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Is It Time to Move the US Healthcare System to Truly Universal Coverage?   

Is It Time to Move the US Healthcare System to Truly Universal Coverage?
By Terry Clark, MD, FCAP

On August 17 a webinar entitled “The US Healthcare Delivery System: Where it Succeeds: How it Fails to Meet the Needs of Patients and Providers and Options for Change” was presented through the Kentucky Medical Association.  The discussion lasted two hours and included presentations by 11 speakers. Physician speakers were mostly associated with the University of Louisville but several were from other institutions or private practices.  Physician speakers were: Drs. Miranda Mosley, Greg Cooper, Heidi Koenig, Eugene Shively, Barbara Cooper, Don Neal, Jane Katz Field, Kevin Pearce, Michael Flynn, and Mark Schroer.  Specialties represented included: Primary Care, General Internal Medicine, General Surgery, Urology, Anesthesia, Pediatrics, OBGYN and Psychiatry.  Kay Tillow is a non-physician with “Kentuckians for Single Payer Healthcare” who also spoke.  The introduction to the program was by Dr. Susan Bornstein.  

The title of the webinar is self-explanatory as far as the topic discussed.  The webinar lasted two hours and it would be impossible to present all of the material in detail. The main points, some repeated by several speakers, will be highlighted in this article.

With the exception of Dr. Cooper, practicing Family Medicine in Cynthiana, the presenters were unanimous in their feeling that the current structure of U.S. healthcare should be changed.  Numerous studies were referenced that seem to show the current system does not provide optimum care for many racial and socioeconomic groups.  Statistics were listed that show our system often ranking between the 10th and 35th percentiles when compared to population health measures in other first world countries (Western Europe, Canada, New Zealand, Australia, Japan, and a few South American countries).  These would include measures of overall life expectancy, neonatal and maternal mortality, numbers of uninsured persons, medical bankruptcies, obesity, prevalence of Type 2 diabetes, per capita drug costs and per capita health expenditures.  

Dr. Cooper emphasized that the U.S. does show excellence in some important measures.  He specifically listed the U.S. as first in survival of myocardial infarction, stroke, post-op infection rates, life expectancy after age 80, development/utilization of newest procedures and drugs, and life expectancy of those with severe/chronic disease.  He pointed out that arguably the most innovative pharmaceutical companies are located in the U.S. Pfizer, Moderna and Johnson & Johnson were instrumental in the unprecedented rapid development of the vaccines against the SARS-CoV-2 virus. However, he also noted that most Big Pharma companies often have joint international ventures and this was true in the pandemic effort as well. 

Most industrialized countries have healthcare systems that provide nearly universal coverage to citizens.  In the U.S., in 2021, 30 million people had no insurance and it is estimated that 90 million are considered to be “underinsured”, with incomes low enough that they cannot afford the deductibles and copays of their policies.  Prior to the implementation of the Affordable Care Act (ACA) in 2014 the number of uninsured was estimated to be close to 50 million.  In 2016 the uninsured number was about 25 million.  The uninsured are largely the working poor in jobs without employment insurance programs, and with incomes too high to qualify for Medicaid in states that declined to expand Medicaid thresholds under the ACA.  

Critics of the current U.S. system seek to find changes that would provide universal coverage and address what is seen as excessive cost compared to most other first world economies.  Speakers in the webinar discussed the most publicized proposals for change: Medicare for All (allowing individuals to purchase coverage under Medicare), Single Payer (federal tax supported model), and a Public Option within the ACA exchanges (which was never implemented due to influence from the insurance lobby).  

The concerns of the physician community regarding “government-controlled healthcare” as opposed to the “independent” providers were surveyed by Dr. Kevin Pearce and associates.  The leading issues were loss of autonomy, loss of income, increased patient waiting times for patients, and loss of financial incentive for drug and medical equipment development.

Proponents of change tried to assuage most of these worries.  They point out that at least half of physicians are now employed by hospital systems or other non-physician corporations and insurance companies control much of the care doctors can offer patients.   It was emphasized that none of the proposed models nationalize hospitals or employ physicians (and neither do most foreign governments). One study showed Canadian doctors in Primary Care earn equal or slightly more than their U.S. counterparts and most other U.S. specialists perhaps slightly less (estimates accounting for currency exchange rates and cost of living differences).  Several European countries have led in innovation despite their “socialist healthcare”.  The Swiss are leaders in research involving spinal cord reinnervation. The big Pharma corporations enjoy large profits and only spend about 10% on research, more is spent on direct to consumer (DTC) advertising.  The U.S. is one of the very few countries that allow DTC.  Many of the European governments spend more %GDP than ours on medical research.  Roughly 25% of the current $4.1 trillion annual healthcare expenditure involves costs for billing private insurance.  Patients in other countries may complain about long wait times for elective surgeries, but generally receive prompt emergency care.  Surveys of European or Canadian citizens rarely express a desire to emulate the U.S. market model.  

Single Payer is the most popular model among activists and recognizes that ultimately all healthcare costs are borne by the taxpayer, whether through insurance premiums, Medicare payroll taxes, federal dollars to Medicaid, or increased charges from providers to cover indigent care. By removing the private insurance middlemen, cost to taxpayers should actually be lower, but through direct tax rather than through employment-based insurance.  More dollars would be available to employers to increase wages if they are not saddled with insurance premiums.  Employers would also no longer face the cost of HR departments managing employee insurance problems.  Employees would have more freedom to move to better jobs if they didn’t face possible loss of health insurance.  They would also be more likely to risk starting their own small businesses. 

In summary, there is great interest in trying to move the U.S. to a system that can offer true universal coverage. Selling benefits of any of the alternative healthcare structures to providers and legislators is a daunting hurdle.  The insurance industry employs hundreds of thousands of people and are reliable equity holdings for investors. Proponents realize that transition would be complicated and disconcerting to the public, but feel the current structure fails too many patients and can be made more cost efficient and more effective for people now having difficulty utilizing the excellent care available in our country.

I urge readers to go to the voluminous medical literature on these issues to formulate their own opinion.

Dr. Clark graduated medical school in 1980 from the University of Michigan, pathology residency at University of Kentucky 1984, fellowship in Surgical Pathology and Cytopathology from the University of North Carolina 1985.  He was an Assistant Professor of Pathology at the University of Kentucky from 1986-1989.  From 1990-2020 he was in private practice with Pathology and Cytology Labs, serving hospitals and surgery centers in Lexington and several others throughout the state of Kentucky. He retired from practice in 2020.   He has been a member of the Lexington Medical Society since 1990.  He serves on the Editorial Board of the Lexington Medical Society.

Suggested References:

Improving the prognosis of health care in the USA Galvani, AP et al Lancet 2020; 395: 524-33

Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care.  Ryan Crowley, BSJ; Hilary Daniel, BS, Thomas G. Cooney, MD. Annals of Internal Medicine, Jan. 21, 2020.

Pandemic or not: America has the Best Health Care in the World.  Hadley Heath Manning,  Independent Woman’s Forum, Acton Institute.  Nov. 24, 2020.