This post is more philosophical and out there than usual, so my apologies ahead of time. Recent conversations about high priced medical care, with finger pointing at the “1% CEOs” and “patients abusing ERs,” got me typing.

As many of my closest friends know, I think choice in life, or free will, is really very limited if it exists at all. Maybe we “choose” ketchup versus mustard. Or maybe it’s all physiology. Who knows. If free will exists, then there are certainly some times in life when we have more of it than others. Our baby Max has virtually none at all today. He’s at our mercy. (Some may say we’re at his, though we at least can choose reusables vs. disposables, breast milk vs. formula, etc.) Prisoners have slightly more free will than Max. People withdrawing from 100mg of methadone a day are pretty comparable… essentially trapped.

Maximum free will exists probably just after college when we’re healthiest, but before we choose a mate, a job and a home. Once those choices are made, then our “free will bubbles” start contracting again. Add a baby to the mix, and the only thing left is late night musings on facebook. All good if you find a pleasant bubble, but a real bummer if not.

That’s the lens through which I see everyone from high paid healthcare CEOs, to patients who visit ERs with colds in the middle of the night. Neither shock me. I think of priests, soldiers, politicians, doctors and terrorists this way too. There’s not a lot of good or evil in my world view. Instead I think of people on a constructivity spectrum. Some are far more constructive than others. But for most of us it’s just action/reaction.

To me we’re more like billiards bouncing, or water molecules flowing around each other. If we’re lucky we flow through more constructive rather than destructive environments. Personally, I’ve lived pretty safely amongst good people most of my life. So offering medical house calls in SLO feels just about right. But if my family was in one of the Twin Towers on 9/11, or on the receiving end of a missile in Iraq, I’d be an entirely different animal today.

All that being said, back to healthcare… On the “micro social physics” side, I view high dollar CEOs and patients as people just trying to optimize their bubbles. If $25m to run a company is within reach, will you turn it down just out of principle? Maybe so. And does an exhausted mother of a screaming baby with no Tylenol, or understanding for Tylenol dosing, have free will to weigh options and make choices at 3am? If an ER is all that’s open, and if MediCal makes that ER visit less costly than Tylenol OTC, then that’s where she goes, or flows. Why point fingers?

On a “macro social physics” level, my perspective on why hospitals charge so much is fairly simple… It’s economics and they can. Hospitals today have virtual monopolies on suffering. As primary care doctors drop out and join hospital systems, those monopolies grow, and so do the prices. Plus we live in an environment where, astoundingly, doctors rarely know prices and patients rarely see prices until weeks after their care.

However, I don’t view large hospital systems themselves as “evil” per se. In fact, it’s logical for these businesses, both “nonprofit” and for profit, to gather as many nuts as possible during this time of so much flux and upheaval in medicine. Who knows where we’ll be in 5-10 years with the ACA, EMRs, ICD-10, “meaningful use,” and expensive new therapies extending lives for decades post retirement. Plus, who knows where Trump or Sanders may truly sit on the constructivity spectrum?

To me, elegant healthcare solutions won’t be found by additional legislation or administrative force, because water is a hard thing to push. Competition via better and more available care, at lower cost, with less administrative harassment, and intelligent use of technology, is how I’d prefer to be “poured” into a more functional system.

As for this human sized molecule, I’m also neither good nor evil. With so many people struggling to find PCPs, and with such high deductibles, and with so much general disgust for US healthcare today, I’m just flowing into what appear to be rapidly widening systemic gaps.

Lucky for me, I’m liking my bubble.