Wed. Sep 28th, 2022

As I retired in January 2020 after a 40-year surgical career, the American College of Physicians published a supplement to its journal, Annals of Internal Medicine, endorsing health care reform — a single-payer system.

These quotes made the case quite clearly and urgently:

— “The U.S. health care system is gravely ill, and the symptoms are many: Costs are too high, many people lack affordable coverage, incentives for hospitals and physicians are misaligned with patients’ interests, primary care and public health are undervalued, too much is spent on administration at the expense of patient care and vulnerable individuals face daunting barriers to care. Health care expenses are the leading cause of private citizen bankruptcies in the United States.”

— “The (American College of Physicians) rejects the view that the status quo is acceptable, or that it is too politically difficult to achieve needed change. Dr. Atul Gawande wrote, ‘Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.’ By articulating a new vision for health care, the (American College of Physicians) is showing a willingness to try to achieve a better U.S. health care system for all. We urge others to join us.”

The buildup to the 2020 election was just getting started and U.S. Sen. Bernie Sanders was beating the drum of “Medicare for All” and making waves. I attended a University of Pennsylvania Leonard Davis Institute of Health Economics conference in February of that year to stoke my passion for reform, only to hear the keynote speaker declare that “Medicare for All” was not politically feasible.

That speaker was Paul Starr, a Princeton University sociology and public affairs professor who won the 1984 Pulitzer Prize for nonfiction for his magnum opus, “The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry.” I was crushed.

If ever the time seemed right, it was 2020.

The pandemic

At that same time, a novel coronavirus was beginning to emerge that seemed certain to change everything. But has it?

Here we are, two and a half years into a pandemic that has left more than 1 million Americans dead and has exposed the shortcomings of our American health care “system.” Those shortcomings are worse than described by the reformers who pushed for “Medicare for All.”

In June, the peer-reviewed journal of the National Academy of Sciences of the United States of America published a study that found that a single-payer universal health care system “would have saved 212,000 lives in 2020 alone” and more than 338,000 lives over the course of the pandemic so far.

That study also found that $105.6 billion of medical expenses “associated with COVID-19 hospitalization could have been averted by a single-payer universal health care system over the course of the pandemic.”

The outlay of health care expenditures and the lives lost because of inadequate health insurance make the need for reform obvious.

“Health care reform is long overdue in the U.S.,” said Alison Galvani, director of the Center for Infectious Disease Modeling and Analysis at the Yale School of Public Health, and that study’s lead author. “Americans are needlessly losing lives and money.”

Wasteful and unjust system

Among reformers there is disagreement about whether incremental change and expansion of the changes begun with the Affordable Care Act (also known as “Obamacare”) or “Medicare for All” is the best way to address our dysfunctional health care system.

Margot Sanger-Katz’s analogy in her New York Times column in September 2019 was a perfect way to describe this choice. Our health care system is an old house. Is it a fixer-upper or should we tear it down and rebuild?

Yes, tearing down and rebuilding this gargantuan component of our economy will be resisted by the owners of the goose that lays the golden eggs, but the longer we wait to reform our health care system, the higher the price we will pay eventually to slay the beast. Business magnate Warren Buffett famously described our profit-driven system as a “tapeworm” that saps the competitiveness and efficiency of our economy, as well as the health of every American.

Our system is wasteful and unjust. Priorities have been forgotten and profits seem to be deemed more important than patient care. The irony of calling for government-run health care in the face of our government’s long history of inefficient bureaucracy is not lost on me, but the administrative bloat and waste in our current way of providing care is — yes, hard to believe — worse. It’s undeniable that in our current system, too few resources are being used to address the social determinants of disease, where real improved outcomes in quality of life and life expectancy lie.

But it is also important to acknowledge that countries that have single-payer health care systems are dealing with increased costs and the dreaded R-word: rationing. Along with the reform of health care financing, we must change how we practice medicine.

We — both patients and providers — must change our culture. We have become addicted to high-tech illness intervention. We need to emphasize low-tech primary care, prevention, education and personal responsibility and undertake serious work altering the social determinants of disease such as poverty and racism.

We must be willing to consider options other than “Medicare for All,” such as an American version of Germany’s system, in which health insurance is mandatory and health care is provided by statute to people who cannot afford it, but people may buy private health insurance if they wish.

First, we must face the fact that our current system of providing health care is too expensive, inequitable and not providing the care we all need and deserve. We can do so much better. As American surgeon Atul Gawande said, this will take “moral clarity,” “ingenuity” and a “willingness to try.”

Dr. Edward T. Chory is a retired general surgery specialist in Lancaster.

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