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Funding is Control

We know the government solutions are unmitigated failures and ludicrously expensive.

We've talked about why addressing our deficit of family doctors in longitudinal practice is critical and described common-sense solutions to deal with that.

We've argued that incentive-driven bottom-up strategies are the fastest and least expensive way to tackle the problem. We've dismissed the government's bogus arguments about doctors not wanting (or being able) to run a business that they say is driving their top-down strategy.

Yet we continue to see one-off rescue funding for clinics, new UPCCs and joint projects. Drip, drip, drip.

Why continue to spend so much more money than is needed, waste valuable resources, and deliver such abysmal results, when there are perfectly reasonable alternatives ready to go?

Control. Power. Oversight.

This is the real reason. Whatever you want to call it.

If you set the terms under which you disperse funding, you have some control of how it's used.

Control isn't a bad thing in itself. But if whoever is in control isn't delivering on what is needed, and is preventing others from doing so, that's a huge problem.

If you're picking and choosing individual projects to fund, you can dictate terms for the people who operate them. If they don't like it, they can do something else. Hello, empty UPCCs!

Want to keep control? Limit the funding to a certain period of time, make people reapply to continue. Change the rules every once in a while. Make sure that everyone remembers who is in charge.

Stifle Dissent

And how likely is someone working at one of these projects to speak out in opposition to government when they know they have to apply for funding again in two years? Funding which is completely at the discretion of the government? Not very likely. And just to be sure, we'll put clauses in the funding that prohibit speaking up.

Make Independent Practice Obsolete

More and more, it's impossible for clinics to survive without applying for individual funding, whether through the MOH, health authorities, or the increasingly byzantine layers of joint committees that ultimately rely on the government for their continued funding and existence.

That's because the basic level of operating funding, which has in the past come from MSP fees that doctors bill for services rendered, isn't enough to survive on. They need additional funding just to survive. Funding that comes through one-off projects that must be individually approved or denied. Funding that comes with strings attached that aren't related to how they deliver services.

This government seems intent on destroying independent practice and ensuring all healthcare is delivered through government-run clinics.

I don't remember them campaigning on a promise to do that.


If you ask them, they'll say they're running clinics to provide the necessary "oversight" to ensure healthcare is delivered properly.

They're obviously failing miserably at that. But they don't answer to anyone. They're not reporting how well they're doing. They're certainly not facing consequences for failing at it.

There are ways to provide for accountability. Rules to follow, mechanisms of enforcement. That's what happens with doctors who practice independently.

Accountability doesn't work when the organization doing the funding, making the decisions, delivering the service, and reporting on the service is the same organization. A preschooler could understand this even if they didn't know what "conflict of interest" means.

The Alternative

The alternative to this top-down, glacial, unaffordable, and inept cesspool of sycophancy we have driving our healthcare system is obvious.

Give control of healthcare delivery to the people who know what they're doing.

Tell them what you value (longitudinal care), align the incentives with that (fees), and get the hell out of their way.

Bottom-up beats top-down when top-down is fucking things up this badly and shows no sign of changing.

Government has to get out of the business of making often arbitrary funding decisions on individual tiny one-off projects.

Do your job. Direct the healthcare system. Stop micromanaging.

The Catch

We know how much this mess is costing us, both financially and in terms of lives lost and suffering.

There's a broad consensus among experts about the common-sense solutions that would get us out of this mess.

The catch — and why we've gone so far down the exact opposite path — is that for these to work, government has to give up some control of healthcare delivery.

Not all control. We need them involved in setting (and hopefully enforcing) the rules. And providing funding. And there are lots of valuable things they can do.

Make no mistake, this is not about delivering healthcare better.

Rational arguments about efficiency and outcomes won't change it.

It's about control.

Why would government want to give up control?

They wouldn't. Unless we force them to.