The struggle to insure that quality healthcare is guaranteed for all the inhabitants of our land—citizens and non-citizens alike—begins with building as strong a consensus as we can that, in the wealthiest nation in the history of the world, people should not be crushed into bankruptcy by a chance illness, or driven into debt by excessive deductibles and co-pays, or completely denied the care they need by insurance company bureaucrats who are ignorant of the art and science of medicine, or by an inadequate governmental compensation system.
For most of the first decade of the twenty-first century,
showed solid majority support (60+%) for the claim that it is “the responsibility of the federal government to make sure that all Americans have healthcare coverage.” Then—with the Republican assault on Obamacare—support declined to around 40+%. Now with the public having seen something of the successes of Obamacare (inadequate though it is), and of Republican mendacity in the fight over “Trumpcare,” we are once again seeing solid majority support (60+%) for the principle that everyone's coverage should be guaranteed.
If support for universal healthcare continues to develop, and if we elect enough candidates pledged to support Medicare for All, it should be possible to move to universal healthcare in the not too distant future. To contribute to such progress is a primary reason for my campaign, although I also want to help us plan now to go beyond simply insuring that everyone has healthcare by addressing workforce and compensation issues to help make sure that, when it arrives, Medicare for All means quality healthcare for all.
If there were one article on American healthcare that I could persuade everyone to read, it would be the physician Atul Gawande’s article, “
The Heroism of Incremental Care
,” in the January 23, 2017, issue of
The New Yorker
. Gawande makes clear how and why the path to lowering health care costs over the long run is providing better quality care. We need to dramatically increase the number of primary care doctors in the country and the compensation provided to these doctors relative to specialists. The United States is 51st in the world in terms of doctors per capita. It is high time for that to change.
Gawande points to studies “demonstrating that states with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke. Other studies found that people with a primary-care physician as their usual source of care had lower subsequent five-year mortality rates than others, regardless of their initial health. In the United Kingdom, where family physicians are paid to practice in deprived areas, a ten-per-cent increase in the primary-care supply was shown to improve people’s health so much that you could add ten years to everyone’s life and still not match the benefit. Another study examined health-care reforms in Spain that focussed on strengthening primary care in various regions—by, for instance, building more clinics, extending their hours, and paying for home visits. After ten years, mortality fell in the areas where the reforms were made, and it fell more in those areas which received the reforms earlier. Likewise, reforms in California that provided all Medicaid recipients with primary-care physicians resulted in lower hospitalization rates. By contrast, private Medicare plans that increased co-payments for primary-care visits—and thereby reduced such visits—saw increased hospitalization rates. Further, the more complex a person’s medical needs are the greater the benefit of primary care.”
In a recent book manuscript addressing the need to restructure our compensation system to encourage doctors to once again make house calls—particularly for elderly patients with multiple medical issues for whom repeated visits to the emergency room are an extraordinary source of strain, expense, and danger—the physician C. Gresham Bayne also calls attention to the ways that providing better quality care is the best path to lowering healthcare costs.
Prior to 1930, encounters with physicians took place in the home about 40 percent of the time. By 1980, that figure was less than 1 percent. For patients with multiple illnesses—especially among the elderly—treatment in the hospital, and often in the hospital emergency room, is both very expensive and difficult and can be the source of further complications. There are more than 130,000,000 emergency room visits in the United States each year. Some 85 percent of these visits are for non-emergency conditions. It would simply be better for everyone involved to treat many of these patients in their own homes. The central problem is getting doctors paid for making such housecalls.
Bayne is part of the independence at home (
) movement that is advocating such change. A pilot program within Obamacare has already proven successful. According to one of the Congressional Sponsors for IAH, Senator Ron Wyden (D-OR), a national rollout of physician housecalls covered by Medicare, such as that demonstrated in the 15 cities with IAH sites, could save $300 billion over ten years.
We, the American people, need to insure that “everyone is included and no one left out of the risk pool”—in other words, we need Medicare for All. But we also need to go beyond this to insure that there are enough primary care physicians in the country that everyone can have a doctor that they can turn to in need, and we must guarantee sufficient compensation to these doctors to encourage them both to enter the field of medicine and to provide such services as housecalls.
Getting rid of some of the administrative bloat associated with our current system of health insurance should help to lower costs, but these initial gains may be offset by the increased demand for services as more people have access to healthcare. Ultimately, the healthcare system can be expected reach an equilibrium that will be less costly as a percentage of our economy than our current system provided we focus on the provision of quality care for all.