How to Get Back on Track with Healthcare
As a physician and scientist, the work of American heroes like Jonas Salk (polio vaccine), Rosalyn Yalow (measuring insulin in blood) and Jack Geiger (community health centers) inspires me. Their work reflects the American triptych of scientific ingenuity, its practical translation, and ultimate delivery to people who need it the most.
During the 20th century, our nation built a shield against disease through groundbreaking research, a sword to protect our elderly and the poor through a progressive healthcare system, and the brains to know which to use and when. However, since then, we have lost our way. More than half of our 17–24 year olds are not eligible to serve in the U.S. military due to obesity and other health issues. To make matters much worse, the current healthcare legislation, which aims to repeal and replace the Affordable Care Act rather than improving it, is a sure sign that we’ve lost focus on what should be a shared goal: devising breakthroughs that change the world, while being the healthiest nation in it.
We need a serious plan to get back on track, even if it is a uniquely American solution.
First, we need to reckon with our nation’s exceptionally dismal 21st century performance. Healthcare is on track to taking up a fifth of the economy, and given its growth at a brisk 5.8 percent per year, it is far outpacing GDP growth. Globally, the United States stands alone as spending the most on healthcare, and by a basic measure of efficiency, we rank 50th, sandwiched between Serbia and Jordan. While domestic profits in the healthcare sector have soared, the equal opportunity to live a long and healthy life has declined in counties scattered across the country.
To move forward, we can’t sugarcoat the harsh fiscal reality: The rising costs of healthcare have wiped out a decade of wage increases, and this has badly hurt America’s working middle-class. Our nation’s growing number of baby boomers and their adult children often find that the burden of caregiving is burning them out, removing them from work and community, and leaving them bankrupt. And the story is worse for poor Americans: Healthcare’s growing percentage of GDP replaces crucial investments in education, communities, and infrastructure, which are necessary to activate the ladders to opportunity.
Secondly, while the terms of debate are large scale and often federally focused, the most promising solutions and their impacts are in our communities. This is also where the greatest bipartisan consensus is to be found. For example, Community Health Centers have expanded to serve 25 million Americans under the past four presidential administrations in order to improve health, create good jobs, and increase economic activity where they exist. They form partners to larger health systems and are intertwined with the network of neighborhood organizations that communities need to thrive. We should continue their expansion and ensure there is a strongly primary care and community-based health workforce to grow with them.
Third, our portfolio of research and development investments should broaden from our overwhelming focus on drug development. Places such as Travis County, Texas, voted to increase taxes so as to pay for a new generation of research and development at UT Austin’s Dell Medical School that is focused on improving population health for everyone in the county. Companies like Oak Street Health and organizations like City Health Works are trying to figure out how to build care models for people with complex social needs, including poverty. Academics like Sanjeev Arora are using telemedicine to provide specialty care in rural areas (Project Echo). We know care delivery needs to change and modernize, but we aren’t investing aggressively enough. We should support a National Institutes of Health center on breakthroughs in care for all Americans.
Fourth, we need to have the hard conversation about what healthcare insurance does and does not do. Americans rightly question why most of their premiums go up faster than inflation, while simultaneously leaving them exposed to higher deductibles. Insurance may be an animal of the capital markets, but it is ultimately a redistribution mechanism to smooth out the varying degrees of risk for poor health that we each represent. Insurance gets very complicated, and to paraphrase Einstein, it should be as simple as possible, but no simpler. We need a national debate on what we, as a nation, are willing to cover for everyone and what communities, families, or individuals should take responsibility for based upon their circumstance. I encourage you to make that the focus of your next town hall with your congressman or senator.
Fifth, to be the best in the world, we need to learn from the best. We have learned from how the CDC builds local rapid response systems for global emergencies; how USAID has played a key role in partnering with PEPFAR to not only treat AIDS, but manage chronic conditions like diabetes; and how U.S. investments in the Global Fund have given rise to community health worker systems across sub-Saharan Africa. We’ve invested in mobile technologies and telemedicine protocols that are reshaping global health. Some of the world’s poorest countries, like Rwanda, have used American support and their own national ingenuity to build cutting edge community health networks that outperform what we have at home. It’s time to learn from abroad and bring the global advantage to American health care.
Finally, we cannot afford to measure progress in how close we are to enacting or blocking legislation. Instead, we must focus on how close we are to addressing the realities of those furthest from the halls of power, profit, and privilege. Practically speaking, this means that until a better solution to covering all Americans through a combination of Medicare and Medicaid is devised, we need to stay the course. In the meantime, we need to come up with better and more humane solutions to making our nation the healthiest for generations to come.
Prabhjot Singh, MD, PhD is the Director of the Arnhold Institute for Global Health and Chair of the Department of Health System Design & Global Health at Mount Sinai Health System. He is the author of Dying and Living in the Neighborhood: A Street-Level View of America’s Healthcare Promise. He is a Fellow with Truman National Security Project. Views expressed are his own.
