medical care in us essay

Should Healthcare Be Free? Essay on Medical System in America

Introduction, problem statement, why healthcare should be free, why healthcare should be paid, works cited.

The US government has historically taken a keen interest in the health of its citizens. As far back as the beginning of the 1900s, President Theodore Roosevelt declared that “nothing can be more important to a state than its public health: the state’s paramount concern should be the health of its people” (Gallup and Newport 135). Despite these, the United States is classified as the nation with the most expensive, and yet inefficient, health care system among developed nations.

An expensive health care system translates to an increasing proportion of the population being unable to access the much needed medical care. The New York Times reports that according to census survey carried out in the year 2007, an estimated 45.6 million people in the USA were uninsured and hence unlikely to receive comprehensive medical care from hospitals (1). Due to the perceived inefficiencies, there has been agreement that the current health care system is faulty and therefore in need of radical changes to make it better.

Majority of American’s are greatly dissatisfied with the current health care system which is extremely expensive and highly inefficient. While an effective system can be deemed to be one which is efficient, acceptable and at the same time equitable, the current system is lacking in this attributes.

The aim of this paper will be to analyze the effects that free health care system in America would have. This paper will argue that a health care system which guarantees free health care for all Americans is the most effective system and the government should therefore adopt such a system.

Free health care would result in a healthier nation since people would visit the doctors when necessary and follow prescriptions. Research by Wisk et al. indicated that both middle and lower class families were suffering from the high cost of health care (1). Some families opted to avoid going to the doctor when a member of the family is sick due to the high cost of visiting the doctor and the insurance premiums associated with health care.

In the event that they go to the doctor, they do not follow prescriptions strictly so as to reduce cost. Brown reveals that “60 percent of uninsured people skipped taking dosages of their medication or went without it because it cost too much” (6). Such practices are detrimental to a person’s health and they cost more in the long run.

The last few years have been characterized by financial crises and recessions which have negatively affected the financial well being of many Americans. In these economic realities, the cost of health care has continued to rise to levels that are unaffordable to many Americans. This loss of access to health care has led to people being troubled and generally frustrated. A report by Brown indicates that the price for prescription drugs in the US has escalated therefore becoming a financial burden for the citizens (6).

The productivity of this people is thereby greatly decreased as they live in uncertainty as to the assurance of their health and thereby spend more time worrying instead of being engaged in meaningful activities that can lead the country into even greater heights of prosperity. Free health care would lead to a peace of mind and therefore enable people to be more productive.

Since medical care is not free, many people have to make do with curative care since they cannot afford to visit medical facilities for checkups or any other form of preventive medical care. This assertion is corroborated by Colliver who reveals that many people are opting to go without preventative care or screening tests that might prevent more serious health problems due to the expenses (1).

Research shows that approximately 18,000 adults die annually due to lack of timely medical intervention (The New York Times 1). This is mostly as a result of lack of a comprehensive insurance cover which means that the people cannot receive medical attention until the disease has progressed into advanced stages. This is what has made medical care so expensive since “sick patients need more care than relatively healthy ones” (Sutherland, Fisher, and Skinner 1227).

This is an opinion shared by Sebelius who reveals that 85% of medical costs incurred in the country arise from people ailing from chronic conditions (1). She further notes that if screened early, these diseases such as diabetes and obesity can be prevented thus saving the medical cost to be incurred in their treatment. It therefore makes sense to have a health care system that makes it possible for everyone to access preventive care thus curbing these conditions before they are fully blown.

While most people assume that free health care will result in better services as more people will be able to access health care, this is not the case. The increase in people who are eligible for health care will lead to an increase in the patients’ level meaning that one may have to wait for long before receiving care due to shortage of medical personnel or the rationing of care.

A European doctor, Crespo Alphonse, reveals that when health care is free, people start overusing it with negative implications for the entire system (AP). In addition to this, free health care would invariably lead to cost cutting strategies by hospitals.

This would lead to scenario where finding specialized care is hard and the rate of medical mistakes would increase significantly. As a matter of fact, a survey on Switzerland hospitals found that medical errors had jumped by 40% owing to the introduction of mandatory health insurance (AP). While it is true that free health care will increase the number of people visiting the doctor, this may be a positive thing since it will encourage preventive care as opposed to the current emphasis on curative care.

Free health care is a move towards a socialistic system. As it is, the US is a nation that is built on strong capitalistic grounds. This is against the strong capitalistic grounds on which the United States society is build on. While detractors of the private insurance firms are always quick to point out that the firms make billions of dollars from the public, they fail to consider the tax that these firms give back to the federal government (Singer 1).

Free health care would render players in the health industry such as private insurance companies unprofitable. Free health care will bring about a shift from a profit oriented system to a more people oriented system. Without money as a motivation, research efforts will plummet thereby leading to a decrease in the medical advancement as investment in research will not be as extensive (Singer 1).

The Associate Press reveals that doctors may also lack to be as motivated if they are no incentives and thereby the quality of their work may weaken (1). As such, a free health care system would have far reaching consequences for the economy of the nation since the health care industry is a profitable industry for many.

The Healthcare system is one of the most important components of the U.S. social system since full productivity cannot be achieved without good health. This paper has argued that a free health care system would be the most effective system for America. To reinforce this assertion, the paper has articulated the benefits that the country would accrue from free health care.

With free health care, all Americans would be able to access health services when they need it leading to increased quality of life. In addition, many people would make use of preventive healthcare services, therefore reducing the financial burden that the expensive curative services result in.

The paper has taken care to point out that free health care has some demerits, most notably of which is overloading the health services with a high number of patients. Even so, the observably advantages to be reaped from the system far outweigh the perceived risks. As it is, decades of reform on the US health care system have failed to provide any lasting solution to the problem.

Making health care free for all may be the strategy that will provide a solution for the ideal health care system that has thus far remained elusive. From the arguments presented in this paper, it can irrefutably be stated that free health care will result in a better health care system for the country.

Associate Press. (AP). Europe’s free health care has a hefty price tag . 2009. Web.

Brown, Paul. Paying the Price: The High Cost of Prescription Drugs for Uninsured Americans. U.S. PIRG Education Fund, 2006.

Colliver, Victoria. “Jump in middle-income Americans who go without health insurance,” San Francisco Chronicle (SFGate), 2006.

Gallup, Andrew, and Newport Francis. The Gallup Poll: Public Opinion . Gallup Press, 2005. Print.

Sebelius, Kathleen. Health Insurance Reform Will Benefit All Americans . 2009. Web.

Singer, Peter. Why We Must Ration Health Care . 2009. Web.

Sutherland, Jason., Fisher Elliott, and Skinner Jonathan. “Getting Past Denial – The High Cost of Health Care in the United States” . New England Journal of Medicine 361;13, 2009).

The New York Times. The Uninsured . 2009. Web.

Wisk, Lauren. High Cost a Key Factor in Deciding to Forgo Health Care . 2011. Web.

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IvyPanda. (2023, October 29). Should Healthcare Be Free? Essay on Medical System in America. https://ivypanda.com/essays/free-health-care-in-america/

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IvyPanda . 2023. "Should Healthcare Be Free? Essay on Medical System in America." October 29, 2023. https://ivypanda.com/essays/free-health-care-in-america/.

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Bibliography

IvyPanda . "Should Healthcare Be Free? Essay on Medical System in America." October 29, 2023. https://ivypanda.com/essays/free-health-care-in-america/.

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Understanding why health care costs in the U.S. are so high

The high cost of medical care in the U.S. is one of the greatest challenges the country faces and it affects everything from the economy to individual behavior, according to an essay in the May-June 2020 issue of Harvard Magazine written by David Cutler , professor in the Department of Global Health and Population at Harvard T.H. Chan School of Public Health.

Cutler explored three driving forces behind high health care costs—administrative expenses, corporate greed and price gouging, and higher utilization of costly medical technology—and possible solutions to them.

Read the Harvard Magazine article: The World’s Costliest Health Care

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Features | Forum

The World’s Costliest Health Care

…and what america might do about it.

May-June 2020

Americans use a  lot  of technologically sophisticated, expensive medical services—slighting more effective,  routine  care. Photograph by Rui Vieira/PA Wire/AP Images

L ONG BEFORE  the presidential primaries, or a paralyzing pandemic,  Harvard Magazine  asked several faculty experts to write about issues that would be shaped by the national elections, that mattered to the future of the country—and that would probably be addressed inadequately during the extended campaign.

One issue was the federal budget and its chronic, enormous deficits. When we approached Karen Dynan and Douglas Elmendorf to explain all that red ink (and what, if anything, to do about it) , the state of play was an unlikely mix: a record U.S. economic expansion and very low unemployment, paradoxically accompanied by trillion-dollar annual deficits and historically low interest rates. Those figures now seem quaint. The coronavirus has caused a precipitous recession, or worse, and attempts to offset potentially cataclysmic job losses are yielding a multi-trillion-dollar budget gap that will need to be paid for some day; at the same time, government interest rates have fallen even further. In this context, Dynan and Elmendorf’s analysis is especially timely and relevant.

Spending on health care is central to the long-term budgetary challenges. So it is especially useful to pair their essay with David Cutler’s nuanced explanations of why American health care costs so much: about $3.5 trillion per year (that’s the  norm , before an emergency like COVID-19)—of which  one-third  is wasted. The sources of that waste, in terms of health value received for dollars spent, may surprise you. It has certainly proven resistant to political repair. Given the relatively poor results Americans receive for all they spend, fixing health care matters: for citizens’ well-being, the country’s fiscal soundness, and extending essential medical services to those who lack access now.

Harvard Magazine  presents these thoughtful commentaries as a service to readers—and as a contribution to better public debate. You can learn more from all three authors on their segments of the Ask a Harvard Professor podcast .

~  The Editors

*      *      *

A lec Smith died of diabetic ketoacidosis, though it is probably fairer to say that he died from high healthcare costs. The 26-year-old from Rochester, Minnesota, had just moved out of his parents’ home and didn’t have enough money to afford his insulin. He decided to ration his remaining supply until his next paycheck, a week later. Alas, he was not able to make it. Alec died alone in his apartment, vomiting and having difficulty breathing, from a condition that never should have occurred.

Alec’s story is extreme in its outcome, but not in its outlines. Nearly half of Americans say they have delayed or skipped medical care because of the cost. People who face higher costs for medical care are diagnosed with cancer at later stages of the disease and take fewer medications . Even the very sick use less care when their out-of-pocket costs rise. Health suffers .

A Medicare enrollee awaits a prescription in Chicago. The U.S. health system entails extraordinary administrative expenses. Photograph by Tim Boyle/Getty Images

The United States has many problems in medical care, from the large share of the population still uninsured (about 10 percent of us) to one of the lowest life expectancies in the developed world. Underlying all these problems is the high cost of medical care. We do not guarantee adequate access to medical care because we cannot figure out how to pay for it.

The harm from high medical spending goes well beyond the medical sector. Many firms have outsourced low-wage workers because providing them health benefits is too expensive. Government spending for schools and environmental programs are starved because resources go to health care instead. Warren Buffett called medical costs the “tapeworm of American economic competitiveness.” Oncologists have invented a term, “financial toxicity,” to consider along with biochemical toxicity in deciding on the appropriate treatment.

Americans agree with Buffett. Two-thirds of Americans want the federal government to regulate the price of medical care. Indeed, the public has a clear theory for explaining high medical spending: unconstrained greed. Pharmaceutical companies put profits above patients, and insurance executives are paid millions to deny coverage. The government should stop both.

And people are right, to a point. Allowing the makers of life-saving medications to price their products without constraint is a recipe for premature death. But the issue is more complex than just greed. Even if the United States cut every pharmaceutical price in half and eliminated all profits on health insurance, the gap between U.S. medical spending and that of other rich countries would fall by less than a quarter. Health care is more than just rapacious profits in drugs and insurance.

The reality is that the healthcare problem is multifaceted. But that is not the same as saying nothing can be done. On the contrary, it means there is even more to do. Three areas are essential to tackle if we want to reduce health spending to near the level in other countries.

Administration Adds Up

The largest component of higher U.S. medical spending is the cost of healthcare administration . About one-third of healthcare dollars spent in the United States pays for administration; Canada spends a fraction as much. Whole occupations exist in U.S. medical care that are found nowhere else in the world, from medical-record coding to claim-submission specialists.

Healthcare administration needn’t be so costly. Even in other countries with multiple payers and private providers—including Germany and Switzerland—healthcare administration is less than half the cost of the U.S. equivalent. The key requirement for reducing administrative costs is standardization. Grocery-store checkout is simple because all products have bar codes and credit-card machines are uniform. Mobile banking is easy because the Federal Reserve has put standards in place for how banks interface with each other. But every health insurer requires a different bar-code-equivalent and payment-systems submission. And even in 2020, it is virtually impossible to send medical records electronically from one hospital to another. Almost all hospitals have electronic medical records, but there is no federal requirement that they interface. Indeed, many providers take active steps to avoid electronic interchange, because keeping records local ensures that fewer patients will switch doctors.

Standardization occurs when big participants decide they want it. In healthcare, the big participant is the government. Only the federal government has the buying power and administrative reach to force payers and providers to adopt billing and interface rules. The federal government could commit to a date by which all interactions are standardized and set up the infrastructure to make that happen. To date, however, the public sector has shirked its responsibility. The federal government sees its role as providing insurance to people—Medicare and Medicaid in particular—but not looking out for the system as a whole. That thinking will need to change if progress is to be made.

Greed and Gouging

Greed is the second part of excessive health spending. The U.S. list price for insulin is 10 times higher than that in Canada. Relief for Alec could have come after a short bus ride north. But pharmaceuticals are not the whole story. Prestigious hospitals charge multiple times what less prestigious hospitals do for the same service. While that may be justified in the case of complex surgery, it surely is not for an x-ray.

It is no mystery why pharmaceutical prices are higher in the United States than in Canada and at star hospitals as compared to community institutions. Prices rise when there is nowhere else to go. Traveling to Canada for insulin is not something most Americans can do—though Alec Smith’s mother now leads such trips, or did when she was able to do so. And few people are willing to switch from a star hospital to a community institution, even if the price is much lower.

Economists’ favorite solution to such “sticky” demand is to help people become more mobile. Play different insulin suppliers off against each other to bargain for a lower price. Have interactive websites to help people shop for lower-priced imaging. Alas, all attempts to make these policies work have so far been unsuccessful. Many employers have created websites where their employees can search for more and less expensive services. Uniformly, they find that raising costs to patients via co-pays and deductibles, for example,reduces utilization but engenders relatively little price shopping. It is not that people think the star hospital is necessarily better. Rather, their physician directs them there, and they are afraid to ask about cheaper alternatives. Pharmaceuticals are a partial exception. People will often choose generic drugs, if available, over a brand name—but they do not do so in sufficient amounts to materially lower the cost of drugs. And federal laws make it illegal for bulk reimportation of drugs from Canada. The result is that star hospitals are overflowing with patients, and insulin prices keep rising.

If prices cannot be tamed by demand, a growing number of economists call for price regulation. Fiat can accomplish what reasoning cannot.

Price regulation is not hard to implement: “Thou shalt not price higher than X” is not a particularly difficult rule to enforce. The state of Maryland does this for hospitals, and most European countries do this for pharmaceuticals.

The major challenge to implementing such a policy is the possible unintended consequences. If pharmaceutical manufacturers or academic hospitals got less money, what would they cut out? Would executive compensation fall (likely a good thing)—or would money for research and development dry up? We are not certain of the answer to this, and so regulation comes with a side dose of concern. That said, every example of a family afraid to visit the emergency department because of the cost, and thus waiting to see if a sick child gets worse , pushes the case for price regulation forward.

In Love with Medical Services

The final part of higher medical spending in the United States is higher utilization . The United States has the most technologically sophisticated medical system of any country, and it shows up in spending: the U.S. has four times the number of MRIs per capita as Canada, and three times the number of cardiac surgeons. Americans don’t see the doctor any more often than Canadians do, and are not hospitalized any more frequently, but when they do interact with the medical system, it is much more intensively.

Outcomes for this greater intensity are not easy to find. Despite the more intensive U.S. cardiovascular care, heart-attack survival is no better. Indeed, U.S. death rates for heart disease have been rising relative to other rich countries. The greater degree of imaging in this country detects more cancers, but many of these would never have become clinically apparent. Many cancers grow slowly, and often the patient dies of something else long before the cancer would have become noticeable.

And even as the United States overdoes high-tech care, it underprovides routine care. Effective medications to treat high blood pressure and high cholesterol have been around for decades, yet only half of people with these risk factors are successfully treated. Mental illness is underdiagnosed and undertreated despite its enormous social cost.

The reason for the disparity between high-tech and routine care is not hard to ferret out. Cardiac surgery and MRIs—famously lucrative—are overprovided, but no one is paid to make sure hypertensive patients take their medications.

An uninsured father and son at a health clinic in Denver. Lack of coverage persists for a significant share of the population. Photograph by John Moore/Getty Images

Addressing the misallocation of medical resources is the most difficult technical challenge in lowering medical spending. How does one get a health system to perform fewer MRIs but do them on the right patients, and use the money saved to extend more primary care? The Canadian policy for overprovision is simple: limit the total amount of high-tech care available. Canadian governments ration the number of scanners that can be bought and how many hospitals can have open-heart surgery facilities. Within the available supply, physicians decide how the services are allocated. In a highly professional system like Canada’s, doctors perform the allocation rules very well. Thus, outcomes are better in Canada than in the United States, at a fraction of the cost.

The U.S. government once tried this type of technology rationing—it went by the name of Certificate of Need regulation. In the 1970s and 1980s, state governments had systems to approve each new scanner or addition to a hospital’s footprint and were supposed to say no when it was not necessary. But the policy was not very effective . Without a firm limit on what was allowed to be spent on medical care, it was too difficult for technology boards to deny hospitals. That set of policies has been left in the dustbin of failed cost-containment efforts.

Over time, insurers evolved other ways to try to restrict care. Some insurers have gone with a high cost-sharing strategy: make people pay more when they use care. Those willing to pay a higher cost can have the service. This is the strategy that leads to high out-of-pocket costs for insulin and emergency-department use. The second strategy is to keep an eagle eye on what physicians want to do, to make sure that all care is medically necessary. While good in theory, the administrative costs of this policy have proven to be a disaster.

The most recent economic idea is shared savings: don’t pay physicians a fee for each service, with higher rates for surgery and imaging than for medical management. Instead, set a target amount of spending for the average patient. If spending comes in below the target and quality is sufficiently high, the provider group gets to share in the savings. Thus, physicians have incentives to limit their own use of imaging to necessary cases and to figure out ways to extend primary-care practice. This policy was first tested in Massachusetts and has since gone national .

To date, there is no evidence that shared-savings programs will lead this country to the much lower Canadian or European levels of medical spending and better health outcomes.

The evidence so far is that shared savings programs have been modestly successful . Cost growth falls in shared-savings programs and quality seems to improve. But the savings are not as big as hoped for. To date, there is no evidence that shared-savings programs will lead this country to the much lower Canadian or European levels of medical spending and better health outcomes.

This discouraging record leads to deep questioning about how to make progress in medical care. Can the current system be a basis for good medical and economic outcomes, or must one make more radical change? Proponents of the latter view fall into two camps. On the left are those who reason that the only successful healthcare models internationally are single-payer systems, so the United States must move in that direction to do materially better. On the right are those who argue that only markets can provide the combination of price and quality that people want, so the country needs to remove government from the equation as much as possible. Not surprisingly, many Democrats espouse the former, and Republicans sign on to the latter.

In Rochester, Minnesota, and elsewhere in the country, people want none of this bigger debate. Phrases like “choice” and “single payer” are not helpful, let alone “incentives for interoperability of healthcare records.” Recall that Americans have a firm view of the problem: greed. Every conversation about something other than greed seems entirely beside the point.

This creates a special problem for the healthcare policymaker. In addition to figuring out what is technically correct, we need to learn how to explain those reforms to worried people. Can we promise that any policy will prevent deaths like Alec Smith’s and not harm people in other ways? Speaking morally, as well as economically, is the biggest challenge in health policy.  

David Cutler is Eckstein professor of applied economics in the Faculty of Arts and Sciences, professor in the department of global health and population at the School of Public Health, and a faculty member at the Harvard Kennedy School.

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Point Turning Point: the Case for Universal Health Care

An argument that the COVID-19 pandemic might be the turning point for universal health care.

Why the U.S. Needs Universal Health Care

As we all grapple with our new reality, it's difficult to think of anything beyond the basics. How do we keep our families safe? Are we washing our hands enough ? Do we really have to sanitize the doorknobs and surfaces every day? How do we get our cats to stop videobombing our Zoom meetings? Do we have enough toilet paper?

Win McNamee | Getty Images

The more we read the headlines, the more we feel the need to do something, or at least say something. Change is happening – ready or not. Maybe talking about some of these important issues can lead to action that will help us steer out of this skid.

Historically, Americans have found ways to meet their circumstances with intention, moving in mass to make heretofore unimaginable change that has sustained and improved our lives to this day. The Great Depression lead to the creation of the New Deal and Social Security. The Triangle Shirtwaist Factory fire brought about change in labor conditions. The Cuyahoga River fire lead to the founding of the Environmental Protection Agency.

Could the COVID-19 pandemic be the turning point for universal health care? We can't think of a more propitious time. In the first two weeks of April, 5.2 million Americans filed for unemployment. Economists believe that 30% unemployment is possible by fall. For most Americans, our health care is tied to our employment, and because of this, millions of Americans are losing their health care just when they may need it the most. Economists predict that health insurance premiums will likely increase by 40% in the next year due to less payers and more who are in need of care and the eventual collapse of private health care insurance .

Our current circumstances have illustrated the need for universal health care in a way that is obvious and undeniable. Below we have listed the most frequent arguments in opposition followed by an evidence-based rebuttal.

1. Point: "Governments are wasteful and shouldn't be in charge of health care."

Counterpoint: In 2017, the U.S. spent twice as much on health care (17.1% of GDP) as comparable Organization for Economic Co-Operation and Development countries (OECD) (8.8% of GDP), all of whom have universal health care. The country with the second highest expenditure after the U.S. is Switzerland at 12.3%, nearly 5% less. Of all these countries, the U.S. has the highest portion of private insurance. In terms of dollars spent, the average per capita health care spending of OECD countries is $3,558, while in the U.S. it's $10,207 – nearly three times as costly.

Bottom line: Among industrialized countries with comparable levels of economic development, government-provided health care is much more efficient and more economical than the U.S. system of private insurance.

2. Point: "U.S. health care is superior to the care offered by countries with universal health care."

Counterpoint: According to the Commonwealth Health Fund , in the U.S., infant mortality is higher and the life span is shorter than among all comparable economies that provide universal health care. Maternal mortality in the U.S. is 30 per 100,000 births and 6.4 per 100,000 births on average in comparable countries, which is nearly five times worse.

In addition, the U.S. has the highest chronic disease burden (e.g., diabetes, hypertension) and an obesity rate that is two times higher than the OECD average. In part due to these neglected conditions, in comparison to comparable countries, the U.S. (as of 2016) had among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.

The Peterson-Kaiser Health System Tracker , which is a collaborative effort to monitor the quality and cost of U.S. health care, shows that among comparable countries with universal health care, mortality rate is lower across the board on everything from heart attacks to child birth. The U.S. also has higher rates of medical, medication and lab errors relative to similar countries with universal health care.

Bottom line: With our largely privately funded health care system, we are paying more than twice as much as other countries for worse outcomes.

3. Point: "Universal health care would be more expensive."

Counterpoint: The main reason U.S. health care costs are so high is because we don't have universal health care. Unlike other first world countries, the health care system in the U.S. is, to a great extent, run through a group of businesses. Pharmaceutical companies are businesses. Insurance companies are businesses. Hospital conglomerates are businesses. Even doctors' offices are businesses.

Businesses are driven to streamline and to cut costs because their primary goal is to make a profit. If they don't do this, they can't stay in business. It could mean that in the process of "streamlining," they would be tempted to cut costs by cutting care. Under the current system, a share of our health care dollars goes to dividends rather than to pay for care, hospitals are considered a "financial asset" rather than a public service entity and a large portion of their budgets are dedicated to marketing rather than patient care.

Given all these business expenses, it shouldn't be surprising that the business-oriented privately funded health care system we have is more expensive and less effective than a government provided universal system. In addition, for the health care system as a whole, universal health care would mean a massive paperwork reduction. A universal system would eliminate the need to deal with all the different insurance forms and the negotiations over provider limitations. As a result, this would eliminate a large expense for both doctors and hospitals.

The economist Robert Kuttner critiques the system this way: "For-profit chains … claim to increase efficiencies by centralizing administration, cutting waste, buying supplies in bulk at discounted rates, negotiating discounted fees with medical professionals, shifting to less wasteful forms of care and consolidating duplicative facilities." As he points out, "using that logic, the most efficient 'chain' of all is a universal national system."

Evidence to support these points can be found in a recent Yale University study that showed that single-payer Medicare For All would result in a 13% savings in national health-care expenditures. This would save the country $450 billion annually.

Bottom line: Universal health care would be less expensive overall, and an added benefit would be that health care decisions would be put in the hands of doctors rather than insurance companies, which have allegiances to shareholders instead of patient care.

4. Point: "I have to take care of my own family. I can't afford to worry about other people."

Counterpoint: It is in all of our best interests to take care of everyone. Aside from the fact that it is the compassionate and moral thing to do, viruses do not discriminate. When people don't have insurance, they won't go to the doctor unless they're gravely ill. Then, they're more likely to spread illness to you and your family members while they delay getting the care they need.

In addition, when people wait for care or don't get the prophylactic care then need, they end up in the emergency room worse off with more costly complications and requiring more resources than if they had been treated earlier. Taxpayers currently cover this cost. This affects everyone, insured or not. Why not prevent the delay upfront and make it easy for the patient to get treatment early and, as an added bonus, cost everyone less money?

In addition, the health of the economy impacts everyone. Healthy workers are essential to healthy businesses and thus a healthy economy. According to the Harvard School of Public Health , people who are able to maintain their health are more likely to spend their money on goods and services that drive the economy.

Bottom line: The health of others is relevant to the health of our families either through containment of infectious diseases such as COVID-19 or through the stability of the economy. Capitalism works best with a healthy workforce.

5. Point: "Entrepreneurship and innovation is what makes the U.S. a world leader."

Counterpoint: Imagine how many people in the U.S. could start their own businesses or bring their ideas to market if they didn't have to worry about maintaining health care for their families. So many people stay tethered to jobs they hate just so their family has health care. With workers not needing to stay in jobs they don't like in order to secure health insurance, universal healthcare would enable people to acquire jobs where they would be happier and more productive. Workers who wanted to start their own business could more easily do so, allowing them to enter the most creative and innovative part of our economy – small businesses.

In his book, "Everything for Sale," economist Robert Kuttner asserts that it's important to understand that businesses outside of the U.S. don't have to provide health care for their employees, which makes them more competitive. From a business point of view, American companies, released from the burden of paying employee insurance, would be more competitive internationally. They would also be more profitable as they wouldn't have to do all the paperwork and the negotiating involved with being the intermediary between employees and insurance companies.

Bottom line: Unburdening businesses from the responsibility of providing health insurance for their employees would increase competitiveness as well as encourage entrepreneurship and innovation, and allow small businesses room to thrive.

6. Point: "The wait times are too long in countries with universal health care."

Counterpoint: The wait times on average are no longer in countries with universal healthcare than they are in the U.S., according to the Peterson-Kaiser Health System Tracker . In some cases, the wait times are longer in the U.S., with insurance companies using valuable time with their requirements to obtain referrals and approvals for sometimes urgently needed treatments. On average, residents of Germany, France, UK, Australia, and the Netherlands reported shorter wait times relative to the U.S.

Bottom line: Wait times are longer in the U.S. when compared with many countries with a universal health care system.

7. Point: "My insurance is working just fine, so why change anything?"

Counterpoint: A comprehensive study conducted in 2018 found that 62% of bankruptcies are due to medical bills and, of those, 75% were insured at the time. Most people who have insurance are insufficiently covered and are one accident, cancer diagnosis or heart attack away from going bankrupt and losing everything. The U.S. is the only industrialized country in the world whose citizens go bankrupt due to medical bills. And, if you survive a serious illness and don't go bankrupt, you may end up buried in bills and paperwork from your insurance company and medical providers. All of this takes time and energy that would be better spent healing or caring for our loved ones. Besides, we don't need to abolish private health insurance. Some countries like Germany have a two-tiered system that provides basic non-profit care for all but also allows citizens to purchase premium plans through private companies.

Bottom line: Private insurance does not protect against medical bankruptcy, but universal health care does. The residents of countries with universal health care do not go bankrupt due to medical bills.

8. Point: "I don't worry about losing my insurance because if I lose my job, I can just get another one."

Counterpoint: We can't predict what will happen with the economy and whether another job will be available to us. This pandemic has proven that it can all go bad overnight. In addition, if you lose your job, there is less and less guarantee that you will find a new job that provides insurance . Providing insurance, because it is so expensive, has become an increasingly difficult thing for companies to do. Even if you're able to find a company that provides health care when you change jobs, you would be relying on your employer to choose your health plan. This means that the employee assumes that the company has his or her best interests in mind when making that choice, rather than prioritizing the bottom line for the benefit of the business. Even if they're not trying to maximize their profit, many companies have been forced to reduce the quality of the insurance they provide to their workers, simply out of the need to be more competitive or maintain solvency.

Bottom line: There are too many factors beyond our control (e.g., pandemic, disability, economic recession) to ensure anyone's employment and, thus, health care. Universal health care would guarantee basic care. Nobody would have to go without care due to a job loss, there would be greater control over costs and businesses would not have to fold due to the exorbitant and rising cost of providing health insurance to their employees.

9. Point: "Pharmaceutical companies need to charge so much because of research and development."

Counterpoint: It's usually not the pharmaceutical companies developing new drugs. They develop similar drugs that are variations on existing drugs, altered slightly so that they can claim a new patent. Or they buy out smaller companies that developed new drugs, thus minimizing their own R&D costs. Most commonly, they manufacture drugs developed under funding from the National Institutes of Health, and thus, the tax payers are the greatest funder of drug development via NIH grants provided to university labs.

Oddly, this investment in R&D does not appear to extend any discount to the tax payers themselves. In "The Deadly Costs of Insulin, " the author writes that insulin was developed in a university lab in 1936. In 1996, the cost of a vial of insulin was $21. Today, the cost of a vial of insulin could be as much as $500, causing some without insurance to risk their lives by rationing or going without. The cost of manufacturing the drug has not gone up during that time. So, what accounts for the huge increase in price? In " The Truth About Drug Companies ," the author demonstrates that drug companies use the bulk of their profits for advertising, not R&D or manufacturing. A universal health care system would not only not need to advertise, but would also be more effective at negotiating fair drug prices. Essentially, the government as a very large entity could negotiate price much more effectively as one large system with the government as the largest purchaser.

Bottom line: Taxpayers contribute most of the money that goes into drug development. Shouldn't they also reap some of the benefits of their contribution to R&D? Americans should not have to decide between their heart medication and putting food on the table when their tax dollars have paid for the development of many of these medications.

10. Point: "I don't want my taxes to go up."

Counterpoint: Health care costs and deductibles will go down to zero and more than compensate for any increase in taxes, and overall health care needs will be paid for, not just catastrophic health events. According to the New York Times , “…when an American family earns around $43,000, half of the average compensation when including cash wages plus employer payroll tax and premium contributions, 37% of that ends up going to taxes and health care premiums. In high-tax Finland, the same type of family pays 23% of their compensation in labor taxes, which includes taxes they pay to support universal health care. In France, it’s 2%. In the United Kingdom and Canada, it is less than 0% after government benefits.”

Bottom line: With a universal health care system, health care costs and deductibles will be eliminated and compensate for any increase in taxes.

11. Point: "I don't want to have to pay for health care for people making bad choices or to cover their pre-existing conditions."

Counterpoint: Many of the health problems on the pre-existing conditions list are common, genetically influenced and often unavoidable. One estimate indicates that up to 50% – half! – of all (non-elderly) adults have a pre-existing condition. Conditions on the list include anxiety, arthritis, asthma, cancer, depression, heart defect, menstrual irregularities, stroke and even pregnancy. With universal health care, no one would be denied coverage.

It's easy to assume that your health is under your control, until you get into an accident, are diagnosed with cancer or have a child born prematurely. All of a sudden, your own or your child's life may rely on health care that costs thousands or even millions of dollars. The health insurance that you once thought of as "good enough" may no longer suffice, bankruptcy may become unavoidable and you (or your child) will forever have a pre-existing condition. Some people may seem careless with their health, but who's to judge what an avoidable health problem is, vs. one that was beyond their control?

For the sake of argument, let's say that there are some folks in the mix who are engaging in poor health-related behaviors. Do we really want to withhold quality care from everyone because some don't take care of their health in the way we think they should? Extending that supposition, we would withhold public education just because not everyone takes it seriously.

Bottom line: In 2014, protections for pre-existing conditions were put in place under the Affordable Care Act. This protection is under continuous threat as insurance company profits are placed above patient care. Universal health care would ensure that everyone was eligible for care regardless of any conditions they may have.

And, if universal health care is so awful, why has every other first-world nation implemented it? These countries include: Australia, Austria, Bahrain, Belgium, Brunei, Canada, Cyprus, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Singapore, Slovenia, South Korea, Spain, Sweden, Switzerland, United Arab Emirates and the U.K.

Changing collective minds can seem impossible. But there is precedent. Once unimaginable large-scale change has happened in our lifetime (e.g. legalization of gay marriage, election of the first black president of the U.S. and the #MeToo movement), and support for universal health care has never been higher (71% in favor, according to a 2019 Hill-HarrisX survey ).

Point: As Chuck Pagano said, "If you don't have your health, you don't have anything."

Counterpoint: If good health is everything, why don't we vote as if our lives depended on it? This pandemic has taught us that it does.

Bottom line: Launching universal health care in the U.S. could be a silver lining in the dark cloud of this pandemic. Rather than pay lip service to what really matters, let's actually do something by putting our votes in service of what we really care about: the long-term physical and economic health of our families, our communities and our country.

Photos: Hospital Heroes

Tags: health insurance , health care , Coronavirus , pandemic , New Normal

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What has the pandemic revealed about the US health care system — and what needs to change?

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With vaccinations for Covid-19 now underway across the nation, MIT SHASS Communications asked seven MIT scholars engaged in health and health care research to share their views on what the pandemic has revealed about the U.S. health care system — and what needs to change. Representing the fields of medicine, anthropology, political science, health economics, science writing, and medical humanities, these researchers articulate a range of opportunities for U.S. health care to become more equitable, more effective and coherent, and more prepared for the next pandemic.

Dwaipayan Banerjee , associate professor of science, technology, and society

On the heels of Ebola, Covid-19 put to rest a persistent, false binary between diseases of the rich and diseases of the poor. For several decades, health care policymakers have labored under the impression of a great epidemiological transition. This theory holds that the developed world has reached a stage in its history that it no longer needs to worry about communicable diseases. These "diseases of the poor" are only supposed to exist in distant places with weak governments and struggling economies. Not here in the United States.

On the surface, Covid-19 made clear that diseases do not respect national boundaries. More subtly, it tested the hypothesis that the global north no longer need concern itself with communicable disease. And in so doing, it undermined our assumptions about global north health-care infrastructures as paradigmatically more evolved. Over the last decades, the United States has been focused on developing increasingly sophisticated drugs. While this effort has ushered in several technological breakthroughs, a preoccupation with magic-bullet cures has distracted from public health fundamentals. The spread of the virus revealed shortages in basic equipment and hospitals beds, the disproportionate effects of disease on the marginalized, the challenge of prevention rather than cure, the limits of insurance-based models to provide equitable care, and our unacknowledged dependence on the labor of underpaid health care workers.

To put it plainly, the pandemic did not create a crisis in U.S. health care. For many in the United States, crisis was already a precondition of care, delivered in emergency rooms and negotiated through denied insurance claims. As we begin to imagine a "new normal," we must ask questions about the old. The pandemic made clear that the "normal" had been a privilege only for a few well-insured citizens. In its wake, can we imagine a health-care system that properly compensates labor and recognizes health care as a right, rather than a privilege only available to the marginalized when an endemic crisis is magnified by a pandemic emergency? 

Andrea Campbell , professor of political science

No doubt, the pandemic reveals the dire need to invest in public-health infrastructure to better monitor and address public-health threats in the future, and to expand insurance coverage and health care access. To my mind, however, the pandemic’s greatest significance is in revealing the racism woven into American social and economic policy.

Public policies helped create geographic and occupational segregation to begin with; inadequate racist and classist public policies do a poor job of mitigating their effects. Structural racism manifests at the individual level, with people of color suffering worse housing and exposure to toxins, less access to education and jobs, greater financial instability, poorer physical and mental health, and higher infant mortality and shorter lifespans than their white counterparts. Residential segregation means many white Americans do not see these harms.

Structural racism also materializes at the societal level, a colossal waste of human capital that undercuts the nation’s economic growth, as social and economic policy expert Heather McGhee shows in her illuminating book, "The Sum of Us." These society-wide costs are hidden as well; it is difficult to comprehend the counterfactual of what growth would look like if all Americans could prosper. My hope is that the pandemic renders this structural inequality visible. There is little point in improving medical or public-health systems if we fail to address the structural drivers of poor health. We must seize the opportunity to improve housing, nutrition, and schools; to enforce regulations on workplace safety, redlining, and environmental hazards; and to implement paid sick leave and paid family leave, among other changes. It has been too easy for healthy, financially stable, often white Americans to think the vulnerable are residual. The pandemic has revealed that they are in fact central. It’s time to invest for a more equitable future.

Jonathan Gruber , Ford Professor of Economics

The Covid-19 pandemic is the single most important health event of the past 100 years, and as such has enormous implications for our health care system. Most significantly, it highlights the importance of universal, non-discriminatory health insurance coverage in the United States. The primary source of health insurance for Americans is their job, and with unemployment reaching its highest level since the Great Depression, tens of millions of workers lost, at least temporarily, their insurance coverage.

Moreover, even once the economy recovers, millions of Americans will have a new preexisting condition, Covid-19. That’s why it is critical to build on the initial successes of the Affordable Care Act to continue to move toward a safety net that provides insurance options for all without discrimination.

The pandemic has also illustrated the power of remote health care. The vast majority of patients in the United States have had their first experience with telehealth during the pandemic and found it surprisingly satisfactory. More use of telehealth can lead to increased efficiency of health care delivery as well as allowing our system to reach underserved areas more effectively.

The pandemic also showed us the value of government sponsorship of innovation in the health sciences. The speed with which the vaccines were developed is breathtaking. But it would not have been possible without decades of National Institute of Health investments such as the Human Genome Project, nor without the large incentives put in place by Operation Warp Speed. Even in peacetime, the government has a critical role to play in promoting health care innovation

The single most important change that we need to make to be prepared for the next pandemic is to recognize that proper preparation is, by definition, overpreparation. Unless we are prepared for the next pandemic that doesn’t happen, we won’t possibly be ready for the next pandemic that does.

This means working now, while the memory is fresh, to set up permanent, mandatorily funded institutions to do global disease surveillance, extensive testing of any at-risk populations when new diseases are detected, and a permanent government effort to finance underdeveloped vaccines and therapeutics.

Jeffrey Harris , professor emeritus of economics and a practicing physician The pandemic has revealed the American health care system to be a non-system. In a genuine system, health care providers would coordinate their services. Yet when Elmhurst Hospital in Queens was overrun with patients, some 3,500 beds remained available in other New York hospitals. In a genuine system, everyone would have a stable source of care at a health maintenance organization (HMO). While our country has struggled to distribute the Covid-19 vaccine efficiently and equitably, Israel, which has just such an HMO-based system, has broken world records for vaccination.

Germany, which has all along had a robust public health care system, was accepting sick patients from Italy, Spain, and France. Meanwhile, U.S. hospitals were in financial shock and fee-for-service-based physician practices were devastated. We need to move toward a genuine health care system that can withstand shocks like the Covid-19 pandemic. There are already models out there to imitate. We need to strengthen our worldwide pandemic and global health crisis alert systems. Despite concerns about China’s early attempts to suppress the bad news about Covid-19, the world was lucky that Chinese investigators posted the full genome of SARS-CoV-2 in January 2020 — the singular event that triggered the search for a vaccine. With the recurrent threat of yet another pandemic — after H1N1, SARS, MERS, Ebola, and now SARS-Cov-2 — along with the anticipated health consequences of global climate change, we can’t simply cross our fingers and hope to get lucky again.

Erica Caple James , associate professor of medical anthropology and urban studies The coronavirus pandemic has revealed some of the limits of the American medical and health care system and demonstrated many of the social determinants of health. Neither the risks of infection nor the probability of suffering severe illness are equal across populations. Each depends on socioeconomic factors such as type of employment, mode of transportation, housing status, environmental vulnerability, and capacity to prevent spatial exposure, as well as “preexisting” health conditions like diabetes, obesity, and chronic respiratory illness.

Such conditions are often determined by race, ethnicity, gender, and “biology,” but also poverty, cultural and linguistic facility, health literacy, and legal status. In terms of mapping the prevalence of infection, it can be difficult to trace contacts among persons who are regular users of medical infrastructure. However, it can be extraordinarily difficult to do so among persons who lack or fear such visibility, especially when a lack of trust can color patient-clinician relationships.

One’s treatment within medical and health care systems may also reflect other health disparities — such as when clinicians discount patient symptom reports because of sociocultural, racial, or gender stereotypes, or when technologies are calibrated to the norm of one segment of the population and fail to account for the severity of disease in others.

The pandemic has also revealed the biopolitics and even the “necropolitics” of care — when policymakers who are aware that disease and death fall disproportionately in marginal populations make public-health decisions that deepen the risks of exposure of these more vulnerable groups. The question becomes, “Whose lives are deemed disposable?” Similarly, which populations — and which regions of the world — are prioritized for treatment and protective technologies like vaccines and to what degree are such decisions politicized or even racialized?

Although no single change will address all of these disparities in health status and access to treatment, municipal, state, and federal policies aimed at improving the American health infrastructure — and especially those that expand the availability and distribution of medical resources to underserved populations — could greatly improve health for all.

Seth Mnookin , professor of science writing

The Covid-19 pandemic adds yet another depressing data point to how the legacy and reality of racism and white supremacy in America is lethal to historically marginalized groups. A number of recent studies have shown that Black, Hispanic, Asian, and Native Americans have a significantly higher risk of infection, hospitalization, and death compared to white Americans.

The reasons are not hard to identify: Minority populations are less likely to have access to healthy food options, clean air and water, high-quality housing, and consistent health care. As a result, they’re more likely to have conditions that have been linked to worse outcomes in Covid patients, including diabetes, hypertension, and obesity.

Marginalized groups are also more likely to be socioeconomically disadvantaged — which means they’re more likely to work in service and manufacturing industries that put them in close contact with others, use public transportation, rely on overcrowded schools and day cares, and live in closer proximity to other households. Even now, more vaccines are going to wealthier people who have the time and technology required to navigate the time-consuming vaccine signup process and fewer to communities with the highest infection rates.

This illustrates why addressing inequalities in Americans’ health requires addressing inequalities that infect every part of society. Moving forward, our health care systems should take a much more active role in advocating for racial and socioeconomic justice — not only because it is the right thing to do, but because it is one of the most effective ways to improve health outcomes for the country as a whole.

On a global level, the pandemic has illustrated that preparedness and economic resources are no match for lies and misinformation. The United States, Brazil, and Mexico have, by almost any metric, handled the pandemic worse than virtually every other country in the world. The main commonality is that all three were led by presidents who actively downplayed the virus and fought against lifesaving public health measures. Without a global commitment to supporting accurate, scientifically based information, there is no amount of planning and preparation that can outflank the spread of lies.

Parag Pathak , Class of 1922 Professor of Economics   The pandemic has revealed the strengths and weaknesses of America’s health care systems in an extreme way. The development and approval of three vaccines in roughly one year after the start of the pandemic is a phenomenal achievement. At the same time, there are many innovations for which there have been clear fumbles, including the deployment of rapid tests and contact tracing.   The other aspect the pandemic has made apparent is the extreme inequality in America’s health systems. Disadvantaged communities have borne the brunt of Covid-19 both in terms of health outcomes and also economically. I’m hopeful that the pandemic will spur renewed focus on protecting the most vulnerable members of society. A pandemic is a textbook situation in economics of externalities, where an individual’s decision has external effects on others. In such situations, there can be major gains to coordination. In the United States, the initial response was poorly coordinated across states. I think the same criticism applies globally. We have not paid enough attention to population health on a global scale. One lesson I take from the relative success of the response of East Asian countries is that centralized and coordinated health systems are more equipped to manage population health, especially during a pandemic. We’re already seeing the need for international cooperation with vaccine supply and monitoring of new variants. It will be imperative that we continue to invest in developing the global infrastructure to facilitate greater cooperation for the next pandemic.

Prepared by MIT SHASS Communications Editor and designer: Emily Hiestand Consulting editor: Kathryn O'Neill

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Free Healthcare in the United States: A Possible Solution to Public Health Disparities

Nov 23, 2020 | Author Hala Atassi , Public Health Policy

Access to healthcare is one of the remarkable indicators that defines the quality of people’s lives. Despite the thousands of advanced technologies and countless healthcare clinics and hospitals, many people still cannot afford healthcare or health insurance. This has been a global concern for years, which many countries have resolved. However, the United States has yet to significantly progress towards making healthcare more accessible to low-income communities. There are many solutions to this problem that can be implemented today, upon which millions of suffering Americans depend.

Some studies have shown over the years that expensive health care is due to the high cost of defensive medicine, or in other words, physicians ordering expensive tests that may be unnecessary, as a way to deflect legal responsibility from themselves. Deviating from defensive medicine in the healthcare industry might impact physicians economically, but more importantly, it will help achieve affordable healthcare. 

Obamacare (the Affordable Care Act of 2010) is one program that focuses on extending healthcare to Americans and reducing public health disparities. This program lays down a foundation that people under the age of 26 will receive accessible care from their parent or guardian’s health care plans. Afterward, they must pay for their health care plan. Also, the program stipulates that the government provides free healthcare to retired adults from age 55 to 64, to avoid any insurance plan complications. Essentially, Obamacare seeks to expand access to healthcare care, regardless of the scale of one’s medical diagnosis, to ultimately save lives that would have been lost due to the inability to pay expensive medical bills.

Easier access to healthcare will result in a healthier nation. The healthcare system is one of the most important components in life, as the United States’ economy cannot be fully efficient and benefit all people until everyone can access quality, affordable healthcare. Free healthcare (or at least cheaper healthcare) would be the most effective system for America, which other countries like Switzerland and Singapore have demonstrated. The money spent by citizens on their healthcare could be redirected to other social support systems in America, like expanding access to nutritious foods as well. Although free healthcare has many perks, it also has disadvantages. Most notably, overloading health services with a large number of patients would overwhelm already busy healthcare systems. Patients may overuse the perk of free healthcare, leaving not taxpayers to suffer, but rather medical professionals and healthcare systems. Even so, the perceptible advantages of affordable healthcare outweigh the disadvantages. As it is, years of attempts to ameliorate the United States healthcare system have failed the American people, and the situation remains devastating and life-threatening for low-income communities. There should be no debate though as to whether America needs to redesign the public health system, as healthcare is a human right, and nobody should be dying because they cannot afford to live, especially when the government has the economic means to take care of them.

Bibliography:

Gerisch, Mary. “Health Care As a Human Right.” American Bar Association , www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/health-care-as-a-human-right/. 

“Free Health Care Policies.” World Health Organization , World Health Organization, 2020, www.who.int/news-room/fact-sheets/detail/free-health-care-policies. 

Gologorsky, Beverly. “Health Care in the US Should Be Affordable and Accessible.” The Nation , 9 May 2019, www.thenation.com/article/archive/tom-dispatch-health-care-should-be-affordable-and-accessible/. 

Luhby, Tami. “Here’s How Obamacare Has Changed America.” CNN , Cable News Network, 8 July 2019, www.cnn.com/2019/07/08/politics/obamacare-how-it-has-changed-america/index.html.

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5 Critical Priorities for the U.S. Health Care System

• Marc Harrison

A guide to making health care more accessible, affordable, and effective.

The pandemic has starkly revealed the many shortcomings of the U.S. health care system — as well as the changes that must be implemented to make care more affordable, improve access, and do a better job of keeping people healthy. In this article, the CEO of Intermountain Healthcare describes five priorities to fix the system. They include: focus on prevention, not just treating sickness; tackle racial disparities; expand telehealth and in-home services; build integrated systems; and adopt value-based care.

Since early 2020, the dominating presence of the Covid-19 pandemic has redefined the future of health care in America. It has revealed five crucial priorities that together can make U.S. health care accessible, more affordable, and focused on keeping people healthy rather than simply treating them when they are sick.

• Marc Harrison , MD, is president and CEO of Salt Lake City-based Intermountain Healthcare.

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The United States Health Care System is Sick: From Adam Smith to Overspecialization

Deanna anderlini.

1 HMNS, The University of Queensland

The United States (US) health care system is sick. High cost affects the nation and the people. The poor outcomes mainly impact the patients. If we do not fix it, the system will implode because of the unsustainable economic burden.

The choice to shape the health care system on the “pin factory” model described by Adam Smith is the cause of the failure. The key players in the health care system are accordingly molded.

Many factors tightly intertwined need to be addressed. Medical education, the role of family doctor, the overspecialization and, not least, the translation of discoveries into clinical practice are among them.

The failure of the US health care system is a complex and multi-factorial issue which requires a global approach.

Introduction and background

Health and equality are inextricably linked. It has been that way in each society, from ancient time till today.

If we think of the health care system as something new, we are wrong. Written records and physical remains found in Deir el-Medina in Egypt reveal the first documented governmental health care system running around 1292 B.C. Workers were entitled to paid sick days and to free check-ups at clinics. Not less astonishing is the excavation of a hospital in the Angkor Wat archaeological site [ 1 ]. At the beginning of the 19th century, a desire to expand medical knowledge arose as the consequence of technological advances (thermometer, stethoscope, vaccine, anesthesia and many more). This encouraged clinical researchers to further specialize because they thought that only specialization would enable them to acquire deeper knowledge. Moreover, the administrative rationality constraints, imposed by the need to manage larger populations, have prompted the gathering of individuals with the same disease and, as a consequence, the emergence of subclinical [ 2 ]. The practice of Medicine shifted from a pre-scientific holistic approach to the modern perspective supported by scientific explanations of pathology. Foucault put the turning point at the reorganization of hospitals and epidemics of the 18th century [ 3 ].

The definition of what means to be healthy has evolved many times since the early days of mankind reflecting beliefs and medical knowledge [ 4 ]. The journey from medical Egyptian papyri to the rod of Asclepius, from Hippocrates to Galen, brought us to the 1948 World Health Organisation (WHO) definition of health as “a state of complete physical, mental and social well-being, not merely the absence of infirmity or disease”. Later the International Conference on Primary Health Care released the Alma-Ata Declaration. It is a milestone in the field of public health: primary health care was identified as the key to reach health for All.

Unfortunately, our 21st-century health care system mirrors the 200 years old model of factory described by Adam Smith with specialists playing the role of pin-makers [ 5 ]. The issue is that we can split a job into smaller parts, but we cannot split the patient into smaller parts without losing the whole view. Fordism applied to health care results in patients becoming bodies made of parts/organs in need of maintenance/service/cure which in turn require factories/clinics. We can see a high resemblance between the factory system masterfully depicted by Chaplin in “Modern Times” and our “Modern Hospitals” filled by medical sub-sub-specializations.

Everything down the path is thought accordingly to that system. We have research trials focus on patients with only one disease to avoid confounding variables (and missing the reality). We see specialists that rarely know how their specific therapies interact with others’. Redundant tests due to lack of communication and discontinuity in the care are the daily routine. Everything, from the medical education to the training, from funding and planning, is compartmentalized in a vicious circle [ 6 - 8 ].

Even more of a concern is that health care treated as a commodity in a market arranged to create value for the provider rather than the patient. As a consequence, the main goal shifts from the wellbeing of people to productivity and making money. The Fordism, well described by Gramsci in his 1934 essay [ 9 ], pervades each and every aspect of the system. Hospitals are built with units looking like the assembly line model of production. The sub-division of medical tasks is the norm [ 10 ].

First and foremost, we have to acknowledge that health care is a multi-factorial service. The only way we can improve it is anything but a global approach, very far from an overspecialized fragmented intervention.

Second, the huge cost related to the health care would make you think that it is strictly dependent on economics, but in reality the major player is politics as “the” political institution decides how to spend the budget: health care is political [ 11 , 12 ].

In this context, even the Affordable Care Act (ACA) becomes not compatible with the Hippocratic ethos of caring and curing because no matter if its goal is a good, affordable care for all Americans, health is now a big business where fee-for-service is the rule: “unfortunately, the goals of the ACA is primarily bureaucratic and financial” [ 13 ] .

We will take into consideration the main points related to health care by defining the problem and our solution.

Health care system

Even conservative estimates suggest that nearly a quarter of US patients suffer multi-morbidity, a figure reiterated in the majority of the countries members of the Organization for Economic Cooperation and Development (OECD). Multi-morbidity is the norm rather than the exception. By the age of 65, almost all people present with two or more diseases, and in developing countries this is true from as early as the age of 55 [ 14 ]. The Robert Wood Johnson Foundation report shows how 75 million Americans with multi-morbidity which represents 25% of the population account for 65% of health expenditure [ 15 , 16 ]. Once more the 2008 WHO report singled out the fragmentation of care as one of the five shortcomings in the way health care is delivered.

A patient is not a patchwork of single symptoms as the physiology of the human body is not a collection of independent modules: he is a complex interacting whole who requires a global approach [ 7 ]. For instance, the outcomes of the fragmented health care system in the US accounted for 100 million medication errors per year as revealed by a study in 2000.

A total of 250,000 or more unnecessary deaths per year due to errors were reported in 2016 [ 17 ]. The U.S. spent about $7,848 per capita in 2008 on health care with specialists as the biggest drivers of the cost. In 2017 the cost rose to 10,833 per capita [ 18 ]. Similar results come from the UK where the latest study, published in 2018, gave an account of more than 200 million medication errors [ 19 ]. The figures are staggering, especially if we compare the cost with poorer outcomes [ 20 ].

New models have been tried with good results. A new model of health care system was established in Appleton: the aim was to deliver a better value to the patient. A group of 16 forward-thinking organizations in North America formed the Health Care Value Leaders Network based on this model. They looked at every step in the process of care and found out that over 80% of all steps do not provide any value. By removing those unnecessary steps, the Network improved quality and reduced the costs. Visits to the ER decreased by 29%, hospital admissions by 11% [ 21 ].

In 2001, the Thailand Universal Coverage Health Insurance started a new system based on a capitation basis: each citizen, either healthy or ill, not covered by insurance must register with a hospital which will get $30 flat rate/year/capita. This way hospital in overpopulated areas, which could not afford to pay staff because located in poor regions, will have enough money to hire more doctors. As a result of the reform, many more citizens will get access to treatments [ 22 ].

The University of Michigan with its project has been able to make huge savings [ 23 ]. The Transforming care at bedside achieved 30% drop in the cost of inpatient care and Gundersen Luthera’s end-of-life care process is 50% less expensive than the national average per Medicare enrollee.

The Meikirch Model conceived in a small village in Switzerland in 2014 began with a new, broader concept of health where biological given potential (BGP) and personally acquired potential (PAP) are taken into consideration [ 24 ]. Accordingly, with the new concept, health value is measured on the outcomes and, financially revolutionary, payment is done neither for-performance nor for value, just for health care based on BGP and PAP.

Harvard economist, Michael Porter suggested a value-based system [ 7 ] where outcomes (including readmission and mortality) are measured and compared. The model has been implemented at the University of Utah Health Care since 2012: the results showed a -15% cost/year and better outcomes. The "opportunity index” which sets initial priorities was instrumental in lowering the costs.

Medical education and the role of university

The two important events that shaped medical education in the US are as follows:

1. The Flexner report published in 1910 suggested higher admission standard for medical schools and to deliver mainly science in teaching and research [ 25 ]. Flexner himself thought that the medical education in the US based on his report had moved too much towards science.

2. The birth of schools of public health in 1916 supported by the Rockefeller Foundation. It generated a schism between Medicine and public health. Earlier, the Pasteur Institute in Paris (1888) and the Koch Institute in Berlin (1891) had been established, but they did not have a major role in the medical education. Nowadays the John Hopkins Bloomberg School of Public Health has 1638 staff, a budget of $529 million and it is one of the top recipients of NIH grants [ 26 ].

The outcome is a fragmented, one-sided education, too narrow for a global view of patients and too rigid to adapt to changing needs of the aging population. The doctor/patient relationship is a very powerful instrument; critics of super specialization which can lead to a distorted relationship has been pointed out by philosophers as Habermas [ 27 , 28 ].

Interdisciplinary and cross-field courses will not solve the problem of the too narrow basic education because they occur at an already highly specialized level. What is needed more is a school delivering a basic general knowledge to everybody and enabling wide communication among students. Specialized professional schools provide a background too narrow, and they predetermine the path of the student at a very early stage, making the exchange of ideas impossible but with people in the same field.

We have to broaden the basic knowledge starting at the undergraduate level because many courses are already too narrow and overspecialized creating young professionals without the flexibility necessary to the continuous changing circumstances and with gaps which will never be filled.

Post-graduate training needs a wider perspective, with biology instead of molecular biology, physiology for scientists, research and analysis methods for doctors [ 29 ]. The quota for training specialists should be controlled to curb the number of specialists and to avoid losing general physicians, a phenomenon occurring not just in the US, but in countries like India and the UK which experience the shortage of general internists [ 30 , 31 ].

There is a push for a “remoralisation” of health professionals’ education contraposed to the entrenched collusion to preserve their influence. Medical education has to be entrenched with values and practice of social justice and equity in health care. Health professionals should also mobilize knowledge. Many important skills – as leadership, management, communication – are neglected in the medical curriculum and this confirms how universities are little appreciated as a core social institution [ 32 ].

Overspecialization

The first US specialty board (Ophthalmology) was established in 1917 followed by dozen other specialties [ 33 ]. Currently, there are over 120 medical specialties and sub-specialties. From 1940, when there was little specialization, to 1975, medical expenses increased from $3 billion to $75 billion. Health care expenditure now constitutes 1/6 of the GDP in the US [ 34 ]. In 2012, Forbes published an article titled: “Why are U.S. health care cost so high?” the answer was: specialists with higher per-procedure rates paid by both private and public payers [ 35 ]. Many other investigations came to the same conclusion: we have too few primary-care physicians and too many specialists.

Overspecialization in health care has been a failure for patients and budget altogether [ 36 ]. Prof. Cueto remarked how essential was to eradicate medical overspecialization. In his view, the top-down health campaigns had to move towards a community participation model [ 37 ]. Specialization is inevitable and useful. The sub-sub-specializations are the real danger. The unbalance between the number of specialists and generalists is the threat. Furthermore, overspecialization favors one-sidedness and it prevents the grasp of a more general global knowledge.

General physician, family doctor

In the marvelous portrait by Balzac, we see the Country Doctor listening to and taking care of the patient in each stage of his life: from birth to death (which is the natural termination of a physical malady) and funeral included. Now that role has left room to the scientific presence of the clinician who makes a diagnosis and prescribes pills excluding the death as not as part of his duty anymore [ 38 ]. The family doctor slowly lost his importance in the health system, more and more under pressure and struggling to bring his help as described by Kafka and Muir [ 39 ]; his satisfaction is now mainly related within the community than to earnings.

The “golden age of Medicine” spanning from 1946 to 1970 is long gone. The time when doctors enjoyed the monopoly of knowledge and great power in society has been superseded by an era where physicians feel cognitive dissonance due to the mismatch between their idea of medicine, as honorable art, and the production lines they now belong to. Academization of other health professions as nurses, radiologists and psychologists has eroded their field of action. The lack of support from the State who “finally caught up with the last guild” makes this profession less attractive to young students.

Despite the fact that general physicians (GPs) are the healthiest segment of populations, they are stressed and burned out, overworked, underpaid, under time pressure to check up patients in less than 10 minutes [ 40 ]. Physicians have to rely more on referrals with rates of referrals doubling in the past decade. Hospitals, organized in super-specialized departments, are also forced to hire highly paid specialists. Last, the lack of professional reward and the wrong diffused social disapproval of the role of GP, explain the decline of the number of students choosing Family Medicine in the last five years, which, in turns, will produce a shortage of the most needed figure in the future [ 41 ].

Keeping in mind that family physicians are the first contact for health problems and they directly address most of the health care needs, they are ideal leaders of the system as stated in 2nd Future of Family Medicine project [ 42 ]. If we want to improve the care for patients, we have to give back the GP his dignity in society. To do so we have to scratch the compensation model, on which the health care system is based now, which rewards piecework, procedures and technology to establish a new system where general physician finally can sit and listen to his patient: time is essential for it.

The Meltzer project was funded under the ACA, and the implementation began in 2012. It describes a model where a single physician provides in- and outpatient care for each patient; this way it enables the necessary global view of the patient and the continuity of care. The workload of the physician, now close to 2000 patients/year, would be 200, giving him time to think and to rebuild the broken doctor/patient relationship [ 43 ]. In his vision, the primary care physician will split his day between the hospital and the outpatients to promote collaboration and spreading of knowledge [ 44 ]. We believe that the main feature to become a good doctor is “interest in humanity” because he only will be able to see the patient as an individual and not as a number.

Translating findings into clinical practice (Valley of Death)

Health is considered a basic right for any human being. When millions of individuals have no access to health care, it goes against human rights’ ethic to financially support medical research if it is not translatable into clinical practice [ 45 ]. Time, minds, money and lives cannot be wasted while a few pursue glory and gratification.

Barriers between scientists and clinicians are rooted first in a decade of specialized education through two languages, so at the end they cannot communicate. Second, they lack a common value system: views, questions and rewards are different. Last, the sources of passion and intensity of emotions do not match: doctors deal with life and death, scientists don’t. These barriers jeopardize the translation of discoveries into practice.

The decision by Pharma giant Pfizer to pull out of research into Alzheimer's is a painful lesson [ 46 ]. The justification for that choice was that “more than 99% of trials for Alzheimer's drugs have failed in the past 15 years”; this mainly happens at phase III. All this is a clear sign that basic-fragmented research is too costly to be feasible any longer. Probably others private research institutions will follow because a positive financial result is at their core. Not less important is the waste of tax-payers money.

Research/funding

Research plays an essential role in improving health care. It requires good minds, time and money. Sadly enough, medical research has never been such a huge pressure from outside forces trying to dictate the agenda [ 47 ]. For too long, scientific productivity of researchers has been measured by the H-Index which depends on the number of papers and citations, but no correlation with the quality of the publications. A new model of funding should be based on the replicability and significance of the protocol; it should reward the rate of translation into practice and the outcomes achieved by the applicant researcher [ 48 ].

Offers of cross-field fellowships and transdisciplinary research awards would be also good incentives to break compartmentalization and to favor future collaborations.

The NIH funding criteria need more than the National Centre for Advancing Translational Sciences announced in 2011 to give clinical research a new life. We believe that seven key points need to be addressed:

1. Financial support for medical students who accumulate $180,000 debt to get graduated.

2. Incentives for physician-scientists who face a longer training period, compared to biomedical researchers.

3. Greater funding for clinicians-scientist.

4. Grants exclusively for translational science.

5. Renewability of funds based on the obtained rate of translated results into practice.

6. Rotation every five years for a clinician to be the principal investigator in basic research and for a biomedical researcher to guide a clinical trial.

7. Not least, the peer-review process must balance its favor equally between hypothesis-driven research and applied research. Only an NIH peer-review panel with equal numbers of MDs and PhDs would reach that goal.

Medical publications

Time has confirmed that a publication in itself does not guarantee the dissemination of results and translation into clinical practice, hence the translation becomes primarily the researcher’s responsibility. Arturo Casadevall pointed out that the way scientists create specialized groups is highly similar to the guild system of the Middle Ages. Moreover, overspecialization is conducive of judging scientific work by the impact factor of the journal in which the paper is published because scientists become less able to evaluate works outside their field of expertise.

Scientists should publish less quantity and more quality papers [ 49 ]. A maximum of one paper/year should be set to give them time to improve the quality.

Publishers, not to forget, are private enterprises listed on share markets [ 50 ] and born to create profits. Nonetheless, they have become an integral part of the medical world. They too should swear to uphold the Hippocratic Oath: “first, do no harm.”

Conclusions

What we need most is the will at the leadership level in each sector to do it, from medical education to research, from funding to planning, not least from publishing journals. Scientific journals are the natural places for debates and meeting points of different fields. They can be the forces promoting a new way of thinking.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

How to build a better health system: 8 expert essays

We need to focus on keeping people healthy, not just treating them when they're sick Image:  REUTERS/Rupak De Chowdhuri

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Introduction

By Francesca Colombo , Head, Health Division, Organisation for Economic Co-operation and Development (OECD) and Helen E. Clark , Prime Minister of New Zealand (1999-2008), The Helen Clark Foundation

Our healthy future cannot be achieved without putting the health and wellbeing of populations at the centre of public policy.

Ill health worsens an individual’s economic prospects throughout the lifecycle. For young infants and children, ill health affects their capacity to acumulate human capital; for adults, ill health lowers quality of life and labour market outcomes, and disadvantage compounds over the course of a lifetime.

And, yet, with all the robust evidence available that good health is beneficial to economies and societies, it is striking to see how health systems across the globe struggled to maximise the health of populations even before the COVID-19 pandemic – a crisis that has further exposed the stresses and weaknesses of our health systems. These must be addressed to make populations healthier and more resilient to future shocks.

Each one of us, at least once in our lives, is likely to have been frustrated with care that was inflexible, impersonal and bureaucratic. At the system level, these individual experiences add up to poor safety, poor care coordination and inefficiencies – costing millions of lives and enormous expense to societies.

This state of affairs contributes to slowing down the progress towards achieving the sustainable development goals to which all societies, regardless of their level of economic development, have committed.

Many of the conditions that can make change possible are in place. For example, ample evidence exists that investing in public health and primary prevention delivers significant health and economic dividends. Likewise, digital technology has made many services and products across different sectors safe, fast and seamless. There is no reason why, with the right policies, this should not happen in health systems as well. Think, for example, of the opportunities to bring high quality and specialised care to previously underserved populations. COVID-19 has accelerated the development and use of digital health technologies. There are opportunities to further nurture their use to improve public health and disease surveillance, clinical care, research and innovation.

To encourage reform towards health systems that are more resilient, better centred around what people need and sustainable over time, the Global Future Council on Health and Health Care has developed a series of stories illustrating why change must happen, and why this is eminently possible today. While the COVID-19 crisis is severally challenging health systems today, our healthy future is – with the right investments – within reach.

1. Five changes for sustainable health systems that put people first

The COVID-19 crisis has affected more than 188 countries and regions worldwide, causing large-scale loss of life and severe human suffering. The crisis poses a major threat to the global economy, with drops in activity, employment, and consumption worse than those seen during the 2008 financial crisis . COVID-19 has also exposed weaknesses in our health systems that must be addressed. How?

For a start, greater investment in population health would make people, particularly vulnerable population groups, more resilient to health risks. The health and socio-economic consequences of the virus are felt more acutely among disadvantaged populations, stretching a social fabric already challenged by high levels of inequalities. The crisis demonstrates the consequences of poor investment in addressing wider social determinants of health, including poverty, low education and unhealthy lifestyles. Despite much talk of the importance of health promotion, even across the richer OECD countries barely 3% of total health spending is devoted to prevention . Building resilience for populations also requires a greater focus on solidarity and redistribution in social protection systems to address underlying structural inequalities and poverty.

Beyond creating greater resilience in populations, health systems must be strengthened.

High-quality universal health coverage (UHC) is paramount. High levels of household out-of-pocket payments for health goods and services deter people from seeking early diagnosis and treatment at the very moment they need it most. Facing the COVID-19 crisis, many countries have strengthened access to health care, including coverage for diagnostic testing. Yet others do not have strong UHC arrangements. The pandemic reinforced the importance of commitments made in international fora, such as the 2019 High-Level Meeting on Universal Health Coverage , that well-functioning health systems require a deliberate focus on high-quality UHC. Such systems protect people from health threats, impoverishing health spending, and unexpected surges in demand for care.

Second, primary and elder care must be reinforced. COVID-19 presents a double threat for people with chronic conditions. Not only are they at greater risk of severe complications and death due to COVID-19; but also the crisis creates unintended health harm if they forgo usual care, whether because of disruption in services, fear of infections, or worries about burdening the health system. Strong primary health care maintains care continuity for these groups. With some 94% of deaths caused by COVID-19 among people aged over 60 in high-income countries, the elder care sector is also particularly vulnerable, calling for efforts to enhance control of infections, support and protect care workers and better coordinate medical and social care for frail elderly.

Third, the crisis demonstrates the importance of equipping health systems with both reserve capacity and agility. There is an historic underinvestment in the health workforce, with estimated global shortages of 18 million health professionals worldwide , mostly in low- and middle-income countries. Beyond sheer numbers, rigid health labour markets make it difficult to respond rapidly to demand and supply shocks. One way to address this is by creating a “reserve army” of health professionals that can be quickly mobilised. Some countries have allowed medical students in their last year of training to start working immediately, fast-tracked licenses and provided exceptional training. Others have mobilised pharmacists and care assistants. Storing a reserve capacity of supplies such as personal protection equipment, and maintaining care beds that can be quickly transformed into critical care beds, is similarly important.

Fourth, stronger health data systems are needed. The crisis has accelerated innovative digital solutions and uses of digital data, smartphone applications to monitor quarantine, robotic devices, and artificial intelligence to track the virus and predict where it may appear next. Access to telemedicine has been made easier. Yet more can be done to leverage standardised national electronic health records to extract routine data for real-time disease surveillance, clinical trials, and health system management. Barriers to full deployment of telemedicine, the lack of real-time data, of interoperable clinical record data, of data linkage capability and sharing within health and with other sectors remain to be addressed.

Fifth, an effective vaccine and successful vaccination of populations around the globe will provide the only real exit strategy. Success is not guaranteed and there are many policy issues yet to be resolved. International cooperation is vital. Multilateral commitments to pay for successful candidates would give manufacturers certainty so that they can scale production and have vaccine doses ready as quickly as possible following marketing authorisation, but could also help ensure that vaccines go first to where they are most effective in ending the pandemic. Whilst leaders face political pressure to put the health of their citizens first, it is more effective to allocate vaccines based on need. More support is needed for multilateral access mechanisms that contain licensing commitments and ensure that intellectual property is no barrier to access, commitments to technology transfer for local production, and allocation of scarce doses based on need.

The pandemic offers huge opportunities to learn lessons for health system preparedness and resilience. Greater focus on anticipating responses, solidarity within and across countries, agility in managing responses, and renewed efforts for collaborative actions will be a better normal for the future.

OECD Economic Outlook 2020 , Volume 2020 Issue 1, No. 107, OECD Publishing, Paris

OECD Employment Outlook 2020 : Worker Security and the COVID-19 Crisis, OECD Publishing, Paris

OECD Health at a Glance 2019, OECD Publishing, Paris

https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf

OECD (2020), Who Cares? Attracting and Retaining Care Workers for the Elderly, OECD Health Policy Studies, OECD Publishing, Paris

Working for Health and Growth: investing in the health workforce . Report of the High-Level Commission on Health Employment and Economic Growth, Geneva.

Colombo F., Oderkirk J., Slawomirski L. (2020) Health Information Systems, Electronic Medical Records, and Big Data in Global Healthcare: Progress and Challenges in OECD Countries . In: Haring R., Kickbusch I., Ganten D., Moeti M. (eds) Handbook of Global Health. Springer, Cham.

2. Improving population health and building healthy societies in times of COVID-19

By Helena Legido-Quigley , Associate Professor, London School of Hygiene and Tropical Medicine

The COVID-19 pandemic has been a stark reminder of the fragility of population health worldwide; at time of writing, more than 1 million people have died from the disease. The pandemic has already made evident that those suffering most from COVID-19 belong to disadvantaged populations and marginalised communities. Deep-rooted inequalities have contributed adversely to the health status of different populations within and between countries. Besides the direct and indirect health impacts of COVID-19 and the decimation of health systems, restrictions on population movement and lockdowns introduced to combat the pandemic are expected to have economic and social consequences on an unprecedented scale .

Population health – and addressing the consequences of COVID-19 – is about improving the physical and mental health outcomes and wellbeing of populations locally, regionally and nationally, while reducing health inequalities.¹ Moreover, there is an increasing recognition that societal and environmental factors, such as climate change and food insecurity, can also influence population health outcomes.

The experiences of Maria, David, and Ruben – as told by Spanish public broadcaster RTVE – exemplify the real challenges that people living in densely populated urban areas have faced when being exposed to COVID-19.¹

Maria is a Mexican migrant who has just returned from Connecticut to the Bronx. Her partner Jorge died in Connecticut from COVID-19. She now has no income and is looking for an apartment for herself and her three children. When Jorge became ill, she took him to the hospital, but they would not admit him and he was sent away to be cared for by Maria at home with their children. When an ambulance eventually took him to hospital, it was too late. He died that same night, alone in hospital. She thinks he had diabetes, but he was never diagnosed. They only had enough income to pay the basic bills. Maria is depressed, she is alone, but she knows she must carry on for her children. Her 10-year old child says that if he could help her, he would work. After three months, she finds an apartment.

David works as a hairdresser and takes an overcrowded train every day from Leganés to Chamberi in the centre of Madrid. He lives in a small flat in San Nicasio, one of the poorest working-class areas of Madrid with one of the largest ageing populations in Spain. The apartments are very small, making it difficult to be in confinement, and all of David’s neighbours know somebody who has been a victim of COVID-19. His father was also a hairdresser. David's father was not feeling well; he was taken to hospital by ambulance, and he died three days later. David was not able to say goodbye to his father. Unemployment has increased in that area; small local shops are losing their customers, and many more people are expecting to lose their jobs.

Ruben lives in Iztapalapa in Mexico City with three children, a daughter-in-law and five grandchildren. Their small apartment has few amenities, and no running water during the evening. At three o’clock every morning, he walks 45 minutes with his mobile stall to sell fruit juices near the hospital. His daily earnings keep the family. He goes to the central market to buy fruit, taking a packed dirty bus. He thinks the city's central market was contaminated at the beginning of the pandemic, but it could not be closed as it is the main source of food in the country. He has no health insurance, and he knows that as a diabetic he is at risk, but medication for his condition is too expensive. He has no alternative but to go to work every day: "We die of hunger or we die of COVID."

These real stories highlight the issues that must be addressed to reduce persistent health inequalities and achieve health outcomes focusing on population health. The examples of Maria, David and Ruben show the terrible outcomes COVID-19 has had for people living in poverty and social deprivation, older people, and those with co-morbidities and/or pre-existing health conditions. All three live in densely populated urban areas with poor housing, and have to travel long distances in overcrowded transport. Maria’s loss of income has had consequences for her housing security and access to healthcare and health insurance, which will most likely lead to worse health conditions for her and her children. Furthermore, all three experienced high levels of stress, which is magnified in the cases of Maria and David who were unable to be present when their loved ones died.

The COVID-19 pandemic has made it evident that to improve the health of the population and build healthy societies, there is a need to shift the focus from illness to health and wellness in order to address the social, political and commercial determinants of health; to promote healthy behaviours and lifestyles; and to foster universal health coverage.² Citizens all over the world are demanding that health systems be strengthened and for governments to protect the most vulnerable. A better future could be possible with leadership that is able to carefully consider the long-term health, economic and social policies that are needed.

In order to design and implement population health-friendly policies, there are three prerequisites. First, there is a need to improve understanding of the factors that influence health inequalities and the interconnections between the economic, social and health impacts. Second, broader policies should be considered not only within the health sector, but also in other sectors such as education, employment, transport and infrastructure, agriculture, water and sanitation. Third, the proposed policies need to be designed through involving the community, addressing the health of vulnerable groups, and fostering inter-sectoral action and partnerships.

Finally, within the UN's Agenda 2030 , Sustainable Development Goal (SDG) 3 sets out a forward-looking strategy for health whose main goal is to attain healthier lives and wellbeing. The 17 interdependent SDGs offer an opportunity to contribute to healthier, fairer and more equitable societies from which both communities and the environment can benefit.

The stories of Maria, David and Ruben are real stories featured in the Documentary: The impact of COVID19 in urban outskirts, Directed by Jose A Guardiola. Available here. Permission has been granted to narrate these stories.

Buck, D., Baylis, A., Dougall, D. and Robertson, R. (2018). A vision for population health: Towards a healthier future . [online] London: The King's Fund. [Accessed 20 Sept. 2020]

Wilton Park. (2020). Healthy societies, healthy populations (WP1734). Wiston House, Steyning. Retrieved from https://www.wiltonpark.org.uk/event/wp1734/ Cohen B. E. (2006). Population health as a framework for public health practice: a Canadian perspective. American journal of public health , 96 (9), 1574–1576.

3. Imagine a 'well-care' system that invests in keeping people healthy

By Maliha Hashmi , Executive Director, Health and Well-Being and Biotech, NEOM, and Jan Kimpen , Global Chief Medical Officer, Philips

Imagine a patient named Emily. Emily is aged 32 and I’m her doctor.

Emily was 65lb (29kg) above her ideal body weight, pre-diabetic and had high cholesterol. My initial visit with Emily was taken up with counselling on lifestyle changes, mainly diet and exercise; typical advice from one’s doctor in a time-pressured 15-minute visit. I had no other additional resources, incentives or systems to support me or Emily to help her turn her lifestyle around.

I saw Emily eight months later, not in my office, but in the hospital emergency room. Her husband accompanied her – she was vomiting, very weak and confused. She was admitted to the intensive care unit, connected to an insulin drip to lower her blood sugar, and diagnosed with type 2 diabetes. I talked to Emily then, emphasizing that the new medications for diabetes would only control the sugars, but she still had time to reverse things if she changed her lifestyle. She received further counselling from a nutritionist.

Over the years, Emily continued to gain weight, necessitating higher doses of her diabetes medication. More emergency room visits for high blood sugars ensued, she developed infections of her skin and feet, and ultimately, she developed kidney disease because of the uncontrolled diabetes. Ten years after I met Emily, she is 78lb (35kg) above her ideal body weight; she is blind and cannot feel her feet due to nerve damage from the high blood sugars; and she will soon need dialysis for her failing kidneys. Emily’s deteriorating health has carried a high financial cost both for herself and the healthcare system. We have prevented her from dying and extended her life with our interventions, but each interaction with the medical system has come at significant cost – and those costs will only rise. But we have also failed Emily by allowing her diabetes to progress. We know how to prevent this, but neither the right investments nor incentives are in place.

Emily could have been a real patient of mine. Her sad story will be familiar to all doctors caring for chronically ill patients. Unfortunately, patients like Emily are neglected by health systems across the world today. The burden of chronic disease is increasing at alarming rates. Across the OECD nearly 33% of those over 15 years live with one or more chronic condition, rising to 60% for over-65s. Approximately 50% of chronic disease deaths are attributed to cardiovascular disease (CVD). In the coming decades, obesity, will claim 92 million lives in the OECD while obesity-related diseases will cut life expectancy by three years by 2050.

These diseases can be largely prevented by primary prevention, an approach that emphasizes vaccinations, lifestyle behaviour modification and the regulation of unhealthy substances. Preventative interventions have been efficacious. For obesity, countries have effectively employed public awareness campaigns, health professionals training, and encouragement of dietary change (for example, limits on unhealthy foods, taxes and nutrition labelling).⁴,⁵ Other interventions, such as workplace health-promotion programmes, while showing some promise, still need to demonstrate their efficacy.

The COVID-19 crisis provides the ultimate incentive to double down on the prevention of chronic disease. Most people dying from COVID-19 have one or more chronic disease, including obesity, CVD, diabetes or respiratory problems – diseases that are preventable with a healthy lifestyle. COVID-19 has highlighted structural weaknesses in our health systems such as the neglect of prevention and primary care.

While the utility of primary prevention is understood and supported by a growing evidence base, its implementation has been thwarted by chronic underinvestment, indicating a lack of societal and governmental prioritization. On average, OECD countries only invest 2.8% of health spending on public health and prevention. The underlying drivers include decreased allocation to prevention research, lack of awareness in populations, the belief that long-run prevention may be more costly than treatment, and a lack of commitment by and incentives for healthcare professionals. Furthermore, public health is often viewed in a silo separate from the overall health system rather than a foundational component.

Health benefits aside, increasing investment in primary prevention presents a strong economic imperative. For example, obesity contributes to the treatment costs of many other diseases: 70% of diabetes costs, 23% for CVD and 9% for cancers. Economic losses further extend to absenteeism and decreased productivity.

Fee-for-service models that remunerate physicians based on the number of sick patients they see, regardless the quality and outcome, dominate healthcare systems worldwide. Primary prevention mandates a payment system that reimburses healthcare professionals and patients for preventive actions. Ministries of health and governmental leaders need to challenge skepticism around preventive interventions, realign incentives towards preventive actions and those that promote healthy choices by people. Primary prevention will eventually reduce the burden of chronic diseases on the healthcare system.

As I reflect back on Emily and her life, I wonder what our healthcare system could have done differently. What if our healthcare system was a well-care system instead of a sick-care system? Imagine a different scenario: Emily, a 32 year old pre-diabetic, had access to a nutritionist, an exercise coach or health coach and nurse who followed her closely at the time of her first visit with me. Imagine if Emily joined group exercise classes, learned where to find healthy foods and how to cook them, and had access to spaces in which to exercise and be active. Imagine Emily being better educated about her diabetes and empowered in her healthcare and staying healthy. In reality, it is much more complicated than this, but if our healthcare systems began to incentivize and invest in prevention and even rewarded Emily for weight loss and healthy behavioural changes, the outcome might have been different. Imagine Emily losing weight and continuing to be an active and contributing member of society. Imagine if we invested in keeping people healthy rather than waiting for people to get sick, and then treating them. Imagine a well-care system.

Anderson, G. (2011). Responding to the growing cost and prevalence of people with multiple chronic conditions . Retrieved from OECD.

Institute for Health Metrics and Evaluation. GBD Data Visualizations. Retrieved here.

OECD (2019), The Heavy Burden of Obesity: The Economics of Prevention, OECD Health Policy Studies, OECD Publishing, Paris.

OECD. (2017). Obesity Update . Retrieved here.

Malik, V. S., Willett, W. C., & Hu, F. B. (2013). Global obesity: trends, risk factors and policy implications. Nature Reviews Endocrinology , 9 (1), 13-27.

Lang, J., Cluff, L., Payne, J., Matson-Koffman, D., & Hampton, J. (2017). The centers for disease control and prevention: findings from the national healthy worksite program. Journal of occupational and environmental medicine , 59 (7), 631.

Gmeinder, M., Morgan, D., & Mueller, M. (2017). How much do OECD countries spend on prevention? Retrieved from OECD.

Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ. 2020;368:m1198.

Richardson, A. K. (2012). Investing in public health: barriers and possible solutions. Journal of Public Health , 34 (3), 322-327.

Yong, P. L., Saunders, R. S., & Olsen, L. (2010). Missed Prevention Opportunities The healthcare imperative: lowering costs and improving outcomes: workshop series summary (Vol. 852): National Academies Press Washington, DC.

OECD. (2019). The Heavy Burden of Obesity: The Economics of Prevention. Retrieved here .

McDaid, D., F. Sassi and S. Merkur (Eds.) (2015a), “Promoting Health, Preventing Disease: The Economic Case ”, Open University Press, New York.

OECD. (2019). The Heavy Burden of Obesity: The Economics of Prevention. Retrieved from OECD.

4. Why e arly detection and diagnosis is critical

By Paul Murray , Head of Life and Health Products, Swiss Re, and André Goy , Chairman and Executive Director & Chief of Lymphoma, John Theurer Cancer Center, Hackensack University Medical Center

Although healthcare systems around the world follow a common and simple principle and goal – that is, access to affordable high-quality healthcare – they vary significantly, and it is becoming increasingly costly to provide this access, due to ageing populations, the increasing burden of chronic diseases and the price of new innovations.

Governments are challenged by how best to provide care to their populations and make their systems sustainable. Neither universal health, single payer systems, hybrid systems, nor the variety of systems used throughout the US have yet provided a solution. However, systems that are ranked higher in numerous studies, such as a 2017 report by the Commonwealth Fund , typically include strong prevention care and early-detection programmes. This alone does not guarantee a good outcome as measured by either high or healthy life expectancy. But there should be no doubt that prevention and early detection can contribute to a more sustainable system by reducing the risk of serious diseases or disorders, and that investing in and operationalizing earlier detection and diagnosis of key conditions can lead to better patient outcomes and lower long-term costs.

To discuss early detection in a constructive manner it makes sense to describe its activities and scope. Early detection includes pre-symptomatic screening and treatment immediately or shortly after first symptoms are diagnosed. Programmes may include searching for a specific disease (for example, HIV/AIDS or breast cancer), or be more ubiquitous. Prevention, which is not the focus of this blog, can be interpreted as any activities undertaken to avoid diseases, such as information programmes, education, immunization or health monitoring.

Expenditures for prevention and early detection vary by country and typically range between 1-5% of total health expenditures.¹ During the 2008 global financial crisis, many countries reduced preventive spending. In the past few years, however, a number of countries have introduced reforms to strengthen and promote prevention and early detection. Possibly the most prominent example in recent years was the introduction of the Affordable Care Act in the US, which placed a special focus on providing a wide range of preventive and screening services. It lists 63 distinct services that must be covered without any copayment, co-insurance or having to pay a deductible.

Whilst logic dictates that investment in early detection should be encouraged, there are a few hurdles and challenges that need to be overcome and considered. We set out a few key criteria and requirements for an efficient early detection program:

1. Accessibility The healthcare system needs to provide access to a balanced distribution of physicians, both geographically (such as accessibility in rural areas), and by specialty. Patients should be able to access the system promptly without excessive waiting times for diagnoses or elective treatments. This helps mitigate conditions or diseases that are already quite advanced or have been incubating for months or even years before a clinical diagnosis. Access to physicians varies significantly across the globe from below one to more than 60 physicians per 10,000 people.² One important innovation for mitigating access deficiencies is telehealth. This should give individuals easier access to health-related services, not only in cases of sickness but also to supplement primary care.

2. Early symptoms and initial diagnosis Inaccurate or delayed initial diagnoses present a risk to the health of patients, can lead to inappropriate or unnecessary testing and treatment, and represents a significant share of total health expenditures. A medical second opinion service, especially for serious medical diagnoses, which can occur remotely, can help improve healthcare outcomes. Moreover, studies show that early and correct diagnosis opens up a greater range of curative treatment options and can reduce costs (e.g. for colon cancer, stage-four treatment costs are a multiple of stage-one treatment costs).³

3. New technology New early detection technologies can improve the ability to identify symptoms and diseases early: i. Advances in medical monitoring devices and wearable health technology, such as ECG and blood pressure monitors and biosensors, enable patients to take control of their own health and physical condition. This is an important trend that is expected to positively contribute to early detection, for example in atrial fibrillation and Alzheimers’ disease. ii. Diagnostic tools, using new biomarkers such as liquid biopsies or volatile organic compounds, together with the implementation of machine learning, can play an increasing role in areas such as oncology or infectious diseases.⁴

4. Regulation and Intervention Government regulation and intervention will be necessary to set ranges of normality, to prohibit or discourage overdiagnosis and to reduce incentives for providers to overtreat patients or to follow patients' inappropriate requests. In some countries, such as the US, there has been some success through capitation models and value-based care. Governments might also need to intervene to de-risk the innovation paradigm, such that private providers of capital feel able to invest more in the development of new detection technologies, in addition to proven business models in novel therapeutics.

OECD Health Working Papers No. 101 "How much do OECD countries spend on prevention" , 2017

World Health Organization; Global Health Observatory (GHO) data; https://www.who.int/gho/health_workforce/physicians_density/en/

Saving lives, averting costs; A report for Cancer Research UK, by Incisive Health, September 2014

Liquid Biopsy: Market Drivers And Obstacles; by Divyaa Ravishankar, Frost & Sullivan, January 21, 2019

Liquid Biopsies Become Cheap and Easy with New Microfluidic Device; February 26, 2019

How America’s 5 Top Hospitals are Using Machine Learning Today; by Kumba Sennaar, February 19, 2019

5. The business case for private investment in healthcare for all

Pascal Fröhlicher, Primary Care Innovation Scholar, Harvard Medical School, and Ian Wijaya, Managing Director in Lazard’s Global Healthcare Group

Faith, a mother of two, has just lost another customer. Some households where she is employed to clean, in a small town in South Africa, have little understanding of her medical needs. As a type 2 diabetes patient, this Zimbabwean woman visits the public clinic regularly, sometimes on short notice. At her last visit, after spending hours in a queue, she was finally told that the doctor could not see her. To avoid losing another day of work, she went to the local general practitioner to get her script, paying more than three daily wages for consultation and medication. Sadly, this fictional person reflects a reality for many people in middle-income countries.

Achieving universal health coverage by 2030, a key UN Sustainable Development Goal (SDG), is at risk. The World Bank has identified a $176 billion funding gap , increasing every year due to the growing needs of an ageing population, with the health burden shifting towards non-communicable diseases (NCDs), now the major cause of death in emerging markets . Traditional sources of healthcare funding struggle to increase budgets sufficiently to cover this gap and only about 4% of private health care investments focus on diseases that primarily affect low- and middle-income countries.

In middle-income countries, private investors often focus on extending established businesses, including developing private hospital capacity, targeting consumers already benefiting from quality healthcare. As a result, an insufficient amount of private capital is invested in strengthening healthcare systems for everyone.

Why is this the case? We discussed with senior health executives investing in Lower and Middle Income Countries (LMIC) and the following reasons emerged:

• Small market size . Scaling innovations in healthcare requires dealing with country-specific regulatory frameworks and competing interest groups, resulting in high market entry cost.
• Talent . Several LMICs are losing nurses and doctors but also business and finance professionals to European and North American markets due to the lack of local opportunities and a significant difference in salaries.
• Untested business models with relatively low gross margins. Providing healthcare requires innovative business models where consumers’ willingness to pay often needs to be demonstrated over a significant period of time. Additionally, relatively low gross margins drive the need for scale to leverage administrative costs, which increases risk.
• Government Relations. The main buyer of health-related products and services is government; yet the relationship between public and private sectors often lacks trust, creating barriers to successful collaboration. Add to that significant political risk, as contracts can be cancelled by incoming administrations after elections. Many countries also lack comprehensive technology strategies to successfully manage technological innovation.
• Complexity of donor funding. A significant portion of healthcare is funded by private donors, whose priorities might not always be congruent with the health priorities of the government.

Notwithstanding these barriers, healthcare, specifically in middle-income settings, could present an attractive value proposition for private investors:

• Economic growth rates . A growing middle class is expanding the potential market for healthcare products and services.
• Alignment of incentives . A high ratio of out-of-pocket payments for healthcare services is often associated with low quality. However, innovative business models can turn out of pocket payments into the basis for a customer-centric value proposition, as the provider is required to compete for a share of disposable income.
• Emergence of National Health Insurance Schemes . South Africa, Ghana, Nigeria and others are building national health insurance schemes, increasing a population’s ability to fund healthcare services and products .
• Increased prevalence of NCDs. Given the increasing incidence of chronic diseases and the potential of using technology to address these diseases, new business opportunities for private investment exist.

Based on the context above, several areas in healthcare delivery can present compelling opportunities for private companies.

• Aggregation of existing players.
• Leveraging primary care infrastructure. Retail companies can leverage their real estate, infrastructure and supply chains to deploy primary care services at greater scale than is currently the case.
• Telemedicine . Telecommunications providers can leverage their existing infrastructure and customer base to provide payment mechanisms and telehealth services at scale. As seen during the COVID-19 pandemic, investment in telemedicine can ensure that patients receive timely and continuous care in spite of restrictions and lockdowns.
• Cost effective diagnostics . Diagnostic tools operated by frontline workers and combined with the expertise of specialists can provide timely and efficient care.

To fully realize these opportunities, government must incentivise innovation, provide clear regulatory frameworks and, most importantly, ensure that health priorities are adequately addressed.

Venture capital and private equity firms as well as large international corporations can identify the most commercially viable solutions and scale them into new markets. The ubiquity of NCDs and the requirement to reduce costs globally provides innovators with the opportunity to scale their tested solutions from LMICs to higher income environments.

Successful investment exits in LMICs and other private sector success stories will attract more private capital. Governments that enable and support private investment in their healthcare systems would, with appropriate governance and guidance, generate benefits to their populations and economies. The economic value of healthy populations has been proven repeatedly , and in the face of COVID-19, private sector investment can promote innovation and the development of responsible, sustainable solutions.

Faith – the diabetic mother we introduced at the beginning of this article - could keep her client. As a stable patient, she could measure her glucose level at home and enter the results in an app on her phone, part of her monthly diabetes programme with the company that runs the health centre. She visits the nurse-led facility at the local taxi stand on her way to work when her app suggests it. The nurse in charge of the centre treats Faith efficiently, and, if necessary, communicates with a primary care physician or even a specialist through the telemedicine functionality of her electronic health system.

Improving LMIC health systems is not only a business opportunity, but a moral imperative for public and private leaders. With the appropriate technology and political will, this can become a reality.

6. How could COVID-19 change the way we pay for health services?

John E. Ataguba, Associate Professor and Director, University of Cape Town and Matthew Guilford, Co-Founder and Chief Executive Officer, Common Health

The emergence of the new severe acute respiratory syndrome coronavirus (SARS-Cov-2), causing the coronavirus disease 2019 (COVID-19), has challenged both developing and developed countries.

Countries have approached the management of infections differently. Many people are curious to understand their health system’s performance on COVID-19, both at the national level and compared to international peers. Alongside limited resources for health, many developing countries may have weak health systems that can make it challenging to respond adequately to the pandemic.

Even before COVID-19, high rates of out-of-pocket spending on health meant that every year, 800 million people faced catastrophic healthcare costs ,100 million families were pushed into poverty, and millions more simply avoided care for critical conditions because they could not afford to pay for it.

The pandemic and its economic fallout have caused household incomes to decline at the same time as healthcare risks are rising. In some countries with insurance schemes, and especially for private health insurance, the following questions have arisen: How large is the co-payment for a COVID-19 test? If my doctor’s office is closed, will the telemedicine consultation be covered by my insurance? Will my coronavirus care be paid for regardless of how I contracted the virus? These and other doubts can prevent people from seeking medical care in some countries.

In Nigeria, like many other countries in Africa, the government bears the costs associated with testing and treating COVID-19 irrespective of the individual’s insurance status. In the public health sector, where COVID-19 cases are treated, health workers are paid monthly salaries while budgets are allocated to health facilities for other services. Hospitals continue to receive budget allocations to finance all health services including the management and treatment of COVID-19. That implies that funds allocated to address other health needs are reduced and that in turn could affect the availability and quality of health services.

Although health workers providing care for COVID-19 patients in isolation and treatment centres in Nigeria are paid salaries that are augmented with a special incentive package, the degree of impact on the quality improvement of services remains unclear. The traditional and historical allocation of budgets does not always address the needs of the whole population and could result in poor health services and under-provision of health services for COVID-19 patients.

In some countries, the reliance on out-of-pocket funding is hardly better for private providers, who encounter brand risks, operational difficulties, and – in extreme cases – the risk of creating “debtor prisons” as they seek to collect payment from patients. Ironically, despite the huge demand for medical services to diagnose and treat COVID-19, large healthcare institutions and individual healthcare practitioners alike are facing financial distress.

Dependence on a steady stream of fee-for-service payments for outpatient consultations and elective procedures is leading to pay cuts for doctors in India , forfeited Eid bonuses for nurses in Indonesia , and hospital bankruptcies in the United States . In a recent McKinsey & Company survey, 77% of physicians reported that their business would suffer in 2020 , and 46% were concerned about their practice surviving the coronavirus pandemic.

COVID-19 is exposing how fee-for-service, historical budget allocation and out-of-pocket financing methods can hinder the performance of the health system. Some providers and health systems that deployed “value-based” models prior to the pandemic have reported that these approaches have improved financial resilience during COVID-19 and may support better results for patients. Nevertheless, these types of innovations do not represent the dominant payment model in any country.

How health service providers are paid has implications for whether service users can get needed health services in a timely fashion, and at an appropriate quality and an affordable cost. By shifting from fee-for-service reimbursements to fixed "capitation" and performance-based payments, these models incentivize providers to improve quality and coordination while also guaranteeing a baseline income level, even during times of disruption.

Health service providers could be paid either in the form of salaries, a fee for services they provide, by capitation (whether adjusted or straightforward), through global budgets, or by using a case-based payment system (for example, the diagnostics-related groups), among others. Because there are different incentives to consider when adopting any of the methods, they could be combined to achieve a specific goal. For example, in some countries, health workers are paid salaries , and some specific services are paid on a fee-for-service basis.

Ideally, health services could be purchased strategically , incorporating aspects of provider performance in transferring funds to providers and accounting for the health needs of the population they serve.

In this regard, strategic purchasing for health has been advocated and should be highlighted as crucial with the emergence of the COVID-19 pandemic. There is a need to ensure value in the way health providers are paid, inter alia to increase efficiency, ensure equity, and improve access to needed health services. Value-based payment methods, although not new in many countries, provide an avenue to encourage long-term value for money, better quality, and strategic purchasing for health, helping to build a healthier, more resilient world.

7. L essons in integrated care from the COVID-19 pandemic

Sarah Ziegler, Postdoctoral Researcher, Department of Epidemiology and Biostatistics, University of Zurich, and Ninie Wang, Founder & CEO, Pinetree Care Group.

Since the start of the COVID-19 pandemic, people suffering non-communicable diseases (NCDs) have been at higher risk of becoming severely ill or dying. In Italy, 96.2% of people who died of COVID-19 lived with two or more chronic conditions.

Beyond the pandemic, cardiovascular disease, cancer, respiratory disease and diabetes are the leading burden of disease, with 41 million annual deaths. People with multimorbidity - a number of different conditions - often experience difficulties in accessing timely and coordinated healthcare, made worse when health systems are busy fighting against the pandemic.

Here is what happened in China with Lee, aged 62, who has been living with Chronic Obstructive Pulmonary Disease (COPD) for the past five years.

Before the pandemic, Lee’s care manager coordinated a multi-disciplinary team of physicians, nurses, pulmonary rehabilitation therapists, psychologists and social workers to put together a personalized care plan for her. Following the care plan, Lee stopped smoking and paid special attention to her diet, sleep and physical exercises, as well as sticking to her medication and follow-up visits. She participated in a weekly community-based physical activity program to meet other COPD patients, including short walks and exchange experiences. A mobile care team supported her with weekly cleaning and grocery shopping.

Together with her family, Lee had follow-up visits to ensure her care plan reflected her recovery and to modify the plan if needed. These integrated care services brought pieces of care together, centered around Lee’s needs, and provided a continuum of care that helped keep Lee in the community with a good quality of life for as long as possible.

Since the COVID-19 outbreak, such NCD services have been disrupted by lockdowns, the cancellation of elective care and the fear of visiting care service . These factors particularly affected people living with NCDs like Lee. As such, Lee was not able to follow her care plan anymore. The mobile care team was unable to visit her weekly as they were deployed to provide COVID-19 relief. Lee couldn’t participate in her community-based program, follow up on her daily activities, or see her family or psychologists. This negatively affected Lee’s COPD management and led to poor management of her physical activity and healthy diet.

The pandemic highlights the need for a flexible and reliable integrated care system to enable healthcare delivery to all people no matter where they live, uzilizing approaches such as telemedicine and effective triaging to overcome care disruptions.

Lee’s care manager created short videos to assist her family through each step of her care and called daily to check in on the implementation of the plan and answer questions. Lee received tele-consultations, and was invited to the weekly webcast series that supported COPD patient communities. When her uncle passed away because of pneumonia complications from COVID-19 in early April, Lee’s care manager arranged a palliative care provider to support the family through the difficult time of bereavement and provided food and supplies during quarantine. Lee could even continue with her physical activity program with an online training coach. There were a total of 38 exercise videos for strengthening and stretching arms, legs and trunk, which she could complete at different levels of difficulty and with different numbers of repetitions.

Lee’s case demonstrates that early detection, prevention, and management of NCDs play a crucial role in a global pandemic response. It shows how we need to shift away from health systems designed around single diseases towards health systems designed for the multidimensional needs of individuals. As part of the pandemic responses, addressing and managing risks related to NCDs and prevention of their complications are critical to improve outcomes for vulnerable people like Lee.

How to design and deliver successful integrated care

The challenge for the successful transformation of healthcare is to tailor care system-wide to population needs. A 2016 WHO Framework on integrated people-centered health services developed a set of five general strategies for countries to progress towards people-centered and sustainable health systems, calling for a fundamental transformation not only in the way health services are delivered, but also in the way they are financed and managed . These strategies call for countries to:

• Engage and empower people / communities: an integrated care system must mobilize everyone to work together using all available resources, especially when continuity of essential health and community services for NCDs are at risk of being undermined.
• Strengthen governance and accountability, so that integration emphasizes rather than weakens leadership in every part of the system, and ensure that NCDs are included in national COVID-19 plans and future essential health services.
• Reorient the model of care to put the needs and perspectives of each person / family at the center of care planning and outcome measurement, rather than institutions.
• Coordinate services within and across sectors, for example, integrate inter-disciplinary medical care with social care, addressing wider socio-economic, environmental and behavioral determinants of health.
• Create an enabling environment, with clear objectives, supportive financing, regulations and insurance coverage for integrated care, including the development and use of systemic digital health care solutions.

Whether due to an unexpected pandemic or a gradual increase in the burden of NCDs, each person could face many health threats across the life-course.

Only systems that dynamically assess each person’s complex health needs and address them through a timely, well-coordinated and tailored mix of health and social care services will be able to deliver desired health outcomes over the longer term, ensuring an uninterrupted good quality of life for Lee and many others like her.

• Wang B, Li R, Lu Z, Huang Y. Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis. Aging (Albany NY) 2020;12: 6049–57.
• WHO. Noncommunicable diseases in emergencies. Geneva: World Health Organization, 2016.
• WHO. COVID-19 significantly impacts health services for noncommunicable diseases. June 2020.
• Kluge HHP, Wickramasinghe K, Rippin HL, et al. Prevention and control of non-communicalbe diseases in the COVID-19 response. The Lancet. 2020. 395:1678-1680
• WHO. Framework on integrated people-centred health services. Geneva: World Health Organization, 2016.

8 . Why access to healthcare alone will not save lives

Donald Berwick, President Emeritus and Senior Fellow, Institute for Healthcare Improvement; Nicola Bedlington, Special Adviser, European Patient Forum; and David Duong, Director, Program in Global Primary Care and Social Change, Harvard Medical School.

Joyce lies next to 10 other women in bare single beds in the post-partum recovery room at a rural hospital in Uganda. Just an hour ago, Joyce gave birth to a healthy baby boy. She is now struggling with abdominal pain. A nurse walks by, and Joyce tries to call out, but the nurse was too busy to attend to her; she was the only nurse looking after 20 patients.

Another hour passes, and Joyce is shaking and sweating profusely. Joyce’s husband runs into the corridor to find a nurse to come and evaluate her. The nurse notices Joyce’s critical condition - a high fever and a low blood pressure - and she quickly calls the doctor. The medical team rushes Joyce to the intensive care unit. Joyce has a very severe blood stream infection. It takes another hour before antibiotics are started - too late. Joyce dies, leaving behind a newborn son and a husband. Joyce, like many before her, falls victim to a pervasive global threat: poor quality of care.

Adopted by United Nations (UN) in 2015, the Sustainable Development Goals (SDG) are a universal call to action to end poverty, protect the planet and ensure that all enjoy peace and prosperity by 2030. SDG 3 aims to ensure healthy lives and promote wellbeing for all. The 2019 UN General Assembly High Level Meeting on Universal Health Coverage (UHC) reaffirmed the need for the highest level of political commitment to health care for all.

However, progress towards UHC, often measured in terms of access, not outcomes, does not guarantee better health, as we can see from Joyce’s tragedy. This is also evident with the COVID-19 response. The rapidly evolving nature of the COVID-19 pandemic has highlighted long-term structural inefficiencies and inequities in health systems and societies trying to mitigate the contagion and loss of life.

Systems are straining under significant pressure to ensure standards of care for both COVID-19 patients and other patients that run the risk of not receiving timely and appropriate care. Although poor quality of care has been a long-standing issue, it is imperative now more than ever that systems implement high-quality services as part of their efforts toward UHC.

Poor quality healthcare remains a challenge for countries at all levels of economic development: 10% of hospitalized patients acquire an infection during their hospitalization in low-and-middle income countries (LMIC), whereas 7% do in high-income countries. Poor quality healthcare disproportionally affects the poor and those in LMICs. Of the approximately 8.6 million deaths per year in 137 LMICs, 3.6 million are people who did not access the health system, whereas 5 million are people who sought and had access to services but received poor-quality care.

Joyce’s story is all too familiar; poor quality of care results in deaths from treatable diseases and conditions. Although the causes of death are often multifactorial, deaths and increased morbidity from treatable conditions are often a reflection of defects in the quality of care.

The large number of deaths and avoidable complications are also accompanied by substantial economic costs. In 2015 alone, 130 LMICs faced US $6 trillion in economic losses. Although there is concern that implementing quality measures may be a costly endeavor, it is clear that the economic toll associated with a lack of quality of care is far more troublesome and further stunts the socio-economic development of LMICs, made apparent with the COVID-19 pandemic.

Poor-quality care not only leads to adverse outcomes in terms of high morbidity and mortality, but it also impacts patient experience and patient confidence in health systems. Less than one-quarter of people in LMICs and approximately half of people in high-income countries believe that their health systems work well.

A lack of application and availability of evidenced-based guidelines is one key driver of poor-quality care. The rapidly changing landscape of medical knowledge and guidelines requires healthcare workers to have immediate access to current clinical resources. Despite our "information age", health providers are not accessing clinical guidelines or do not have access to the latest practical, lifesaving information.

Getting information to health workers in the places where it is most needed is a delivery challenge. Indeed, adherence to clinical practice guidelines in eight LMICs was below 50%, and in OECD countries, despite being a part of national guidelines, 19-53% of women aged 50-69 years did not receive mammography screening.4 The evidence in LMICs and HICs suggest that application of evidence-based guidelines lead to reduction in mortality and improved health outcomes.

Equally, the failure to change and continually improve the processes in health systems that support the workforce takes a high toll on quality of care. During the initial wave of the COVID-19 pandemic, countries such as Taiwan, Hong Kong, Singapore and Vietnam, which adapted and improved their health systems after the SARS and H1N1 outbreaks, were able to rapidly mobilize a large-scale quarantine and contact tracing strategy, supported with effective and coordinated mass communication.

These countries not only mitigated the economic and mortality damage, but also prevented their health systems and workforce from enduring extreme burden and inability to maintain critical medical supplies. In all nations, investing in healthcare organizations to enable them to become true “learning health care systems,” aiming at continual quality improvement, would yield major population health and health system gains.

The COVID-19 pandemic underscores the importance for health systems to be learning systems. Once the dust settles, we need to focus, collectively, on learning from this experience and adapting our health systems to be more resilient for the next one. This implies a need for commitment to and investment in global health cooperation, improvement in health care leadership, and change management.

With strong political and financial commitment to UHC, and its demonstrable effect in addressing crises such as COVID-19, for the first time, the world has a viable chance of UHC becoming a reality. However, without an equally strong political, managerial, and financial commitment to continually improving, high-quality health services, UHC will remain an empty promise.

1. United Nations General Assembly. Political declaration of the high-level meeting on universal health coverage. New York, NY2019.

2. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10 years on. Institute of Health Equity;2020.

3. National Academies of Sciences, Engineering, and Medicine: Committee on Improving the Quality of Health Care Globally. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: National Academies Press;2018.

4. World Health Organization, Organization for Economic Co-operation and Development, World Bank Group. Delivering quality health services: a global imperative for universal health coverage. World Health Organization; 2018.

5. Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 2018;6(11):e1196-e1252.

6. Ricci-Cabello I, Violán C, Foguet-Boreu Q, Mounce LT, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review. European Journal of General Practice. 2015;21(3):192-202.

7. Valtis YK, Rosenberg J, Bhandari S, et al. Evidence-based medicine for all: what we can learn from a programme providing free access to an online clinical resource to health workers in resource-limited settings. BMJ global health. 2016;1(1).

8. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America . Washington, DC: National Academies Press 2012.

• Issue Brief

Health Care Costs: What’s the Problem?

The cost of health care in the United States far exceeds that in other wealthy nations across the globe. In 2020, U.S. health care costs grew 9.7%, to $4.1 trillion, reaching about $12,530 per person. 1 At the same time, the United States lags far behind other high-income countries when it comes to both access to care and some health care outcomes. 2 As a result, policymakers and health care systems are facing increasing demands for more care at lower costs for more people. And, of course, everyone wants to know why their health care costs are so high.

The answer depends, in part, on who’s asking this question: Why does U.S. health care cost so much? Public policy often highlights and targets the total cost of the health care system or spending as a percentage of the gross domestic product (GDP), while most patients (the public) are more concerned with their own out-of-pocket costs and whether they have access to affordable, meaningful insurance. Providers feel public pressure to contain costs while trying to provide the highest-quality care to patients.

This brief is the first in a series of papers intended to better define some of the key questions policymakers should be asking about health care spending: What costs are too high? And can they be controlled through policy while improving access to care and the health of the population?

What (or Who) Is to Blame for the High Costs of Care? 

Total U.S. health care spending has increased steadily for decades, as have costs and spending in other segments of the U.S. economy. In 2020, health care spending was $1.5 trillion more than in 2010 and $2.8 trillion more than in 2000. While total spending on clinical care has increased in the past two decades, health care spending as a percentage of GDP has remained steady and has hovered around 20% of GDP in recent years (with the largest single increase being in 2020 during the COVID-19 pandemic). 1 Health care spending in 2020 (particularly public outlays) increased more than in previous years because of increased federal government support of critical COVID-19-related services and expanded access to care during the pandemic. Yet, no single sector’s health care cost — doctors, hospitals, equipment, or any other sector — has increased disproportionately enough over time to be the single cause of high costs.

One of the areas in health care with the highest levels of spending in the United States is hospital care, which has accounted for about 30% of national health care spending 3 for the past 60 years (and has remained very close to 31% for the past 20 years) (Figure 1). Although hospital spending is the focus of many cost-control policies and public attention, the increases are consistent with the increases seen across other areas of health care, such as for physicians and other professional services. Total spending for some smaller parts of nonhospital care has more than doubled over the past few decades and makes up an increasing proportion of total spending. For instance, home health care as a percentage of total spending tripled between 1980 and 2020, from 0.9% to 3.0%, and drug spending nearly doubled as a proportion of health care spending between 1980 and 2006, from 4.8% to 10.5%, and currently represent 8.4% of health care spending. 1  

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The largest areas of spending that might yield the greatest potential for savings — such as inpatient care and physician-provided care — are unlikely to be reduced by lowering the total number of insured patients or visits per person, given the growing, aging U.S. population and the desire to cover more, not fewer, individuals with adequate health insurance. 

In the past decade, policymaker and insurer interventions intended to change the mix of services by keeping patients out of high-cost settings (such as the hospital) have not always succeeded at reducing costs, although they have had other benefits for patients. 4  

Breaking Down the Costs of Care

Thinking about total health care spending as an equation, one might define it as the number of services delivered per person multiplied by the number of people to whom services are delivered, multiplied again by the average cost of each service: 

Health Care Spending=(number of services delivered per person)×(number of people to whom services are delivered)×(average cost of each service) 

Could health care spending be lowered by making major changes to the numbers or types of services delivered or by lowering the average cost per service? 

Although recent data on the overall utilization of health care are limited, in 2011, the number of doctor consultations per capita in the United States was below that in many comparable countries, but the number of diagnostic procedures (such as imaging) per capita remained higher. 5 Furthermore, no identifiable groups of individuals (by race/ethnicity, geographic location, etc.) appear to be outliers that consume extraordinary numbers of services. 6 The exception is that the sickest people do cost more to take care of, but even the most cost-conscious policymakers appear to be reluctant to abandon these patients. 

In addition to the fact that the average number of health care services delivered per person in the United States was below international benchmarks in 2020,7 the percentage of people in the United States covered by health insurance was also lower than that in many other wealthy nations. Although millions of people gained insurance8 through the Affordable Care Act and provisions enacted during the COVID-19 pandemic, 10% of the nonelderly population remained uninsured in 2020. 9 When policymakers focus on reducing health care spending, considering the equation above, and see that the United States already has a lower proportion of its population insured and fewer services delivered to patients than other wealthy nations, their focus often shifts to the average cost of services.

It's Still the Prices … and the Wages 

A report comparing the international prices of health care in 2017 found that the median list prices (charges) for medical procedures in the United States heavily outweighed the list prices in other countries, such as the United Kingdom, New Zealand, Australia, Switzerland, and South Africa. 10  

For example, the 2017 U.S. median health care list price for a hospital admission with a hip replacement was $32,500, compared with $20,900 in Australia and $12,200 in the United Kingdom. In comparisons of the list prices of other procedures, such as deliveries by cesarean section, appendectomies, and knee replacements, the U.S. median list prices of elective and needed services were thousands of dollars — if not tens of thousands of dollars — more. 10 Yet, the list price for these services in the United States is often much higher than the actual payments made to providers by public or private insurance companies. 11

Public-payer programs (particularly Medicare and Medicaid) tend to pay hospitals rates that are lower than the cost of delivering care12 (though many economists argue these payments are slightly above actual costs, and providers argue they are at least slightly below actual costs), while private payers historically have paid about twice as much as public payers. 13 (See another brief in this series, “ Surprise! Why Medical Bills Are Still a Problem for U.S. Health Care ,” for more information about public and private payers’ role in health care costs.) However, the average cost per service is still high by international standards, even if it’s not as high as list prices may suggest. The high average costs are partially driven by the highly labor-intensive nature of health care, with labor consuming almost 55% of the share of total U.S. hospital costs in 2018. 14 These costs are growing due to the labor shortages exacerbated by the COVID-19 pandemic. 

Reducing U.S. health care spending by reducing labor costs could, theoretically, be achieved by reducing wages or eliminating positions; however, both of those policies would be problematic, with potential unintended consequences, such as driving clinicians away from the workforce at a time of growing need. 

Wage reductions, particularly for clinicians, would require a vastly expanded labor pool that would take years to achieve (and even then, lower per person wages for nonphysicians may not decrease total spending related to health care labor). 15 Reducing or replacing clinical workers over time would require major changes to policy (both public and private) and major shifts in how health care is provided — neither of which has occurred rapidly, even since the implementation of the Affordable Care Act. 

What’s a Policymaker to Do?

Nearly one in five Americans has medical debt, 16 and affordability is still an issue for a large proportion of the population, whether uninsured or insured, which suggests that policymakers should focus on patients’ costs. This may prove more impactful to the individual than reducing total health care spending. 

A majority of the country agrees that the federal government should ensure some basic health insurance for all citizens. 17,18 Although most Americans consider reducing costs to individuals and expanding insurance coverage to be important, no clear consensus about who should bear any associated increased costs exists among patients or policymakers. Half of insured adults currently report difficulty affording medical or dental care, even when they are insured, because of the rising total costs of care and the increasing absolute amount of out-of-pocket spending. 19 Out-of-pocket spending for health care has doubled in the past 20 years, from $193.5 billion in 2000 to $388.6 billion in 2020. 1 These rising health care costs have disproportionately fallen on those with the fewest resources, including people who are uninsured, Black people, Hispanic people, and families with low incomes. 19 Increased cost sharing through copays and coinsurance may force difficult spending choices for even solidly middle-class families. 

The severity and burden of out-of-pocket spending are hidden by the use of data averages; on average, U.S. residents have twice the average household net adjusted disposable income 20 of many other comparable nations and spend more than twice 21 as much per capita on health care. Yet, for those who fall outside these averages — average income, average costs, or both — the financial pain felt at the hospital, clinic, and pharmacy is very real. 

In any given year, a small number of patients account for a disproportionate amount of health care spending because of the complexity and severity of their illnesses. Even careful international comparisons of end-of-life care for cancer patients demonstrate costs in the United States are similar to those in many comparable nations (although U.S. patients are more likely to receive chemotherapy, they spend fewer days in the hospital during the last 6 months of life than patients in other countries). 22 Similarly, although prevention efforts may delay or avoid the onset of illness in targeted populations, such efforts would not significantly reduce the number of services delivered for many years and may lead to an increase in care delivered over the course of an extended life span.

To the average person in the United States, immediate cost-control efforts might best be focused on reducing the cost burden for families and patients. Policymakers should continue to seek ways to promote better health care quality at lower costs rather than try to achieve unrealistic, drastic reductions in national health care spending. Investing in prevention, seeking to avoid preventable admissions or readmissions, and otherwise improving the quality of care are desirable, but these improvements are not quick solutions to lowering the national health care costs in the near term. Long-term policy actions could incrementally address health care spending but should clearly articulate the problem to be solved, the desired outcomes, and the trade-offs the nation is willing to make (as discussed in two companion pieces). 

The U.S. health care system continues to place a disproportionate cost burden on the patients who can least afford it. In the short term, policymakers could focus on targeted subsidies to specific populations — the families and individuals whose household incomes fall outside the average or who have health care expenses that fall outside the average — whose health care costs are unmanageable. Such subsidies could expand existing premium subsidies or triggers that increase support for costs that exceed target amounts. Targeted subsidies are likely to increase total health care spending (especially public spending) but would address the problem of cost from the average consumer, or patient, perspective. Broader policies to ease costs for patients could also be considered by category of service; for instance, consumers have been largely shielded from the increased costs of care related to COVID-19 by the waiving of copays for patients and families. These policies would likely increase national spending as well, but they would make medical care more affordable to some families.

Download Brief

Cite this source: Grover A, Orgera K, Pincus L. Health Care Costs: What's The Problem? Washington, DC: AAMC; 2022. https://doi.org/10.15766/rai_dozyvvh2

• Centers for Medicare & Medicaid Services. National Health Expenditure Data. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet . Published Dec. 1, 2021. Accessed Feb. 24, 2022.
• Schneider EC, Shah A, Doty MM, Tikkanen R, Fields K, Williams RD II. Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries. Washington, DC: The Commonwealth Fund. https://doi.org/10.26099/01DV-H208 . Published August 2021. Accessed April 21, 2022.
• Centers for Medicare & Medicaid Services. National Health Expenditure Data: Historical. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical . Published Dec. 15, 2021. Accessed April 22, 2022. 
• Berkowitz S, Ricks KB, Wang J, Parker M, Rimal R, DeWalt D. Evaluating a nonemergency medical transportation benefit for accountable care organization members. Health Affairs. 2022;41(3):406-413. doi:10.1377/hlthaff.2021.00449.
• Organisation for Economic Co-operation and Development. Health Care Utilisation. Paris, France: Organisation for Economic Co-operation and Development. https://stats.oecd.org/index.aspx?queryid=30166# . Published Nov. 9, 2021. Accessed Feb. 24, 2022.
• Abelson R. Harris G. Critics question study cited in health debate. New York Times. June 2, 2010. https://www.nytimes.com/2010/06/03/business/03dartmouth.html?ref=business&pagewanted=all . Accessed Feb. 24, 2022.
• The Commonwealth Fund. Selected Health & System Statistics: Average Annual Number of Physician Visits per Capita. https://www.commonwealthfund.org/international-health-policy-center/system-stats/annual-physician-visits-per-capita . Published June 5, 2020. Accessed April 21, 2022.
• Tolbert J, Orgera K. Key Facts About the Uninsured Population. San Francisco, CA: KFF. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ . Published Nov. 6, 2020. Accessed April 21, 2022.
• Tolbert J, Orgera K, Damico A. What Does the CPS Tell Us About Health Insurance Coverage in 2020? San Francisco, CA: KFF. https://www.kff.org/uninsured/issue-brief/what-does-the-cps-tell-us-about-health-insurance-coverage… . Published Sept. 23, 2021. Accessed April 21, 2022.
• Hargraves J, Bloschichak A. International Comparisons of Health Care Prices From the 2017 iFHP Survey. Washington DC: Health Care Cost Institute. https://healthcostinstitute.org/hcci-research/international-comparisons-of-health-care-prices-2017-ifhp-survey . Published Dec. 2019. Accessed April 21, 2022.
• Bai G. Anderson G. Extreme markup: The fifty US hospitals with the highest charge-to-cost ratios. Health Affairs. 2015;34(6):922-928. doi:10.1377/hlthaff.2014.1414.
• Congressional Budget Office. The Prices That Commercial Health Insurers and Medicare Pay for Hospitals’ and Physicians’ Services. Washington, DC: Congressional Budget Office. https://www.cbo.gov/system/files/2022-01/57422-medical-prices.pdf . Published January 2022. Accessed April 21, 2022.
• Lopez E, Neuman T, Jacobson G, Levitt L. How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature. San Francisco, CA: The Henry J. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/ . Published April 15, 2020. Accessed March 22, 2022.
• Daly R. Hospitals Innovate to Control Labor Costs. Westchester, IL: Healthcare Financial Management Association. https://www.hfma.org/topics/hfm/2019/october/hospitals-innovate-to-control-labor-costs.html . Published Oct. 1, 2019. Accessed Feb. 24, 2022. 
• Batson BN, Crosby SN, Fitzpatrick, JM. Mississippi frontline: Targeting value-based care with physician-led care teams. J Miss State Med Assoc. 2022;63(1):19-21. https://ejournal.msmaonline.com/publication/?m=63060&i=735364&p=20&ver=html5 .
• Kluender R, Mahoney N, Wong F, et al. Medical debt in the US, 2009-2020. JAMA. 2021;326(3):250-256. doi:10.1001/jama.2021.8694.
• Jones B. Increasing Share of Americans Favor a Single Government Program to Provide Health Care Coverage. Washington, DC: Pew Research Center. https://www.pewresearch.org/fact-tank/2020/09/29/increasing-share-of-americans-favor-a-single-government-program-to-provide-health-care-coverage/ . Published Sept. 29, 2020. Accessed April 21, 2022.
• Bialik K. More Americans Say Government Should Ensure Health Care Coverage. Washington, DC: Pew Research Center. https://www.pewresearch.org/fact-tank/2017/01/13/more-americans-say-government-should-ensure-health-care-coverage/ . Published Jan. 13, 2017. Accessed March 22, 2022.
• Kearney A, Hamel L, Stokes M, Brodie M. Americans’ Challenges With Health Care Costs. San Francisco, CA: The Henry J. Kaiser Family Foundation. https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/ . Published Dec. 14, 2021. Accessed Feb. 24, 2022.
• Organisation for Economic Co-operation and Development. Income. Better Life Index. Paris, France: Organisation for Economic Co-operation and Development. https://www.oecdbetterlifeindex.org/topics/income/ . Accessed April 21, 2022.
• Wager E, Ortaliza J, Cox C; The Henry J. Kaiser Family Foundation. Health System Tracker. How Does Health Spending in the U.S. Compare to Other Countries? San Francisco, CA: The Henry J. Kaiser Family Foundation. https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries-2/ . Published Jan. 21, 2022. Accessed April 21, 2022.
• Bekelman JE, Halpern SD, Blankart CR, et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. JAMA. 2016;315(3):272-283. doi:10.1001/jama.2015.18603.

You are free to use it as an inspiration or a source for your own work.

In the United States, there has long been discussion about the quality and nature of the delivery of healthcare.  The debates have included who may receive such services, whether or not healthcare is a privilege or an entitlement, whether and how to make patient care affordable to all segments of the population, and the ways in which the government should, or should not, be involved in the provision of such services.  Indeed, many people feel that the healthcare in this country is the best in the world; others believe tha (The Free Dictionary)t our health delivery system is broken.  This paper shall examine different aspects of the healthcare system in our country, discussing whether it has been successful in providing essential services to American citizens.

The delivery of healthcare services is considered to be a system; according to the Free Diction- ary (Farlex, 2010), a system is defined as “a group of interacting, interrelated, or interdependent elements forming a complex whole.” This is an apt description of our healthcare structure, as it is compiled of patients, medical and mental health providers, hospitals, clinics, laboratories, insurance companies, and many other parties that are reliant on each other and that, when combined, make up the entity known as our healthcare system.

Those who believe that our healthcare system is the best in the world often point to the fact that leaders as well as private citizens from countries throughout the world frequently come to the United States to have surgeries and other treatments that they require for survival.  A more cynical view of this phenomenon is that if people have the money, they are able to purchase quality care in the U.S., a “survival of the fittest” situation.  Those who lack the resources to travel to the U.S. for medical treatment are simply out of luck, and often will die without the needed care.

In fact, reports by the World Health Organization and other groups consistently indicate that while the United States spends more than any other country on healthcare costs, Americans receive lower quality, less efficient and less fairness from the system.  These conclusions come as a result of studying quality of care, access to care, equity and the ability to lead long, productive lives.  (World Health Organization,2001.) What cannot be disputed is that the cost of healthcare is constantly rising, a fact which was the precipitant to the large movement to reform healthcare in our country in 2010.  More than 10 years ago, the goal of managed care was to drive down the costs of healthcare, but those promises did not materialize (Garsten, 2010.) A large segment of the population is either uninsured or underinsured, and it is speculated that over the next decade, these problems will only increase while other difficulties will arise (Garson, 2010.)

When examining the healthcare system, there are three aspects of care that call for evaluation: the impact of delivering care on the patient, the benefits and harms of that treatment, and the functioning of the healthcare system, as described in an article by Adrian Levy.  Levy argues that each of these outcomes should be assessed and should include both the successes and the limitations of each aspect.  The idea is that there should be operational measurements of patients’ interactions with the healthcare system that would include patients’ experiences in hospitals, using measurements of their functional abilities and their qualities of life following discharge.  The results of patients’ interactions with the healthcare system should be utilized to develop and improve the delivery of healthcare treatment, as well as to develop policy changes that would affect the entire field of healthcare in the United States.

One view of the state of American healthcare is that the system is fragmented; there have been many failed attempts by several presidents to introduce the idea of universal healthcare.  Instead, American citizens are saddled with a system in which government pays either directly or indirectly for over 50% of the healthcare in our country, but the actual delivery of insurance and of care is undertaken by an assortment of private insurers, for-profit hospitals, and other parties who raise costs without increasing quality of service (Wells, Krugman, 2006.) If the United States were to switch to a single-payer system such as that provided in Canada, the government would directly provide insurance which would most likely be less expensive and provide better results than our current system.

It is clear that throwing money at a problem does not necessarily resolve it; the fact that the United States spends more than twice as much on healthcare provision as any other country in the world only makes it more ironic that when it comes to evaluating the service, Americans fall appallingly flat.  In my opinion, if the new healthcare reform bill had included a public option which would have taken the profit margin out of the equation, the nation and its citizens would have been in a much better position to receive quality healthcare.  The fact that people die every day from preventable illnesses and conditions simply because they do not have affordable insurance is a national disgrace.  In addition, many of the people who have been the most adamantly against government “intrusion” into their healthcare are actually on Medicaid or Medicare, federally-funded programs.  Their lack of understanding of what the debate actually involves is striking, and they are rallying against what is in their own best interests.  These are people that equate Federal involvement in healthcare as socialism.  Unless and until our healthcare system is able to provide what is needed to all of its citizens, all claims that we have the best healthcare system in the world are, sadly, utterly hollow.

Adrian R Levy (2005, December). Categorizing outcomes of Health Care delivery. Clinical and investigative medicine, pp. 347-351.

Arthur Garson (2000). The U.S. Healthcare System 2010: Problems Principles and Potential Solutions. Retrieved July 3, 2010, from Circulation: The Journal of the American Heart Association: http://circ.ahajournals.org/cgi/reprint/101/16/2015

The Free Dictionary. (n.d.). Farlex. Retrieved July 3, 2010. http://www.thefreedictionary.com/system

World Health Organization. (2003, July). WHO World Health Report 2000. Retrieved July 3, 2010, from State of World Health: http://faculty.washington.edu/ely/Report2000.htm

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Why the US healthcare system is failing, and what might rescue it

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• Arnold Relman , professor emeritus of medicine and social medicine, Harvard Medical School, Boston, Massachusetts, USA
• arnoldrelman{at}gmail.com

The US healthcare system is by far the most expensive in the world, but it now leaves about 50 million of its citizens totally without coverage and fails to provide adequate protection for millions more. And the quality of care is on average inferior to that of countries that spend much less. Can the rise of multispecialty groups make US medical care much more affordable and efficient?

The US healthcare system seems headed for bankruptcy because of its ever increasing and unsustainable costs. These costs will be effectively controlled only by legislative reforms in the insurance and payment for medical care, but the prospects of such legislation will depend on a more favourable political climate and stronger public support. However, legislation will accomplish little unless the organisation of medical services also changes. The recent movement of US physicians into large multispecialty groups suggests that this reorganisation of medical care may already be under way. If this trend continues, it could not only facilitate the enactment of legislation, but also help to make our medical care much more affordable and efficient.

At present, most US physicians are in solo practice or belong to small, single specialty partnerships, but new social and economic forces are beginning to make employment in large multispecialty groups a more attractive option. About a quarter of all US practitioners are now employed in such groups, which are being formed by independent physician organisations and by hospitals. If their number continues to increase and if they eventually represent the great majority of practising physicians, a wave of legislative reforms could be initiated that transforms our currently dysfunctional healthcare system. But before I say more about this move towards group practice and how it might improve prospects for reform, readers need to understand how and why our health system has been failing. I should also describe the extensive health legislation enacted by the Democrats in 2010, and explain how it falls short of providing the kind of major reforms that would be required to rescue our healthcare system.

The US system is a confusing hodgepodge that makes no sense to informed observers. Although it is by far the most expensive in the world, it now leaves about 50 million of its citizens totally without coverage and fails to provide adequate protection for millions more. Most people also have no support for the cost of long term or rehabilitative care. And, despite huge expenditures, the quality of care is highly variable—but on average inferior to many advanced countries that spend much less. The best physicians and hospitals and the best care available in the US are among the finest to be found anywhere, but access to that care is grossly uneven. Many receive substandard care and far too many receive virtually no care except when illness is far advanced or there is an emergency. 1 2

Why the huge cost and the inefficiency?

What explains this paradox? Why do we spend so much on medical care without anything like a commensurate return, and how does our system differ from those in other countries that spend barely half as much but do so much better? In my view, by far the most important explanation—the primary cause of our unique problems—is that the US, alone among all advanced Western countries, has allowed its healthcare system to become a market and its physicians to behave as if they were in business. 3 In the US medical care has become a huge, competitive industry with many private investors, but with relatively little government regulation. Involving more than $2.7 trillion (£1.7 trillion; €2 trillion), the US healthcare industry now constitutes nearly 18% of our entire economy and it continues to expand. Its growth has slowed during the past two years, largely reflecting the effect of the recession in reducing employment based insurance and the ability of most people to afford care that is not mostly paid by insurance. Expenditures will probably resume their rise when the economy improves and new federal commitments to pay for care are implemented in the years ahead.

The US is a clear example of what happens when medical care becomes a commodity in trade rather than a social service. Because the market for medical care differs so much from other markets, classical market forces do not exert their usual control over buyers and sellers and hence do not regulate supply and demand. 4 In the US medical market, those who largely control the supply of services (physicians) also largely determine the demand. Of course, the patients’ complaints, illnesses, and injuries also play an important role, but it is the physician who interprets them and knows what services are needed for diagnosis, treatment, and prevention. It is also the physician on whom the consumer (that is, the patient) relies for advice. The fee for service payment system through which most physicians are paid gives them a strong economic incentive to be overly generous in their recommendations and provision of services, especially since they are well aware of their reimbursement for the services they provide, but are usually unfamiliar with the charges made to insurers by laboratories, hospitals, and other facilities for the services they recommend.

These facilities, whether paid for each individual item of service or for an episode of care (for example, a day in the hospital or a visit to a clinic), also have strong economic incentives to maximise the volume of their profitable services and increase the referral of paying patients. So, in addition to direct marketing to consumers, they encourage doctors to use their facilities and to refer patients by offering many kinds of favours and financial arrangements. Medical products (prescription drugs, devices, and equipment), which account for more than 15% of costs, are also promoted by manufacturers like commodities in trade rather than being used only according to medical need. Marcia Angell’s much discussed 2011 article documents this behaviour by manufacturers of psychoactive drugs. 5 To increase their sales, manufacturers depend on direct marketing to patients, and give financial and other inducements to the physicians who prescribe them. While not unique to the US, these practices are more pervasive in the US than elsewhere. The conflicts of interest that stem from attempts by manufacturers to influence the behaviour of physicians add to the unnecessary costs of the system.

Not only is there little or no government regulation of the volume of services and products in the US healthcare market, but there is also very little regulation of prices—far less than in most other advanced countries. The commercial competition encouraged by this lax regulation affects the behaviour of all players in the market. No more than half of the US health economy involves investor owned organisations and institutions, but most of the others (so called not-for-profits) also see themselves as businesses competing for market share, so they act very much like their for-profit, investor owned competitors. Virtually all organisations and many physicians seek to maximise their income. The net result is the virtually unrestrained growth of health costs, driven not simply by medical need but by economic incentives.

In addition to the cost of a medical care system driven by these economic incentives, there is the huge cost exacted by the dependence of the US system on private for-profit insurance plans. Numbering in the hundreds, but increasingly being consolidated within a relatively few giant corporations, these private plans insure or provide billing and collecting services for more than half of the total population. This includes most of those covered through their place of employment and those who are self insured. In addition, about a quarter of those over 65 have opted to have Medicare pay for their care through private plans, apparently in response to vigorous marketing by private insurers who offer a few services not available in Medicare. Altogether, private insurance plans comprise a huge and growing industry, with a gross income of more than $800bn. Their profits and business overheads vary considerably but average between 15% and 25% of their premiums. The US government estimates private insurance plans added over $150bn to the cost of healthcare in 2011. 6 (The overhead expenses of Medicare are less than 5% of total expenditures.) Despite their claims to the contrary, these plans add little or nothing to the value of the insurance they sell or service that is even close to their added cost. 7 No other country is as dependent on relatively unregulated private for-profit insurance plans as is the US. Other advanced countries, such as France and Switzerland, include private insurance plans as a central part of their health system, but these plans are not-for-profit and are much more tightly regulated by government than in the US.

The costs of both halves of the US healthcare system—the publicly insured and the privately insured—have been rising at an unsustainable rate, but over the years the privately insured half has risen slightly more rapidly. Despite its much lower overheads and its not-for-profit organisation, the rising cost of public insurance has continued to follow the inflationary trajectory of the private sector. This rise is explained in part by the ageing of the population and the increasing number of citizens reaching the Medicare eligible age of 65. But the chief reasons are that the payment methods and the economic incentives of doctors and hospitals are largely the same throughout the system.

Furthermore, since both public and private insurance plans function largely through billing by fee for service, they are both open to fraudulent billing and inflated charges that enable unscrupulous providers to game the system and extract larger than justified payments. Estimates often made in the media by experts place the cost of fraud and abuse at about 5% to 10% of the total cost of personal care. Another factor driving costs in both publicly and privately insured sectors of the US system is the fear of malpractice litigation and the so called defensive behaviour of physicians who order many tests and procedures to protect themselves against possible lawsuits if anything should go wrong. There are no reliable estimates of how much unnecessary medical service results from defensive practice, but most experts agree it may be a significant but not major contribution to health costs.

The Affordable Care Act of 2010

Although the crisis in the US system is primarily caused by its costs, most of the healthcare legislation enacted in the past few years has been concerned with extending and protecting insurance benefits. A landmark bill, the Affordable Care Act (ACA) was passed by the Democratic controlled Congress in March of 2010. An excellent, readable summary of this huge and complicated legislation can be found in a recent book by McDonough. 8 Democrats have acclaimed the ACA as a major step forward in solving the US system’s problems, but many liberals, like me, have reservations. 9 The act does promise to cover more of the cost of drugs, to offer subsidised private coverage to about 16 million uninsured citizens, to help states extend Medicaid coverage to another 16 million and prevent private insurers from denying coverage to those with pre-existing illnesses or dropping coverage of those who develop expensive illnesses while being insured. Most of these benefits are not scheduled to start until 2014—although a few have already begun. The law does contain major advances but, despite its name, it has no provisions that will reliably control rising costs. To persuade the politically powerful private insurance industry to support (or, at least, not oppose) the passage of this legislation, President Obama had to agree to include in the law a requirement that all uninsured individuals buy private insurance or be fined—the so called insurance mandate. He also agreed to eliminate from the law a provision that would have allowed those with private insurance to choose a “public option,” that is, to choose a public plan similar to Medicare.

Republicans are strongly opposed to the ACA, and particularly to its insurance mandate. They believe it gives more power to the executive branch of government than the US Constitution allows, and they have brought the issue to the Supreme Court, which heard the case in March and will probably announce a decision in June. The ACA will be a central issue in the upcoming presidential campaign, with all potential Republican nominees pledged to seek immediate legislative annulment of the law if they are elected—assuming it is still standing after the Supreme Court hands down its opinion. The future shape of our healthcare system will therefore depend greatly on legal and electoral decisions made this year.

Some provisions in the ACA that have not yet been fully implemented, and a few initiatives already started by private insurers experiment with replacing the fee for service payment system with new arrangements. They pay providers for episodes of care, or encourage groups of physicians to share in any savings from assuming the comprehensive care of a designated panel of patients. These physician groups, affiliated with one or more hospitals, are called “accountable care organisations” and 32 such organisations in various parts of the country have recently signed contracts to try this model. It is much too early to know whether these initiatives will save money and be acceptable to doctors and their patients—or even whether they can function as expected—but they are being hailed by the Obama administration and by those who believe that modest changes in the present insurance and payments systems can control costs and improve the quality of care. I believe this is unrealistic, because they may never be fully completed and because they do not address the basic problems with the current system. 9

Major reform is needed

I am convinced that the impending national cost crisis and the bankruptcy of our healthcare system will not be averted unless there is much more drastic and systematic reform. 7 We will have to replace all our insurance systems, public and private, with a single public plan that guarantees universal access to prepaid, comprehensive care, and this plan should be funded by a progressive healthcare tax that all citizens (including government officials) must pay according to their means. Prepaid comprehensive care funded in this way would give government firm control over its total health expenditures while leaving decisions on the specific use of available resources where it should be—in the hands of physicians and their patients. By setting the rate of the healthcare tax, government would in effect be capping its costs. Any medical services provided outside the system would be at the patients’ expense.

To provide this kind of prepaid comprehensive care, we will need a reorganised medical care system based on private, non-profit, multispecialty group practices, in which physicians are paid largely or entirely by salary. If fee for service payment is to be largely or entirely replaced by prepaid, capitated payment, we will need medical organisations that can accept such payment and distribute an agreed, total percentage to physicians through salaries. The kind of multispecialty group practice that I have described in more detail elsewhere would be the ideal organisation to serve this function. 10

There are ample reasons and considerable empirical evidence to suggest that group practices can deliver care more efficiently than unorganised physicians in solo or small, single specialty partnership practices who compete for income and depend on fee for service payment. 11 Multispecialty groups usually include adequate numbers of primary care physicians who integrate and moderate the procedure based behaviour of the specialists. Most experts agree that substantial savings, as well as improved care, can be anticipated when primary care physicians collaborate with specialists in well organised groups. Without the fee for service incentive, prepaid salaried groups of this kind are less driven to unnecessary or duplicative services. And if the system is funded entirely by government without involving bills, the costs of insurance overheads and fraudulent billing are avoided. The potential savings would be enormous—a reduction of 30% to 40% in total expenditures would be a conservative estimate.

Multispecialty practices—the future

Multispecialty, physician managed group practices already exist in many parts of the US, mostly in the west, and least in the southeastern states. Some are well known, long established, and highly reputed. Only a few groups pay full salaries and most are still dependent on fee for service payment from multiple public and private insurers. However, the number of group practices in the country of all kinds and the number of physicians employed in these practices are increasing rapidly. There are at present over 400 such groups, employing nearly 200 000 physicians (about 25% of all practising physicians). These numbers are increasing at about 10% per year, according to information recently given to me by the American Medical Group Association, the organisation that represents most multispecialty groups.

There are many reasons why so many US physicians seem to be abandoning private practice in favour of seeking employment in large groups. Many starting physicians have acquired large personal debts during the course of their education and cannot afford the investment and financial risk of setting up their own practice. The supporting staff and facilities available in group practices and the assistance they offer with the business and administrative expenses of practice are very attractive; so are the retirement and fringe benefits. Furthermore, young US physicians nowadays are much more interested than formerly in practice settings that allow them to share responsibilities with colleagues and to work specified hours rather than assuming the heavy time demands of solo or small partnership practice. This is particularly true of women physicians, who shortly will constitute half of the physician workforce. But physicians of both genders are increasingly interested in a professional career that allows them more time for family and personal affairs. Employment (full or part time) in large groups provides that opportunity.

For their part, hospitals and physician organisations are eager to establish group practices because of the growing interest of public and private insurance plans in controlling costs by contractual arrangements with groups of physicians rather than individual practitioners. If this trend continues, soon the great majority of US physicians will be employed in large multispecialty groups and the prospects for major reform of the healthcare system will have greatly improved.

With so many physicians employed in multispecialty practices it would be much easier to institute new payment methods that replace insurance based reimbursement for itemised services with tax supported prepaid access to comprehensive care. If group practice proves popular with patients and physicians, and is increasingly perceived as an effective way to control costs and improve quality of care, it would also be much easier to persuade physicians in the groups to accept payment by salaries instead of fee for service. Popular pressure on Congress to enact reforms that are now politically impossible is more likely to be successful when most physicians are happily employed in multispecialty groups, and these groups are delivering good, affordable care.

Fierce resistance to reform can be expected from the private insurance industry, from Republicans in Congress, and from all those with vested financial interests in the status quo, so it is quite possible that the necessary legislation would be stalled until our health system faces bankruptcy, or even for an indefinite time after that. The misguided view that healthcare is primarily a business and that it requires the intervention of private insurance plans is so deeply embedded in US culture that legislation changing it to a universal right supported by government may be a long time in coming, and will certainly depend on how the political climate changes. But sooner or later reality will prevail, because a health system largely shaped by free market forces and heavily dependent on private insurance will never provide the whole US population with good medical care at an affordable cost.

The inevitable change in the health system, when it finally comes, won’t be achieved by a single legislative act of Congress. There will probably be stepwise increments—perhaps starting with reforms in various states. But I am convinced that tax supported, not-for-profit multispecialty group practice is necessary for the rescue of the US healthcare system. So the prospects for major health reform in the US depend on whether its physicians continue to choose employment in groups, and whether insurance plans are ultimately replaced by a single public payer that provides universal access to comprehensive care rather than itemised reimbursement for services.

Arnold Relman biography

Arnold Relman was editor of the New England Journal of Medicine from 1977 to 1991. He is the author of A Second Opinion: Rescuing America’s Health Care . He qualified in medicine at Columbia University, New York, in 1946, and then began research in nephrology and electrolyte balance while at Yale. In 1966 and 1974 he coedited two volumes of Controversy in Internal Medicine.

Cite this as: BMJ 2012;344:e3052

Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

Provenance and peer review: Commissioned, externally peer reviewed.

• ↵ Davis K, Schoen C, Stremikis K. Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally: 2010 update. The Commonwealth Fund, June 2010.
• ↵ Squires DA. The U.S. health system in perspective: A comparison of twelve industrialized nations. The Commonwealth Fund, July 2011.
• ↵ Relman AS. A second opinion. Rescuing America’s health care. Public Affairs, 2010.
• ↵ Arrow KJ. Uncertainty and the welfare economics of medical care. American Economic Review 1963 ; 53 : 941 -73. OpenUrl CrossRef Web of Science
• ↵ Angell ME. The epidemic of mental illness: Why? The New York Review , June 23, 2011 :20-2.
• ↵ Keehan SP, Sisko AM, Truffer CJ, et al. National health spending projections through 2020: Economic recovery and reform drive faster spending growth. Health Aff 2011 ; 30 : 1594 -1605. OpenUrl Abstract / FREE Full Text
• ↵ Relman AS. In dire health. The American Prospect 2012 ; 23 : 34 -7. OpenUrl
• ↵ McDonough JE. Inside national health reform. University of California Press, 2011.
• ↵ Relman AS. Health care: The disquieting truth. The New York Review 30 September 2010 :45-8.
• ↵ Relman AS. How doctors could rescue health care. The New York Review 27 October 2011 :14-18.
• ↵ Enthoven AC, Tollen LA, eds. Toward a 21st century health system. The contributions and promise of prepaid group practice. Jossey-Bass, 2004.

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Health Care in America

Michael Winther June 15, 2009 Essays

An IPS Essay By Michael R. Winther, President of the Institute for Principle Studies

The following article was originally published in early 1994. At the time that he wrote this article, Mike Winther was the Executive Director of the Society for Handicapped, a Modesto, California-based charity. Although this article was written over a decade ago, we feel that it is still timely and relevant to the health care crisis that is once again front-page news in America. We hope this re-publishing will be of educational benefit to our current readership.

Introduction

The debate over health care in America is now front-page news almost every day. Everyone seems to agree that there is something wrong with the system and that something should be done—but what should we do? This issue is obviously important to all Americans, but it is of vastly greater importance to those who, because of disability or age, find themselves more dependent on medical care than the average American. The truth of the matter is that the disabled and elderly stand to benefit most from a good medical care system. Conversely, it is the disabled and elderly who will suffer the most from a bad system.

In this series of articles, we will attempt to go past the political game-playing and look at the real causes and solutions of our health care woes. We will also look at the experiences of other industrialized nations that have tried systems very similar to what is being proposed in America.

PART ONE: Making the Proper Diagnosis

A good physician never prescribes medicine without first giving the patient a complete examination. The doctor knows that selecting the right medication depends on properly diagnosing the patient’s condition. An incorrect diagnosis could result in the wrong drug being administered. The wrong medicine will certainly not promote the patient’s health, and it may even prove fatal.

As we tinker with the health of an entire nation, should we be any less diligent in our diagnosis? After all, a doctor’s incorrect diagnosis harms only one patient, but a misdiagnosis of our nation’s health care system could devastate the health of ten’s of millions.

As I watch the health care debate, one of my greatest concerns is that there is very little emphasis on identifying the causes of the problem. Yes, everyone knows that health care costs are going through the roof, but do we really understand why? I doubt that one person in 100 really understands why costs are out of control, but most of these people think they have a solution anyway. Before we discuss possible solutions, let’s make sure that we understand the problems and their causes. I have identified six factors that contribute substantially to the escalating cost of America’s health care.

Causes of high health care costs:

1. Inadequate supply of health care providers. 2. Over-use of services (excess demand). 3. Lack of consumer price consciousness. 4. Excessive regulation & mandated costs. 5. High risk lifestyles and activities of Americans. 6. Excessive litigation & liability costs.

While this is certainly not a comprehensive list, it covers the causes most frequently identified by “experts” on all sides of the political fence. If this list does reflect the major causes of rising health care costs (which I believe it does), then any real “solution” to the health care crisis must address most, if not all, of these problems. Therefore, any “cure” that does not address these problems, or that makes one of these factors worse, is certainly the wrong medicine.

PART TWO: Supply & Demand

A look at “supply”.

The first two items of the list relate to the supply and demand for medical care. An understanding of supply and demand is absolutely essential to any discussion of prices. Price is simply where supply and demand meet. In this regard, medical care is no different than any other product or service. Everyone has heard of “supply and demand”, but few people have applied this basic concept to medical care.

Imagine for a minute what would happen if we convinced one-half of America’s doctors to retire. This instant shortage of doctors would result in long waits, and those doctors remaining in practice would raise their rates significantly. The reduced supply creates shortages and price increases.

Instead of retiring doctors, what if could magically double the number of well trained and qualified physicians? There would certainly be little or no wait to see a doctor, and prices for an office visit would drop considerably. The increased supply creates better availability and reduced prices.

The idea of increasing the number of doctors, nurses, etc. is a sensitive issue with medical professionals who don’t want to see the standards of their profession compromised—or to see their profession flooded with additional competition. But the truth of the matter is that there is no oversupply of health care providers; in fact, just the opposite is true. Statistics on the average work week of U.S. physicians reinforces what local doctors tell me: they are working very long hours, they are seeing more patients than ever before, and they still cannot keep up with demand. An article appearing in the July 27th issue of the Washington Times stated that, “U.S. physicians fresh out of their residencies are being riddled with job offers.” The article continues, “Two-thirds of young doctors receive at least 50 job offers during their residencies and almost 50 percent receive more than 100.”

The U.S. has approximately 120 medical schools that each average about 100 admissions a year. U.C. Davis Medical School, with 93 positions, has over 5,000 applicants each year. Some medical schools will have over 10,000 applications this year. Unfortunately, many of our best and brightest students will never make it into medical school.

Instead of increasing medical school enrollment, some medical schools have actually reduced the number of annual admissions. In the mid 1980’s, U.C. Davis Medical School admitted 100 students each year; they now admit 93.

As our population has grown larger and older, our supply of trained doctors, nurses, and other professionals has not kept up with the increased demand. It should come as no surprise that health care costs are rising. What is surprising is that none of the current health care proposals make any effort to deal with the supply of health care providers.

A Look At “Demand”

The demand for health care services is indeed increasing significantly in America. There are four major causes of this surge in demand: 1) the aging of America, 2) poor health habits and lifestyles of Americans, 3) the needs of Canadians and others who purchase much of their medical care in the U.S., and 4) the increasing prevalence of third party payers (insurance). The first two factors on this list are widely discussed in the media, but the last two are largely ignored.

Most commentators have discussed the impact of an aging population on the demand for medical care. As medical science enables us to live longer, it also increases the number of years that we consume medical care. It should be obvious that the elderly generally consume more medical care services than the young. As the baby boom generation approaches their golden years, this too will place added stress on our health care providers. The aging “problem” (while it is a contributor to rising demand) is really not a problem as much as it is a tribute to the successes of our health care providers and medical technologies. This “problem” is the result of a health care system that works relatively well.

A second factor affecting the need for health care stems from the risky lifestyle choices of some members of society. Risky behaviors (such as smoking, drug abuse, and gang membership, to name just a few) result in a heavy burden on our medical care system. While these problems will always be with us, we must be careful that our public policy on health care does not encourage these risky activities. In politics there is a well-proven rule of thumb which states, “Subsidize an activity and you will get more of it; tax an activity and you will have less of it.”

Make no mistake—universal health care makes the health-conscious taxpayer pay for the excessive medical needs of those who choose not to protect their health.

In many industrialized countries with government-run health care systems, drug abusers and prostitutes are provided plentiful and free medical care (at taxpayer expense), while many elderly and disabled are denied medical procedures because they are less productive members of society. If you think that this dangerous policy can’t happen here, you should spent some time studying some of the health care reform packages being proposed in Washington… it may very well happen here.

The third factor placing high demand on our health care delivery system may surprise many readers. In addition to serving the needs of Americans, our health care providers are also providing care to many residents of other countries. Of primary significance are Canadians, many of whom travel to the U.S. for medical services.

Due to the geography of Canada, most Canadians live in the southern third of the country and can travel to the U.S. in a short amount of time. Because of Canada’s socialized health care system, many Canadians face long waits for medical procedures that are readily available in the U.S. For example, the wait for a pap smear in most areas of Canada is 5 months, and the wait for hip replacement surgery is about 18 months. The result is predicable: many Canadians, especially middle and upper income families, find it tempting (even necessary) to come to the U.S. for care. These people come to the U.S. and pay full price for the services of our doctors, clinics, and hospitals instead of utilizing the nearly “free” Canadian medical care that they have already paid for with their tax dollars. In some cases, the Canadian government will pay part of the bill for the U.S. hospital visit, but many Canadians come knowing that they will pay much, if not all, of the cost.

How significant is this medical border crossing? While precise figures are not available, some sources estimate that as many as 25% of Canadians come to the U.S. for a significant portion of their medical care. These are important things to remember when someone tells you that the Canadian system is desirable because they have lower per capita health care costs.

The fourth significant factor causing higher demand for health care stems from the increased dependence on third party payers (health insurance). As more and more people obtain comprehensive health insurance, we have fewer cost-conscious consumers when it comes to buying medical care. This is true of both private insurance and government insurance. I have to confess that our family is more likely to go to the doctor when we have met our deductible—knowing that our insurance will be paying all, or most, of the bill. This is human nature, and it is a very good reason why universal comprehensive health insurance will significantly increase demand for medical care.

Some argue that over-utilization can be prevented as long as there is a small co-payment required of the insured with each doctor visit. Co-payments do prevent some over-utilization, but for most people, a $5 co-payment is a very small discouragement when the consumer perceives that they are getting a $40, $50, or $60 visit for their five dollars.

A local college professor who teaches finance has frequently been quoted as saying, “Insurance is best when it covers the unlikely.” This is sound advice that applies equally well to all types of insurance. When insurance begins to cover likely and routine expenses, it is never a smart economic decision. Low deductible, comprehensive coverage encourages people to over-utilize services. This increased demand results in upward pressure on medical prices.

Imagine, for a moment, what would happen if everyone’s auto insurance covered routine maintenance like oil changes and wiper blades. You could just go to your mechanic, have the work done, and the mechanic would be reimbursed by your insurance company. Mechanics would certainly be very busy. In fact, I can imagine that a system such as this would improve the profitability of an auto shop to the extent that many new shops would open up, and existing shops would hire more mechanics.

Now imagine what would happen if we passed a law that limited the supply of mechanics. Certainly the cost of auto repair and the cost of auto insurance premiums would go through the roof. Sound familiar?

When families purchase only catastrophic health coverage and pay for other health care costs from their own pockets, studies show that overall health expenses plummet.

We need to preserve people’s choice to purchase any type of insurance they desire, but unfortunately our tax code encourages the purchase of low deductible health insurance by employers. Many employees covered by these plans would likely choose higher deductible insurance (or simply major medical insurance) were it not for the fact that the employer can provide this benefit tax-free.

Health insurance is an important and necessary part of any good health care system, but health insurance, like all insurance, is only cost effective when it covers unlikely events like major surgeries or illnesses. Our present government policy encourages employers and consumers to make insurance purchase decisions that would normally be unwise. The end result is that millions of consumers have no desire to spend their health care dollars wisely, and many are encouraged to over-utilize the system. Should we be surprised that health care prices are rising?

What will happen to demand—and subsequently to prices—if we pass public-financed comprehensive universal health insurance for everyone?

PART THREE: Is Rationing In Our Future?

The concept of “rationing” is somewhat foreign to most Americans. Sure, some may remember rationing of gasoline and other strategic materials during World War II, but most of us have no concept of how difficult life can be when a vital product or service is rationed by the government. Nevertheless, unless enough Americans object, we will be under a rationing system for our health care within a few short years. If you think that health care rationing won’t happen in American, please read on.

The early Clinton plan is brazen enough to implement rationing and to call it exactly that. However, I suspect that before this legislation—or any similar legislation—is passed, all references to rationing will be given more acceptable names. It might be called “managed allocation of resources” or any number of other euphemisms, but in principle, the result will be the same: rationing.

In a recent article in the Journal of the American Medical Association, David Orentlicher (a medical doctor and attorney) writes:

As the United States moves toward a system of universal access to basic health care benefits, it is clear that not all medically beneficial treatments will be provided. While there is a good deal of wasteful health care spending, most commentators believe that sufficient cost savings cannot be achieved without some restrictions on useful services.

This conclusion should not surprise anyone who has read the first two articles in this series. Since the supply of medical care in America is being artificially limited, and since demand is increasing, price increases are the natural result. If we don’t do anything to increase the supply of medical care (and none of the current proposals do), then the only way to reduce cost is to artificially cut off demand (rationing). **Stacey, this is a potential pull quote.**

The evidence that any form of universal health care (socialized medicine) will result in rationing is overwhelming. First, every country that has adopted any form of national health care or universal health care has made the rationing of services part of their system. Second, those promoting universal health care in America readily grant that rationing will be necessary. Third, even our current publicly-funded health programs for the indigent, elderly, and disabled, limit necessary and beneficial care.

Fortunately, under our current (non-universal) system, only the government payments for medical care are rationed. This means that a government decision not to provide a particular medical procedure does not prevent the patient from finding outside funding for the cost. In our present system, friends, family, charities, and other civic-minded groups can “chip in” to pay for the necessary service. This would not be the case under most universal health care programs, which would actually ration the medical care itself. Under these proposals, certain procedures would be unavailable to certain individuals regardless of their ability to pay.

While this is not a very pleasant picture for anyone, it is especially bleak for the disabled. An inevitable result of rationing is that society (government) will have to decide which procedures will do the most “good” and which patients will “benefit” most from the medical care. The result is that health care dollars will go disproportionately toward the young and able. The experience of the industrialized countries of Europe supports this conclusion. Not only are the disabled and elderly refused treatment that is available to younger or non-disabled patients, but these systems encourage those with disabilities to volunteer for euthanasia (mercy killing).

In Holland, for example, doctors suggest suicide to non-terminally ill debilitated patients. The Washington Times has reported that “voluntary euthanasia” is a common and accepted practice in the Netherlands. According to the London Sunday Observer, euthanasia is administered to people with diabetes, multiple sclerosis, and rheumatism. Articles in British medical journals have reported that cost containment is the overriding goal of most European medical systems. There is no better way to contain costs than to eliminate those requiring significant amounts of medical care.

In America we have gone to considerable effort to prevent discrimination against the disabled. Congress has passed many laws attempting to protect the rights of the disabled, including the recent Americans With Disabilities Act (ADA). Despite all of these laws, however, many legal and medical experts believe that the coming health care rationing will allow methods of rationing that would make it very difficult for some disabled to receive certain types of medical care. One of these experts is David Orentlicher, who is quoted above. In his recent article, he discusses many of the legal issues relating to the Americans with Disabilities Act and health care rationing. He makes a strong case for the view that ADA would probably not prevent the adverse impact of rationing on the disabled and elderly.

As discussed in parts one and two of this series, the real solutions to the high cost of our medical care involve increasing the supply of health care providers and reducing reliance on third party payers. Unfortunately, the major media and our elected officials ignore this important issue.

When we look at the health care systems of Europe and Canada, it is clear that their systems are inferior to our own. Why then do our politicians push us to adopt plans like the systems in Canada and Europe? The problem with the entire health care debate is that everyone is looking to a government-mandated, government-run system as the solution to a “crisis” that may not be as bad as the proposed solutions.

We should remember that everyone suffers when care is rationed, but certainly the aged and disabled have the most to fear.

PART FOUR: The Big Squeeze!

Charities & non-profit organizations are being squeezed out of health care.

Every year in America, non profit organizations and charities raise hundreds of millions of dollars to help provide medical care and medical devices to the indigent. These groups include churches, service clubs, foundations, professional associations, and a variety of other charities. They are able to provide funds (and—as a result—medical care) to countless numbers of low income people without the permission of any government agency. But under the leading health care “solutions” being proposed in Congress, many of these organizations will be put out of the charitable health care business.

Raise the money, buy the care.

In our current health care system, as with almost every area of our economy, money can buy almost any product or service deemed necessary by the consumer. While this is a frightening thought to those with thin pocketbooks, at least this system provides an open door through which charities can provide assistance. As the director of an organization that devotes a portion of its budget to purchasing medical devices for those with limited income, I am concerned about high health care prices, but I am even more concerned about health care availability. Higher prices may require us to raise more money to help someone, and higher prices may even reduce the number of people that we are able to help, but at least we can still help. However, if the health care is unavailable or if it is rationed, no amount of fundraising will buy the necessary services for our clients.

Under these proposed health care plans, there will be two types of health care: affordable care and no care. **Potential pull-quote** If the government makes health care available through its “rationing” plan, it will be affordable. But if it is on the wrong side of the government’s coverage charts, then it will not be available at all, regardless of cost.

Where does this leave our charitable efforts? It means that some organizations will close their doors. Others will simply redirect their efforts away from health care to other activities. This will inevitably leave more people without care, and it will greatly increase the financial burden on government as it tries to fill the gap.

As government does more in a specific area, private charities will generally do less. **Potential pull-quote**

PART FIVE: Cost Vs. Availability

While visiting a retired relative recently, I picked up a magazine off the coffee table. It was a well known and widely circulated publication that is received by millions of retired Americans. One of the articles featured a survey that asked senior citizens in many industrialized countries to state their greatest health care concern. A high percentage of seniors in America stated that the cost of health care was their greatest concern. Seniors in other countries, however, didn’t seem to find cost to be a problem at all.

The article pointed out that the U.S. is the only industrialized country lacking some form of universal socialized health care. This observation is quite correct. The fact that the government pays for much, if not all, of people’s health care in these other countries (Europe and Canada) would certainly explain the survey results. Conspicuously absent from the article, however, was any mention of what the European and Canadian seniors felt was their greatest health care concern. However, based on what we know about these systems, we can confidently conclude that availability and waiting times would probably be at the top of the list for residents in these countries.

If you can’t get medical care, does it really matter whether it is because of cost or because of rationing? The only way to make more medical care available to some without taking it away from others is to have more providers in the system.

PART SIX: Is Health Care More Important Than Freedom?

The trend in modern society is toward the pursuit of more and more security. We want guaranteed employment, guaranteed retirement benefits, and guaranteed health care. The pursuit of these securities is a noble personal and family objective, as long as it remains a private pursuit. But as soon as our attempts to gain security enlist the use of government, our society sacrifices freedom of choice. Our grandparents called that freedom liberty.

In the public sector, any attempt to guarantee security will come at the expense of someone’s liberty. Government cannot give to one person without taking away from another. Both the “giver” and the “getter” lose freedom of choice in the process. The “giver” loses the ability to decide how to spend their money, since it is taxed away in order to fund health care services for the “getter”. And since a government that funds a program has the right to control how the funds are used, the “getter” loses the ability to make decisions about how, when, and where to purchase their medical care. Under a universal health care system, most Americans become both “givers” and “getters”, and are denied personal liberties on both sides of the system.

The irony of the whole political process is that the more we strive for economic security, the less of it we have. There are some widely accepted rules of economics that account for this (which I won’t delve into here), but we can see evidence of this principle throughout America and the world.

The efforts of Europe and Canada to guarantee universal health care, as discussed in our section on rationing, resulted in more health care security for some but far less for others. These nations have traded a health care system that previously limited access based on ability to pay for one that now limits access based on government rationing and scarcity.

Nothing in these programs produced any more health care—they just changed the allocation of existing resources, and charged the taxpayers for the bureaucracy necessary to accomplish the task.

Here are some questions to ponder:

Should we have the freedom… … to choose our own doctor? … to chose the type of treatment we desire? … to choose how we pay for our medical care? … to purchase only high deductible, catastrophic health insurance? … to purchase low deductible, comprehensive health insurance? … to choose not to purchase health insurance at all?

Personally, I want the freedom to make each of these decisions. As an individual, I may not always make the best decision, but my motives will always be pure. I will learn from my mistakes because I will suffer the consequences of them. And no one else will suffer for my mistakes. Can the same be said of any mandatory public-funded system?

PART SEVEN: What Should Be Our Public Policy on Health Care?

1) Modify our government policies that limit the supply of health care providers.

We need more doctors, more nurses, and more trained health technicians—not less. However, our current system allows the supply of these important professionals to be artificially capped.

2) Review government regulation of the health care industry to reduce unnecessary and duplicative regulations and paperwork.

In a recently published book, Edward Annis, M.D., former President of the AMA, claims that prior to Medicare, the average physician spent one-fifth of his or her time caring for the poor. But today, the average physician spends one-fifth of his or her time on regulatory paperwork.

Experts disagree as to how much government paperwork adds to the cost of medical care, but even the most avid proponent of the government regulation will admit that at least 20% of health care costs are for government paperwork. Even President Clinton in his State of the Union Address in 1993 admitted that regulations add over 20% to American’s health care costs, and some sources claim that the figure is closer to 35%.

The only way to reduce these costs is to have less government involvement in health care. More government involvement in medicine will only increase paperwork and regulatory costs.

3) Health insurance needs to cover less not more.

Health insurance, like any other insurance, should cover the “expensive and unlikely” costs, not the “affordable and likely” costs. We need to eliminate tax incentives that encourage employers to buy insurance coverage for “affordable and likely” costs. It is this “over-insurance” that encourages consumers to over-utilize services, thus placing upward pressure on medical care prices.

When government provides full coverage for all, or part, of Americans, it creates the same upward pressure on prices. The result of universal health insurance will be a rapid rise in medical care prices. The only way to curtail these rising costs will be to reduce demand by rationing care.

What Can One Person Do?

1) Write to your representatives in the U.S. Congress and the U.S. Senate. Let them know that you oppose socialized medicine in any form. Encourage them to explore the real solutions outlined above.

2) Inform your friends and associates about the dangers of socialized medicine and rationing. Explain how rationing always discriminates against the disabled and the elderly. Explain that health care providers and individuals should decide who gets medical care—not the government. Provide them with a reprint of this article that we have published on this subject.

3) Write a letter to the editor of your local newspaper explaining just one or two of the issues discussed in these articles.

PART EIGHT: The Danger of Compromise

As discussed in previous sections, the leading health care reform proposals coming out of Washington D.C. contain some very radical and very undesirable features. These proposals are certainly dangerous to the health of Americans. Hopefully Americans will wake up, and these proposals will be soundly defeated. Unfortunately, the media has convinced most Americans that government action of some kind must be taken. So even if the Clinton proposal is defeated, there will probably be some “compromise” legislation that will pass. This “compromise” health care reform may only be half as bad as the Clinton proposals, but it will still ignore the real causes of our problems and will either fail to eradicate escalating costs, or it will ration access to necessary and beneficial care.

There is a well-used political strategy called the dialectic. Most readers may have used one or more variations of this technique in business negations. This strategy works like this: Let’s assume that your 13-year-old wants a $5.00 raise in his allowance. Let’s also assume that your teenager knows that you probably won’t give him as much as he asks for. Instead of asking for five dollars, the astute teen asks for an eight dollar raise, hoping that, after some discussion and debate, you will compromise and provide a raise in the five dollar range. Of course, the teenager would love an eight dollar raise, and if by reason of some temporary insanity you feel generous and consent to the initial request, you will get no complaint from your teenager.

The shrewd teen also knows that it is easier to obtain a lavish allowance in stages rather than all at once. Each compromise raise in allowance places the teenager closer to the ultimate goal.

Politics is no different. Those who want draconian proposals like the Clinton plan will strive for their goal relentlessly, but if it looks like their objective is out of reach, they will gladly negotiate a compromise that gives them part of what they want.

It is perhaps the “compromise” health care plan that is more difficult to defeat, and therefore more dangerous. After months of political battle, the opposition to socialized medicine will become fatigued by the issue. And when the compromise legislation shows up, it will receive much less opposition than would have been the case had it been the first and primary proposal.

Of course, if it passes, the less objectionable compromise legislation will be amended and expanded little by little. Within a decade, it may bear a surprisingly close resemblance to the original proposal, which was rejected as being too expensive, too restrictive, and otherwise undesirable.

Those who are concerned about issues like freedom of choice in health care, government spending and deficits, and the rights of the disabled and elderly to access health care, should oppose socialized medicine in any form. We should accept no compromise that enables government to restrict our freedom to choose providers, facilities, or treatments. We should accept no compromise that ignores the shortages of many types of health care professionals. We should accept no compromise that frees people from responsibility for their poor lifestyle choices. We should accept no compromise that crowds private charities out of providing health care. And last, but not least, we should accept no compromise that moves our country toward systems that have failed in the rest of the world.

In the words of Ben Franklin, “They that can give up a little essential liberty to obtain a little temporary safety deserve neither liberty nor safety.”

More than 20 Years Later

We should not make the mistake of assuming that the socialization of health care is a Republican vs. Democrat issue. Socialist thinking has permeated both political parties—and much of modern Christianity as well. A recent cover of Newsweek magazine boldly proclaimed: “We are all socialists now.” Unfortunately, this isn’t far from the truth.

It is ironic (but not surprising) that the most significant steps toward more socialism in medical care came not under the Clinton administration, but under the administration of George W. Bush. In 2003, Congress passed, and President Bush signed, the Medicare Prescription Drug, improvement, and Modernization Act, which expanded public funding and government control of America’s health care.

In 2007, United Press International quoted David Walker, then U.S. Comptroller General, as saying that this act (Medicare’s prescription drug program) might be the most financially irresponsible U.S. legislation passed in 40 years. This bill was commonly recognized as the single largest federal entitlement program since Lyndon Johnson’s Great Society. This “compromise” health care reform may only be half as bad as the Clinton proposals, but it will still ignore the real causes of our problems and will either fail to eradicate escalating costs, or it will ration access to necessary and beneficial care.

Bill and Hilary Clinton did not immediately achieve all of their health care objectives, but as was predicted in the 1994 article (our lead article for this issue of Principle Perspective), the proposed Clinton plans paved the way for compromise and then gradual steps toward their goal. The boldness of the Clinton health care effort made it possible for a Republican president to do what Hilary and Bill could not do, because the prescription drug plan seemed tame by comparison. This is a classic example of the dialectic strategy at work—thesis, antithesis, and then synthesis. These steps, if repeated, make the radical seem less radical—even reasonable.

Americans should not accept any “victory” in a watered-down, compromise version of a health care bill. Any and all movement toward the expansion of government involvement in health care should be emphatically opposed. Proponents of limited government and free markets need to go beyond defensive strategies. It is not enough to work to stop the further advances of socialism; instead, proponents of free markets need to become aggressive in promoting the repeal of older socialist programs. No matter how good the defense, no sports team ever wins without at least some offense.

Home — Essay Samples — Nursing & Health — Affordable Care Act — Health care in the United States

Health Care in The United States

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After assessing the lungs of a deceased patient, the thoracic surgeon Thomas Charrier (second from right) gives the green light for transplantation to his colleagues on the phone at the Foch hospital in Suresnes, Paris. This and all photos below taken on 9 December 2022 by Christophe Archambault/AFP. Courtesy Getty Images

Last hours of an organ donor

In the liminal time when the brain is dead but organs are kept alive, there is an urgent tenderness to medical care.

by Ronald W Dworkin   + BIO

My patient was dead before I even saw her. She had been in a car accident. Now she was scheduled for organ donation.

She was called an ‘ASA 6’. To estimate operative risk, the American Society of Anesthesiologists (ASA) has a classification system built around how sick a patient is, ranging from a healthy ASA 1 to a moribund ASA 5, the latter meaning someone is not expected to live 24 hours. When the system was created in the mid-20th century, a sixth class for dead people seemed pointless. Death was known to the dead only, and life to the living only, and between the two there had been no bridge. When the definition of death changed in the late 1960s, making it possible for a person to be ‘brain dead’ but with organs still very much alive and available for donation, a bridge appeared and a sixth class was created in the early 1980s. Since 1988, when officials started collecting organ transplant data, almost a million organ transplants have been performed in the United States. Most of the organs have come from brain-dead donors. In 2021 alone, the US had almost 10,000 such donors.

When told of my upcoming case, I had mixed feelings. On the one hand, being in perfect health, unaccustomed to suffering and therefore easily disconcerted by the thought of death, I was horrified. My attitude toward death was like that of a young person standing blindfolded and tied to a post, awaiting a volley from a firing squad. The whole concept made my blood run cold. Yet the case also aroused in me a feeling of relief. Simply put, there was no risk of malpractice, as my patient was already dead. Many anaesthesiologists have such self-centred thoughts when taking care of ASA 6 patients.

I n her early 30s, she had a youthful face, without the traces of severe illness that ICU patients typically have. With her hair wrapped inside a bright, polka-dotted kerchief, she gave off an expression of almost pleasant, good-humoured cheeriness.

Who was this young person whose life had been tragically snuffed out? I jabbed into every crack of her medical record to find out. But little had been written down. Both her life and death seemed simple enough to be chronicled in a few lines. Something had happened inside her brain with the car accident, and the end came.

We wheeled her toward the operating room. Before departing, I pulled the sheet over her exposed feet. Why? I had an objection to her being dead, but I had an even more serious objection to her being undignified. With my patient still partly in the world of the living, I wanted to keep a place for her in the part that pretends to be genteel.

Six hours she had been officially dead. Now she had re-entered the world of the living

When we arrived in the operating room, something turned over inside me, sank, and went cold. After all, she was dead. The day before, she was as whole as me – and now look. She would never rise again.

After we moved her from the gurney to the operating table, the doctors and nurses, so used to taking care of living patients, stared at one another stupidly, as if not knowing why they had come together or why they stood around the table. For a brief moment, each one of us likely had the same supernatural vision, how for the past six hours, after being declared brain dead, this woman had lain under the measureless power of death. Six hours she had been officially dead. Six times had the hour hand on the clock moved – and she had lain dead. Now she had re-entered the world of the living. I would support her blood pressure and pulse. I would make her blood bright red with oxygen. Indeed, she might even wake up and look at us, I fantasised. She might be raised from the dead.

Ghoulish thinking, yet I do not write about this case to be ghoulish. Nor am I trying to stake out a new position in the bioethics debate. My purpose is more practical. Today, artificial intelligence (AI) looms over medical practice. Although unlikely to replace doctors completely, AI makes some medical activities especially ripe targets for takeover, including the harvesting of organs from brain-dead donors. And why not? Bedside manner and the common touch cease to be concerns. Using AI machines rather than doctors to harvest organs also promises to save money.

Yet this impersonal, nonhuman method of organ retrieval may discourage people from becoming organ donors , or from letting dead relatives become so, thereby exacerbating the current organ shortage. People will see pictures of organ retrieval being carried on all around by inanimate machinery in a room completely abandoned by human beings. Bodies will be brought in and sent out, while the invisible, sleepless work of the machines goes on. ‘Please, tell me this is not my end,’ people will fret privately. And they will resist consenting to organ donation.

O rgan retrieval can take place at odd hours because the time between retrieval and transplantation must be minimised. A donor heart or lungs can last only four to six hours outside the body. A kidney, liver or pancreas can last a bit longer. Because donation and transplantation must be synched perfectly, surgical teams must be allowed to work at any hour of the day.

Although donors are dead, managing their anaesthesia can be tricky. To keep their organs healthy, their physiology must be carefully attended to, yet brain death affects each organ system differently. High intracranial pressure can lead to an enormous outpouring of adrenaline, which can injure the heart and other organs as circulation fails. Brain death can cause pulmonary oedema (fluid in the lungs), making it hard to oxygenate the blood, thereby damaging the organs by a second route. Brain death also wreaks havoc on the body’s endocrine system, causing vital hormone levels to fall and damaging organs by a third route.

My patient lay stretched out on the table. The room was silent, as I had not yet placed any vital sign monitors on her body. It was a sinister silence. The monitors typically emit sounds that resemble the unconcerned twitter of birds. In an operating room, they symbolise life. Their absence suggests that a patient is not alive. In fact, mine wasn’t.

Nature will never permit anyone to know the exact point where brain death becomes real death

Ready to cut, the surgeon spoke through his headphones to surgeons in other cities waiting for the organs. The rest of us said nothing as he gave them an estimated time of arrival. The team had a real need for a stout word in these last few moments before the operation began. Sensing the mood, the surgeon said some dignified things about how our patient was giving other people a chance to live. Everyone nodded in agreement. He seemed thankful and sincere, yet he had to be that way for, at such a moment, anyone with even a modicum of intelligence would have felt anything else as an affront.

The surgeon cut into the patient’s chest. Almost immediately the patient’s heart rate and blood pressure jumped. It resembled the powerful surge of life that comes during a period when a person’s very existence and survival are at stake. The jump originated in a spinal reflex that stimulated the woman’s sympathetic nervous system below the level of the brain. Still, it seemed a manifestation of her will to live. Even more so when her hand moved – a sure sign of life! But that, too, was mediated through a spinal reflex.

I gave the patient some anaesthetic gas. I also gave her some opioids. Why the latter? After all, a dead patient doesn’t feel pain. In part because opioids help to lower heart rate and blood pressure directly, but also, I must admit, because I thought my patient might still be a ‘little alive’, whatever that means, and therefore in pain. Irrational on my part, yes, but the secret of life, including the definition of life, still remains the deepest and most mysterious one. Here Nature permits no eavesdroppers; never will she permit anyone to know the exact point where brain death becomes real death. At this, she draws a veil. I wanted to hedge my bets.

The woman’s blood pressure soon dropped too low. I poured fluid into her intravenous line. In the meantime, the surgeon moved hurriedly to extract her heart, clamping the large blood vessels leading both to and from it. Our fast pace betrayed another incongruence. Speed is thought to be a bit unrefined in an operating room. True, it is needed to save money, but ideally the operating room is an ordered world with calm transitions, a world without haste, except during an emergency to save a patient’s life. The visibly hasty fashion in which I and the surgeon worked made it seem like one of those urgent situations. In fact, I was trying to keep her circulation going long enough for the surgeon to tear her heart out.

I transfused a unit of blood, as excessive blood clotting, common after brain death, had made her dangerously anaemic. I turned on the warming mattress lying underneath her to keep her body temperature from dropping below 36 degrees Celsius. Brain death interferes with the body’s ability to regulate temperature, and the resulting hypothermia poses a risk to the organs. Finally, I gave her insulin to control her blood sugar level, as brain death often causes blood sugar to rise. All of these are routine lifesaving measures. In the past, I had used them to fight off death in my sickest patients, but here I had to remind myself that my patient was already dead.

T he surgeon removed her heart. The irrevocable instant had come. It was as when a train starts with a violent jerk, as if to overcome a disinclination to change its state of inertia. For many in the operating room, this was the moment when the woman’s life really ended.

A minute before, I had heard the melodies of the electrocardiogram (EKG) and pulse oximeter without really thinking about them. An anaesthesiologist’s ear is so capable of adapting itself that a continuous din, like the noise of a street or the rushing sound of a river, adjusts itself completely to their consciousness. But the unexpected halt in the sounds startled me into listening – and looking. I stared over the ether screen into the woman’s now-vacant chest cavity. It was shameful and terrible to gaze upon. Part of me felt as if I had abetted a murder around the corner.

I tried to make this last sigh worthy of the moment, a sigh that only another human being could replicate

The surgeon injected the heart with cold preservative and put it in a box. His next target was the lungs. He asked me to manually give the woman one last deep breath so that he could confirm that all parts of her lungs had been expanded before their removal. The breath I gave her was slow and gentle, like a sigh. Indeed, medically speaking, it was a sigh. On ventilators, there is a function labelled ‘sigh’ which, when pressed, gives a patient a single sustained deep breath to open up the lung’s small air sacs. Almost proudly, I imagined the sigh I gave this woman to be more human than what a machine could give. Compressing the anaesthesia bag with my hand, I imagined how she might have sighed in the past, on her own, in the face of some bitter reality, some trick or force of fate, crushing her heart but also uplifting her. I tried to make this last sigh worthy of the moment, a sigh that only another human being could replicate, a deep breath that begins with disappointment, passes into resignation, and ends in acceptance. I crafted that last sigh as if it were the epilogue to a tragedy.

When the woman exhaled her last bit of sigh, I removed her breathing tube. The surgeon took out her lungs and stapled her windpipe shut. At this point, there was little for me to do, and my inactivity plunged me into a sense of nothingness. I felt I was going to gag on my thoughts if I didn’t do something. I walked away from my patient to look inside a cupboard. I opened a few drawers. Then I felt badly for doing so. Although one of us was dead, still there seemed to be two of us here. It’s as if the woman and I were friends and I didn’t want to leave my friend. I went back and stood by her head.

The surgical team removed the rest of her organs and the case finished. Here the woman and I reached a parting of the ways. I stared at her face seriously and fixedly as though I wanted to look my fill and imprint forever on my memory her image. I cannot recall for how long I looked. Great moments are always outside of time.

Our relationship proved significant. Nothing is more characteristic of the total lack of spiritual connection between myself and other patients than the fact that I have forgotten most of their names and faces. But this woman’s name and face I remember. And when I speak of memory, I do not mean something akin to a register kept in a well-ordered office, a place in which documents are laid away in store. I mean something submerged in the rushing stream of my blood, memory as a living organ in which every feeling experienced that day retains its natural essence, its original intensity, its primary historical form.

M y patient lived longer than what her death certificate says. She lived in my mind during the organ retrieval and continues to live in my memory because I do not want to forget her, and because I cannot forget her. Although I know only her general outlines, our connection satisfies some deep law of harmony underlying all life, in which every person must enter into communion with another person in order fully to live. By that standard, my patient lived past her official time of death.

When AI replaces the anaesthesiologist during organ retrievals, you, the organ donor, will not live any longer than what’s listed on your death certificate. The air inside the operating room is already cold, dry and unpleasant. Various monitors will sit on the top shelf of the anaesthesia machine, regulated by AI. Their special melodic rings will no longer be necessary, as their data will be sent along to AI in silence. Care will be delivered without the mediation of human minds, senses or hands.

Before your lungs are removed, the machine’s ventilator bellows will go up, down, up, down. Capable only of whooshing and not ringing, the bellows will seem to call sadly through the cold air to the monitors sitting above, waiting fruitlessly for a response. What a simple, insignificant movement: up, down, up, down, never getting away from the same place. It will be the only activity surrounding your head amid the metal machines, with their cold, menacing gleam. Nobody will be sitting next to you to wonder about what you were like, or about the things that distinguished your personality and made it special. A vision of the future arises: similarly deserted operating rooms with AI machines all moving automatically, while the people who used to work in them have gone off somewhere to sit dreamily on the grass beneath the sky.

Medicine has tapped a new source of organs in the form of donation after circulatory death

It seems a decidedly unpleasant environment in which to meet one’s end, and enough to discourage those on the fence from becoming potential organ donors. Rather than live a bit longer in the mind of another person, rather than have that person think about you and wonder about you, entertain irrational imaginary concerns about you, slip a little extra narcotic into your intravenous line ‘just in case’, engage in metaphysical speculations about your breathing pattern, and imagine you a friend, you will be alone on the table, and your surgery will more closely resemble a bandit raid. The machines will be determined to take everything, every organ. Reduced to financial terms, it will be as if you were left penniless.

Worse, a new danger will come to overlie the chilling sense of emptiness, scaring even more people away from becoming organ donors. Because there are already too few brain-dead donors – each year, more than 8,000 people in the US die while on the waiting list for organs – medicine has tapped a new source of organs in the form of donation after circulatory death (DCD). These organ donors are not brain dead, although many of them are unconscious. Instead, they lack circulatory or respiratory activity after being disconnected from artificial life-support systems. Without such activity after a few minutes of so-called ‘no touch’, they are declared dead, and their organs become available for donation. Their numbers have been growing over the past two decades. Today, they account for about 10 per cent of transplanted organs in the US.

The problem is that certain medicines necessarily given to these donors before death, but in expectation of death, may hasten their death. The medicines are given for the sole purpose of making their organs more viable for transplantation. Heparin, for example, prevents blood clotting, while phentolamine dilates blood vessels and improves blood flow to the organs. Yet heparin also increases the chances of bleeding into the brain, while phentolamine may lower blood pressure to the degree that a person goes into shock. Although these patients are near death for other reasons, the medicines may become their actual cause of death. This makes doctors uneasy; hence the rule not to give these medicines to donors prone to bleeding or with low blood pressure.

Y et the rule risks driving away potential donors, who will naturally think: ‘Doctors won’t give you these medicines to kill you; on the other hand, they won’t give you these medicines to help you. At some point, doctors aren’t really on your side. But when?’ As the number of brain-dead donors drops, medicine will increasingly rely on DCD donors to compensate. Already sensitised by the image of surrendering their organs to machines in a metallic desert, potential donors will fear being herded into the ‘imminent death’ category to meet some organ quota, a fear only heightened when word gets out that doctors are not always their advocates.

Currently, doctors in the US must get consent before declaring people DCD donors, but another model, called the ‘presumed consent model’, already operates in other countries and allows the recovery of organs without prior authorisation. A cascade of events threatens to turn organ retrieval into a kind of science-fiction nightmare, where organ shortages lead to medicines being given to people to preserve their organs while possibly hastening their death, all without telling them the plan or asking for their permission.

My experience in the operating room serves as a warning to those eager to cut corners and replace doctors with AI machines

Whenever people start to think about becoming an organ donor, they immediately make a leap to their own precious person. Who am I, what am I, what am I without my organs, and so forth. It is part and parcel of being a human being. That some people are willing to surrender their organs after death suggests that, to feel oneself human, they need more than merely having a whole body; they also need an atmosphere of simple humanity. To feel human, people need to feel that they occupy space in the thoughts and feelings of others. It is why they consider becoming organ donors in the first place. They imagine helping others by giving up a part of themselves in the future. In exchange, they imagine the recipients thinking from time to time about what they, their donors, were like. In that way, the donors feel a connection with whomever those recipients might be, and feel somehow fulfilled.

I’d like to think that caring for my brain-dead patient satisfied some small part of this need to feel human, whether on the part of my patient before she died and who perhaps lived in expectation of becoming a donor one day, or on the part of her relatives who gave their consent to the procedure after she was declared brain dead. Either way, I connected with her or with her family.

My experience in the operating room serves as a warning to those eager to cut corners and replace doctors with AI machines willy-nilly. You don’t satisfy people’s urge to feel human by making the bridge to the next world a totally inhuman one.

The lesson extends far beyond organ donation. AI promises to make healthcare quicker, more precise, and error-free. To the degree that it replaces doctors and nurses, it portends a massive shift in medicine that seems to come every 30 years, when people are so overwhelmed by the burden of their own technological creations, they need every iota of their strength to adjust. Once again, with the advent of AI, advancements promise to put healthcare on an entirely new footing and, once again, the inevitable backlash will be there. So it was in the 1960s, when new medical technologies and procedures, such as home dialysis machines and coronary artery bypass surgery, improved life, and yet, during this same period, the medical profession’s reputation plummeted, as patients complained that doctors had grown cold and impersonal. So it was in the 1990s, when the rise of managed care promised greater efficiency at less cost, and a ‘win-win’ strategy anchored in preventive medicine, led to a patient rebellion against being treated like cattle, including their inability to choose their own doctor, and rushed visits to practitioners ‘on the plan’.

Now, in the 2020s, the stage is set for outrage, yet again. AI promises to elevate healthcare; but, to the degree that it replaces doctors and nurses, it also threatens to depersonalise patients and to wash off their distinctive colours until everyone has the same drab tint. In the crucible that looms, patients are going to rebel. And it is in the arena of organ donation, where they face death by machine, that they are likely to baulk loudest, and first.

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When Prison and Mental Illness Amount to a Death Sentence

The downward spiral of one inmate, Markus Johnson, shows the larger failures of the nation’s prisons to care for the mentally ill.

Supported by

By Glenn Thrush

Photographs by Carlos Javier Ortiz

Glenn Thrush spent more than a year reporting this article, interviewing close to 50 people and reviewing court-obtained body-camera footage and more than 1,500 pages of documents.

• Published May 5, 2024 Updated May 7, 2024

Markus Johnson slumped naked against the wall of his cell, skin flecked with pepper spray, his face a mask of puzzlement, exhaustion and resignation. Four men in black tactical gear pinned him, his face to the concrete, to cuff his hands behind his back.

He did not resist. He couldn’t. He was so gravely dehydrated he would be dead by their next shift change.

Listen to this article with reporter commentary

“I didn’t do anything,” Mr. Johnson moaned as they pressed a shield between his shoulders.

It was 1:19 p.m. on Sept. 6, 2019, in the Danville Correctional Center, a medium-security prison a few hours south of Chicago. Mr. Johnson, 21 and serving a short sentence for gun possession, was in the throes of a mental collapse that had gone largely untreated, but hardly unwatched.

He had entered in good health, with hopes of using the time to gain work skills. But for the previous three weeks, Mr. Johnson, who suffered from bipolar disorder and schizophrenia, had refused to eat or take his medication. Most dangerous of all, he had stealthily stopped drinking water, hastening the physical collapse that often accompanies full-scale mental crises.

Mr. Johnson’s horrific downward spiral, which has not been previously reported, represents the larger failures of the nation’s prisons to care for the mentally ill. Many seriously ill people receive no treatment . For those who do, the outcome is often determined by the vigilance and commitment of individual supervisors and frontline staff, which vary greatly from system to system, prison to prison, and even shift to shift.

The country’s jails and prisons have become its largest provider of inpatient mental health treatment, with 10 times as many seriously mentally ill people now held behind bars as in hospitals. Estimating the population of incarcerated people with major psychological problems is difficult, but the number is likely 200,000 to 300,000, experts say.

Many of these institutions remain ill-equipped to handle such a task, and the burden often falls on prison staff and health care personnel who struggle with the dual roles of jailer and caregiver in a high-stress, dangerous, often dehumanizing environment.

In 2021, Joshua McLemore , a 29-year-old with schizophrenia held for weeks in an isolation cell in Jackson County, Ind., died of organ failure resulting from a “refusal to eat or drink,” according to an autopsy. In April, New York City agreed to pay $28 million to settle a lawsuit filed by the family of Nicholas Feliciano, a young man with a history of mental illness who suffered severe brain damage after attempting to hang himself on Rikers Island — as correctional officers stood by.

Mr. Johnson’s mother has filed a wrongful-death suit against the state and Wexford Health Sources, a for-profit health care contractor in Illinois prisons. The New York Times reviewed more than 1,500 pages of reports, along with depositions taken from those involved. Together, they reveal a cascade of missteps, missed opportunities, potential breaches of protocol and, at times, lapses in common sense.

Prison officials and Wexford staff took few steps to intervene even after it became clear that Mr. Johnson, who had been hospitalized repeatedly for similar episodes and recovered, had refused to take medication. Most notably, they did not transfer him to a state prison facility that provides more intensive mental health treatment than is available at regular prisons, records show.

The quality of medical care was also questionable, said Mr. Johnson’s lawyers, Sarah Grady and Howard Kaplan, a married legal team in Chicago. Mr. Johnson lost 50 to 60 pounds during three weeks in solitary confinement, but officials did not initiate interventions like intravenous feedings or transfer him to a non-prison hospital.

And they did not take the most basic step — dialing 911 — until it was too late.

There have been many attempts to improve the quality of mental health treatment in jails and prisons by putting care on par with punishment — including a major effort in Chicago . But improvements have proved difficult to enact and harder to sustain, hampered by funding and staffing shortages.

Lawyers representing the state corrections department, Wexford and staff members who worked at Danville declined to comment on Mr. Johnson’s death, citing the unresolved litigation. In their interviews with state police investigators, and in depositions, employees defended their professionalism and adherence to procedure, while citing problems with high staff turnover, difficult work conditions, limited resources and shortcomings of co-workers.

But some expressed a sense of resignation about the fate of Mr. Johnson and others like him.

Prisoners have “much better chances in a hospital, but that’s not their situation,” said a senior member of Wexford’s health care team in a deposition.

“I didn’t put them in prison,” he added. “They are in there for a reason.”

Markus Mison Johnson was born on March 1, 1998, to a mother who believed she was not capable of caring for him.

Days after his birth, he was taken in by Lisa Barker Johnson, a foster mother in her 30s who lived in Zion, Ill., a working-class city halfway between Chicago and Milwaukee. Markus eventually became one of four children she adopted from different families.

The Johnson house is a lively split level, with nieces, nephews, grandchildren and neighbors’ children, family keepsakes, video screens and juice boxes. Ms. Johnson sits at its center on a kitchen chair, chin resting on her hand as children wander over to share their thoughts, or to tug on her T-shirt to ask her to be their bathroom buddy.

From the start, her bond with Markus was particularly powerful, in part because the two looked so much alike, with distinctive dimpled smiles. Many neighbors assumed he was her biological son. The middle name she chose for him was intended to convey that message.

“Mison is short for ‘my son,’” she said standing over his modest footstone grave last summer.

He was happy at home. School was different. His grades were good, but he was intensely shy and was diagnosed with attention deficit hyperactivity disorder in elementary school.

That was around the time the bullying began. His sisters were fierce defenders, but they could only do so much. He did the best he could, developing a quick, taunting tongue.

These experiences filled him with a powerful yearning to fit in.

It was not to be.

When he was around 15, he called 911 in a panic, telling the dispatcher he saw two men standing near the small park next to his house threatening to abduct children playing there. The officers who responded found nothing out of the ordinary, and rang the Johnsons’ doorbell.

He later told his mother he had heard a voice telling him to “protect the kids.”

He was hospitalized for the first time at 16, and given medications that stabilized him for stretches of time. But the crises would strike every six months or so, often triggered by his decision to stop taking his medication.

His family became adept at reading signs he was “getting sick.” He would put on his tan Timberlands and a heavy winter coat, no matter the season, and perch on the edge of his bed as if bracing for battle. Sometimes, he would cook his own food, paranoid that someone might poison him.

He graduated six months early, on the dean’s list, but was rudderless, and hanging out with younger boys, often paying their way.

His mother pointed out the perils of buying friendship.

“I don’t care,” he said. “At least I’ll be popular for a minute.”

Zion’s inviting green grid of Bible-named streets belies the reality that it is a rough, unforgiving place to grow up. Family members say Markus wanted desperately to prove he was tough, and emulated his younger, reckless group of friends.

Like many of them, he obtained a pistol. He used it to hold up a convenience store clerk for $425 in January 2017, according to police records. He cut a plea deal for two years of probation, and never explained to his family what had made him do it.

But he kept getting into violent confrontations. In late July 2018, he was arrested in a neighbor’s garage with a handgun he later admitted was his. He was still on probation for the robbery, and his public defender negotiated a plea deal that would send him to state prison until January 2020.

An inpatient mental health system

Around 40 percent of the about 1.8 million people in local, state and federal jails and prison suffer from at least one mental illness, and many of these people have concurrent issues with substance abuse, according to recent Justice Department estimates.

Psychological problems, often exacerbated by drug use, often lead to significant medical problems resulting from a lack of hygiene or access to good health care.

“When you suffer depression in the outside world, it’s hard to concentrate, you have reduced energy, your sleep is disrupted, you have a very gloomy outlook, so you stop taking care of yourself,” said Robert L. Trestman , a Virginia Tech medical school professor who has worked on state prison mental health reforms.

The paradox is that prison is often the only place where sick people have access to even minimal care.

But the harsh work environment, remote location of many prisons, and low pay have led to severe shortages of corrections staff and the unwillingness of doctors, nurses and counselors to work with the incarcerated mentally ill.

In the early 2000s, prisoners’ rights lawyers filed a class-action lawsuit against Illinois claiming “deliberate indifference” to the plight of about 5,000 mentally ill prisoners locked in segregated units and denied treatment and medication.

In 2014, the parties reached a settlement that included minimum staffing mandates, revamped screening protocols, restrictions on the use of solitary confinement and the allocation of about $100 million to double capacity in the system’s specialized mental health units.

Yet within six months of the deal, Pablo Stewart, an independent monitor chosen to oversee its enforcement, declared the system to be in a state of emergency.

Over the years, some significant improvements have been made. But Dr. Stewart’s final report , drafted in 2022, gave the system failing marks for its medication and staffing policies and reliance on solitary confinement “crisis watch” cells.

Ms. Grady, one of Mr. Johnson’s lawyers, cited an additional problem: a lack of coordination between corrections staff and Wexford’s professionals, beyond dutifully filling out dozens of mandated status reports.

“Markus Johnson was basically documented to death,” she said.

‘I’m just trying to keep my head up’

Mr. Johnson was not exactly looking forward to prison. But he saw it as an opportunity to learn a trade so he could start a family when he got out.

On Dec. 18, 2018, he arrived at a processing center in Joliet, where he sat for an intake interview. He was coherent and cooperative, well-groomed and maintained eye contact. He was taking his medication, not suicidal and had a hearty appetite. He was listed as 5 feet 6 inches tall and 256 pounds.

Mr. Johnson described his mood as “go with the flow.”

A few days later, after arriving in Danville, he offered a less settled assessment during a telehealth visit with a Wexford psychiatrist, Dr. Nitin Thapar. Mr. Johnson admitted to being plagued by feelings of worthlessness, hopelessness and “constant uncontrollable worrying” that affected his sleep.

He told Dr. Thapar he had heard voices in the past — but not now — telling him he was a failure, and warning that people were out to get him.

At the time he was incarcerated, the basic options for mentally ill people in Illinois prisons included placement in the general population or transfer to a special residential treatment program at the Dixon Correctional Center, west of Chicago. Mr. Johnson seemed out of immediate danger, so he was assigned to a standard two-man cell in the prison’s general population, with regular mental health counseling and medication.

Things started off well enough. “I’m just trying to keep my head up,” he wrote to his mother. “Every day I learn to be stronger & stronger.”

But his daily phone calls back home hinted at friction with other inmates. And there was not much for him to do after being turned down for a janitorial training program.

Then, in the spring of 2019, his grandmother died, sending him into a deep hole.

Dr. Thapar prescribed a new drug used to treat major depressive disorders. Its most common side effect is weight gain. Mr. Johnson stopped taking it.

On July 4, he told Dr. Thapar matter-of-factly during a telehealth check-in that he was no longer taking any of his medications. “I’ve been feeling normal, I guess,” he said. “I feel like I don’t need the medication anymore.”

Dr. Thapar said he thought that was a mistake, but accepted the decision and removed Mr. Johnson from his regular mental health caseload — instructing him to “reach out” if he needed help, records show.

The pace of calls back home slackened. Mr. Johnson spent more time in bed, and became more surly. At a group-therapy session, he sat stone silent, after showing up late.

By early August, he was telling guards he had stopped eating.

At some point, no one knows when, he had intermittently stopped drinking fluids.

‘I’m having a breakdown’

Then came the crash.

On Aug. 12, Mr. Johnson got into a fight with his older cellmate.

He was taken to a one-man disciplinary cell. A few hours later, Wexford’s on-site mental health counselor, Melanie Easton, was shocked by his disoriented condition. Mr. Johnson stared blankly, then burst into tears when asked if he had “suffered a loss in the previous six months.”

He was so unresponsive to her questions she could not finish the evaluation.

Ms. Easton ordered that he be moved to a 9-foot by 8-foot crisis cell — solitary confinement with enhanced monitoring. At this moment, a supervisor could have ticked the box for “residential treatment” on a form to transfer him to Dixon. That did not happen, according to records and depositions.

Around this time, he asked to be placed back on his medication but nothing seems to have come of it, records show.

By mid-August, he said he was visualizing “people that were not there,” according to case notes. At first, he was acting more aggressively, once flicking water at a guard through a hole in his cell door. But his energy ebbed, and he gradually migrated downward — from standing to bunk to floor.

“I’m having a breakdown,” he confided to a Wexford employee.

At the time, inmates in Illinois were required to declare an official hunger strike before prison officials would initiate protocols, including blood testing or forced feedings. But when a guard asked Mr. Johnson why he would not eat, he said he was “fasting,” as opposed to starving himself, and no action seems to have been taken.

‘Tell me this is OK!’

Lt. Matthew Morrison, one of the few people at Danville to take a personal interest in Mr. Johnson, reported seeing a white rind around his mouth in early September. He told other staff members the cell gave off “a death smell,” according to a deposition.

On Sept. 5, they moved Mr. Johnson to one of six cells adjacent to the prison’s small, bare-bones infirmary. Prison officials finally placed him on the official hunger strike protocol without his consent.

Mr. Morrison, in his deposition, said he was troubled by the inaction of the Wexford staff, and the lack of urgency exhibited by the medical director, Dr. Justin Young.

On Sept. 5, Mr. Morrison approached Dr. Young to express his concerns, and the doctor agreed to order blood and urine tests. But Dr. Young lived in Chicago, and was on site at the prison about four times a week, according to Mr. Kaplan. Friday, Sept. 6, 2019, was not one of those days.

Mr. Morrison arrived at work that morning, expecting to find Mr. Johnson’s testing underway. A Wexford nurse told him Dr. Young believed the tests could wait.

Mr. Morrison, stunned, asked her to call Dr. Young.

“He’s good till Monday,” Dr. Young responded, according to Mr. Morrison.

“Come on, come on, look at this guy! You tell me this is OK!” the officer responded.

Eventually, Justin Duprey, a licensed nurse practitioner and the most senior Wexford employee on duty that day, authorized the test himself.

Mr. Morrison, thinking he had averted a disaster, entered the cell and implored Mr. Johnson into taking the tests. He refused.

So prison officials obtained approval to remove him forcibly from his cell.

‘Oh, my God’

What happened next is documented in video taken from cameras held by officers on the extraction team and obtained by The Times through a court order.

Mr. Johnson is scarcely recognizable as the neatly groomed 21-year-old captured in a cellphone picture a few months earlier. His skin is ashen, eyes fixed on the middle distance. He might be 40. Or 60.

At first, he places his hands forward through the hole in his cell door to be cuffed. This is against procedure, the officers shout. His hands must be in back.

He will not, or cannot, comply. He wanders to the rear of his cell and falls hard. Two blasts of pepper spray barely elicit a reaction. The leader of the tactical team later said he found it unusual and unnerving.

The next video is in the medical unit. A shield is pressed to his chest. He is in agony, begging for them to stop, as two nurses attempt to insert a catheter.

Then they move him, half-conscious and limp, onto a wheelchair for the blood draw.

For the next 20 minutes, the Wexford nurse performing the procedure, Angelica Wachtor, jabs hands and arms to find a vessel that will hold shape. She winces with each puncture, tries to comfort him, and grows increasingly rattled.

“Oh, my God,” she mutters, and asks why help is not on the way.

She did not request assistance or discuss calling 911, records indicate.

“Can you please stop — it’s burning real bad,” Mr. Johnson said.

Soon after, a member of the tactical team reminds Ms. Wachtor to take Mr. Johnson’s vitals before taking him back to his cell. She would later tell Dr. Young she had been unable to able to obtain his blood pressure.

“You good?” one of the team members asks as they are preparing to leave.

“Yeah, I’ll have to be,” she replies in the recording.

Officers lifted him back onto his bunk, leaving him unconscious and naked except for a covering draped over his groin. His expressionless face is visible through the window on the cell door as it closes.

‘Cardiac arrest.’

Mr. Duprey, the nurse practitioner, had been sitting inside his office after corrections staff ordered him to shelter for his own protection, he said. When he emerged, he found Ms. Wachtor sobbing, and after a delay, he was let into the cell. Finding no pulse, Mr. Duprey asked a prison employee to call 911 so Mr. Johnson could be taken to a local emergency room.

The Wexford staff initiated CPR. It did not work.

At 3:38 p.m., the paramedics declared Markus Mison Johnson dead.

Afterward, a senior official at Danville called the Johnson family to say he had died of “cardiac arrest.”

Lisa Johnson pressed for more information, but none was initially forthcoming. She would soon receive a box hastily crammed with his possessions: uneaten snacks, notebooks, an inspirational memoir by a man who had served 20 years at Leavenworth.

Later, Shiping Bao, the coroner who examined his body, determined Mr. Johnson had died of severe dehydration. He told the state police it “was one of the driest bodies he had ever seen.”

For a long time, Ms. Johnson blamed herself. She says that her biggest mistake was assuming that the state, with all its resources, would provide a level of care comparable to what she had been able to provide her son.

She had stopped accepting foster care children while she was raising Markus and his siblings. But as the months dragged on, she decided her once-boisterous house had become oppressively still, and let local agencies know she was available again.

“It is good to have children around,” she said. “It was too quiet around here.”

Read by Glenn Thrush

Audio produced by Jack D’Isidoro .

Glenn Thrush covers the Department of Justice. He joined The Times in 2017 after working for Politico, Newsday, Bloomberg News, The New York Daily News, The Birmingham Post-Herald and City Limits. More about Glenn Thrush

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News Release

US Department of Labor obtains judgment to recover $152K in back wages, damages owed to Bronx medical care provider’s employees

NEW YORK –  The U.S. Department of Labor has obtained a consent judgment to recover $152,000 in back wages and liquidated damages for nine people employed by a Bronx medical care provider that routinely failed to pay them overtime for hours over 40 in a workweek because their employer wrongly classified them as exempt from certain federal regulations.

The action in the U.S. District Court for the Southern District of New York on May 10, 2024, requires Bronx Urgent Care P.C. to pay $152,000 – $76,000 in back wages and an equal amount in liquidated damages – to the affected workers. The court also affirmed $8,000 in civil money penalties assessed by the department because of the violations’ willful nature. 

The judgment follows an investigation by the department’s  Wage and Hour Division that found the employer, which operates as Bronx Urgent Care, owner Basil Bruno, and operations manager Samuel Singer violated the Fair Labor Standards Act by misusing the exemption and paying the affected workers their regular hourly rates for all hours worked, including hours over 40 when the Fair Labor Standards Act requires payment of overtime wages at time and one-half rates. 

“Our investigation and the outcome in this case show the Wage and Hour Division is committed to protecting a worker’s right to be paid all the wages they rightfully earn ,” said Wage and Hour Division District Director Jorge R. Alvarez in New York City . “Employers who fail to comply with federal labor laws often learn that violations lead to costly consequences far above the amount of wages they should have paid.” 

In addition to the wage recovery, damages and penalties assessed, the court order also forbids Bronx Urgent Care from future violations of FLSA provisions.

“The U.S. Department of Labor will take all necessary legal actions, including recovering back wages, seeking damages and assessing penalties, to hold employers who violate the law accountable,” said Regional Solicitor of Labor Jeffrey S. Rogoff in New York.

View the consent judgment .

The division’s New York City District Office conducted the investigation. The department’s Office of the Solicitor in New York litigated, leading to the negotiated settlement.

Learn more about the Wage and Hour Division , including a  search tool to use if you think you may be owed back wages collected by the division. Employers and workers can call the division confidentially with questions, regardless of where they are from. The division can speak with callers in more than 200 languages through the agency’s toll-free helpline at 866-4US-WAGE (487-9243). Download the agency’s  Timesheet App  for iOS and Android devices – free and available in English and Spanish – to track hours and pay.