In 1962, psychiatrist and Holocaust survivor Dr. Victor Frankl proposed a powerful idea: that a Statue of Responsibility should be erected on the West Coast, perhaps Alcatraz Island, to complement the Statue of Liberty in New York. While the Statue of Liberty symbolizes the freedom we possess, the Statue of Responsibility would remind us of the duties required to uphold that freedom.
The crisis in U.S. healthcare—defined by escalating costs and inconsistent outcomes—is, at its core, a crisis of responsibility. We have a system where patients, providers, payors (insurers), and regulators have largely decoupled risk and reward, allowing costs to balloon without accountability.
To fix this, responsibility must be re-established across all four pillars. If any one party commits to true responsibility, they can create the market conditions necessary to force the others to follow suit. As noted in my previous article on Friedman’s observations, the central issue is the absence of market dynamics, which distorts nearly every decision made in the system: How Incentives and Bureaucracy Shape American Healthcare.
The path to restoring these dynamics requires radical structural change centered on prevention, transparent incentives, and increased competition.
Step 1: Re-establishing Primary Care as the Market Baseline (PCMH)
We must fundamentally reshape how we pay for the vast majority of our care. Primary care accounts for approximately 70% of a patient’s health needs. Our next-generation healthcare system should be modeled largely on the Patient-Centered Medical Home (PCMH) concept.
Under this model, patients pay a monthly fee for their primary care provider (PCP) and their associated wellness services. This is not insurance; it is a subscription for management and access. Insurance is reserved for its original purpose: covering unplanned, catastrophic, or large expenses, similar to your homeowners or auto insurance policy (hopefully minus the climate risk).
Crucially, to shift the system from reactive sickness care to proactive wellness management, patients will be required to have an annual physical and full blood panel. This mandatory check-up is the key enforcement mechanism. It will immediately find the estimated 25% of the population with undiagnosed or unmanaged chronic conditions like diabetes (high A1C), hypertension, and heart disease. Bringing these cases under consistent management is the single fastest way to reduce overall utilization.
Evidence shows that comprehensive chronic disease management reduces costly acute events like hospitalizations and emergency room visits. Studies tracking patients enrolled in such programs, including the Chronic Disease Self-Management Program (CDSMP), have demonstrated significant health and economic benefits, reporting substantial cost reductions, often in the range of 10–15% of a patient’s annual healthcare expenditures, simply by avoiding unnecessary acute care.
Step 2: Introducing Transparency to End-of-Life Care
The cost of end-of-life care in the U.S. is ballooning and often represents spending on interventions that provide minimal clinical benefit. While this is a sensitive topic, responsibility requires us to address it with transparency and dignity.
Industry and regulators should partner to develop a simple, open-source AI model designed to predict the likelihood of a successful clinical outcome for major, high-cost interventions. The inputs would be objective data points like:
Age and Frailty Score
Comorbidities (e.g., number and type of existing conditions)
BMI and A1C Levels (markers of metabolic health)
Specific Proposed Treatment
Luckily, this data should be readily available since under fee-for-service, we have tried every conceivable treatment on every patient group in the chasing miracle cures and maximization of billings.
The key to public trust is that the model’s feature importance must be open source. All stakeholders—patients, doctors, and the public—must know precisely why a prediction was made. This prevents it from being perceived as a black box or a “death panel.”
If the model predicts that a certain intervention is highly unlikely to have a positive impact, insurance would not be required to cover it. The patient or their family, exercising their ultimate freedom of choice, can still obtain the intervention by choosing to pay directly for the cost of the procedure. This restores market principles to the highest-stakes medical decisions while preventing the broader system from being bankrupted by low-efficacy spending.
Step 3: Fostering Real Competition by Deregulating Providers
A critical flaw in the PCMH model is the historically low ratio of patient to provider, which limits accessibility. This scarcity, however, is manufactured.
The scarcity of medical professionals, particularly physicians and nurses, is largely perpetuated by unnecessary state-level licensing and certification rules that restrict the supply of talent. Quality control is necessary, but it should be moved closer to the point of care.
We can solve the provider scarcity issue by removing restrictive state licensing for nursing and perhaps even MDs. Instead, quality assurance will be handled by the large, competitive organizations that employ the practitioners, such as Kaiser, Mayo, Jefferson Health, or large integrated PCMH groups.
These organizations already have rigorous internal credentialing processes and far more reputational and financial skin in the game than any state board. By decentralizing quality control to the market players, we remove artificial barriers, increase the supply of qualified practitioners, and foster genuine competition based on price, access, and outcome quality.
Commitment to Responsibility
A Statue of Responsibility on Alcatraz would be a daily reminder that freedom without duty is chaos. Similarly, a functional healthcare system cannot exist when the four parties—patients, providers, payors, and regulators—are free from the consequences of their choices. By mandating proactive care, introducing transparent outcome models, and unleashing market competition among providers, we can finally inject the responsibility needed to create a system that is both affordable and high-quality. Let’s erect this Statue of Responsibility and have it symbolize our commitment to making the hard changes necessary to put our healthcare towards a better future.