Big America

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John Dos Passos—an American novelist of the early 20th century—perfectly summarized what has gone wrong with the United States.

When Dos Passos left Communism and joined the editorial team at National Review in the 1950s, he told William F. Buckley (paraphrased) that he became a Communist because he was against big business. He then moderated his position when he realized the evils of big labor. Finally, he arrived as a man of the right when understood that he was against anything “big.”

Thomas Jefferson, too, opposed big human enterprises. In various letters, Jefferson warned against the growth of American cities. “[Cities are] pestilential to the morals, the health, and the liberties of man. . . . When we get piled upon one another in large cities, as in Europe, we shall become as corrupt as Europe,” he wrote to James Madison from France. Even better, a modern writer described this missive from Jefferson as “unacceptable” by modern rules of thought:

“The mobs of great cities add just so much to the support of pure government, as sores do to the strength of the human body. It is the manners and spirit of a people which preserve a republic in vigor. A degeneracy in these is a canker which soon eats to the heart of its laws and constitution.” 

Big cities were the bane of late 19th century republics, but Jefferson would have been as anti-big as Dos Passos had he lived to witness the rise of bigness in all things American: big government, big media, big education, big medicine, big pharma, big politics, big body mass index.

The dangers of bigness are too many to list here, but bigness begets sloth and decadence, as Jefferson recognized 230 years ago.

Yesterday, I encouraged unreasonableness.

Be Unreasonable

Opposing bigness is, itself, unreasonable. The history of human institutions tells us that success breeds growth and growth stimulates competition, which eventually results in consolidation. Once the consolidation bug bites, it displaces all other forms of activity. Business executives, once bitten, think of nothing but acquisitions and mergers.

I once worked for a startup whose investors decided a merger was their best hope for a profitable exit. Once they decided to merge—long before identifying a possible buyer or seller—all innovation stopped. New ideas, it seems, frighten merger investors because they introduce uncertainty. And no sooner had we been acquired by a former competitor than we began searching for a new target to buy or sell ourselves to.

Thus, a company that falls in love with M&A stops creating value. It stops doing the real work. Peter Drucker observed the same in the 1950s when he wrote, “Managers spend so much time on mergers and acquisitions because it is more fun than doing actual work.”

Big Medicine is, perhaps, the most ominous and omnipresent proof of the dangers of bigness. When I was a kid, there were no hospital “systems” to speak of. At least, not in St. Louis, Missouri. There were simply hospitals: St. John the Baptist, St. Mary’s, Alexian Brothers, Jewish, Barnes, etc. These hospitals relied on benefactors and patients. Doctors were mostly independent businessmen whose affiliation with a given hospital was limited to the right to admit patients.

Then, the 1970s happened. Doctors formed into groups, supposedly to offload the business side of medicine to professionals in that realm, allowing the physicians to focus on patient care. But those doctors groups swelled from a handful of like-minded physicians into behemoths of dozens or hundreds of “healthcare providers” in multiple specialities. Doctors became employees of corporations.

At the same time, hospitals gave up on their benefactors and pursued M&A. Barnes and Jewish and Washington University merged into one. Soon, all the hospitals in the greater St. Louis area were simply branches of some larger corporation, often headquartered in another state.

Finally, when hospital corporations ran out of hospitals to acquire and doctors’ groups ran out of physicians to hire, the two titans merged together, usually with the hospital corporation buying the doctors’ groups. Now, almost all doctors are employees of a giant corporation. Like all employees, they do not act on their training and experience, but simply follow the company’s procedure manual. They do not treat patients—they comply with policy. They do not calculate dosages mentally, but type in variables on a computer screen to learn the result. (Does someone really need a decade of medical education to obey a software algorithm?)

Love the few remaining independent physicians among us, friends, for they are your only hope. Look for “functional medicine” clinics as your first line of care and treatment, for these facilities are small, independent, and staffed with doctors and other professionals who believe, first, in promoting health and avoiding disease, not in treating problems. They are physicians of my great-grandfather’s style, about whom I wrote several weeks ago:

Physician, Heal Thy Art

Big Medicine should be particularly frightening because it is a threat to every human life. It has also become a threat to the republic itself, as we witnessed during the Covid pandemic, when most Americans cheered the suspension of human rights. Big Medicine has the power, not just to heal, but also to kill.

But medicine isn’t the only field where bigness threatens all. In fact, I challenge you to name a single discipline or sector of the US economy where a few gigantic corporations do not dominate everything inside and outside their own industry. The banking system. This amazing Sankey diagram was published in 2016, and bank consolidation has only increased since:

Last week, the Fed issued more emergency funds to banks than ever before—many billions more than the height of the financial crisis in 2008. The remaining regional and community banks will soon fall into one of these four remaining mega banks. And, then, the four will collapse into one under the ultimate ownership of the Fed.