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20th Birthday Classic: “Healthcare” vs. “Health Care”: The Definitive Word(s)

This is the last of the classics that THCB will run to celebrate our 20th birthday. And we are finally tackling the most important of questions. Is what we call this thing one word or two? Back in 2012 Michael Millenson had the definitive answer–Matthew Holt

By MICHAEL L. MILLENSON

A recent contributor to this blog wondered about the correctness of “health care” versus “healthcare.” I’d like to answer that question by channeling my inner William Safire (the late, great New York Times language maven). If you’ll stick with me, I’ll also disclose why the Centers for Medicare & Medicaid Services is not abbreviated as CMMS and reveal something you may not have known about God – linguistically, if not theologically.

The two-word rule for “health care” is followed by major news organizations (New York Times, Washington Post, Wall Street Journal) and medical journals (New England Journal of Medicine, JAMA, Annals of Internal Medicine). Their decision seems consistent with the way most references to the word “care” are handled.

Even the editorial writers of Modern Healthcare magazine do not inveigh against errors in medical care driving up costs in acutecare hospitals and nursinghomes. They write about “medical care,” “acute care” and “nursing homes,” separating the adjectives from the nouns they modify. Some in the general media go even farther, applying the traditional rule of hyphenating adjectival phrases; hence, “health-care reform,” just as you’d write “general-interest magazine” or “old-fashioned editor.”

Most importantly of all, the Associated Press decrees that the correct usage is, “health care.” That decision is not substantive – there is absolutely no definitional difference between “health care” and “healthcare,” despite what you might read elsewhere — but stylistic. As in The Associated Press Stylebook.

The AP is a cooperative formed back in 1846 by newspapers to share reporting via a wire service. Today, the AP calls itself the backbone of global news information, serving “thousands of daily newspaper, radio, television, and online customers….On any given day, more than half the world’s population sees news from the AP.” When that news arrives in text format, its spelling is determined by the AP stylebook. Which means a few billion people see the spelling, “health care.”

A stylebook? Isn’t spelling determined by dictionaries? Perhaps, but when you’re sharing content on deadline across the world, it helps if everyone agrees to refer to, say, the Midwest, not the Mid-West, and to use other common linguistic conventions.

Stylebooks differ. The AP would say that health care is two words; the Chicago Manual of Style, popular in academia, would write that as 2 words, but agree with the premise.

So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. A successful lobbying campaign on behalf of the lower-case form helped persuade the AP to adopt the new spelling in its 2010 stylebook update.

When Modern Hospitals changed its name to become Modern Healthcare back in 1976, it did so in part to seem, well, modern. It hadn’t been that many years, after all, since airplanes were flown by air lines, not airlines. Then, in the business-oriented 1980s, “healthcare system” became a convenient linguistic upgrade of the dowdy “hospital” that had gobbled up ownership of doctors’ offices providing outpatient (not out-patient) care.

At the same time, a growing number of companies decided to make this expansive new word part of their proper name or, at the very least, their style sheet. For instance, HCA, founded in 1968 as Hospital Corporation of America, today describes itself as “the nation’s leading provider of healthcare services.” The Reuters news service, heavily involved in business news, now uses “healthcare” in its stories.

The 2001 Institute of Medicine report Crossing the Quality Chasm provides a snapshot of the term’s transition. The report declares, “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.” The author of that ringing statement is the Committee on the Quality of Health Care in America.

However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999. AHRQ was a renamed and refocused version of the old Agency for Health Care Policy and Research, created in 1989. AHCPR, in turn, had almost been named the Agency for Health Care Research and Policy until an alert Senate staffer realized that the abbreviation would be pronounced, “ah, crap.”

Speaking of abbreviations, Tom Scully, the first administrator of the Center for Medicare & Medicaid Services, once explained to me why it is known as CMS, not CMMS. It seems that Health and Human Services Secretary Tommy Thompson wanted an agency name with a catchy three-letter abbreviation, like FTC or CIA, to replace the old HCFA (Health Care Financing Administration). So a legal opinion was obtained from the HHS counsel that employing an ampersand to separate the words “Medicare” and “Medicaid” permitted the use of the CMS designation. Some might suspect this Solomonic ruling of caving in to a bit of pressure from above.

Which brings us to God. Some years back, the AP decided that while “God” would remain capitalized (the pope was not similarly blessed), the second reference would be “his,” not “His.” As influential as the AP might be in this world, those concerned with a Higher Authority still write about God as if He were something more than an ordinary man.

I keep waiting for the AP editor who made that decision to be struck down with lightning by the Deity. But, on the other hand, She may have a sense of humor.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.

What Robotaxis Mean for Healthcare

BY KIM BELLARD

You may have seen that last week the California Public Utilities Commission (CPUC) gave approval for two companies to operate self-driving taxicabs (“robotaxis”) in San Francisco, available 24/7 and able to charge fares.  Think Uber or Lyft but without drivers. 

It has seemed inevitable for several years now, yet we’re not really ready.  It reminds me, of course, of how the future is coming fast for healthcare too, especially around artificial intelligence, and we’re not really ready for that either.

The two companies, Cruise (owned by GM) and Waymo (owned by Alphabet) have been testing the service for some time, under certain restrictions, and this approval loosens (but does not completely remove) the restrictions. The approval was not without controversy; indeed, the San Francisco police and fire departments,  among others, opposed it. “They are failing to regulate a dangerous, nascent industry,” said Justin Kloczko, a tech and privacy advocate for consumer protection non-profit Consumer Watchdog.  

The companies brag about their record of no fatalities, but the San Francisco Municipal Transportation Agency has collected almost 600 “incidents” involving autonomous vehicles, even with what they believe is very incomplete reporting.  “While we do not yet have the data to judge AVs against the standard human drivers are setting,” CPUC Commissioner John Reynolds admitted, “I do believe in the potential of this technology to increase safety on the roadway.”

I’m willing to stipulate that autonomous vehicle technology is not quite there yet, especially when mostly surrounded by human-driven vehicles, but I also have great confidence that we’ll get there quickly, and that it will radically change not just our driving but also our desire for owning vehicles. 

One of the most thoughtful discussions I’ve on the topic is from David Zipper in The Atlantic. He posits: 

A century ago, the U.S. began rearranging its cities to accommodate the most futuristic vehicles of the era, privately owned automobiles—making decisions that have undermined urban life ever since. Robotaxis could prove equally transformative, which makes proceeding with caution all the more necessary.

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Data Democracy! ‘Dr. Google’ (2023) Vs. ‘Every Man His Own Physician’ (1767)

BY MICHAEL MILLENSON

Every Man His Own Physician - Google Books
In the 18th-century, a pre-Google guide offered democratization of medical information

In 1767, as American colonists’ protestations against “taxation without representation” intensified, a Boston publisher reprinted a book by a British doctor seemingly tailor-made for the growing spirit of independence.

Talk about “democratization of health care information,” “participatory medicine” and “health citizens”! Every Man His Own Physician, by Dr. John Theobald, bore an impressive subtitle: Being a complete collection of efficacious and approved remedies for every disease incident to the human body. With plain instructions for their common use. Necessary to be had in all families, particularly those residing in the country.

Theobald’s fellow physicians no doubt winced at the quotation from the 2nd-century Greek philosopher Celsus featured prominently on the book’s cover page.

“Diseases are cured, not by eloquence,” the quote read, “but by remedies, so that if a person without any learning be well acquainted with those remedies that have been discovered by practice, he will be a much greater physician than one who has cultivated his talent in speaking without experience.”

Translation: You’re better off reading my book than consulting inferior doctors.

To celebrate Americans’ independent spirit, I decided to compare a few of Dr. Theobald’s recommendations to those of his 21st-century equivalent, “Dr. Google.” Like Dr. Google, which receives a mind-boggling 70,000 health care search queries every minute, Dr. Theobald also provides citations for his advice which, he assures readers, is based on “the writings of the most eminent physicians.”

At times, the two advice-givers sync across the centuries. “Colds may be cured by lying much in bed, by drinking plentifully of warm sack whey, with a few drops of spirits of hartshorn in it,” writes Dr. Theobald, citing a “Dr. Cheyne.” Dr. Google’s expert, the Mayo Clinic Staff, proffers much the same prescription: Stay hydrated, perhaps using warm lemon water with honey in it, and try to rest. Personally, I think “sack whey” – sherry plus weak milk and sugar – sounds like more fun.

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Revisualizing and Recoding Healthcare

BY KIM BELLARD

Two new books have me thinking about healthcare, although neither is about healthcare and, I must admit, neither of which I’ve yet read. But both appear to be full of ideas that strike me as directly relevant to the mess we call our healthcare system.  

The books are Atlas of the Senseable City, by Antoine Picon and Carlo Ratti, and Recoding America: Why Government Is Failing in the Digital Age and How We Can Do Better, by Jennifer Pahlka.  

Dr. Picon is a professor at The Harvard Graduate School of Design, and Professor Ratti is head of MIT’s Senseable Lab. Drawing on the Lab’s work, they write: “We hope to reveal here an urban landscape of not just spaces and objects, but also motion, connection, circulation, and experience.” I.e. dynamic maps. Traffic, weather, people’s moment-by-moment decisions all change how a city moves and works in real time.

Dr. Picon says. 

These maps are a new way to apprehend the city, They’re no longer static. Maps provide a way to visualize information. They’re crucial to diagnosing problems. I think they provide a new depth…It’s a little bit like the discovery of the X-ray. You can see things within cities that were not previously accessible. You don’t see everything, but you see things you were not able to see before.

So I wondered: what would a dynamic map of our healthcare system look like?  

I’m telling you, just a map of what happens between drug companies, PBMs, health plans, pharmacies, and patients would open people’s eyes to that particular insanity in our healthcare system.  Now repeat for the millions of other ecosystems in our healthcare system.  If that kind of dynamic mapping — showing all the complexities, bottlenecks, circuitous routes, and redundancies within the system — wouldn’t lead to health care reform, I don’t know what would.

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Healthcare: Make Better Mistakes

BY KIM BELLARD

I saw an expression the other day that I quite liked. I’m not sure who first said it, and there are several versions of it, but it goes something like this: let’s make better mistakes tomorrow.

Boy howdy, if that’s not the perfect motto for healthcare, I don’t know what is.

Health is a tricky business.  It’s a delicate balancing act between – to name a few — your genes, your environment, your habits, your nutrition, your stress, the health and composition of your microbiome, the impact of whatever new microbes are floating around, and, yes, the health care you happen to receive. 

Health care is also a tricky business. We’ve made much progress in medicine, developed deeper insights into how our bodies work (or fail), and have a multitude of treatment options for a multitude of health problems. But there’s a lot we still don’t know, there’s a lot we know but aren’t actually using, and there’s an awful lot we still don’t know. 

It’s very much a human activity. Different people experience and/or report the same condition differently, and respond to the same treatments differently. Everyone has unique comorbidities, the impact of which upon treatments is still little understood. And, of course, until/unless AI takes over, the people responsible for diagnosing, treating, and caring for patients are very much human, each with their own backgrounds, training, preferences, intelligence, and memory – any of which can impact their actions. 

All of which is to say: mistakes are made. Every day. By everyone. 

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Bluesky Ahead

BY KIM BELLARD

I’ve been thinking about writing about Bluesky ever since I heard about the Jack Dorsey-backed Twitter alternative, and decided it is finally time, for two reasons. The first is that I’ve been seeing so many other people writing about it, so I’m getting FOMO.  The second is that I checked out Nostr, another Jack Dorsey-backed Twitter alternative, and there’s no way I’m trying to write about that (case in point: Jack’s Nostr username is: npub1sg6plzptd64u62a878hep2kev88swjh3tw00gjsfl8f237lmu63q0uf63m.  Seriously).

It’s not that I’ve come to hate Twitter, although Elon Musk is making it harder to like it, as it is that our general dissatisfaction with existing social media platforms makes it a good time to look at alternatives.  I’ve written about Mastodon and BeReal, for example, but Bluesky has some features that may make sense in the Web3 world that we may be moving into. 

And, of course, I’m looking for any lessons for healthcare.

Bluesky describes itself as a “social internet.”  It started as a Twitter project in December 2019, with the aim “to develop an open and decentralized standard for social media.”   At the time, the ostensible goal was that Twitter would be a client of the standard, but events happened, Jack Dorsey left Twitter, Elon Musk bought it, and Bluesky became an independent LLC.  It rolled out an invite-only, “private beta” for iOS (Apple) users in March 2023, followed by an Android version in mid-April (again, invite-only).  People can sign up to be on the waitlist.  There are supposedly over 40,000 current users, with some million people reportedly on the waitlist.

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I Have Some Silly Questions

BY KIM BELLARD

Last year I used some of Alfred North Whitehead’s pithy quotations to talk about healthcare, starting with the provocative “It is the business of the future to be dangerous.”  I want to revisit another of his quotations that I’d like to spend more time on: “The silly question is the first intimation of some totally new development.” 

I can’t promise that I even have intimations of what the totally new developments are going to be, but if any industry lends itself to asking “silly” questions about it, it is healthcare. Hopefully I can at least spark some thought and discussion.  

In no particular order:

Why do we prefer to spend money on care when people are no longer healthy than we do on keeping them healthy?

The U.S. healthcare system well known for being exorbitantly expensive while delivering rather mediocre results.  Everyone laments it but we keep throwing more money into the system that is producing these results. 

We’d be smarter to invest in upstream spending.  Like making sure people get enough to eat, with foods that are good for us.  We’d rather spend money on diabetes or obesity drugs rather than addressing the root causes of each disease.  Or like making sure the water we drink, the air we breathe, the things we eat, aren’t polluted (how many toxins or microplastics have you ingested today?).  Not to mention reducing poverty, improving education, or fixing social media. 

We know the kinds of things we should do, we say we want to do them, but we lack the political will to achieve them and the infrastructure to ensure them.  So we end up paying for our neglect through our ever-more expensive healthcare system.  That’s silly.

Why is everything in healthcare so expensive? 

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What is Health Care’s LEGO?

BY KIM BELLARD

Last week the esteemed Jane Sarasohn-Kahn celebrated that it was the 65th anniversary of the famous LEGO brick, linking to Jay Ong’s blog article about it (to be more accurate, it was the 65th anniversary of the patent for the LEGO brick). That led me to read Jens Andersen’s excellent history of the company: The LEGO Story: How a Little Toy Sparked the World’s Imagination.  

But I didn’t think about writing about LEGO’s until I read Ben’s Cohen’s Wall Street Journal profile of  University of Oxford economist Bent Flyvbjerg, who studies why projects succeed or fail.  His advice: “That’s the question every project leader should ask: What is the small thing we can assemble in large numbers into a big thing? What’s our Lego?”

So I had to wonder: OK, healthcare – what’s your LEGO?

Professor Flyvbjerg specializes in “megaprojects” — large, complex, and expensive projects.  His new book, co-authored with Dan Gardner, is How Big Things Get Done. Not to spoil the surprise (which would only be a surprise to anyone who hasn’t been part of one), their finding is that such projects usually get done poorly.  Professor Flyvbjerg’s “Iron Rule of Megaprojects” is that they are “over budget, over time, under benefits, over and over again.”

In fact, by his calculations, 99.5% of such projects miss the mark: only 0.5% are delivered on budget, on time, and with the expected benefits.  Only 8.5% are even delivered on budget and on time; 48% are at least delivered on budget, but not on time or with expected benefits.  

As Professor Flyvbjerg says: “You shouldn’t expect that they will go bad. You should expect that quite a large percentage will go disastrously bad.” 

He has two key pieces of advice.  First, take your time in the planning process: “think slow, act fast.”  As Dr. Flyvbjerg and Mr. Gardner wrote in a Harvard Business Review article recently, “When projects are launched without detailed and rigorous plans, issues are left unresolved that will resurface during delivery, causing delays, cost overruns, and breakdowns….Eventually, a project that started at a sprint becomes a long slog through quicksand.” 

Second, and this is where we get to the LEGOs, is to make the project modular; as Mr. Cohen puts it, “Find the Lego that simplifies your work and makes it modular.”

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Start the Revolution without Us

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BY KIM BELLARD

Well, as usual, there’s a lot going on in healthcare.  There’s the (potential) Amazon – One Medical acquisition, the CVS – Signify Health deal, and the Walmart – United Healthcare Medicare Advantage collaboration.  Alphabet’s just raised $1b.  Digital health funding may be in somewhat of a slump, but that’s only compared to 2021’s crazy numbers. Yep, if you’re a believer that a revolution in healthcare is right around the corner, there’s a lot of encouraging signs.  

But I was in a Walmart the other day, and my thought was, these people don’t look like they care much about a revolution in healthcare. In fact, they don’t look like they much care about health generally.  That’s not a knock on Walmart or Walmart shoppers, that’s an assessment about Americans’ appetite for changes in our health care.  

That’s not to say we like our healthcare system.  A new AP-NORC survey found that 56% felt that the US did not handle healthcare well (curiously, 12% thought we handled it extremely/very well – huh?).  Prescription drugs, nursing homes, and mental health rated especially low.  We’d like the government to do more, but not, it would seem, if it means we pay higher taxes.

Much of what is wrong is our own fault. We know that we eat too many processed foods, that the food industry scientifically preys on us to target our weaknesses for fat, sugar, and salt, that we’d rather sit than drive and drive than walk, and that we are poisoning our environment, and, in turn, ourselves.  Given a choice between short term benefits versus long term consequences, though, we’ll eat that Oreo every time, literally and metaphorically.

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An Upside Down Future for Healthcare

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BY KIM BELLARD

I find myself thinking about the future a lot, in part because I’ve somehow accumulated so much past, and in part because thinking about the present usually depresses me.  I’m not so sure the future is going to be better, but I still have hopes that it can be better.  

Two articles recently provided some good insights into how to think about the future: Kevin Kelly’s How to Future and an except from Jane McGonigal’s new book Imaginable: How to See the Future Coming and Feel Ready for Anything―Even Things That Seem Impossible Today that was published in Fast Company.

I’ll briefly summarize each and then try to apply them to healthcare.

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