Ch 3.7 | ⚕️Health care: A call for understanding and change
Our health care system is a huge challenge.
Health care policy is a contentious issue in the U.S., with ongoing debates surrounding topics like the role of private insurance, the possibility of a single-payer health care system, the regulation of drug prices and how to address health disparities.
Health insurance prices continue to rise, as does the cost of everything else. But the health care system itself faces significant challenges, in large part because of a lack of alignment with wellness outcomes. While the Affordable Care Act made strides in increasing coverage for Americans, millions still lack health insurance, and the cost of health care remains a significant burden for many. Meanwhile, there is a growing recognition of the importance of mental health, but access to mental health services remains limited for many Americans, and many are crippled by anxiety and depression. And, the fastest-growing drug problem in the United States isn’t "illegal" drugs, it is prescription drugs, which are profoundly affecting the lives of teenagers.
There are no easy answers to these problems because health care in the United States is a complex and polarizing issue. It's a multilayered system that is funded by a combination of public and private sources, and it has both some of the world's highest quality care and some of the highest costs.
According to this article in Time Magazine:
The U.S. now spends more than $4 trillion a year on health care. That’s nearly 20% of gross domestic product. Yet U.S. life expectancy lags literally dozens of other nations—including Portugal, Slovenia, and Turkey—by as much as seven years. If trends continue, we will drop to 64th in the world in life expectancy by 2040, though we will continue to spend significantly more per capita than nearly any other nation.
In fact, the United States spends more per capita — $12,555 — on health care than any other country, despite an estimated 85 million individuals who are uninsured or underinsured due to high deductibles and copayments. For comparison, countries with universal health care systems, such as the United Kingdom, Canada, France and Germany, spend between $5,493 and $8,011 per capita.
To coin a phrase, we have a "health care industrial complex" in America. Yet these significant expenditures, which account for more than 18% of our gross domestic product, have not led to superior health care outcomes.
For instance, life expectancy in the United States is lower than in Germany by about 4.5 years, and the U.S. struggles with a high infant mortality rate compared to many other developed nations. Factors contributing to high health care costs in the U.S. include the price of medical services and procedures, the cost of pharmaceuticals, administrative overhead, and the high cost of insurance.
And yet, the quality of care in the United States is not uniformly superior to that in other developed nations. While the U.S. excels in areas such as medical research, certain specialized treatments and wait times for surgeries, it struggles with health care outcomes like life expectancy and rates of chronic disease, which are on par with or worse than many other developed nations.
Other countries have approached health care quite differently, providing single-payer, government-run systems or a mix of private and public options. Perhaps some of the most successful can serve as a model for us. But, with so much on the line and competing interests' well-funded lobbying groups ready to do battle, it's far from clear whether reform of our health care system can happen anytime soon.
I rarely meet people who think our current health care system is great — certainly not doctors! Moreover, I don't know anyone who would design the system we currently have — other than those who are profiting from it!
Access to health care is inequitable
There are notable disparities in health outcomes in the U.S. based on socioeconomic status, race and geography. Low-income individuals, racial and ethnic minorities, and those living in certain regions are more likely to experience poor health outcomes.
Health insurance relies on the private sector
During World War II, health care was offered as a way to attract workers because employers had few other options. Few people had private insurance then, but now a layoff can jeopardize your access to care. Since that time, the U.S. health care system has heavily relied upon private, for-profit sectors including health insurance companies, the pharmaceutical industry, and medical equipment suppliers. Some view this focus on profit as a factor in health care accessibility and affordability issues.
For example, reports suggest that around 68,000 Americans die annually due to lack of access to needed care, while in the same time frame, major health insurance companies collectively make significant profits. Meanwhile, as some American families grapple with high health care costs that can lead to financial hardships, top executives in the industry have seen substantial compensation packages. Moreover, about a quarter of Americans reportedly struggle to afford prescribed medicines, even as top pharmaceutical companies continue to make substantial profits.
Health care disparities
The U.S. health care system has a cruel tendency to delay or deny high-quality care to those who are most in need of it but can least afford its high cost. This contributes to avoidable health care disparities for people of color and other disadvantaged groups. Today in the United States, an estimated 112 million adults, or about 44 percent of the adult population, find themselves wrestling with the economic challenges of medical care. Around 30 percent of adults have reportedly skipped medical treatment due to cost concerns, reflecting an increase over previous years.
The COVID-19 pandemic has exacerbated these issues, drawing attention to the intersections of public health and health care accessibility. Reports suggest that a significant portion of COVID-related deaths and infections may be linked to lack of health insurance coverage.
Since the onset of the pandemic, life expectancy in the U.S. has seen a decrease, currently estimated at 76.3 years – its lowest point since 1997. An additional concern lies in the potential loss of Medicaid coverage for an estimated 15 million Americans, as certain pandemic-era eligibility policies come to an end.
Health insurers may discourage care to hold down costs
Many health insurance companies restrict expensive medications, tests and other services by declining coverage until forms are filled out to justify the service. True, this can prevent unnecessary expenses being imposed on the patient — and to the insurance company. Yet it also discourages care deemed appropriate by your physician. This can make for shortsighted decisions.
For example, when medications are prescribed for rheumatoid arthritis, coverage may be denied unless a cheaper medication is prescribed, even if it has little chance of working. A survey found that 80% of physicians reported that this led people to abandon recommended treatments; 92% thought it contributed to care delays. And because the expensive medication may prevent future knee or hip replacements, delay may ultimately prove more costly to insurance plans and patients while contributing to more suffering.
Investments in health care seem misdirected
Emphasizing technology and specialty care
Our system focuses on disease, specialty care and technology rather than preventive care. During my medical training, I received relatively little instruction in nutrition, exercise, mental health and primary care, but plenty of time was devoted to in-patient care, intensive care units, and subspecialties such as cardiology and gastroenterology. Doctors practicing in specialties where technology abounds (think anesthesiology, cardiology or surgery) typically have far higher incomes than those in primary care.
Overemphasizing procedures and drugs
Here's one example: A cortisone injection for tendonitis in the ankle is typically covered by health insurance. A shoe insert that might work just as well may not be.
Stifling innovation
Payment structures for private or government-based health insurance can stifle innovative health care delivery. Home-based treatments, such as some geriatric care and cancer care, may be cost-effective and preferred by patients. But, because current payment systems don't routinely cover this care, these innovative approaches may never become widespread. Telehealth, which could bring medical care to millions with poor access, was relatively rare before the pandemic, partly due to lack of insurance coverage. And yet telehealth has flourished by necessity, demonstrating how effective it can be.
Fragmented care
Harvard Medical School put it best:
One hallmark of U.S. health care is that people tend to get care in a variety of settings that may have little or no connection to each other. That can lead to duplication of care, poor coordination of services, and higher costs. A doctor may prescribe a medicine that has dangerous interactions with other medicines the person is taking. Medicine prescribed years earlier by a doctor no longer caring for a person may be continued indefinitely because other doctors do not know why it was started. Often doctors repeat blood tests already performed elsewhere because results of the previous tests are not readily available.
Defensive medicine
More from Harvard:
Medical care offered primarily to minimize the chance of getting sued drives up costs, provides little or no benefit and may even reduce the quality of care. Malpractice lawsuits are so common in the U.S. that for doctors in certain specialties, it's not a matter of if but when they are sued. Though it's hard to measure just how big the impact of defensive medicine is, at least one study suggests it's not small.
Even insured Americans spend more out of pocket for their health care than people in most other wealthy nations. Some resort to purchasing medications from other countries where prices are far lower. The status quo may be acceptable to insurers, pharmaceutical companies, and some health care providers who are rewarded handsomely by the system, but it is not sustainable.
Obamacare
Healthline covered the pros and cons of Obamacare:
The Affordable Care Act, also known as Obamacare, was signed into law in 2010. It aimed to provide affordable health insurance coverage for all Americans. The ACA was also designed to protect consumers from insurance company tactics that might drive up patient costs or restrict care. Millions of Americans have benefitted by receiving insurance coverage through the ACA. Many of these people were unemployed or had low-paying jobs. Some couldn’t work because of a disability or family obligations. Others couldn’t get decent health insurance because they had a preexisting medical condition, such as a chronic disease.
As I've argued, we are living in an era of growing income and wealth inequality, so the one thing I can say confidently about the ACA is it has reduced inequality! Obamacare is a starkly redistributive law. Not only did it subsidize health insurance for those with low and middle incomes, but it also raised taxes on high earners. This mix of policies made the law controversial, and it can be difficult to see beyond the partisan debate.
The conservative case against Obamacare can take a lot of different forms, but it often focuses on the expansion of government regulation and spending. An article from Vox addresses those concerns. And an article by the Heritage Foundation, a conservative think tank, lists “8 Reasons to Still Hate Obamacare:
Health insurance is more expensive than ever. …
Entitlement spending has exploded. …
Obamacare has not stopped the stampede of rising health care costs. …
Americans are paying more money for less health coverage. …
Fewer insurance choices. …
Medicaid enrollment is exploding. …
Nearly 30 million Americans still uninsured. …
Obamacare continues to ignore obvious cost-saving alternatives.
Meanwhile, The Atlantic took a look at "The Real Reason Republicans Couldn’t Kill Obamacare."
Despite the foregoing, in the case of health care reform there is actually more in common between the contesting parties than appears from the overheated debates. Both want to assure better access to medical care by a combination of expanding government programs — like a reformed Medicaid program — and by offering assistance to citizens who cannot afford insurance premiums.
What I do know is that other countries have solved the problem and appear to be doing a much better job of taking care of their citizens.
The question going forward is whether there will be the trust, will and vision necessary to build something better. It won't be easy, but the alternative — continuing to complain while waiting for the system to implode — is unacceptable.
In light of these realities, I would argue that it's time for a renewed focus on balancing the needs of patients with the economic realities of providing health care.
However, solutions to these problems will require careful, nonpartisan discussion and consideration of both the benefits and trade-offs associated with any proposed changes to the system. To get there, we desperately need to "unrig" the system!
As a final personal health care note: If you haven't yet read “Outlive - The Science & Art of Longevity” by Peter Attia, it's a great book and worth reading.