The Flesh Trade
a short story about an American healthcare system
America should have a different healthcare system. Even the villains of that system, who cost us half a trillion dollars a year, agree. “No one would design a system like the one we have,” admitted the CEO of UnitedHealth Group. This just days after health insurance CEO Brian Thompson was gunned down, (allegedly) by modern day social bandit Luigi Mangione.
This killing was met with much ambivalence, and even a little glee, by the general public, which in turn provoked a wave of pearls clutched so hard they crumbled into dust. The media midwits who have rushed to defend health insurers and CEOs from the terrorism of Bluesky jokes and Facebook laugh reacts have been quick to argue that the assassination won’t do anything to improve the state of healthcare. This seems to me naive at best and deliberately consent-manufacturing at worst. After all, the last few weeks have seen more critical discussion of our private insurance system (by both the media and regular people) than any time since the the Democratic primary debates of 2019. Back then — before the Dem establishment rallied around the most health insurer-friendly candidate to drive Sanders out of the race — a single payer Medicare for All system (or at least some public option) seemed to really be on the table for America. And now the health reform imagination is booting up once again. One may not like it, but Luigi put health insurers on the rhetorical defensive and got people talking.
So let’s talk about it. To my mind — having worked for several years in healthcare nonprofits and spent several more campaigning for Medicare for All — there are three main ways that our current system makes life in America worse.
First, it’s expensive. Americans spend more per capita on healthcare than any other nation, and we get significantly worse care for our money. A lot of this is administrative bloat — paying the employees of all the various health insurance companies, and also the billing staff that every provider has to hire to deal with those companies. But a lot is profit extraction too (and enormous executive salaries/bonuses).
Second, the coverage is bad. To extract those profits, private insurers have to underdeliver. They need to deny claims, or refuse to cover more expensive drugs or procedures, or find other excuses to not actually cover the costs their customers are paying them to cover ($5k deductibles, having some providers be ‘out of network,’ etc.). And as a result, many people end up not getting the care they need — or they go bankrupt trying to stay alive. Those who have recently risen to the defense of private insurance love to parrot the PR line that “every system rations care.” But no other wealthy country’s system produces so much poverty, or makes itself so inaccessible to the poor. We avoid the European wait times the shills harp on about with a rationing system that distributes care to those with wealth and denies it to those without — as though that were a more just system than asking everyone to wait their turn.
Third, the patchwork, employer-based system creates precarity and power imbalances. For most Americans, every time we move or change jobs (or get fired!) we end up at least temporarily uninsured. One of my great fears is getting hit by a car during one of these lapses, and ending up saddled with a lifetime of medical debt. It’s just a constant low-level anxiety that everyone below the upper-middle class experiences on American soil. And having insurance tied to employers ties workers to bosses, particularly those with ongoing medical conditions. We would be more free to quit bad jobs — or standup to shitty managers, or strike — if losing a job didn’t literally put our health at risk. Many significant shifts in the class struggle are potentially locked behind a reform like Medicare for All.
America has had this rotten situation for so long, that fixing it feels more futuristic and far out than robots and moon-bases — even though we can literally drive to countries with much more humane systems. When I heard of the Thompson assassination, the first thing I thought of was Cory Doctorow’s novella Radicalized (found in his collection of the same name), in which angry Americans in a cancer support group turn to Mangione-style terrorism, and eventually win the healthcare reform that peaceful means have so far failed to deliver. This story seems to me much more usefully speculative than a lot of stuff written in the fantastical mode we call “science fiction,” featuring starships and sentient AIs and other such magicks. A single payer system would be a more profound change to most Americans’ lives than much of that technologically styled wizardry.
So I thought this might be a good time to share one of my own stories of a possible healthcare future. I wrote “The Flesh Trade,” which you can read below, some years ago, for a contest about the future of American healthcare. After that, there wasn’t a huge market for this kind of niche policy-oriented spec fic, so I decided to save it for a rainy day.
This story concerns itself with system redesign beyond the first layer of abolishing for-profit insurance. There are three top-level questions to designing a healthcare system:
Single-payer or multi-payer: does the state pay for healthcare with taxes, or do you have a patchwork system with many payers (i.e. insurance companies), to whom individuals pay premiums (or get premiums paid for them by employers, etc.)?
Single-player or multi-player: do all providers work for the payer(s) (a la the UK’s NHS), or do you have many privately employed or self-employed providers?
Service billing or empanelment: do providers / provider groups / hospitals get paid by billing the payer(s) for the services they provide (each patient visit, each medicine dispensed, each operation performed), or are they paid a lump sum to keep a bunch of people healthy and they try to do that as cheaply as possible?
That gives us lots of design space even within a single payer system. I’d be quite curious to see SF writers and design fiction practitioners take on exploring these options. In “The Flesh Trade,” I cover single-payer/multi-player/empanelment. I’d argue that this is a normatively better system than we currently have, by a wide margin, but, as usual, I find it still leaves plenty of room for competition and profit wrangling, particularly as global heating takes its toll on health…
Short Story: “The Flesh Trade”
“We want Coronado,” I began.
It was a bold ask, and I knew she knew it. The neighborhood had consistently housed the cheapest, healthiest tranche of Medicare members in the Valley. Young artists and yoga coaches, biking to studios in the warehouse district, content to split cozy sharehouses until they got pregnant and petitioned for some retrodense McMansion in Ahwatukee. Fitness racks at every tram stop, vegan restaurants up and down N 7th Street, the best heat management around. Coronado was an empanelment goldmine, fifteen blocks wide. We wanted it back.
The Mayo-Abrazo negotiator, Diane Merlo, sized me up. “Tough sell for our providers. We have very deep roots in that community.”
“Roots? You bit it out of our northern border twelve years ago,” I said. “Then you plopped down a half-baked wellness center, so the fed audit wouldn’t notice that Banner has a full hospital a block away. We both know Phoenix is gerrymandered all to hell. But when I’m at conference cocktail parties, that’s the horror story that gets me laughs.”
“And yet, Ms. Gresten, members in Coronado haven’t complained to CMS. Maybe the Banner-Dignity brand isn’t a good fit for their lifestyle?”
A cheap shot, not a good start. Merlo stroked at her tablet. I worried I’d overplayed my hand. Then she looked up. “Anything else you want?”
I stopped holding my breath, sucked in chilly, sterile hospital air. A haboob was blowing, topsoil collapse in SoCal sending a billion pounds of dust tumbling east. Overworked air purifiers gave the conference room a chemical sweetness you could taste.
Once upon a time, before the feds took over the insurance business, you could just bet on who would be healthy and who would get sick, need care, cost money. Get healthy people on your rolls, kick costly ones off—or charge them more. People paid up either way, because life and death isn’t a market choice. Lots of money sloshed around healthcare then, and everyone got a cut: insurers, hospital groups like Merlo and I represented, pharma, medical device manufacturers, those doctors who advertised in now-extinct in-flight magazines.
But now, with everyone covered, empanelment was territorial. The feds paid monthly Medicare rates based on the patient’s medical history, demographics—a million metrics, crunched by algorithm. You kept patients in your coverage zone healthy, whatever it cost. Providers could tighten belts, sneak in convenience charges, but the rates were the rates, and regulators at the Center for Medicare Services made sure no one got squeezed out of care they needed, no matter how expensive.
So if Banner-Dignity wanted to get rich off single-payer healthcare, we had to know the deltas. Invest in neighborhoods that would get healthier, short the ones that would get sicker. Profit was the difference between how much the government thought each member’s care would cost, and the million daily dice rolls of reality.
This was meta-risk, and the only way to win was to predict the churn of culture- and climate-driven migrations, the future health of towns and neighborhoods, identity groups and subcultures—and predict it better than both the feds and our competitors.
So Merlo flicked an empanelment map onto our shared workspace, highlighted Coronado. Banner-Dignity and Mayo-Abrazo sliced up Phoenix and Tucson fine and twisted, like colorful squid fighting to the death. Outside the cities, rural provider groups held blocky splotches. And outside Arizona? Just the endless red of the MediCorps, the federal public provider option that reformers were using to push out the multi-player system state by state.
I rattled off border neighborhoods we hoped to grab when the CMS tweaked the map: Lawndale, Casitas Lindas, Papago Vista, down to shoring up our eastern flank with Maple-Ash, Date Palm Manor, Baseline-Hardy. Government algorithms were supposed to carve up the state to maximize member convenience, spread out patient loads, but “convenience” left a lot of gray area. Backroom agreements by hospital groups helped CMS settle the ambiguity.
“You’re a woman of conservative taste,” Merlo said. “Good housing, good services, high turnover, decent Provisioned Prosperity metrics. All sprawl-repaired in the ‘20s and ‘30s. Utilization costs have hovered seven points below capitation rates for decades. Of course, those rates are low for the demographics you’re getting, so you won’t be raking it in. Honestly, I expected a more ambitious package. Unless—don’t tell me you’re considering layoffs?”
She was taking the bait. I tried to act annoyed. “Nothing so dramatic. Our patient experience lab is planning a branding stir-up. We want a membership base that will appreciate our new look.”
Merlo’s smirk made me want to drag her outside to choke on the summer air. I’d braved dust storms and flash floods, snowbirds and parkour moms, lost cause right-wingers and vortex hippies—all to get the intel we had today. I preferred the field: trendcasting, chasing down costly hot spots. Making sure Banner-Dignity’s predictions models had the best inputs and biases around. That had been winter though, when you could go outside. For the summer, I was stuck in this conference room.
“These were our initial recommendations,” Merlo said, lighting up territories for Mayo-Abrazo to claim.
Her picks didn’t surprise me. They were after sedentary residents in middling housing stock—a standard Mayo play. Every year they over-recruited an army of physicians, fresh out of their first or second round of med school. Those they couldn’t use they made block docs. House calls, neighborhood fitness challenges—boring stuff. But block docs usually raised a hood’s fortunes, so Mayo was always hungry for new territory with uncompetitive housing. Somewhere to dump their next harvest of excess providers without breaking budget.
“We’ll need an additional adjustment if you want Coronado,” Merlo said. “Something similarly well positioned to compensate.”
This was it, the barbed line I needed her to swallow. I paused, then said, “We’d be willing to put Salt River Gardens on the table.”
“Interesting.” Merlo raised her eyebrows.
“We’ve tapped out our easy growth there,” I shrugged.
Her posture said she’d bought it. “Let’s run the numbers, see how all that scores, hm?”
We set algorithms to check the trade for hidden patterns or anomalies, calculate expected profit and strains on infrastructure. Then we had to run the draft proposal by the feds.
“So, Ashmi,” she used my first name, intentionally familiar. “Have you thought about what you’ll do if MediCorps comes here?”
It was a common question these days—last days in Saigon style. I shrugged. “Move, I guess. Lots of firms are experimenting with meta-risk speculation. Art dealers, media collectives, branding innovators. Health isn’t my passion, and working in a single-player system doesn’t sound fun. I’m here for the competition.”
“Aren’t we all?” Merlo said. “With algos outperforming markets a little more each year, capitalism’s shunk so small they can drown it in a bathtub. Now enterprise is dominated by data-minded thrill seekers—like us.”
“What about you?” I asked, then added: “Diane.”
“Actually, I’m hopeful Mayo can stay private. There’s a contingent in Washington keen to keep one ‘laboratory of democracy’ running. They won’t let Arizona stay multi-player, but they might let one provider group keep a private monopoly. As a calibration measure.”
“A monopoly? Why not just leave it market?” This was all news to me. Mayo must have lobbyists bringing them intel—an illegal but hard to police practice.
“That’d be impolitic, I guess. But budget hawks want to see how much profit we can eek out, then tick down MediCorps’ funding accordingly.”
“How do you know Mayo-Abrazo is going to be the single private player?” I asked, annoyed at the presumption.
Merlo looked at me pityingly. “Who else would it be? We’re a very storied brand.”
“Are mergers in the works?” I might as well try to find out what I was in for.
“Oh, I don’t know the details. I think if the plan goes through, CMS will simply assign us the whole state as empanelment territory over the next couple cycles. Rather makes what we’re doing today feel a bit irrelevant, don’t you think?”
“Are you trying to demoralize me?” I fumed.
“Not at all!” Merlo looked genuinely surprised. “No, sorry, I skipped the good bit. What I’m getting at, Ms. Gresten, is that you should come work for me.”
I almost choked.
“Banner-Dignity’s inputs have performed well since you came on,” she explained. “I could use you as a field researcher. Let you stick to what you’re good at, and we can forget about the gerrymandering, the flesh trade.”
I had come expecting Merlo to maybe slip me a bad deal—but not poach me. Was this some trick to get my guard down? What if it wasn’t?
I liked my work. I got to explore the city, talk to people, crunch numbers, solve puzzles. Once I ran down an allergy spike to an unreported chemical spill, got it cleaned up. Actually improved some patients lives there, which felt nice.
Maybe I could keep hotspotting for Mayo or CMS if they took over. But then I’d be just like everyone else: workaday rank-and-file, collectively tapping the ball down the road of provisioned prosperity. I liked games zero sum. I wanted to keep scoring goals.
And I was going to score one today. I’d shown weakness to pique Mayo’s greed, and if the draft panned out, I would feed them territory that was about to go down hard. Salt River Gardens had avoided the worst of the Valley’s heat island for decades. But I’d walked the sludgy Salt River with a wet-bulb sensor rig. I knew that boutique real estate better than anyone, and my models showed a cascade of climate collapse ahead. Overdevelopment to the south would torque the urban-thermodynamics just enough to wipe away the neighborhood’s oasis. The subdivisions would have to scramble to put up shades and A/C corridors. Whatever hospital group covered it would be taking in hundreds of extra heat victims in a few years. It was not worth Coronado, not by a long shot.
This was my coup, my hard short. I knew the future, and Merlo didn’t. But if they wanted all the territory anyway, my bets just didn’t matter.
A notification popped up on our workspace. The feds had signed off on our draft.
“A pleasure doing business with you,” Merlo said. “Whatever happens in the next year, there’s a spot on my team if you want it.”
“I’ll walk you out.”
We shuffled past modular taupe offices, down stairs, through the highly oxygenated jungle of the first floor waiting room. Immuno-grouped patients sprawled on beds of soft moss. Then out into the plastic tunnel, quivering with the pelting dust. The sky was a moldy, uncanny orange. Neither of us looked up. Summer was just like this: if not the dust, the boiling sun, weeks above 120 F.
I stopped Merlo as she entered the tunnel.
“You said you were here for the competition, like me?” It came out like a question. “Will you miss the game if Mayo takes over?”
“Oh, there would still be competition,” Merlo said. “Us versus CMS, with stakes of survival every time we don’t beat their models. Chess instead of Risk. And as the single player, we wouldn’t just bet on the meta-risk. We’d identify and mitigate it. Which means that we’d actually be improving people’s lives.”
“You sound like you’re pitching MediCorps takeover as much as Mayo-Abrazo,” I said.
“What can I say?” She waved at the sky. “It’s hot. I’m tired of fighting over the shade.”
She started walking again.
I thought of the allergy spike I’d helped clear up, the grateful cards that came to my office. Maybe that could be enough.
“Wait,” I said. Here there were few cameras; the microphones would be whited by the wind. I stepped close, just in case. “Salt River Gardens. My intel says...it’s going to get bad. That’s why we traded it. But if you invest now, people there might be okay.”
Merlo’s eyebrows went up. She nodded.
“Thank you,” she said. And that was it. She walked off into the risky world.
2024 Award Eligibility
Nominations are open or soon opening for various SFF awards (such as the Hugos and the Nebulas), and I once again have two pieces that are eligible in the Best Short Story categories:
“The Concept Shoppe: A Rocky Cornelius Consultancy” appeared in Escape Pod. In this followup to my 2023 story “The Uncool Hunters,” creative consultant extraordinaire Rocky Cornelius is back to help with the launch of a post-apocalyptic-themed boutique grocery in quake-rocked LA — until things get a little too post-apocalyptic…
“The Weather Out There” appeared in Long Now Ideas. What would it be like to talk to faraway aliens, messages taking decades to cross the murk of deep space? What would it feel like if, one day, they went silent?
If you are the nominating sort, I’d be honored if you included them in your nominations ballot. You can also help by telling your friends about them, or sharing them on social media. If you’re a SFWA member, you can also give these a like in the Nebula Reading List. Thank you for the support.
Art Tour: Crow and Girl
I’ve spotted work by this artist in my neighborhood before. This one is on a local bar/cafe. I asked the proprietor who the artist was, and he told me Nathan Beddington. Unfortunately, web searches have so far failed to turn up such an artist. Will update you if I find out more…
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