COMMENTARY

One Step Forward, Two Steps Back: The US Healthcare Struggle

Jeffrey A. Lieberman, MD

Disclosures

July 26, 2017

Hello. This is Dr Jeffrey Lieberman of Columbia University in New York City, speaking to you today for Medscape.

Everyone knows that healthcare legislation has been in the news lately. The major issue for Congress and the administration is now coming to a head with a proposed vote in the Senate, reconciliation with the House Bill, and potential signing by President Trump if the legislation should pass in both of those bodies. This would not necessarily represent progress, however, despite claims made by political parties.

Let me put this in context. The healthcare system in the United States is of paramount importance and of the highest priority. The primary role of our government is to protect its citizens. Of course, war is one way to do that, but equally important is the health of the people, and also the economy.

The biggest threat to the economy is not the solvency of Social Security in an aging population; the biggest threat is healthcare and the costs that have been rising during the past several decades. These costs have been scaring the "bejeezus" out of healthcare economists who say that something must be done to rein in costs and provide more cost-effective healthcare.

Think about it: The US economy spends about $3.3 trillion a year on healthcare.[1] That is roughly $10,000 for every person in the United States, and it amounts to 17% of our gross domestic product (GDP). If the current rate of increase continues, healthcare spending is predicted to rise to 20% of the GDP by the year 2025. Right now, the government, through Medicaid and Medicare, pays 50% of these costs. The rest is paid for by private insurance or out of pocket. Hospitals are the primary recipients of these funds, accounting for about one third of costs. Physicians and healthcare providers of various types account for another 20% of the costs, and prescription drugs account for 10%.

Why has it been so difficult to devise a coherent and well-functioning policy? In contrast to many other countries in the world, the US government has not embraced healthcare as its responsibility to provide.

A Basic Right or a Commodity?

First, we must answer this question: Is healthcare a right or is it a commodity? If it is the former, then the question is, how can it be provided? How much are we prepared to pay for it? Therein is the problem. Ideologically, our government has an aversion to single-payer funded healthcare. It is regarded as socialized medicine, something too left of center, in terms of governmental policy, than the capitalist private enterprise system that has dominated in the United States. A single-payer system is not even mentionable, politically. As a result, we are left with a policy that can only be realized by threading a moving needle, or like a Rubik's Cube or a maze with no exit. The impediments that restrict the range of options amount to running a gauntlet in service to special interests.

These special interests include the insurance companies, which have a big stake in this because they make a lot of money by providing private health insurance through businesses and employment, and by individual subscription. Next, hospitals are the largest single recipient of healthcare expenditures. Healthcare providers, first and foremost physicians, have a stake in this because it is their livelihood. Patients and advocacy groups have different perspectives on what should be provided and to what extent. Then there are the interests of other parties, such as the personal-injury lawyers who belong to an industry that survives by policing the healthcare system and profession for any type of malpractice that should be prosecuted.

Given these different interests with opposing or conflicting points of view, it is hard to come up with a policy that is solely focused on providing the best quality of care to all Americans. The principles that must inform the development of any policy include the need to contain costs so that they do not rise at such a rapid level as they have over the past several decades.

People must have access to healthcare and be able to afford it. It should be cost-efficient and eliminate waste and fraud. It should be of good quality. And it needs to be geographically distributed to make it available to people throughout the United States.

To do this, the government officials who are going to make these determinations or come up with the proposed policy to address the hard questions must be willing to confront those questions. Is health care a right or a commodity? I believe nearly everyone comes out on the side of healthcare being a right. In that case, how much will we spend for it? Will we spend 10% of our GDP, 15% of our GDP, or 20% of our GDP? Do we want everyone to have access to everything or are we going to necessarily limit care to what is affordable and what seems to be the most sensible? But if we limit care, that is a slippery slope that ends in rationing. Clinically, that does not sell.

Other aspects need to be considered. Medications and devices are regulated by the US Food and Drug Administration. There are no price controls or regulation of drug pricing when new medications or devices are introduced. Should there be?

What is the role of the federal and state governments in terms of paying for healthcare? Should they shoulder all of the financial burden? Or should they contribute only to special or disadvantaged groups such as the elderly or the poor, leaving the employed, the middle class, and the affluent to get insurance through their employers or to pay for their own individual policies?

What about the insurance companies? Should they be regulated in a way that requires them to provide what are deemed to be fair and equitable policies for benefits and premiums? It is easy to provide cheap insurance for everyone, but to do that, the companies may have to carve out mental health care, cancer care, or end-of-life care. That may result in huge self-pays. We probably also want to think about tort reform, because defensive medicine, which accounts for a lot of money, is a direct result of personal injury lawyers who go after doctors for anything that seems actionable.

Once the policy team has made these decisions, we will need to align the providers, hospitals, physicians, and allied health professionals so that they are deployed in a way that will meet population needs for healthcare. This involves consideration of workforce needs. How many physicians and what kinds of specialties or primary care areas do we need? How many nurses and other allied health professionals? How should they be distributed geographically? Finally, the curricula of the schools that educate and train healthcare professionals need to be aligned with the way healthcare is supposed to be delivered in the context of this policy and is endorsed and financed by the national healthcare policy.

I do not know how all of this gets sorted out. It is a Gordian knot, but it is solvable. All of the variables in the equation are known. The problem is that they have been given equal weight and are skewed in a way that does not necessarily lead to a solution that serves the best interest of the American people. That is the challenge. One thing for sure is that the current situation is not sustainable. Healthcare will grow to cost too much or will become so chaotic and dysfunctional that too many people will not be getting care, resulting in tremendous political backlash.

We hope that our government can respond to this challenge before it comes to that sort of crisis. Unfortunately, the current machinations in regard to the House bill and the Senate bill, which would repeal Obamacare and replace it with this new legislation, do not seem to be the answer. We need a process that goes beyond it.

I would like to end by telling you how we might be able to effect healthcare reform, but I have to ponder that further because it calls for an activism that we have not been able to mobilize as yet. Perhaps that will be the topic of a future video blog.

Thank you for listening today. This is Dr Jeffrey Lieberman of Columbia University, speaking for Medscape.

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