Today’s professional white collar workers are about to get the same treatment as steel and auto workers received in the 1970s and 80s. Back then the narrative was unequivocal. Manufacturing was dominated by overpaid highly unionized workers who were lazy and entitled. Wages and benefits were too high. Productivity and innovation were being stifled by bureaucratic nonsense. American workers were uncompetitive in the face of alternative global options. And corporate profits were diminished as too much value was squandered on inefficient labor practices. Add the environmental reforms of the Nixon era after entire rivers began to catch fire and burn and heavy industry up and left places like Youngstown, Akron, Buffalo, and Pittsburgh.
Tens of thousands of people were put out of work and many became part of a permanently underemployed caste that never recovered. There was a corresponding ripple effect of associated failed local businesses, declines in real estate values, municipal revenue shortfalls, and a downward spiral of intangible community losses. Meanwhile, society didn’t much care. We all wanted cheap consumer products and “shareholder value.” Sacrifices had to be made along the way. The losers just had to reinvent themselves or suck it up. Okay… Hold that thought.
It was time for my annual check up last week, but my doctor’s office is practicing social distancing these days. I was instructed to have my blood and urine collected at the hospital lab as usual, only this time with all the Covid-19 precautions.
I stood on the six foot marks taped to the linoleum in the corridor with my mask and hand sanitizer. Once I was admitted by security I sat in the lobby to wait my turn and speak with a clerk. Eventually I was called and asked for documentation and my insurance card. I was prepared for the usual scenario.
“You’re not in the system.” Yes, I’m in the system. I’ve been coming here for twenty years. You’re the same lady who tells me I’m not in the system every single time. You told me about how your grandkid lost his first tooth last time I was here. The time before that you were finalizing your divorce. Before that you had just bought a house in Walnut Creek. She gave me a look like she had no control over the data base. She re-entered my information into the computer all over again as usual. I reminded myself I’m one of the lucky Americans who actually has health insurance.
I sat back down and waited until I was called again. I entered a curtained room and a phlebotomist took the required samples. Of the hour it takes to visit the lab the actual blood draw itself lasts for five minutes.
A week later I got a call from the woman who usually greets me at the doctor’s office. Normally she would weigh me, take my temperature, and check my blood pressure. But this time I was in my apartment in San Francisco and she was at her home in a distant suburb. So I was asked to do these things to myself. I already have a bathroom scale and a digital thermometer and I borrowed a blood pressure cuff from a neighbor who works at a clinical lab. She typed in the numbers I gave her over the phone then she instructed me to log in to an app.
Fifteen minutes later my doctor appeared on my laptop screen and reviewed my lab results. It was the usual. I’m too fat. Big surprise. Otherwise I’m in tolerable shape for a pudgy middle aged guy. I asked him how he likes the new arrangement and he was sanguine. There’s not much choice.
For the record, my doctor isn’t actually a “doctor.” He’s a physician’s assistant. When I first started going to this office a long time ago I saw a proper doctor. But insurance reimbursements changed, state and federal regulations changed, liability protocols changed, and the medical industry experienced multiple waves of consolidation and restructuring. Most older independent doctors took retirement. Younger doctors were absorbed into big health corporations as employees. And those corporations placed physician assistants under the legal auspices of a much smaller number of doctor/administrators. They sign off on the paperwork of their underlings, but rarely interact with patients.
Soon after my video conference with my doctor I got a phone call from the same lady who talked me through my weight, temperature, and blood pressure. She was in the process of setting up my next appointment when the call broke up and our connection died. That’s when I got on the app and scheduled my own appointment without her.
Years ago I used to get my prescriptions filled by a neighborhood mom and pop pharmacy. They went the way of the dodo as competition from national chains squeezed them out. I noticed how relentless these chains are at eliminating labor from their business model.
Over time insurance companies began to push customers into online mail order pharmacies which skip physical shops entirely. A giant centralized warehouse and logistics hub in Nevada (for tax purposes) replaced the chain store locations. Every month I found myself spending an hour or more on the phone with a call center trying to get exactly the same prescription filled. Every so often there was a new merger or restructuring with a new set of protocols and each time I was required to wait on hold as someone in Atlanta or the Philippines asked me the same questions over and over. Why? Who knows… It was all part of their macro efficiency plan.
I had a particularly bad set of experiences with a call center pharmacy last year. My old insurance company merged with another company and the hybrid had trouble managing its own internal data. Each half of the newly joined company was eager to shift me (a “cost center”) off to the other. I was repeatedly referred back and forth for hours and neither was authorized to fill the prescription. I snapped. That’s when I found a new company that has been genuinely better. My doctor sent an electronic prescription to them and a couple of days later the pills arrived in the mail. Full stop. Why couldn’t the old companies do that? As far as I can tell the new company started from scratch and created a fully automated system loaded up with algorithms. It wasn’t just the automation, but the fresh culture minus the legacy entanglements that made things better.
What I’m seeing next is a tech response to health clinics like One Medical and Forward which have streamlined office visits, lab work, prescriptions, and virtual interactions. An appointment is made with a cell phone app, sign in occurs with an iPad, patients scan themselves with a fancy machine, and doctors (or doctor equivalents) are accessed either in person or via technology. When necessary a phlebotomist is scheduled and sent to you. And of course there are loads of specialized WiFi enabled wearable devices to keep track of health in real time in the Cloud.
The old wisdom assumes innovation creates more jobs than it destroys. That may very well be true. But the people who take those new jobs aren’t necessarily the same as the people who are made redundant. The nurse at the doctor’s office, the clerk who processes insurance information at the lab, and the call center pharmacy folks are unlikely to find new positions writing computer code for the companies that make their jobs redundant. This isn’t a technological problem. It’s not even an economic problem. It’s a cultural and political problem and we don’t have a plan for how to deal with it. We’re all living in Youngstown now.