Healthcare has proven to be the ultimate enigma for American policymakers. This year has brought wave after wave of political controversy, but nothing else has so comprehensively perplexed Republicans and Democrats alike. Hell-bent on dismantling the infrastructure left behind by Obama, President Trump regularly issues statements promoting the repeal and replacement of the Affordable Care Act, despite a glaring absence of viable alternatives. “Obamacare. . . . Repeal it, replace it, get something great,” President Trump once assuredly announced in a campaign speech.[1] Yet, by February, only a month into his presidency, this tune of confidence had waned into a humble acceptance of reality. “Nobody knew that healthcare could be so complicated,” Trump then conceded.[2] Considering we’ve been battling the healthcare beast for decades, it’s more like nobody knew that we could be so wrong on healthcare.
For months now, the future of the American healthcare system has hung in the balance, and much of the debate has centered around the provision of healthcare coverage. Staunch proponents of Obamacare celebrate the hike in “covered lives” as irrefutable proof of its supremacy, while proposed alternatives are measured almost exclusively on their ability to expand coverage. Politicians, along with the mainstream media, have developed a dangerous obsession with using coverage as a measure of our healthcare system, a statistic that fails to evaluate the true quality of any insurance.[3] Insurance coverage in its own right does not increase the life expectancy of Americans, work to prevent the onset of chronic diseases, or improve any of the health metrics by which the American healthcare system already falls so far behind—only high-quality, accessible medical care can. Coverage does not inherently translate to care, and until we begin to look past the numbers of mere coverage and work to provide more affordable, higher quality care to more Americans, the fight to revive a failing American healthcare system will be fruitless.
The need for a shift in perspective is striking in a Boston Globe article detailing the stories of Americans unable to access care despite being covered under the ACA.[4] This inability to receive needed care has become a harsh reality for Ohio residents Amete Kahsay and her husband, who are covered under the high-deductible ($13,200), low-level “family” plan they could afford. After an emergency room visit that drained her savings of $1,700, Kahsay now returns to her native country, Ethiopia, to receive major medical care. Once an adamant supporter of Obamacare, Kahsay explains, “Now, unless I get very, very sick, like only if it’s life-threatening, I won’t go to the doctor. I just lay down and take a rest.” Mrs. Kahsay has health insurance. She is one of the 20 million or so more Americans covered under Obamacare, but if she still cannot access quality care, have we really succeeded? Is her “covered” status alone helping her live a happier, healthier life?
The healthcare system in the U.S. has historically trailed behind those of practically all comparable, developed nations and yet, the current narrow-minded focus of the healthcare debate has done little to combat its shortcomings. In a 2015 comparison against 12 other high-income countries, the U.S. had the highest obesity rate, the highest infant mortality rate, the greatest consumption of prescription drugs, and the highest percentage of its elderly population with 2 or more chronic conditions.[5] Perhaps most demoralizing, Americans at birth are predicted to live shorter lives than the citizens of all of these countries. As Americans, we often pride ourselves on being exceptional, on being number one. With healthcare, though, it seems we’re number one in all the wrong categories.
For decades, progressive critics of the traditional private insurance market have attributed these statistics to a lack of coverage in the U.S., calling attention to the superior health of countries with universal healthcare.[6] Herein lies the fundamental misunderstanding—the best healthcare systems in the world do not derive their success from bestowing coverage, but from providing excellent care. They are the best at making organized, evidence-based medicine accessible to their citizens. They are the best at regularly evaluating their health systems for quality assurance. They are the best at prioritizing preventative care and minimizing the prevalence of expensive chronic conditions. Boiling these systems down to the mere coverage they provide is entirely missing the point.
One of the most commonly referenced countries in the healthcare debate is Sweden, which consistently tops the rankings of global healthcare systems. When looking at the structure and function of the Swedish health system, the origin of their healthcare prowess quickly becomes evident.[7] By Swedish law, all citizens must have access to their general practitioner within seven days. Practices are organized using a team-based approach and are often comprised of nurses, midwives, physiotherapists, psychologists, and gynecologists, in addition to general practitioners. Care for psychiatric issues, such as substance abuse disorders, is widely and readily available in both inpatient and outpatient facilities—a far cry from the virtually nonexistent mental health infrastructure of the U.S. And, most impressively, the costly consequences of smoking, hazardous drinking, insufficient physical activity, and unhealthy eating habits are mitigated by physicians who are trained in psychological counseling techniques.[8] These are the things that change a nation’s health on the macro scale, not hollow statements promoting the expansion of coverage.
At first mention of any Nordic healthcare system, some will scoff, rattling off a long list of reasons why the United States can never achieve a system as successful.[9] A sizably larger population and far greater economic inequality are just a few among the many, and admittedly these arguments are not invalid—with one catch: they all focus on the economic inviability of adopting single-payer health insurance, without realizing that not one of Sweden’s transformative policies mentioned above is a direct product of government-issued healthcare. These policies transcend the economic and political underpinnings of healthcare that for too long have been used as excuses for the inferior health of the United States. There’s no doubt that many aspects of American demographics and economics represent potential barriers to the seamless adoption of a single-payer system, but a single-payer system is not necessarily needed to achieve the quality, sophisticated healthcare available in Sweden. Adopting some of these proven, structural healthcare strategies would drastically improve the health and wellbeing of Americans, regardless of who is managing the provision of health insurance.
As many of these structural strategies are instituted at the patient-physician level, insiders’ perspectives on the state of the American healthcare system are invaluable resources. Dr. Budd Shenkin is an executive committee member of the American Academy of Pediatrics and the president of Bayside Medical Group, formerly the largest privately-held primary care group in the San Francisco Bay Area. A pediatrician and preventative care physician by training, Dr. Shenkin has written extensively on American healthcare policy and structure. In an email to me, Dr. Shenkin echoed many chief concerns, noting: “The problem with the ACA is that the result could be near universal crappy health insurance. . . . [A]ccess to high quality care is a huge problem.” With American statistics surrounding lifestyle diseases so grim, one would imagine that access to preventative care would be of top priority; however, Dr. Shenkin calls access to preventative care a “huge issue” and one that will “grow and grow.” The reimagining of healthcare as a public, government-administered good is a proposition that continues to accrue substantial support and is not at all an issue in principle.[10] What should not be tolerated is the establishment of any new healthcare system that promises Americans the world, while failing to provide them true and reliable access to care.
The intense debate surrounding the future of American healthcare is productive, but only if it has a precise and logical objective. The goals of this national conversation must start to reach farther than simply increasing coverage and begin to better address what Americans can and should expect from coverage. Engineering a system is only half of the battle; measuring it with nuanced and revealing metrics is arguably the more difficult task. The Affordable Care Act, estimated to cost the federal government almost $1.5 trillion from 2015 to 2024, is much too costly of a system to be measured with a misleading and incomplete metric of effectiveness.[11]
As politicians today triumphantly parade around numbers of coverage as proof of success, they naively overlook the millions of covered individuals who cannot receive the quality healthcare they deserve. As much as we want it to be, insurance coverage itself is not a golden ticket to a healthy life. It is reliable access to quality care that will make or break the health of America.
References
[1] Rechtoris, Mary. “8 Donald Trump quotes on healthcare — ‘Repeal it, replace it, get something great!’.” Becker’s Hospital Review. August 16, 2016.
[2] Howell Jr., Tom. “Trump: Nobody knew that health care could be so complicated.” The Washington Times. February 27, 2017.
[3] Roy, Avik. “Why Health Insurance is Not the Same Thing as Health Care.” Forbes. October 15, 2012.
[4] Jan, Tracy. “Critics say high deductibles make insurance ‘unaffordable’.” Boston Globe. November 16, 2015.
[5] Squires, David, Chloe Anderson. “U.S. Health Care from a Global Perspective.” The Commonwealth Fund. October 8, 2015.
[6] “Medicare for All: Leaving No One Behind.” Berniesanders.com.
[7] Glenngård, Anna. “The Swedish Health Care System.” The Commonwealth Fund.
[8] “Disease Prevention in the Swedish Healthcare System: Health situation, national guidelines and implementation.” Socialstyrelsen: The National Board of Health and Welfare. May 2013.
[9] Edsall, Thomas. “Why Can’t America Be Sweden?” The New York Times. May 29, 2013.
[10] Kiley, Jocelyn. “Public support for ‘single payer’ health coverage grows, driven by Democrats.” Pew Research Center. June 23, 2017.
[11] Banthin, Jessica, Sarah Masi. “Updated Estimates of the Insurance Coverage Provisions of the Affordable Care Act.” Congressional Budget Office. March 4, 2014.
