COMMENTARY

'I'm Mad as Hell!': Healthcare in America Today

Jeffrey A. Lieberman, MD

Disclosures

March 20, 2017

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Hello. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today from Medscape. The title of my comments could be called, "I'm mad as hell and I'm not going to take it anymore!" You might recognize this phrase from a movie that came out in the 1970s called Network, and I will explain why this is apt in a moment.

In the news, there are many political issues that are roiling our country, from immigration to terrorism to healthcare, among others. Healthcare, of course, is something that is of great concern to us as healthcare professionals. Frankly, the debate over our healthcare system—whether to repeal the Affordable Care Act (ACA), how to replace it, what to replacement it with, to scrap it, to fix it—is, to me, seemingly adolescent, immature, senseless, and represents an unserious effort by the government to tackle one of the most complex and consequential issues that face us.

What does this have to do with the movie Network and "I'm mad as hell"? This movie, which won an Academy Award, was written by a playwright and screenwriter named Paddy Chayefsky. Paddy died prematurely, tragically from cancer in 1981. His work was quite impressive and a really predictive prescience of the future. One movie that he wrote was called The Hospital. This came out in [in 1971], starring George C. Scott as the lead character. He played a chief of staff in a major New York hospital. The story is about the psychological difficulties he was facing in his career as a physician but while trying to manage a major urban teaching hospital in a society that made excessive demands, placed regulations, and under-resourced it, creating a situation that was all but untenable. Even though that film was made [almost] over a half-century ago, it still seems very relevant today, and for anybody who has not seen it, I recommend that you see it on Netflix or Amazon. I am sure it is available.

Chayefsky followed that up several years later with Network, which was a movie about a television news anchor modeled after Walter Cronkite, whose program's ratings were down and, while he was being sacked, developed a psychotic break. His psychosis was paraded on his program as something novel and innovative in programming and got great ratings. In the course of his ranting during one of his programs, he enumerated all of the things that we as citizens of the country suffered in the context of slings and arrows of outrageous fortune that were solvable, but which were not being dealt with by the powers that be, whether it was a municipal state, federal government, or whatever. He then exhorted all of the viewers to get up, go to the window, open it up, and to shout out the loudest they could, "I'm mad as hell and I'm not going to take this anymore!" That struck a chord in people and it reflected a feeling that individuals have in a country where there are systemic problems that persist, affect everybody, and are not being addressed adequately. I think we can clearly say that this is the case for healthcare.

Why is it that healthcare should be such an unsolvable problem that would be the source of so much difficulty? It is mainly because of the fact that healthcare is something that has to be ubiquitously available to people. There is cost associated with it and it requires providing people with equal access or some level of access and a way of financing that care. Herein lies the problem. As healthcare has become more sophisticated over the past century, particularly the past several decades, the cost of delivering healthcare has increased. This has brought many benefits—quality of life, reduction of disease morbidity/mortality, increased survival rates— but it comes at a price. The price has been reflected, among other ways, by an increasing proportion of the gross domestic product that is consumed by healthcare expenditures. Back in the '50s and '60s it was around 5%; now it is verging on 20% and rising higher than inflation.[1]

There has been no successful effort to try to develop a healthcare policy and system of financing that has been successfully developed and implemented. As a result, this problem has been muddling along with rising rates, only being dealt with by the brute force of the marketplace. The last serious attempt to try to develop a top-down comprehensive reform in mental health policy was during the first Clinton administration of the 1990s, which was really doomed to failure by, among other things, the "Harry and Louise" commercials,[2] almost from the start.

The next effort occurred with the ACA that President Obama, with much effort and travail, managed to get passed and to sign into law. It has been, albeit with a great deal of difficulty and complaint, implemented these past several years. It is now precisely this, which was a rallying cry of the presidential campaign and is a goal of repeal in the current administration and Congress.

What is wrong with this? The problem is that while the ACA certainly is not the ideal solution (it is imperfect), it represented, at the very least, an effort to do something. It cannot be repealed without being replaced. It is not clear that there is anything that has been well thought out that would be better to replace it.

What should be done? I am not a politician, I am not a legislator, I am not an economist. I am a physician, but it seems to me that this is not rocket science. This really is something for which common sense could articulate the questions and develop a way to answer.

 
The first question is, is healthcare a right or is it a commodity?
 

The first question is, is healthcare a right or is it a commodity? If it is a commodity, then you get what you pay for. If it is a right, then everybody deserves it. If it is a right, then it is the government's responsibility to ensure that everyone deserves it. If that is the case, as was suggested with the passage of the Medicare and then Medicaid legislation, then how much is the government prepared to spend? How do we in a society want to spend? Is it 5% of our GDP? Is it 25% of our GDP? That determines how much money we can spend on delivering healthcare to the entire population.

This then needs to be translated into an infrastructure, work force, and financing system that will enable this care to be provided at whatever level we as a society, represented by our government, have determined should be done. What are the benefits and what are the limitations? Are we going to give everything possible to everyone through end-of-life care or are we going to have to ration it?

This is not an unprecedented situation; other countries have dealt with this already. There are single-payer systems, there are single-provider systems, there are hybrid systems. There are nonexistent healthcare systems. We really have a default system in which nobody has taken the responsibility to try to develop something in an enlightened fashion, and the result is what we have, which is not working.

Another issue that must be considered in any serious approach to try to deal with healthcare has to do with how we view biomedical research and the advances that it provides. The real solution to disease care cost is through research which provides, ostensibly, a better understanding and better treatments—and, ultimately, cures for illness. We have seen this over history how scientific breakthroughs lead to medical innovations that lead to reduction of disease and mortality, reduction in cost, greater productivity, longer lives.

Right now, we barely fund biomedical research. I say that as a researcher who has been feeding at the trough of the National Institutes of Health (NIH) for my entire career, but I really feel that this is the case. Even though the United States is the most generous country in the world in funding biomedical research, it is still inadequate. What do I mean by inadequate? The federal budget is $4 trillion. The amount of that budget, which is consumed by the Centers for Medicare & Medicaid Services, which is what the government uses to fund healthcare for older people and poor people, is over one fourth of that. We are spending between one fourth and one third of our total federal budget on healthcare. The amount of money that is given to the NIH, which funds the vast majority of biomedical research—our hope for the future—is $33 billion.[3] That is like 0.8% of the federal budget. If we break that down into the disease areas, the amount of money that is spent on mental healthcare and addictions, is a pittance. It is maybe $2 billion of that $33 billion. It is a fraction per capita of what cancer gets, of what cardiovascular disease gets.[4] It is not that we want to take money away from our colleagues in other disciplines, but the fact is that when you look at the expense caused by mental health disorders and addictions, it certainly is at the top of the disease areas and warrants more equitable funding for research.

What kind of logic applies to spending 0.8% of your budget on something that is the greatest threat to the nation's economy, which is healthcare costs, which are already consuming over one fourth of the federal budget? In other countries, the European Union, Asian countries, Singapore, China, Japan, they are spending from 4% to 12% on biomedical research and development.

Finally, I would say that, because we are talking about how we would affect meaningful changes that would really enhance our healthcare in this country and the progress we make through research, which ultimately has to be translated into therapeutics, we need to do things to the regulatory agencies, the federal government, that are rate-limiting steps in this process. First and foremost among this is the US Food and Drug Administration (FDA). The FDA approves all drugs and devices; it is antiquated legislation that has been amended many times. The FDA is tasked with something that is really an insurmountable challenge. It is underresourced. It could benefit from legislative reform, increased resourcing, and more effective leadership.

In regard to the latter, I am really sorry to say that the former FDA Commissioner, Dr Robert Califf, who came to the FDA from Duke where he was a cardiologist and the director of the Duke Institute for Clinical Research, which was an academic clinical researcher organization that conducted comparative effectiveness studies, was the best qualified individual in the history of the FDA. However, his tenure lasted only a year and he has already had to submit his resignation, which was accepted, and we are awaiting appointment of a new director. That is not an auspicious start, but I just want to mention this in connection with the FDA, which I think is part of the grand solution to how we finance healthcare.

If we do not make reform of healthcare policy, and how we finance it, a political imperative, we are going to continue with the same dysfunctional, inefficient, overly expensive system until there is a crisis, and that calls the question. I do not see how any mature, serious society with a functioning government should allow that to happen.

Thank you very much for listening today. I am Dr Jeffrey Lieberman, of Columbia University, speaking to you today from Medscape.

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