Prescription For a Sick System: Dr. Kathie Allen on Healthcare

In this special op-ed by invitation, former Democratic candidate for Congress in Utah’s 3rd congressional district and current candidate for Utah State Senate District 8, Dr. Kathie Allen shares her personal experience as a practicing physician on the American health care system.

Op-Ed: Reflections Upon Healthcare Reform from a Family Physician
By Kathie Allen, M.D.

As the Healthcare debate rages across the US, two big ideas seem to be at its forefront. Both ideas are being advanced by Republicans, and both are wrong.
Idea #1 is that healthcare is a “good” or a “commodity,” Outrage resulted when Representative Jason Chaffetz declared, “Americans have choices. And they’ve got to make a choice. And so maybe, rather than getting that new iPhone that they just love, and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care.”

Their was a huge backlash to this remark because people instinctively know that annual healthcare premiums do not correlate with upgrades to one’s mobile phone.Republicans think that buying health care is like buying anything else. But there are several ways in which health care does not behave like a commodity, as noted by Cynthis Levine-Rasky:

1. When seeking healthcare, patients are driven by need in the here-and-now. A patient cannot shop around for the best deal and the healthcare market is not subject to supply versus demand. Having lots of clinics and providers available does not drop the price of healthcare. Patients have no bargaining power with respect to pricing.

2. Patients lack information to make informed consumer choices. Consumer Reports does not evaluate surgical centers or medical equipment. Patients depend upon physicians to make these decisions, and they do not have the training to evaluate which product gives the most value for the money.

3. The profit motive, inherent in the free market, is not appropriate in health care because it interferes with the relationship of trust between physician and patient. Each patient should be able to rest secure that their physician is motivated by commitment to quality, not profit.

Ask yourself when was the last time you were intrigued by an ad promoting 2 appendectomies for the price of one.

Ask yourself what crosses your mind first when you receive a dreaded call that your child is in the Emergency Room with critical injuries. Shopping for the cheapest available service does not cross our minds at such moments of crisis.

Healthcare is not a commodity and should not be treated as one. With a commodity, the higher the quality, the more expensive it is. For instance, a Tesla costs way more than a Honda Civic. With healthcare, the opposite is actually true. The best quality healthcare lowers costs in the long run because it is based upon prevention of diseases as well as their early detection and treatment. When chronic diseases like diabetes and heart disease are prevented, the savings to our healthcare delivery system are immense!

Idea #2 is that patients bear direct responsibility for their illnesses and accidents, as though each episode of illness could have been prevented by making other “lifestyle choices.”

Many diseases have multiple causes, including genetics, the environment, age, sex, and social factors.

Although lifestyle choices do influence some diseases, the cause and effect relationship between lifestyle and chronic disease is much more complex than Chaffetz implied. Smokers do have higher incidences of lung cancer. But the allegation that you can avoid cancer, accidents, and other medical calamities by leading a “clean” life is false. Many diseases have multiple causes, including genetics, the environment, age, sex, and social factors. For instance, people who live in poverty choose foods which are inexpensive but lack nutritional value and are loaded with ingredients which promote obesity. The obesity can lead to diabetes. But genetics also plays a significant role in the development of diabetes, high blood pressure, and high cholesterol. The inheritance patterns of these diseases are complex and interrelated. Any primary care physician will tell you that a patient with type 2 diabetes is also highly likely to also have high blood pressure and high cholesterol, because these diseases are genetically linked.

People do not choose to be ill and devastating diseases like cancer can happen to anyone. It’s akin to defensive driving: you can be the best driver in the world, but you can still have an accident due to icy road conditions. The tendency of the right-wing to blame people for common human problems generates a society of meanness and defies the founding fathers’ intentions that the government should provide for the “common good.” Is childhood cancer or juvenile diabetes a lifestyle choice? What about clearly inherited diseases such as muscular dystrophy(MS)? I can’t think of anything more inhumane than blaming people for being sick.

People do not choose to be ill and devastating diseases like cancer can happen to anyone.

I prefer to live in a world where people are not merely “created” equal, but are treated with respect and goodwill throughout the life cycle. Recent studies show that people living in poverty or with chronic depression and anxiety have alterations to brain structure due to the stresses they face trying to cope with basic needs. The hippocampus, an organ essential for memory and learning, shrinks in these situations. When the brain is bombarded by worries, the objectivity and calm reasoning associated with creativity and problem-solving are vastly diminished. Fortunately, this is a reversible condition. The hippocampus assumes its normal size with resolution of anxiety and depression. The GOP message of “personal responsibility” for poverty and disease flies in the face of scientific reality.

What is a humane solution to our healthcare mess? Tedious as it may be, we need to examine some numbers and some statistics. Healthcare amounts to around 18% of our GNP, far higher than other countries. The average cost of healthcare per person per year in the USA, now tops $10,000, the most of any developed country, and more than twice the amount of the second place country.

Compare the costs of public programs with those that are privately administered. Administrative costs of Medicare in 2015 for the public Part A and B plans were only 1.5%. Medicare Advantage plans (private Part D plans) were 6.4%, whereas costs range from 20- 40% in the private sector. These private market administrative costs are due to billing, compliance with regulations, advertising and other marketing costs, and, of course, profit. A review of CEO salaries of health insurance companies reveals that they make between $20 and $30 million dollars per year. I can hear the capitalists groaning that a top-tier CEO should be able to make whatever the market bears, but I would counter that this is a poor use of money in a market with finite resources.

The value of a non-profit healthcare system is that many of these administrative costs go away. There is no need to advertise, no duplication of services (especially in a one-payer system), and no need to pay exorbitant salaries, bonuses, or dividends to share-holders. The cost of the system could be further reduced by eliminating onerous regulations and bureaucratic red tape that burden providers and patients.

All insurance works via risk-sharing, but the larger the pool of patients, the more costs can be controlled. The reason some promote a single-payer solution is that, in covering all Americans, the risks are spread across the entire population, including young, healthy kids and adults. The inclusion of low-risk patients lowers the costs for everyone.

Most countries offer a basic public plan that is government-sponsored, with optional private plans that people can buy if they have special needs or just want “Cadillac” services. Contrary to popular belief, many countries allow their municipalities or districts to administer the plan, making it not truly “single payer.”The money may be collected at a national level, but the administration may be localized.

Defining which services to include in a “basic benefit plan” can be tricky. The essential services covered by the ACA are an excellent starting point in formulating what might be included. Accidents, childhood diseases, chronic disease, preventive services, and maternity benefits are some examples, Services that are not essential for everyone, such as infertility or plastic surgery, would fall under the private plans.

Paying for everyone to have healthcare is part of the debate we faced in 2017 and will continue to face going forward. There are proposals in Congress on how to finance universal healthcare. Bernie Sander’s plan imposes a tax on consumers of 2.2% and additional new taxes on the wealthiest Americans. His plan rolls out Medicare to younger and younger populations so that everyone is covered within 5-10 years. The Conyers plan in the House of Representatives adds a very small tax on each trade made on Wall Street, as well as some tax increases.

The most important point to remember is that our current system has so much inherent waste that a goodly amount of new financing would come from simply eliminating that waste. If people’s taxes were increased by 2.2%, as Senator Sander’s bill recommends, most people would see out-of-pocket costs either decline or stay level. Remember that Americans spend $10,000 per year per person already, and the price is bound to keep increasing. You’d have to be making around $300,000 a year to not break even or actually see savings.

Healthcare reform is indeed very complex and I have only scratched the surface here. In my opinion, it will require some of the finest minds in the country to effect the changes we need. This think tank should include providers, patients, bioethicists, insurance actuaries, administrators, and others who can make a commitment to finding something that meets the needs of citizens at an affordable cost to all. Fixing a problem of this magnitude will take open mindedness and cooperation from everyone, and a willingness to examine the actual data instead of insisting upon old paradigms that have been proven to be ineffective.
Conservatives will undoubtedly argue against not-for-profit health care, but a primarily not-for-profit health insurance industry is the only sustainable solution that makes sense, as every other developed country has already concluded. Allowing corporations to draw large profits directly off the misfortunes of the ill is not a morally defensible position. Though transitioning to a universal system will have its inconveniences, in the long run, it will serve us well. The public deserves no less.

Dr. Kathie Allen is a Democratic Candidate for Utah State Senate District 8. She advocates for people as doctor and patient. Follow her on Twitter @KathieAllenMD