by Errington C. Thompson, MD –
A couple of weeks ago, I had the pleasure of being one of several speakers addressing the benefits of having a single-payer healthcare system in the United States.
All of us made the same argument that a single-payer health care system simply makes sense: It is more cost-effective. It is fair. It is moral. Most of all, it delivers better outcomes: it keeps people healthier and improves both life expectancy and quality of life, which is—or should be—the purpose of any healthcare system you design. It is also why almost every developed country in the world has gone to a single-payer health care system.
Universally, good systems cost less, do more
That’s it in a nutshell, but I would like to talk in more detail about some of the benefits that do not make the headlines. One of the biggest problems in our current healthcare system is that it is high-cost with low efficiency. Anyone can go on the World Health Organization’s website and compare the healthcare that is delivered here in the United States versus healthcare that is delivered in Japan, Singapore, Canada, or the United Kingdom—each of which has a different system. Our per capita expenditure is two or three times that of almost every country in the industrialized world. Yet, looking at almost any parameter of healthcare, the healthcare that is delivered in the United States has worse outcomes than any other country in the industrialized world. How is that possible?
Primarily, it is because we live in a country of extremes. There are Americans with immense wealth, and at the same time, some Americans live in intense, oppressive poverty. It is in this dichotomy where we find our healthcare disparities.
In the U.S., less money = less health
While I was at LSU in Shreveport, I was very interested in breast cancer. This is a survivable disease: as most everyone knows, early-stage breast cancer is relatively easily treatable. Yet our results showed a huge disparity in the outcomes for our poor patients compared to more affluent ones. LSU was a charity hospital, which meant that if you could not afford to pay for services, the hospital would figure out some way to write off the expenses—while we provided the same treatment to rich and poor alike. But we found that patients who were poor (or minorities) had significantly higher rates of recurrence and mortality. This simply did not make sense.
We pored over the data for weeks before the answer slowly appeared. In the early 1990s, early-stage breast cancer was treated with surgery, radiation, and chemotherapy. Radiation consisted of a treatment to the breast, five days a week for six to eight weeks. The chemotherapy consisted of taking a drug every day for two to five years. What we learned was that our poor patients would miss a day here or day there, sometimes skipping weeks at a time, because of other family obligations, financial needs, or no transportation. Patients would decide to spend their money on gas or food rather than the co-pay of their chemotherapy. This is the reason their outcomes were worse.
Some conservatives say that their higher mortality rate was their own fault: by skipping their medications, they made bad choices. But if the choice is between taking a drug that will finally show its efficacy two to five years from now, versus feeding your children dinner tonight or putting gas in the car so you can get to work tomorrow … is that really a choice?
Many years ago the New England Journal of Medicine published a landmark study that compared the rate of cardiac catheterization among patients who presented to the hospital on the East Coast and the West Coast (specifically, if I remember the study correctly, this was Los Angeles versus New York). The study found that patients with the exact same symptomatology received vastly different care, depending upon where you lived. In Los Angeles you are more likely to get a cardiac catheterization if you presented with chest pain. But in New York, you are more likely to be admitted to a cardiac unit and get medical management for your chest pain. Although outcomes were the same (days in the ICU, days in the hospital, and mortality rate), the costs were vastly different. So we have to ask ourselves, why does one medical community rely on a lower-cost, highly effective treatment modality, while another prefers an equally effective but far more expensive one? (And, as Americans, shouldn’t we get great cost-effective care no matter where we live in this nation?)
The sum is greater than its parts
It is critically important for us to think about our healthcare system as more than simply doctors, nurses, and hospitals. The system must be all-encompassing, which means reform must also include rehabilitation centers and nursing homes. And it must have high, achievable standards for those institutions, just as for hospitals and medical personnel. Yet, as anyone with a sick or elderly relative or friend knows, the care that is delivered in rehabilitation centers and nursing homes can vary widely, from state-of-the-art caring for patients to places that might remind you of a medieval torture chamber.
Recently, there was a shooting at a New York hospital: one doctor died and several other hospital employees were injured. The shooter was a doctor who had been fired from the hospital several years earlier. He obviously had anger management issues, and he also clearly had some sort of mental problem. That, too, has to be addressed by any universal healthcare system. I am not saying that every shooting can be prevented. I am saying that we can reduce the amount of gun violence by mentally unstable patients if we had a system in which all patients had access to the mental health care that they needed.
In all the discussions about “repeal and replace,” and even in progressive talk about improving Obamacare, almost nobody is talking about dental care. Yet dental care is as important as seeing your family physician every year. Just a couple of years ago, I saw patient in his mid-40s, a middle-class taxpayer who worked for living. He had lousy health insurance and no dental coverage, and he developed tooth pain. Over a period of three weeks he was bounced from one emergency room to another, to try to find the care that he needed. Finally, at one of these emergency rooms, he collapsed in septic shock. He was put on the ventilator, was in the ICU for more than a week, and was taken back to the operating room on three separate occasions in order to get the infection under control.
All of this was preventable. This guy’s pain, the operations, the hospital stays, and huge expenses—whether paid by him or the hospitals or from tax money—could all have been prevented with adequate dental care. That’s why dental and periodontal care, including preventive care, maintenance (regular cleanings), and acute care, should be covered by every health insurance plan available, because the fact is that an untreated tooth or gum infection can lead to a host of other problems, including massive infections and even death!
Repeal and replace … or rebuild and reform?
So, as Republicans continue to debate how to take away healthcare from 22 million or 23 million American citizens, we need to seriously look at how we improve our healthcare system. A single-payer system can really encompass a complete healthcare blanket. We can decrease preventable deaths. We can improve the care that is delivered at the small rural and regional hospitals. We can improve the care that is delivered in all nursing homes throughout the United States. We can get Americans the mental healthcare and the dental healthcare that they need.
This is a righteous vision. This is a Christian vision. This is a moral vision. This is also a realistic vision, not some pie-in-the-sky socialist fantasy. All we have to do is look at what the rest of the world has accomplished in universal healthcare. And then, all we have to do is demand better for ourselves.