Poor Health Care


Leonard Zwelling



These are two articles from The New York Times on Tuesday, February 20. I’m depressed.

The first talks about how the Trump Administration is trying to convince well people to buy short term health insurance plans that do not contain the minimum benefits of most ObamaCare plans and do not cover pre-existing conditions. They are cheaper, but worse.

The next is a long piece by Abby Goodnough that shows how middle class people in America have poorer access to meaningful health insurance than do some poor Americans who qualify for Medicaid.

What these articles are really about is inequities in access to health insurance which is not the same as disparities in access to health care. The ACA was a piece of legislation that was mostly aimed at expanding access to health insurance and succeeded on a smallish scale (probably about 10 to 13 million got insurance of the 50 million who needed it). The ACA did spur Medicaid expansion in some states (not Texas). Of course, the current administration is trying desperately to unwind what good the ACA has done. The Trumpees are doing this through their support for block grants to states in lieu of Medicaid expansion and some maneuvers such as those the first article delineates.

Class, it’s time to review the key facts of health care reform.

In reality, health care reform is about increasing access so that health care is available to all people as each individual needs it. It is about lowering the overall health care bill in the U.S. that now exceeds $3 trillion per year and is over 17.8% of the GDP. And it is about improving the quality of health care which is the hardest of the three to measure and this will lead to the greatest arguments. Let’s put that one on hold for a second.

If we really want to give everyone access to the health care he or she needs, only a single payer system will do that. Essentially, everyone throws in some money for everyone to use as they need it. The amount of money that each person must throw in should be determined by the overall need to provide good care to all (the annual U.S. healthcare bill) and the ability of people to pay for it. It should not be determined solely by who is the sickest. It is not unreasonable to ask able-bodied people to try to work to be included in the system. But surely, everyone should be in. Let’s get the employers out so they can use their money to pay people more. Let’s do away with the insurance companies that add no value to the equation. Let’s train more doctors and relieve them of the burden of huge debt in exchange for their giving service to the country where their efforts are most needed like the inner cities and rural areas.

This does not mean the government should provide the health care. It shouldn’t. Doctors and physician extenders do that and should. But these providers (I hate that word) can offer competitive pricing and what the government will pay for any interaction with the health care system could be determined by knowledgeable experts (doctors) and that’s what the price will be. This does not preclude establishing concierge practices for those who wish to pay for that service, but most Americans will not be able to afford this.

As for cost, the answer to that one becomes obvious, too. We need to do less. I am constantly surprised at the poor care given to many people with cancer who luckily wind up at MD Anderson where the right thing gets done and the patient has the greatest chance to get well thanks to the unbelievably skilled clinical faculty.
This will take an upheaval of the entire health care system. Doctors have to be very quick to refer the most complex patients to centers of excellence where unusual patients can be helped. The centers, by contrast, need to turn away patients with routine problems easily handled outside academia. In other words, we could save a lot of money if we got organized.

These stories of hardships imposed on much of Middle America give me the blues. Like so many other issues, in the area of health care and health insurance, Americans making between $50,000 and $100,000 are bearing an inordinate burden when the poor have access to other solutions.

This can all be changed. All we need is the will in Congress to do so. And this time, do it right!

Access to affordable health care should be a right of citizenship not a privilege only for the rich or an entitlement only for the poor and for those over 65.

Leonard Zwelling