Reign of Terror Vibes

And the failure of engineering in our healthcare system.

I didn’t always have the swagger I do now. Somewhere on my timeline I acquired this superpower to perform, to get hard stuff done, to see myself as a D1, 6’ 3” athlete that knows she is going to win.¹ I love how my swagger steps in to charm strangers upon introduction with statements like, “Oh, me? I am an engineer. Jack of all trades, master of none.” I love how my swagger took over during a job interview once, “Tell us, how you get stuff done when there is too much to do and not enough hours in the day?”

Me: “I don’t have that problem. I have high executive function.”

Mic drop.

Spoiler: I didn’t get the job and I don’t regret my response. I have swagger.

I carry that swagger into my Senior Design class. My swagger keeps my students from nodding off. I am competing for their attention. I am competing for their trust. I am competing for a permanent place in their thinking and to be the voice they hear in their head when they need to make a hard decision because the Design Process is a Decision Process. I push them to contemplate the difference between a bad decision and good decision. In class, I recount, with notable swagger and criticism, terrible engineering failures that happened because of bad decisions made by people like them, experts in subjects like dynamics or thermodynamics or materials or by people who usurped the engineers.²

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I wrote about teaching my senior design students Root Cause Analysis here:

Post-Election Loss 101: Root Cause Analysis

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I teach them, usually for the first time, that as engineers, they will always be in a dilemma. That there will always be tradeoffs in design choices. More often than not the C-Suite and Boards will not want to hear that there are tradeoffs between cost, risk, and performance when designing solutions:

To reduce cost while keeping risk the same, performance must be reduced but To reduce risk while keeping cost the same, performance must be reduced but To reduce cost while keeping performance the same, higher risks must be accepted but To reduce risk while keeping performance the same, higher costs must be accepted.

Source: NASA Systems Engineering Handbook

What this engineering riddle means is that no amount of marketing by the DOGE goons (who are not engineers³) or bro-casts promoting increasing efficiency ad infinitum can change these engineering fundamentals.

“Increasing efficiency” by reducing costs means you reduce performance or increase risk.

And no where in the history of the Earth is that more obvious than in the American healthcare system. Or at least it seems obvious. We are always reading about new programs or technologies will help drive down costs and improve patient health but we all know it can’t be true because we participate in the system. We pay the bills and fight the denials and billing errors.

More than 18% of our GDP is tied up in healthcare and yet health outcomes in the U.S. are the worst of the 10 countries recently analyzed by David Blumenthal et al.

Table 1. From “ Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System” where 10, is the lowest, 1 is the highest performing. Source

The authors of the study noted with sterility:

The quality of coverage is also worse in the U.S. than in other countries. Among Americans with insurance, nearly a quarter are underinsured, facing high deductibles and copayments that reduce the effectiveness of their insurance in assuring access to needed care.²⁷ None of the other countries in our analysis places its covered residents in such financial jeopardy.⁴

Mirror, Mirror 2024: A Portrait of the Failing U.S. Health Care System

You don’t need an engineering degree to read that analysis to rightly conclude that the insurance products were not designed to meet healthcare needs.

The authors found Americans live the shortest lives and have the most avoidable deaths compared to other countries in the study.

How can it be that we spend so much money on healthcare and we don’t have good health outcomes?

This is a question I pose to my senior design students towards the end of the year as we have to cover the societal and cultural impacts of engineering.

It is a rhetorical question. They have no idea why. They have only known life post ACA and don’t have to really worry about insurance for four more years or paying healthcare bills.

Thanks, Obama and every Democrat that voted to pass the ACA!

I remind them that engineering affects nearly every aspect of our lives. Roads. Phones. Heated seats. Needles. Medicine. Healthcare.

We discuss how the healthcare system was not designed to improve health outcomes. That may be the intention but it is not a design requirement of the system. We debate that instead of making healthcare more affordable, technology designed by engineers has primarily benefited the most expensive and complex parts of the healthcare system.

Can you spell AI? Or Big Pharma?

Engineering has failed to address the underlying systemic issues contributing to high costs and poor performance in healthcare.

Why?

Because cost saving innovations that are deployed are usually at the expense of performance. While performance innovations are costly and only available to those with the resources to access them.

Because when something is developed that does improve health outcomes but lowers revenue, it is zapped out of existence, not adopted, buried.

Because engineers don’t run or get elected to office.

Because people don’t like change.

Because stakeholders like profits.

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Politicians, engineers, and healthcare executives have left us with a healthcare system that is neither low cost or high performing for health outcomes and where revenue is the metric of success or failure. By design. By making decisions. There are serious societal effects from such gross negligence and maleficence in decision-making.

We all have been watching a Hollywood version of such effects play out in real life since last Wednesday when the CEO of United HealthCare was shot and killed in Manhattan. We read the stories about the bullet casings found at the scene of the crime with the words: "deny," "defend" and "depose." We all saw the reactionary memes. We read the horrible social media stories people and their families shared about health services denied by UHC. The media pumped out stories about UHC using AI to make those claim denials at much higher rate than the rest of the industry. We wondered at Blue Cross Blue Shield reversing a plan to not cover anesthesia after a certain duration during surgery (a story that is a little complex depending on your sources). We consumed the gossip about corporations scrubbing CEO and board identifying information from their website along with the desire to implement better security at the executive level as covered by TFN. And finally we all got the breaking news that the arrest of the alleged shooter was made at McDonald's in Altoona, Pennsylvania on Monday December 9th, 2024.

Up next: the criminal justice system will do its thing. The media will cover it. We all go back to fumbling our way through the kludge that is our healthcare system, hoping for the best or at least not the worst.

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Or is this a prelude to something else?

Something no one really wants. Something we have seen before. Violence is a choice. Violence fails in the end. The Reign of Terror left the French people just as destitute, starving, and unemployed as they were at the beginning of the Revolution.

This is my fear.⁵

Image 1. The Death of Marat in 1793 by Jacques-Louis David. (Source)

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But my hope is, that this might be the opportunity for politicians, executives, care providers and the engineers to make a different set of decisions. To step-up and intentionally design a healthcare system that puts patient outcomes first.

Engineers have a choice to limit their societal role to creating technologies or to bring their swagger and shape how technologies are used to benefit society.

We all have choices.

Let’s make good ones.

Katrina is two-time US Senate candidate with three patents, a PhD in Agricultural Engineering, three brilliant kids. She is deeply devoted to her cats, Penelope and Conan O’brien and her dog, Jack. She also has a loyal, charming and supportive husband who has encouraged her to stay on this path.

1. Mikeala Foecke is the GOAT. She is my swagger avatar.

2. I am looking at you Veeps at Morton Thiokol that overrode the objections of engineers to launch the Challenger shuttle in 1986.

3. Elon Musk is not an engineer. He has a degree in Physics. It is not the same thing.

https://timesofindia.indiatimes.com/technology/tech-news/elon-musk-says-college-is-overrated-advocates-for-electricians-plumbers-over-a-four-year-degree/articleshow/114570592.cms

4. Bold-ed, by me, for emphasis. Remember I have swagger.

5. I took a class about the French Revolution. I could go on with more parallels with our current climate but it might be just a little too esoteric.