Healthcare in America
Louis J Auguste
“The first wealth is Health.” This statement by Ralph Waldo Emerson, is universally endorsed. Everyone strives to protect himself or herself from illness in order to live a long life. This journey is seen more often than not as an individual endeavor, without consideration for the impact that the health of others may have on each one of us. An individual or a group of individuals may avail themselves of all the possible resources to achieve the best health status possible, regardless of the rest of their communities. At times, this individual welfare may even be at the expense of the rest of their communities, when resources are scarce. Depending on your position on the economic or social ladder, you may argue whether healthcare is a right or a privilege. Should it be limited to the few who can afford it or should everyone be entitled to it? In a way, this divergence of opinion fuels the on-going discourse about healthcare in America.
Another well-known thinker, Winston Churchill also opined, “Healthy citizens are the greatest asset any country can have.” A nation is in and of itself a complete integrated living entity, where one organ depends on the other in order to survive and where a diseased limb can threaten the viability of the entire organism. Society needs rich investors and smart scientists, but it also needs farmers and day laborers. Everyone living in this country is part of that societal structure, no matter his or her wealth, level of education, legal or illegal immigration status, race or ethnic origin. All segments of the population are interconnected and all contribute to the well-being of the community.
Instead, we have a society divided between blue states and red states, democrats and republicans, whites and non-whites, where the “haves” could not care less about the “have-nots” and intend to take every possible step to keep the status quo. Thus, we see the worst education system, the worst pollution levels, the most hazardous living conditions, the lowest levels of public services in the poor neighborhoods, creating a vicious cycles where the children born in these conditions and in these environments are ill-equipped to compete in the job market and condemned generations after generations to remain in the lowest strata of society. They are condemned also to perform poorly in all the health indices, when compared to the wealthier sectors of the community. Indeed, vital statistics have confirmed that the standard of living in these poor communities, whether they be in the Bronx or in Appalachia, the South side of Chicago or the Native American Reservations, is on par and often lower than that of many third world countries.(1,2)
Socio-economic factors account for at least 80 % of the health issues of our communities.(3) Adult and child mortalities soar when most of the municipal incinerators are located in these underprivileged neighborhoods, when there is no access to clean water, when the schools are underperforming, when one is forced to perform the riskiest jobs, often with inadequate personal protection, because that is the only job opportunity that one may have. The average life expectancy will be shorter when most of the industries have moved away from your neighborhood and even the few that are left prefer to hire outside of your community. It will be shorter when the community is overrun with drugs and violence. It will be shorter when there is no food safety; the community has no access to fresh produce and can only purchase stale food at the local bodegas.
The result of these unfavorable socio-economic factors is poor health and healthcare disparity. Those who are lucky enough not to deal with these daily nightmares, often build a wall around themselves, their families and their world. In fact, they do even more, by taking legislation that will limit access to care in the poorest communities, as we have seen in the southern states that chose not to implement the Medicaid expansion or the health care exchanges under the Affordable Care Act. One of the harshest debates during the preliminary discussion related to this important health measure focused on whether care should be provided to illegal immigrants. Yet, these economic or political refugees are parts of this society. They mow our lawns. They raise our children, they harvest our grapes and oranges, they slaughter the chickens that we eat every day, etc… They bring a lot of energy to this society, but they bring also their own illnesses. Thus, we have to consider the negative externalities of their presence. The grandmothers who overstay their visa and remain to care for their grand children may infect them when their dormant tuberculosis is reactivated. Immigrants from malaria-infested regions can transmit the disease in tropical parts of the country where the proper insect-vectors exist. We can reduce the budget of social programs, by excluding the poor and undocumented workers from the ranks of the beneficiaries, but the marginal cost associated with these externalities increases the social cost well beyond the individual cost of medical care.
Therefore, the creation of health or rather the preservation of wellness does not start in hospitals or medical clinics. It requires that the entire premise of community relations in this country be reevaluated. This is far from being a plea for communism, which has failed miserably. It may be considered somewhat unrealistic and utopian. However, a willingness to forgo excessive gains at the expense of underpaid and overworked employees, a fair tax system on the richest 1 % of the population that will support some of the social programs in this country, eventually a system that offers equal opportunities for education and employment to every member of the community, without regard to their race, color, sexual orientation or creed, will break the cycle of poverty and allow everyone to contribute to this society. Elevating the standard of living of the entire population may be the best healthcare initiative and the most effective way to combat healthcare disparity.
Still this achievement, even if such program is adopted, will be at least years if not decades away. Meanwhile, there is an urgent need to reform the American health care system, one where according to the Institute of Medicine, nearly 100,000 individuals annually fall victims to medical errors.(4) The headline for the improvement of our health care system could be the “Triple Aim” promoted by Berwick in 2008, which insists on : Quality, Access and Cost.(5) The Affordable care Act,(6) despite its clumsiness and despite the multiple efforts by the opposing forces to limit its impact, managed to narrow the gaps between ethnic groups when it comes to screening for the most common illnesses, as shown by the Kaiser Family Foundation study in 2013.(7) It is not clear at this point how much of this law will survive the assaults of the current administration, but one of its concepts in my view represents the best option for universal and high quality health care in this country. It is the ACO model or Accountable Care Organization. As designed, primary care providers assume the coordination of care for at least 5,000 Medicare beneficiaries per unit. These providers are assembled under a unified leadership that will assume risk and responsibility for the quality and the cost of the care provided to their customers (6). These goals will be achieved through : disease management programs, improved care coordination, alignment of incentives for physicians and hospitals through shared savings, operating within a patient-centered home, and supported by a robust information technology system.
I envision that operating under a single payer system, this model could provide universal access to Americans. Indeed, unless they expressly did not want to be part of the system or they could show they had other means to access health care, every member of the community would be assigned to a regional care center and to a primary care provider. These centers would be distributed within easy reach of public transportation for all the assigned populations and with afterhours services, so that the day laborers would not need to visit the emergency department for the most banal ailment, wasting their time and already scarce community resources. Adequate payment would be provided for coordination of care by the primary care providers. Full coverage for all screening procedures approved by the United States Preventive Services Task Force would be offered without any co-pay or deductibles. Specialist consultations would be available upon referral from the primary care physicians, preferably on the same day, under one roof or within easy reach. Since 125 million Americans out of a population of 314 millions live with chronic illnesses, disability and/or functional limitations, management guidelines and algorithms would be established for all chronic illnesses, including mental disorders and addiction problems, setting standards for care that would be updated through an integrated robust IT system, as more information became available. Free transportation and escort services would be available when necessary. Homebound individuals would benefit from house calls by physicians or physician extenders depending on the extent of their needs. Contractual agreements would be signed with specialty centers and hospitals that have demonstrated excellent outcomes and accept competitive bundled payments for their services. Working in close cooperation with the physician coordinators of care, navigators would be essential to monitor compliance and facilitate the interaction between the different providers of services. Significant incentives would be offered for the patients to promote their engagement and their activation in all aspects of their health care.
This entire structure would be supported with a single robust truly national Information Technology system affording medical evidence for rational and both patient- and disease-specific decision-making and allowing to share files, images and lab results between primary care providers, specialists and hospitals, from coast to coast, through a unified Electronic Health Record system.
Finally, integral to the medical care, social and economic resources would be allocated to affect the social determinants of health, including housing, assistance with employment, transportation, safe neighborhoods, adequate schools and environments free of toxic agents and conducive to healthy physical activities.
This IT infrastructure will also be the backbone of a quality-monitoring platform that will focus on outcomes and not on processes. The assessment of outcomes should take into account the relevant environmental context of the individual and focus both on immediate and long-term impact of the health care interventions. The piece-meal approach practiced by the current third party commercial insurance providers has led to cost-containment efforts that are incremental, ineffective and at times even counterproductive. The real emphasis should shift from volume to value defined as the ration of health outcomes over the cost of care. To paraphrase Michael Porter, in health care, stakeholders have myriad, often conflicting goals, however, improving performance and accountability depends on having a shared goal that unites interests and activities of all these stakeholders.(8)
In conclusion, this form of universal health care model has all the necessary features to satisfy the Triple Aim of Health Care. These aims are not necessarily synergistic since improving access and quality of care may lead to increase cost. Presently, health care represents nearly 20 % of the national budget. A myopic view of the problem may lead to the hysteria that we are witnessing these days in the government. One consideration that seems to be absent from the discussion is that every patient that does not have health insurance eventually becomes the responsibility of the entire community. In addition, it is more cost effective for example to take care of someone’s diabetes and arterial hypertension than to provide them with chronic hemodialysis or a kidney transplant or to take care of a paralyzed stroke victim, or providing social security to a family who has lost its wage earner to a myocardial infarction.
Furthermore, the conservative segment of the population scoffs at the attempt to provide health care to all Americans. Yet, they consider it normal that the CEO of United Health Care be given a severance package of $1.6 billion worth of stock options(9), that the CEO of AETNA collected an annual salary of $22.2 million(10) and that the CEO of a local health system received a salary of $10 million for the 2014 fiscal year.(11) A single payer system, along with a redesign of the health care system, would eliminate these abominations and go a long way to expand and finance health care coverage to a broader segment of the population and improve the health status of the entire country.
1- Summary of Vital StatiSticS 2014 the city of New york – NYC.gov
www1.nyc.gov/assets/doh/downloads/pdf/vs/2014sum.pdf – consulted on June 3, 2017.
2- World Health Statistics 2014
www.apps.who.int – consulted on June 3, 2017
3- B. Booske et al., “Different Perspectives for Assigning Weights to Determinants of Health,” County Health Rankings Working Paper. Madison (WI): University of Wisconsin Population Health Institute, 2010d
4- Kohn K.T., Corrigan J.M., Donaldson M.S., “To Err is Human: Building a Safer Health System” Washington, DC National Academy Press, 1999.
5- D.M. Berwick, T.W. Nolan, J. Whittington, “The Triple Aim: Care, Health and Cost,” Health Affairs 27, No 3 (2008); 759-769.
6- Patient Protection Affordable Care Act
7- Salganicoff, A., Ranji, U., Beamesderfer, A. and Kurani, N. : Women and Health Care in the Early Years of the Affordable Care Act – Key Findings from the 2013 Kaiser Women’s health Survey, The Henry Kaiser Family Foundation Report, May 2014.
8- Porter, M.E.: What is Value in Health Care? N. Engl. J. Med. 363:26(December 23, 2010); 2477 – 2481.
9- Freed J. UnitedHealth Panel May Face Security, San Francisco Chronicle, April 23, 2006.
10-Forbes: Home Page for the World’s Business Leaders”. 2004
11-Vincent I. and Klein M.: “This Guy Makes $10 millions to Head a Nonprofit.” NY Post 2015/11/29
Louis Joseph Auguste, MD
Louis J Auguste, MD, FACS
Surgical Oncology/General Surgery
Clinical Professor of Surgery
Hofstra Northwell School of Medicine