In Health Care, Meritocracy Is on the Road to Recovery

Watching Pete Hegseth navigate his Senate confirmation hearing as Secretary of Defense earlier this month, I was startled by the directness of his testimony. Hegseth boldly proclaimed his intent to create “a Pentagon laser-focused on war-fighting, lethality, meritocracy, standards, and readiness. That’s it. That is my job.” 

His presentation had me wondering, what exactly was the “job” of the health-care establishment?

What impressed me about Hegseth was his willingness to condense the military’s mission down to a single, simple, stark word: “Lethality.” Given even the Pentagon’s limited resources, any function—or any instruction—that does not advance that mission is on the chopping block under his watch.

Lacking firm direction, the health-care establishment has yielded over time to a collective of special interests whose shared mission might be summarized not in a word but in an acronym, DEI—diversity, equity, and inclusion—a mission as amorphous and malleable as “lethality” is concrete.

Hegseth has an advantage. The president has the power to change the culture of the Pentagon with the stroke of a pen. The Hydra-headed health-care monster is not so easily slain. No one person or agency has the power to control it. That said, change now appears inevitable. 

When last I wrote about DEI in medicine for Ingram’s two years ago, I titled the article, “Patients beware, meritocracy is now on life support.” Now, much to my surprise, meritocracy is on the road to recovery.

The journey down that road, however, will be slow. What has hindered recovery these past several years is the absence of any real discussion of DEI’s value. During the George Floyd summer of 2020, the DEI collective proved powerful enough to put COVID-19 on hold for a couple of weeks to encourage protest. That muscle flex cowed would-be DEI dissenters into submission.

In February 2021, Howard Bauchner, then editor of the Journal of the American Medical Association, joined the ranks of the cowed. His case is instructive. On a JAMA podcast, one of his deputy editors, Dr. Ed Livingston, interviewed Dr. Mitchell Katz, the head of the New York Hospital Association, on the subject of “structural racism.” 

Raised in a Jewish home where bigotry was as unwelcome as a pork cutlet, Livingston defended his profession, claiming that unequal black patient outcomes were not the result of personal bias by health professionals, but by larger societal and biological issues. Protested Livingston, “I feel like I’m being told I’m a racist in the modern era because of this whole thing about structural racism.”

Livingston’s protest was not appreciated. Not at all. Martin Luther got less blowback after posting his 95 theses on the Wittenberg cathedral door than Blauchner got for giving Livingston a platform. And unlike Luther, Bauchner felt compelled to grovel. A statement that began—“Comments made in the podcast were inaccurate, offensive, hurtful, and inconsistent with the standards of JAMA”—could only get cringier from there.

Bauchner’s groveling only inflamed the protest. Under pressure, JAMA forced Livingston to resign, shamed Katz, and put Bauchner on administrative leave, ultimately coercing his resignation, as well. This was the smackdown heard around the health-care world. Dissidents got the message.

In the wake of JAMA’s surrender, the American Medical Association issued a lengthy report doubling down on its commitment to equity. The report impressed with its utter lack of self-awareness. After openly endorsing viewpoint discrimination and oppressing dissenters, the AMA called for “eliminating all forms of discrimination, exclusion and oppression.” 

To call this thinking “Orwellian” is being charitable.

As the November election reminded us, most Americans are weary of being scolded. Cracks in the DEI foundations started showing in 2023 when individual states, starting with Florida and Texas, dismantled their state-sanctioned DEI establishments. 

Under pressure from stockholders, corporations began doing the same. The U.S. military and the FBI have promised to end DEI as well, and all other government agencies will likely follow. The medical establishment is on notice.

There is, however, a natural solution. It begins with the recognition that DEI is not a mission in itself, but a way to facilitate the essential mission of health care. As a one-word summary of that mission, I would argue that “outcome” works a whole lot better than DEI. If DEI can show a net enhancement of that mission, all the better.

Although spared any serious debate during the presidential campaign, health-care outcomes per dollar spent are in something close to free fall. In the past 20 years, life expectancy in the U.S. has flatlined. Americans can now expect to live four years less than citizens of other developed countries. In those same 20 years, health-care spending per capita has more than doubled. We greatly outspend any other nation, but the effects of that care are not reflected in the way that matters most: the preservation of life.

To be fair, much U.S. health spending is outcomes-neutral but still valuable. No other nation, for instance, can match the amenities of our inpatient care or the accessibility of our outpatient procedures. There is a reason 42 percent of Canadians would be willing to swallow their pride and come to the U.S. for serious care, and it isn’t because of equity.

There is, I am sure, a case to be made for our investment in DEI as a way to facilitate better outcomes. The problem, however, is that its champions insist on making their case in a vacuum. They have their own journals, their own cliques, their own conferences, their own gurus. The one word that does not describe this collective is “inclusive.”

The future of health-care depends on DEI dissidents finding their courage and DEI champions finding their nerve. As available resources contract and the mood in Washington shifts, the champions of DEI will have to make their case in the public square. 

To this point, unfortunately, they have had very little practice.