart disease,?and is one of the leading causes of death. Yet research and community experience show that diabetes is mostly treatable, and, in many cases, the progression from prediabetes to full-blown diabetes can be slowed or even prevented. Just taking a small amount of the money now being spent on dealing with later-stage diabetes and diverting it to prevention would pay back many times over in reduced cost and suffering.[16]

Imagine freeing trillions of dollars a year by eliminating waste and improving our handling of chronic diseases. Perhaps some of that money would even wind up in the pockets of workers in the U.S. who haven’t seen much of a raise in decades because they and their employers have had to spend so much on health care. Many workers’ salaries could be tens of thousands of dollars a year higher without the drag created by health insurance.

Cost control will take time. A long time. Americans don’t pay twice as much for care per capita because they get twice as much care or care that’s twice as good; they pay twice as much because prices of treatment, drugs, and everything else are twice as high in the U.S. But those setting the prices in the U.S. will defend them as hard as possible. No one will be shamed into easily giving up their share of the $4 trillion health care system.

But there is enormous pressure to fix the problem. Dave Chase has a chapter in his book Relocalizing Health titled, “Health Care Is Stealing Millennials’ Future, but They Will Take It Back.” He describes a hypothetical millennial who earns a steady salary, culminating in them making $180,000 a year at age 65. That millennial would earn $3.85 million in salary over their career — and would pay $1.9 million for health care. How does spending half your salary on health care make sense, especially when you know that so much is wasted? How much longer will people tolerate this kind of excess expense?

The federal government, spurred by employers and voters being bankrupted by the health care system, will have to do something. We believe in markets as much as anybody, but the lack of transparency in health care and insurance means what we have at the moment isn’t a real market. Government has the power to set the rules for a market, and even a few conceptual changes — such as a requirement for far more transparency — would do a lot to get us from where we are today to the Future Perfect.?

Based on all the likely progress, here’s the type of future history the federal government or health care providers might write to guide their planning:

Future History Scenario: Healthier Health Care – and Why 90 Is the New 70, March 6, 2050

WILLIAMSBURG, Va. – Jack and Jill went up the hill to fetch a pail of water. Jack fell down and broke his crown, and Jill came tumbling after.

The two 12-year-olds, who were participating in a reenactment of life in colonial times on a school field trip, immediately received text messages on their watches from a chatbot asking if they were okay or if they needed to speak with a doctor. Jill dusted herself off and was found to be fine, but sensors suggested Jack might have a concussion — the accelerometer in his watch showed a stop sudden enough that it might be dangerous. His parents had had him swallow a tiny sensor that morning because he seemed to be coming down with something, and that sensor, too, detected signs of a potential concussion. It relayed the data to his watch, which, based on the permissions he and his parents had established with their care provider, sent the information on to his doctor. The doctor’s computer system analyzed the data, compared it against Jack’s records and against relevant research, then notified the doctor’s nurse practitioner that there was likely a problem.

This evaluation was more complicated than most, because Jack has a genetic disorder that requires monitoring, yet within 30 seconds of the tumble the nurse practitioner called the teacher in charge of the school trip. The nurse practitioner examined Jack via video call and decided he was likely concussed but didn’t need to go to a nearby clinic for examination. The teacher called Jack’s parents, summoned an autonomous car, and sent him home, along with one of the adult volunteers who had come along for the trip.

Total price: $25 for the quick consultation with the nurse practitioner, $15 for the auto ride, and, later, $5 for a pill. Total time elapsed for the diagnosis: two minutes.

There was no calling a health insurer and waiting on hold to be transferred yet again… and again to figure out what treatment was covered under Jack’s plan and where to take him for treatment. There was no ambulance and no trip to the emergency room, so there were no bills trickling in for weeks from doctors who took a brief look at Jack and who all bill separately from the hospital. Instead, the bills, which were below the parents’ deductible, were processed via blockchain and automatically paid by the parents within seconds, so there was no involvement of administrators, meaning no additional costs for the health care system. An insurance company never even got involved. There were no worries by the health care provider about nonpayment and, thus, no need for followup communications.

It was all administrative bliss; the system had worked exactly as designed, doing the right thing for the injured kid in the shortest time possible at a cost that made sense for all involved.

If a time traveler from the 2020s — when the U.S. health care system was mired in administrative complexity and seemed on the verge of bankrupting consumers, employers, and the U.S. government — had been there to see this all play out, they’d have been amazed at the quality and low cost of today’s system. They’d? have been even more amazed that most of our health care system’s efforts were actually focused on health, rather than sickness.?

Take Jack’s father, Ray, who was recently diagnosed with prediabetes; he has a long family history of high blood pressure and diabetes. Thirty years ago, Ray might have been resigned to the gradual progression to full-blown diabetes, as happened to both his parents. But, as is becoming the norm today, Ray is working with his doctor to delay — and even prevent — this progression. Ray is already a medical miracle. Even before his fight with diabetes, he benefited from the Law of Zero on genomics and had doctors use CRISPR to edit his genome and cure a debilitating disease. He now wears a watch that not only counts his steps and measures his heart rate but that also takes blood pressure readings and collects other vital signs. Ray’s contact lenses contain sensors that measure the glucose level in his blood, among other things, and both he and Jack’s mom swallow a sensor about the size of a grain of sand daily that tracks other vital signs. Once a month, they ingest a sensor that checks for blood disorders, including indicators of certain forms of cancer. Any anomalous data gets reported immediately to their doctors’ AIs, via the wireless connection in their smartwatches. If the parents ever get sick or detect something abnormal (an odd stomachache, a mole, whatever) they can contact a doctor directly and quickly set up a telemedicine connection.

The parents have also opted to provide additional data via a miniature camera in a pendant they wear around their necks that’s triggered every time they eat or drink something. As part of Ray’s diet plan to ward off diabetes, the images the pendant takes are analyzed to estimate portion size and nutritional content. The system includes ways for people to deviate from the plan occasionally and remove items so the system won’t feel draconian.?

Over the last 12 months, Ray gradually reduced his body weight by seven percent and has been holding steady at his new weight. His doctors believe this weight loss will dramatically reduce Ray’s chances of developing diabetes. His lower weight and increased physical activity have also lowered his blood pressure and decreased his risk for cardiovascular disease and strokes.

Based on all the daily inputs and the broader set of information that turns out to correlate so well to health (e.g., genetics, income level, ZIP code, and education level), the AI that monitors Ray calculates a health score, biological age, and life expectancy.. Based on developments in behavioral economics that go well beyond the traditional appeals to reason, Jack’s parents are connected to friends via social networks that help them encourage each other about health. The parents also chosen to get pinged on their watches — on a carefully irregular basis, so the messages don’t become routine and get tuned out — with messages that reinforce a healthy lifestyle. For instance, Jack’s parents are occasionally asked to perform a nontraditional test of fitness, such as squeezing something that measures grip strength or seeing how many push-ups they can do, based on the growing realization that measures such as walking speed can tell more than an official vital sign like heart rate and certainly more than a mostly discredited measure like body mass index.[17]?

All the data provided by Jack’s parents and other voluntary participants in the health system ?gets rolled up with information from others into a sort of national health dashboard that not only registers progress but suggests where more effort could help. Everyone in this type of program gets to see where they are nationally, adjusted for age, genome, income, location, etc. The ranking has turned out to matter more than most anything in terms of motivating good behavior, as has been shown in other spheres.[18]

No one has been forced to do anything. But people become healthier because they want to be healthier, and now can be continually advised on how to get there. No, it’s not everyone, but it’s enough people to make a real difference. National dashboard results show millions of Americans are making significant improvements along three major risk factors — poor diet, inactivity, and smoking — and the health of the nation is improving.

***

As Jack arrived home from his school trip, his grandparents met him on the walk leading to the front door. This house, like so many these days, has a large vegetable garden where there once would have been a driveway or garage, both of which are no longer needed because of AVs. The grandparents lived across town but summoned an autonomous car as soon as Jack’s mom asked them to help out, and the two-seater dispatched by the grandparents’ subscription service dropped them off just ahead of Jack.

The grandparents, in sometimes-dodgy health, have managed to stay in their home for years longer than they would have in the past, when they would have had to move into an expensive, assisted-living facility. They have a robot that checks their vital signs daily, makes sure they’re taking their various medications, and talks to them to detect any slurring of speech or other neurological issues. The robots can assist with many tasks, including some surprising ones, like finding an elusive piece to a jigsaw puzzle — machine vision turns out to be great for determining shapes and detecting slight differences in color. Jack’s grandmother has palsy in her right hand, which is quite weak, but she has a flexible glove she can put on that serves as an exoskeleton, steadying her hand and strengthening her grip.[19]

While the aging grandparents need a fair number of tests, they can do most of them by themselves at home because of the great expansion in the DIY market for health.[20] These days, doctors are only pulled into the loop when there are anomalies or when advice is needed. Sensors, of course, sound an alarm if the people being monitored have a heart problem or fall. Cameras in the house can, with the grandparents’ permission, be turned on so they can be monitored — or so they can talk with their children and grandchildren. Prepared food and medications are easily delivered by AV. And the grandparents retain access to friends (most of them still in the same old neighborhood) and family because the Laws of Zero have wiped out the time, distance, and other constraints that existed before AVs came along.

Jack’s grandparents actually represent the biggest cost burden that has developed over the past three decades. They, and others of their generation, are living years longer than they used to, and older folks will always consume more care than younger ones. That’s especially true now because diseases that would previously have been fatal can be treated as chronic diseases, meaning more doctor visits and medications. But those additional years in a person’s life span are now much healthier and happier than they used to be.

“90 is the new 70,” Jack’s grandmother says.

So the cost burden of the older generation is — unlike the cost burden of the past — one families are delighted to carry.

Footnotes:

[1] AI will be tricky, because it can unintentionally incorporate bias. If the data used to train the AI reflects, say, racial bias, then recommendations about health behavior can be skewed. But there are techniques to correct for bias, and the benefits of AI are already obvious — for instance, in some work happening now, the Office of National Coordinator on Health Information Technology is matching patients with chronic and end-stage renal disease to the most effective treatments based on specific health conditions based on specific health conditions, patient preferences and genetic/phenotypic profiles.

[2] Researchers at MIT, Draper, and Brigham and Women’s Hospital have developed an ingestible capsule that can reside in the stomach for at least a month, not only taking sensor readings but dispensing medications, controlled by signals sent via Bluetooth. https://news.mit.edu/2018/ingestible-pill-controlled-wirelessly-bluetooth-1213?

[3] Therapy can be delivered in similar fashion. An Israeli startup named Bionaut Labs has developed robots the size of a grain of rice that can carry medicine to the exact spot in the body where it’s needed. That precision should greatly reduce the side effects that come from, say, chemotherapy or radiation, which currently have to be applied to relatively broad areas. While the tiny robots are currently designed to deliver therapeutics, future versions could provide electrical stimulation, thermal ablation, or radioactive plaque to treat other diseases.?

[4] https://www.theatlantic.com/magazine/archive/2019/07/american-health-care-spending/590623/

[5] We acknowledge that Facebook has an easier time of it because it steers us toward things we already want to do: “Here, watch this video from someone whose politics match yours.” A message of, “Don’t drink that Coca-Cola” is tougher to sell.

[6] While the first case of COVID-19 was diagnosed in the U.S. on Jan. 19, 2020, studies have since found the virus had infected people at least a month earlier; it was simply undetected at the time. https://fortune.com/2020/12/01/december-2019-covid-arrival-us/ In the future, AI will spot a new virus far faster.

[7] The Veterans Administration is doing some pioneering work on suicides, including pushing diagnostic and treatment capabilities out to kiosks and even individuals’ laptops so that veterans have access to help at any time.

[8] https://www.strategy-business.com/article/Plumbing-the-depths?gko=33e0b&utm_source=itw&utm_medium=itw20200407&utm_campaign=resp

[9] While it’s been possible for going on 20 years to sequence the amino acids that make up a protein, knowing the sequence isn’t as helpful as originally hoped. The key to understanding how proteins interact in our tissues and to predicting what drugs might bond with them is knowing what shape a protein folds itself into, and computing the shape based just on the genetic sequence turned out to be a wildly hard problem. Knowing the shape of a protein required a chemical process that typically took a year, required a device as big as a football stadium, and cost $120,000 for a single protein. As a result, only 170,000 of the hundreds of millions of proteins known to exist have been modeled. In 2020, however, Google’s DeepMinds research arm demonstrated it could compute how proteins would fold themselves — and could do so more accurately than the messy, expensive chemical process. While the implications of the breakthrough in understanding proteins have yet to play out, they figure to be profound. https://fortune.com/2020/11/30/deepmind-protein-folding-breakthrough/

[10] Approximations already exist, including at this site: https://en.wikipedia.org/wiki/RealAge. They will improve and become widely available and used.

[11] The Department of Labor is attempting this sort of shift in thinking for government benefits. The DOL has produced an integrated portal for all benefits, and it uses AI to customize recommendations for each person by identifying benefits someone didn’t ask about but might qualify for.

[12] The Surgery Center of Oklahoma is a prime example of this sort of specialized facility operating today. So-called medical tourism also provides examples – though requiring much more than a car trip or short flight. You can go to India, have very high-quality open-heart surgery and be charged $2,100 — versus a charge of $100,000 to $150,000 in the U.S. https://www.strategy-business.com/article/Physician-Disrupt-Thyself?gko=90272

[13] The team at NASA became very attached to the Mars rover known as Opportunity, which was supposed to last only 90 days but transmitted signals for 15 years from the surface of Mars. It signed off in 2018 by signaling, “My battery is low, and it’s getting dark.” The NASA team tried a number of “wake-up songs,” including Gloria Gaynor’s “I Will Survive.” Without a response, the team finally played Billie Holiday’s version of “I’ll Be Seeing You” to the robot. Many on the NASA team teared up. Source: https://abc30.com/science/my-battery-is-low-and-its-getting-dark-opportunitys-last-message-to-scientists/5137455/

[14] https://jamanetwork.com/journals/jama/article-abstract/2752664?

[15] https://qz.com/1010259/the-100-billion-per-year-back-pain-industry-is-mostly-a-hoax/

[16] Intermountain Health and Trinity Health are two organizations doing a good job on prediabetes and, more generally, on focusing on prevention rather than just on sick care.

[17] Experts estimate that perhaps 20-30 percent of Americans can do a single push-up. https://www.theatlantic.com/health/archive/2019/06/push-ups-body-weight-bmi/592834/

[18] Opower has proved to be very effective at getting people to reduce their electricity use by letting them know how it compared with their neighbors’, adjusted for factors such as size of dwelling and number of people living in it. Oracle bought the startup for $532 million in 2016, where Opower is now a product line.?

[19] Such a glove is already being developed. https://www.gatesnotes.com/About-Bill-Gates/My-visit-to-a-Harvard-robotics-lab

[20] Already well underway. https://www.ozy.com/fast-forward/finding-your-inner-doctor-the-rise-of-new-age-diy-tools