Changing The US Health Care System: Reform, Revolution, or Rebellion
This story originally appeared in the Yiddish Forward. This translation appears by arrangement with them.
As a physician in the public sphere I frequently hear about patients’ experiences in the US health care system. Some are horrible, some scary, and some just incomprehensible. A doctor calls a patient with a blood test result, doesn’t find him at home, and gives up — without trying to reach the patient by letter or electronic message. Another doctor makes inappropriate remarks about her patient’s appearance. A third patient, a woman with a chronic, rare disease, can’t convince her doctor that she has something real and not imaginary. He never heard of it and didn’t bother to Google it.
Though the stories are different the weaknesses of our healthcare system are well known. Here I’ll summarize them briefly, asking the question: Given that many attempts to improve the system have failed, what should be done next, and how can real change be achieved?
The defects of our system fall into several categories: the experience of the individual, economic barriers, and societal injustice. Of course, at bottom they’re all connected, but we have to start somewhere.
1. Individual experience
When you go to the doctor, you often feel like you’re not listened to, you’re rushed and demeaned, leaving without an understanding of a real plan to get treated. There’s no relationship with anything more than a computer. When you have to see specialists can’t they just talk to each other? Who can make that happen? Why is this so hard in 2018?
2. Economic barriers
Some people love to say that America is Number One. They’re right about one thing, the USA spends the most money in comparison with other rich countries and gets the worst results. Why is that? Most health economists believe that the American system suffers from two basic weaknesses: the prices are too high and too much is done. Too much means too many prescriptions, procedures, tests, and operations, without evidence that they help. And the pricces? What’s charged is what the system incentivizes. There’s no reason to charge reasonable prices. And so it goes on, a vicious cycle, which no one has managed to stop (though the vertiginous increases in health costs have slowed a bit recently, thanks to the Affordable Care Act — which yet lives!).
3. Injustice in society
It’s been said more than once that there is no health without justice. When many poor people have no access to healthy food (in my city, Baltimore, and even in the culinary capital of New York), or other essentials like clean water (cf. Flint, Michigan), let alone jobs, it’s impossible to live without disease. In a society where violence against black people is a daily occurrence, how can health be achieved?
So how can everything be changed for the good? Some parts of our broken system are being patched over in various corners of the country. Obamacare has provided more health insurance. More medical and nursing students are learning how to communicate with patients with empathy. Maybe the wave of gun violence will be contained. But these are not systematic changes.
I see three possibilities of advancing such far-reaching change.
Reform is the most conservative approach, according to which it’s enough to try and use the current political institutions, the laws that already exist, to try and help more people with their health needs. “Just expand Medicare and Medicaid,” the reformers argue. “Let’s make coalitions of groups with common interests.”
Revolution is something else again — an attempt to accomplish something that hasn’t been tried before. Single-payer health care systems are old news in the rest of the world but until recently used to sound radical to the average American.
If these approaches don’t bring results, maybe the word rebellion is appropriate. Rebellion against control by pharmaceutical companies, for profit companies, and those authorities who don’t grant equal access to health or healthcare. What this would look like is a discussion for another time, but right now we need a reminder that the status quo is something we might need to escape.