What is college? What is health care?

The problem with “free college” is: What is college?

The problem with “healthcare is a right” is: What is healthcare?

I know, I know. The only “sophisticated” answer is that these things just go without saying. Who asks that? We just all know what these things are, right? Its not that hard.

But these questions are so key, so central. They begin and end the debates. If something is a right what is that a right to? What, exactly, should we expect from these rights?

Start with college. If it ought to be free, then what counts? What institutions? What formats? Who decides? And what happens when college just isn’t the best way to get educated or learn a trade? Certainly this will happen one day—just a few generations ago almost no one went to college, and those who did had quite a different experience than students today. Were they exercising this same right back then? When college changed, and when it changes again, will we still have a right to a free version of what existed before, when we thought up the right in the first place?

Now to health care. What is for me health care is not for you health care. I often go to the beach to clear my mind. It’s the healthiest thing I do each week—a true medicine for my body and spirit. Without this, my mental health would suffer. Others, however, find no such cure there. Others turn to other activities, and some to drugs—legal and illegal. For them, this is health care.

Health care. Care of health. Wellness maintenance. Body optimization.

(Already the problem emerges.)

Health care is not some coherent, boxed-up good. It’s not a cut-and-dry service. What counts as health care today—massages, chiropractic, Xanax-before-the-dentist—did not count just a few years ago. Insurance didn’t cover. Many common modern-day treatments, or the causation between treatments and wellness—didn’t even exist.

The questions, then: Did our grandparents have a right to the services we claim today are “health care?” A right they simply could not exercise because the suppliers of that right did not yet exist? And do individuals have any say about what, for them uniquely, constitutes a health care good or service?

No, you say. This is ridiculous, you say. I’m being unnecessarily difficult, you say.

I won’t concede that. My question is eminently fundamental. If I have a right to free college, what is college? If I have a right to health care, with is health care?

Hospital reform = health care consolidation?

My wife sent me this great article by health care reporter Lola Butcher. In it, Butcher explains why the traditional “volume-based” payment system for the general acute care hospital is “in its death throes.” In its place, hospital executives are exploring new business models that incorporate hospitals into a larger continuum of health care services, including both pre- and post-acute services, hospice and palliative care and even patient-centered medical homes that emphasize planned and consistent care over episodic inpatient treatment.

Indeed, regardless of payer mix, bed size or ownership status, the business model for American hospitals is in a time of upheaval. As health care moves from a volume-based payment system to one that rewards value — cost divided by quality — inpatient hospital utilization is no longer the breadwinner it used to be. In fact, emerging pay models discourage hospital use as much as possible.

Among several examples, Butcher cites Mountain States Health Alliance, which is in the middle of a 10-year strategic plan to move away from a “hospitalcentric” business model to one based on managing population health and accepting financial risk. Some components of MSHA’s plan involve increasing outpatient and retail services to offset reduced inpatient revenues, establishing a community-based “accountable care organization” and, of course, reducing operating costs.

This is all interesting, but my question is: Don’t these services already exist elsewhere? Take a look around almost any hospital and you’ll find various clinics nearby delivering the full spectrum of health care services. What hospitals like MSHA are doing, then, is nothing more than consolidating the breadth of health care services under one financial roof.

Maybe I just don’t understand the benefits of this. I know that scale can help reduce costs (think Walmart), but I’m not convinced that this isn’t anything more than hospitals buying into enterprises that might be profitable on their own, but don’t change the fact that inpatient stays have become a moneysuck for hospitals and prohibitively expensive for many people. Think Facebook’s recent $19B buy of WhatsApp — a product Facebook says won’t be integrated with their flagship social networking service and does nothing in the way of solving Facebook’s other problems. In the end, the problems of rising costs and falling demand for inpatient stays remain, and it spells disaster for those of us (that is, all of us) who will need inpatient stays at some point or another.