Moving to (More) Universal Health Care

This week the United States Supreme Court decided upon the constitutionality of the individual mandate component of the Affordable Care Act (ACA), known as ObamaCare. Therefore, it seems an appropriate time to revisit the controversial topic of the American health care delivery system. Whether or not the United States does eventually adopt the Obama prescribed change to the system (the Republicans are promising to try to overturn the ACA), there should be little debate to one key aspect: the current US model of health care delivery is a failure and needs to be overhauled. There are many who argue this point, but the facts are overwhelming: the current US system is the most expensive, provides the least value, and is associated with more tragedy than any other industrialized country. I will elaborate with statistics, many of which are culled from the 2009 book by the journalist, TR Reid, titled “The Healing of America.” First, US health care is the most expensive, with health care representing 16.5% of gross domestic product. France is at number 2 at 11.0% — a whopping difference. It gets worse: we spend over twice as much per capita as Japan does for health care. And, we as Americans are not getting value for what we are paying. We rank last in industrialized countries in treating curable diseases. We are 23rd of 23 countries evaluated for “healthy life expectancy at age 65” (a measure of a health care quality), with Japan (who, remember, pays less than half what we do) coming in first.  At the other end of age, the US infant mortality rate is 23rd of 23 wealthy countries, twice as high as Japan’s. There are many other such sobering statistics. Furthermore, our system is associated with the most tragedies of any other wealthy country — both medical and economic. It has been estimated that more than 20,000 Americans die each year due to lack of health care. Additionally, according to Harvard, 700,000 Americans go bankrupt each year due to medical bills, versus none in Japan, France, Germany, etc. These are truly tragic statistics.

It is beyond the scope of this editorial to explain why we allow this expensive, inefficient, destructive system to perpetuate. Clearly, our political model has challenged our ability to bring about change. It would be such a coup to bring about effective health care reform, that it is a guarantee that one political party is going to resist it happening under the other’s watch. Thus, we have the absurdity of the Republican candidate for this year’s presidential election actively campaigning against health care change, when he was most responsible for effective health care change under his direction as Governor of Massachusetts.

Why are Americans so resistant to change of such an expensive and inefficient system? A lot is due to narrow focus on specific features. Many are understandably afraid of government control, especially in rationing of care. However, this argument frequently fails to acknowledge that currently we are faced with drastic rationing of care, being done in a non-transparent manner by insurance companies. Furthermore, there are several health care delivery models which do not rely on government intrusion, yet ironically we in America have come to accept and defend one of the most controlling government models of any country — Medicare.

In many ways, the proposed ACA changes to our system may perpetuate the worst of our health care system, by potentially giving more, rather than less, influence to the insurance industry. How many interventional cardiologists have not suffered the ill effects of insurance company denials, rationing of care, disincentives, etc.? More importantly, how many of our patients have suffered from such behaviors? I fear that much of this will increase with the ACA, as the insurance companies will seek ways to make up for the requirements to insure everybody.  

There are many other aspects of the ACA that make me uncomfortable — however, suggestions for alternative approaches have been notably lacking. For the reasons mentioned above, we need to start moving somewhere else than where we are. Moving toward a more universal health care is a good place to start, but much more will need to be done.   

Dr Goldberg is the Director of the Cardiac Catheterization Laboratory at the University of Washington Medical Center in Seattle, Washington where he is a Clinical Associate Professor of Medicine. He is also the Chief Clinical Officer of Cardiac Dimensions, Inc. He is a Fellow in the Society of Cardiovascular Angiography and Intervention, as well as in the American College of Cardiology. Email: stevgold@u.washington.edu