Healthcare in America: One Physician’s Perspective

Successful interventions were the norm, often with the most dramatic improvements occurring following surgery. My practice of OB-GYN encompassed issues from pregnancy and reproductive health to contraception, depression, sexual assault, marital dysfunction, sexually transmitted diseases, and more—a breadth that I found engaging and fulfilling. With my patients, I shared moments of profound happiness and—inevitably—of tragedy and loss, frequently foreseeable, yet at times deeply intimate.

I discovered that I often preferred to work with medically indigent, disenfranchised patients whose needs were the most profound and for whom my work seemed to have the greatest impact. It was amongst those outside of our employment-based healthcare system—and too often unable to access even our underfunded public health programs— that I found my work the most fulfilling.

Over time, the contrasts between the care and outcomes of patients who did participate in workforce-based health coverage and those who did not become increasingly stark. In the period bracketed by my career, the system for providing health services in our country changed radically, narrowing access even as the knowledge, skills, and tools at its disposal expanded exponentially.

In my earliest experience, medical care was still based on relationships. I had no doubt of that physician-patient relationship as central, sacred, and inviolable. In that model, decisions about care were based on the judgment of a doctor who had an enduring relationship with the patient, informed by some access to the accumulated body of scientific medical knowledge. The beloved television image of a wise, devoted family practitioner (Marcus Welby, MD) embodied a practice ethos and level of personal attention that both doctors and patients consider “right.” This Norman Rockwell–drawn “family doctor” was the first, and often the most trusted source consulted for diagnosis and care.

Fifty years later, medical care is very much more scientifically fact-based, calling upon previously unimagined technology, startling discoveries about biologic processes at the cellular level, and an almost-unmanageable rate of expansion of understanding of the causes and disease and pathologies. Where once we trusted Dr. Welby, evaluation and management of many health problems now depend on hugely sophisticated—and expensive—automated machines, and a rigorous adherence to clinically validated treatment protocols, methodologies, and clinical templates. Primary care relationships remain and are still valued, but by-and-large the kinds of health service to be administered is determined through diagnostic routines commonly subcontracted to specialists designated by a hospital (or insurer), with treatments managed according to accepted science-based methods. Compared with performance when I began my practice, the efficiency and efficacy of medicine have increased, and patient outcomes are much improved. For decades, mortality declined and previously serious, even fatal, conditions were pushed back or held at bay.

Along the way, what used to be a myriad of community-based health providers centered on local hospitals coalesced into now dominant regional, or super regional, multi-hospital systems that expanded into all facets of health service, including the acquisition of many formerly independent physician practices and multi-specialty clinics. Networks aggregating multiple services and their providers have been set up not just by hospitals, but also by insurers, employers, unions, universities, religious groups, governmental entities, foundations and other not-for-profit organizations, and aggressive for-profit corporations.

The healthcare landscape now is dominated by large enterprises that whether legally organized as not-for-profit or for-profit—all compete for patients, market share, and revenues. But their economic competition focuses on lowering costs for insurers and other payers, not of holding down what patients must pay—and only indirectly by emphasizing quality and comfort (unless you are a patient with very generous coverage or are quite wealthy). Healthcare is not just “big business,” it is the biggest component of our national economy, comprising about 17 percent of our GDP. It continues to grow and, as our population ages, its share of the economy may reach 20 percent. The trillions of dollars spent annually on healthcare drive often meteoric advances in every facet of the system. But despite the huge sums invested and the near-miraculous developments they generate, care continually becomes more expensive, not less, and grows less, not more, accessible to many of our citizens.

The gains and improvements in the capability of our healthcare system are of no benefit to those who cannot gain access to them. For most purposes, access (beyond emergency services) is effectively limited to those who have insurance coverage—and that coverage began with, and largely remains a byproduct of employment. Coverage beyond the employed (and dependents) is obtained, if at all, from federal and state programs (Medicare, for those who were in the labor force; Medicaid, for the categorically indigent; The Children’s Health program; the VA; and whatever remains of the ACA, or “Obamacare”). Care for seniors and (at least in theory) for our veterans, is well-embedded politically, but care for the tens of millions who are neither remains the subject of a rancorous, unending debate over who should be covered, and who should pay for whatever coverage is provided.

In this debate, healthcare loses its intimacy and much of its humanity. The term becomes a political abstraction devoid of its essential empathy. Instead, it is the fulcrum for ideological advantage, hopelessly entangled in partisan arguments over whether healthcare should be considered a privilege rather than a right. A viewpoint that I find lacking in compassion and far too often mean-spirited however widely held it may be.

Under any rational analysis, healthcare services constitute a public good just as do roads, schools, or police and fire services. They comprise a major part of the public sector in all developed economies because they are essential to both individual and aggregate welfare, regardless of the differences in financing, administrative, or delivery systems.

Economics cannot ascertain satisfactory market equilibrium conditions for this product category. There are no meaningful substitutes for the maintenance of life and wellbeing. Most health services are not subject to global supply. Demand grows with population and median age and with development of new or better services, and may effectively be infinite. While supply is responsive to pricing but also by the need for regulation and oversight.

The special regimes needed to maintain the quality and safety of the goods and services that together comprise healthcare inherently impose substantial indirect costs, to which are added the profits of most insurers and many providers, the costs incurred and profits sought by those who develop new (and always expensive) drugs and devices, and the amounts added to every paid bill to cover the costs of providing uncompensated care and of defending against inevitable legal claims.

The net of all these factors is a system very much different than the one I entered a lifetime ago. It is larger, less personal, and infinitely more complex. It is not amenable to simplistic reductions and is not going to return to the Marcus Welby days (if it was ever there at all). None of this complexity, however, means that we cannot create and operate a system that ensures to everyone in our society the same opportunity to maintain their physical well-being through the application of medical knowledge and technology. We cannot assure comparable health or longevity to every- one, but we can provide everyone the care that will give them the best opportunity for a healthy life and achieving their potential. We could, but we don’t.

Why? What happened to healthcare, something that everyone wants and needs? There are difficult issues regarding the proportion of resources that should be expended on end-of-life care—a debate on which I venture no opinion here—but for infants, children, and the pre-Medi- care population no one argues against the utility or desirability of care. Yet the potential lack of access to care increasingly haunts those who currently do have insurance coverage as well as those who do not: This concern devolves down to the question of who will pay for care when it is needed. All of the perturbations and innovations in the market for healthcare and the means of its delivery have not generated an effective means of assuring universal access, and will not so long as healthcare remains the symbolic focus of disagreement political philosophies over the role government should play in our individual welfare.

My perspective is of course colored by personal professional experiences. I remember instances too well in which the system failed those it supposedly serves—as when pregnant women delayed seeking care because of burdensome, intimidating, or impossible (for them) documentation requirements. Or because they could not find available providers or transport, and consequently suffered compromised outcomes for mother, child, or both. Other factors—usually meaning other manifestations of poverty—were often at work, but taken together they are my memory of too many women accepting deficient care, or none, because they lacked the means to obtain services in their own best interests for that of their children.

We have the world’s greatest medical capacity but a compromised and for many recipients a mediocre, delivery system. While of great potential, the system is highly fragmented but poorly coordinated, in many respects due to the single-minded insistence that a competitive market model is the best way to elicit and distribute healthcare goods and services. The result is not just redundant competing system, but significant expenditures on non-price means of attracting patients—often through brand-enhancing marketing, and inducing (or purchasing) physician loyalty. Healthcare is not treated as something everyone can receive: it is a growth industry that demonstrates little if any interest in the part of the population for whom no deep pocket will pay.

Some numbers readily show the dilemma: US healthcare spending in 2016 was $3.3 trillion. or $10,348 per capita. The comparable figure in 1960 was $146. With adjustment for inflation, the cost is now nine times what it was when we were in middle school. Projections for 2023 will bring that amount to $14,944 each, a rise from 5 percent of GDP in 1960 to 17.9 percent in 2016, and 20percent in 2023.

Government programs accounted for about half (49 percent) of these expenditures in 2016—an amount actually lower than in 2006 (52 percent) because of payments made from insurance coverage under the Affordable Care Act. In 2016, the proportion of the population covered by a payment system was 91 percent—the highest on record. Private insurance paid 34 percent of total expenditures, and 11 percent was paid by patients themselves.

Health insurance did not become a central need until there were effective means of diagnosing and treating medical problems. Although the first insurance programs evolved during the Great Depression, the great impetus for them arose during World War II together with rapid advances in technology and care. By accident of history, health insurance was categorized as a non-taxable employment benefit. That status became embedded after the War in national private enterprise labor contracts, governmental entities, and non-union employers in general. This was not the result of extensive analysis of the advantages, or the implications, of linking health coverage to employment: it was expedient and addressed an issue created by wage and price controls.

After the war, this funding mechanism became the default model in the US. As Europe rebuilt and the rest of the world developed, health benefits had no history of linkage to the workplace, and (for societies able to fund universal coverage) became the presumptive burden of the central government.

In the US, there was no political mandate for universal coverage. Provision of healthcare for the elderly, as an added part of social security, and creation of a joint federal-state program to cover the poor, both were enacted over bitter, unyielding political opposition during the honeymoon of Lyndon Johnson’s Great Society. Although Medicare became an almost untouchable part of the political firmament (no doubt in part because even politicians have parents, and because it was supposedly perpetually funded by a payroll tax), Medicaid—a program for the poor, paid for by “others”—never became politically sacrosanct, and has been subjected to attacks and reductions throughout its history.

Beyond these programs, health coverage for the unemployed and marginal members of our society has been grudging and inadequate, increasingly tied to politically-driven conditions and limitations. Perhaps this is because poverty in America is considered by many to be associated with being a minority—African American, Hispanic, Middle Eastern—at a time of growing nativism. Usually, though, the rationale for not providing care to this part of our population invokes the vocabulary of budgets and economics: it would just be too expensive to add those people to the insured. In this ideological trench warfare, it does not matter that the coverage at issue (Obamacare) benefits millions of non-minority, non-foreign-born, non-“alien” adults, many of whom work, but for employers without health plans. A national coverage system looks to its opponents too much like welfare, an unearned and undeserved gift for the unworthy.

We do not use such labels for recipients of public schooling, or those who drive on public roads or who use public libraries. We deem basic housing, and sufficient food, to be “rights” and generally make them available even with a persistent level of political opposition. What I find incomprehensible is why healthcare services—the lack of which is surely as detrimental to its victims as are inadequate nutrition or insufficient police protection—is not considered a comparable shared responsibility. It is necessary, and effectively unavailable without a government operated risk pooling system.

A public healthcare system is inescapably expensive and requires difficult decisions about what services can be provided and to whom. But those decisions need not be made on the bases of personal wealth, employment, language, or social engagement. Decisions based on costs and benefits can be applied categorically by looking at the medical condition and prospects of each patient individually. Perhaps some treatments cannot be provided because they cost too much in return for too little gain in health or quality of life. But those are not the decisions we are making now. We deny care because of economics and employment status—factors that may affect medical status but are not controlling of it.

Without elaboration, a number of established, but seldom noted, factual observations can help us move past the rhetoric and characterizations that seem to paralyze our ability to acknowledge what we should do. One observation is that the provision of healthcare to those who cannot afford it is cost effective. Those who are injured or ill are less able to participate in the workforce and contribute to taxes. Children born without appropriate prenatal care are more likely to need the extraordinarily expensive service of neonatal hospital units. Patients who do not obtain early diagnosis and regular treatment of chronic conditions risk becoming constant users of emergency services, often at great expense. Even without regard to any ethical demands, we make of ourselves, providing care to those who currently cannot obtain it (unless they literally are at peril of death) is a form of investment, not just an expenditure. Returns on that investment will be received over the lives of the patients through the tax revenues they generate and the later health costs they avoid. We do not have the data or equations needed to calculate “net savings,” but the logic is compelling and serves to reduce if not to eliminate the objection based on cost.

It is worth noting that most nations in Europe and a number in Asia and elsewhere find it possible to fund universal systems. They have economic systems, national priorities, and tax structures different from ours, but they nonetheless are functioning democracies in which the voters accept that to maintain their health systems they must pay the needed taxes. I do not mean to minimize the difficulty of adopting such a system ourselves, but experience elsewhere demonstrates that such systems are not mathematical or economic impossibilities. They are a function of understanding and political will—factors that are not immutable, even in the United States.

I favor a single-payer system, using public corporations, quasi-public agencies, even private for-profit enterprises, to manage the financial aspects of our health system while permitting delivery of care to be a private function (along with public provision). This arrangement would channel much of the health revenue now consumed by marketing, executive pay for bloated bureaucracies, insurance sales, underwriting, policy administration costs, billing, and corporate profits into patient care. To a meaningful degree, it will free physicians, hospitals, and clinics from the expenses of multiple overlapping departments and layers devoted to compliance and administration of the multiple-payer system.

This fundamental restructuring should save administrative costs estimated to approach $400 billion a year—potentially enough to fund essential care to all uncovered Americans without out-of-pocket expense to them.

Physician providers could continue to earn fees for service compensation under contracts or subcontracts with single-payer, as would hospitals, diagnostic facilities, and other providers. Payments could be standardized (regionally or nationally) and patients would—in most communities—retain a choice of providers, while providers could have greater control over the size and breadth of their practices.

Over time, expenses currently paid by patients in the form of premium payments, copays, and deductibles would be converted into taxes that would spread those costs over the entire tax-paying population. Receipt of care would not involve any patient expenditure at all. Everyone would be covered, access would be universal, consumer choice would be preserved, and greater financial efficiency would be possible.

This model is based on reducing the extraordinary overhead costs created by the Byzantine complex of entities that currently implement their own agendas in every niche of healthcare services down to a consistent, simplified, smaller group of participants. The same logic ultimately will take us to universal single-payer coverage, in which a single buyer (realistically, the federal government or its designee) is the sole purchaser of essential healthcare services, with the power to set prices, standards, and policies for care.

Discussion of this proposal must start with the political determination of whether healthcare is or should be the right of every American, and of what it means to have such a right. It is not established in the Constitution (as currently interpreted, at least) nor enacted into law. Universal coverage is a moral but not a legal mandate—now. My own experience convinced me that such access to healthcare has dignity equal to other rights not enumerated in the Constitution but recognized as implicit in our social contract, and should be secured by law. I felt that way when I began my career, and at its end.

This perspective is open and will evoke criticism, even fervent objection, by some. I acknowledge from the start that arranging for equitable delivery of modern healthcare is a complex challenge for which there is no simple solution. But we have learned that the marketplace will not provide universal access, so we must look beyond assumptions that tinkering with it will work, that we must preserve profit potential, market competition, and economic spheres of influence for all current players. It is not working, and I maintain that this traditional business model is not appropriate for managing healthcare.

The only logical alternative that can achieve universal coverage is a unified governmental responsibility for the provision of this public good. Attaining that objective will require political agreement on what the goal is, a realistic statement of the national healthcare mission: a universally accessible, and greatly more efficient, integrated delivery system. I believe it can be done.

No such system now exists but its implementation would express our humanity and, commitment to all our citizens. Manifesting the values of social justice and equality that are the foundation of our society.