In discussions on The Bob Zadek Show, “one size fits all” is the phrase guests and host use for centralized rules that apply a single standard to people, places or cases that differ. The phrase appears in episodes on medicine, pandemic policy, education and the strategy of the liberty movement, and in each it names the same objection: a uniform rule overrides individual circumstance, market pricing or local knowledge.
Medicine: coding and price controls
Dr. Jeffrey Singer, describing Medicare’s reimbursement system, said the code for removing a gallbladder pays a set amount regardless of the surgeon: the physician with the best record in the state and the lowest complication rate receives the same payment as one performing the operation for the first time. “It’s one size fits all,” he said, unlike professions in which excellence can be rewarded by charging more Will Americans Accept Second Class Medicine? (2013).
Singer traced the system to a coding system created in the early 1980s, when the American Medical Association lobbied Congress for and received a monopoly on designing the codes. Each year the AMA produces thousands of codes covering procedures, services and diagnoses, and physicians submitting bills to Medicare must describe their work through those codes. Singer said that even when a code did not describe his patient’s problem or the service he rendered, he had to choose the closest fit in order to be compensated. Bob Zadek framed the change for listeners: where a patient once paid a predetermined bill for a visit, the patient is now “a series of codes,” and the physician’s office must develop the skill of converting treatment into as many codes as possible to maximize payment.
Singer added that in the mid-1980s, during the Reagan administration, Medicare instituted price controls on top of the coding system. A commission decides what each procedure code is worth, and Medicare sends physicians a book each October listing the reimbursement for each code. Hospitals operate under an analogous system of diagnostic related groups, or DRG codes. Singer said the rules also bar him from reducing his fee for a patient of limited means, because that would be discriminatory — he gave the example of an 80-year-old widow living on a fixed income, whom he is not allowed to charge less. Zadek contrasted this with law practice, where attorneys set hourly rates and are tested against the market every day, and where Singer noted a lawyer may adjust a fee for a client who cannot pay the rate.
Singer described the downstream effects on medical practice. Physicians hire certified coding specialists, now a field of its own, who translate a doctor’s account of a service into code numbers; Singer said a coding specialist may tell him that describing his work one way pays 20 percent less and another way pays 20 percent more. He said the need to supply a payable diagnosis distorts data: a patient who comes in concerned about a breast mass and turns out to have none cannot be billed for “normal exam,” so the closest available diagnosis, such as breast pain, is recorded instead, which he said makes epidemiological data suspect. He characterized the profession’s acquiescence to the coding system as the beginning of a cancer that affected its professionalism.
Pandemic policy and local control
Jeff Hewitt, a Riverside County supervisor, applied the phrase to California’s pandemic response. Zadek asked him about Governor Newsom’s approach for the entire state as opposed to county by county, and about the tension between Sacramento and Riverside County Commonsense COVID Response (2020). Hewitt noted that California has 58 counties, that Alpine County has 1,200 people while Los Angeles County has 10 million, and that what fits one has no relationship to the other — which is why, he said, the top-down approach never works all that well.
Hewitt described Riverside County’s early role in the pandemic: a chartered jet landed at March Air Reserve Base in his district on January 29 carrying 195 U.S. citizens who had been diplomatic personnel in Wuhan, and the county’s public health officer, Dr. Kaiser, imposed a 14-day quarantine before the federal government followed. None of those people turned out to have the disease. He said Newsom was among the first to impose a full lockdown and shelter-in-place order to flatten the curve, and that early on officials were looking at a disease that might have the mortality rate of SARS or MERS while spreading like the flu; as it turned out, the mortality rate was much lower and would probably be close to that of the typical seasonal flu. Hewitt, who said he holds a Bachelor of Science in biology from San Bernardino State, began plotting the numbers himself and concluded the situation was not what people were saying it was. He singled out the governor’s criterion that a county could have no death in 14 days due to COVID, which he called the most ridiculous one and impossible in a county as large as Riverside. He said he made public statements against the orders, that the governor is not a king, and that he could not convince his colleagues to go against them.
Asked whether counties would seek more local control, Hewitt said he did not think that was naive, and that changes would have to be made at the ballot box — whether in the eight constitutional offices of the state or in the makeup of the state assembly or senate. He predicted a day of reckoning in three to six months when the economic fallout and real numbers came in, and said many politicians would be uncomfortable about having bought into tactics of fear and the wholesale usurpation of constitutional rights. He said he is active in CSAC, the state group of counties, and NACo on the national scene, and looked forward to building coalitions with other counties. He described his board as diverse — one African American, one Hispanic, a Jewish woman and two white guys, with two Democrats, two Republicans and a Libertarian — and said he and Sheriff Chad Bianco disagree on many things but can work together for their constituents.
Education and the liberty movement
On schooling, Zadek argued that government-run education is structurally burdened by one size fits all and cannot deliver a specialized product suited to a gifted child, a less gifted child, or a child oriented toward the arts rather than the sciences Parents Voting With Their Kids’ Feet (2021). He said public schools reduce education to the lowest common denominator, while private and charter schools have learned to tailor it, and that the public will demand from education what it expects from every other good or service. He also noted that equity concerns are used to argue it is unfair to devote tax dollars to more gifted students at the expense of less gifted ones.
Matt Welch agreed and described the trend in public school policy before and during the pandemic as getting rid of gifted and talented programs and, in New York especially, specialized high schools. He said the objection is that students should not rise too far above the trend line, because if the demographics of those who do are not what officials would like, the result must be institutionally or structurally racist. Welch said enrollment in New York had grown uninterrupted for a decade, then declined 7 percent in his district overnight in the first year it radically overhauled admissions policies and eliminated student performance metrics; he said this is happening nationwide. He described the two developments as compounding: just as families learn they can tailor-make a homeschooling product, public schools say they will do no specialization at all.
The phrase also appears in a discussion of movement strategy. Matt Warner of Atlas Network said that freedom leads to prosperity because it allows constant learning and correction, and that trying to apply very crude rules that one size fits all does not work How to leverage resources within the liberty movement (2020). He described a broad network of think tanks whose members gather to learn from one another without someone in charge deciding what everyone should do, supported by awards, case studies, competitions, competitive grant-making and peer-driven training programs.
Across episodes: no development
The excerpts show the phrase used in four episodes across eight years — a 2013 discussion of Medicare reimbursement, a 2020 conversation about pandemic restrictions, a 2020 discussion of movement strategy, and a 2021 conversation about schooling — but they show no development in the idea itself: in each, “one size fits all” names a uniform rule that overrides individual circumstance, and the speakers treat it as a defect of centralized administration rather than a position to be argued against.
What the sources do not cover
The excerpts do not state the name of any bill, the holding of any case, or the amendment on which any case turned. They do not give the founding date of the coding system beyond the early 1980s, the name of the commission that sets code values, or the outcome of any litigation over the pandemic orders. The education excerpt breaks off before any further exchange, and the medical excerpt ends at the beginning of a segment on boutique and concierge medicine.