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Glenn D. Braunstein, M.D. Headshot

Debt, Deficit Denial: Why We Must Fix U.S. Health Care

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As partisans wrangle over fiscal matters like entitlements and taxes, what is getting overlooked is the more real and basic need to reform a huge and inefficient driver of America's economy: our health care delivery system. We spend far more than any other country on health care. Yet our citizens don't live as long as people in many other countries. Many of our health outcomes lag far behind other developed nations. The disparities in even basic care are too great between rich and poor. And too many Americans lack basic health insurance coverage.

The costs of providing health care in this country grow ever more painful and unsustainable. We spend $7,538 per person on health care, the highest rate in the industrialized world. That's more than twice the average amount spent by 15 countries analyzed by the Organization for Economic Cooperation and Development.

Even if you've still got a job with decent health insurance, skyrocketing costs affect you. Since 2001, the Kaiser Family Foundation reports, family health insurance premiums have increased 113 percent; annual premiums for employer-sponsored family health coverage grew to $15,073 this year, up 9 percent from last year.

Big Costs, Shortfalls in Care
For the enormous sums we plow into health care, we might at least expect every American to get needed medical care. Not so. We also might expect that we would live longer, healthier lives than anyone on the face of the earth. Also, not so.

Compared to Australia, Canada, Germany, the Netherlands, New Zealand and the United Kingdom, the U.S. comes in dead last in five areas of health system performance: quality, efficiency, access to care, equity and the ability to lead long, healthy productive lives, reports the Commonwealth Fund, a foundation supporting independent research on health care issues.

The U.S. ranks last on measures of safe patient care, and second to last on coordinated care. We also came in last in infant mortality and on potentially preventable deaths before age 75. Overall, we don't live as long as people in those developed countries. Our failure as a country to ensure basic health care for all of its citizens is in part to blame. The most recent report from the U.S. Census Bureau shows that the number of uninsured Americans has ticked up to 49.9 million people, up from 49.0 million in 2009. The increase, while small, is significant to the one million or so more people no longer covered. In California, nearly one in five residents lacked health insurance in 2010, the eighth highest rate in the nation. That hits hard for 7.2 million Californians affected.

The current economic downturn is adding to our health problems. Some 15 percent of people ages 18 to 64 say they have delayed or avoided medical care because of the cost, and 11 percent didn't fill their prescription orders due to cost. Health insurance coverage for most of us today is subject to change if we shift jobs or lose our work, if we marry or if we divorce. Studies have shown that people without health insurance suffer more disease and don't live as long as people with insurance, and the downward spiral in health is even greater for people in their 50s and 60s. Because so many of us are a pink slip away from losing health insurance, and with the endemic job cuts we've seen recently, by the time big parts of the Boom Generation hit the Medicare magic age of 65, they well could end up costing the system more to make up for unmet needs.

Another big problem with having so many uninsured people is that they have less access to preventive and continuing care, so often the only way they then can get services is via the Emergency Room.

If our nation's health care system could get these sick folks covered and make it easier for them to get preventive care, we could both improve their health and provide primary care in a much more efficient way than through the Emergency Room.

When the uninsured need ER care, hospitals provide for them, regardless of their ability to pay. There are costs for that unpaid care, however, and they're now shifted onto others in the system: Doctors and hospitals find they must increase their charges to paying patients to provide emergency care for the uninsured; patients with insurance, in turn, submit higher medical bills to their insurers, who, in turn, increase premiums for us all.

What once were confident comparisons with health-care systems in Canada and Europe -- replete with suggestions that Americans don't have to wait in line for appointments and can get costly treatments even if they are old and infirm -- have faded. Now, it's rare for politicians to boldly state, as they often did even a few years ago, that America is the best place on earth to be if you happen to get sick.

A Big 'Yes!' for Universal Access

As a physician at a large nonprofit academic medical center that cares for many uninsured and underinsured patients, I strongly advocate for universal coverage for basic medical care, which will provide access to health care for everyone.

The health reform legislation that some opponents are so eager to kill -- without providing concrete, sound alternatives -- could push the country to a better place by covering 30 million more Americans.

That's good, though it could be better, and I would underscore my belief that the wealthiest nation in the world ought to provide all its citizens with access to health care. Universal coverage is essential, but by no means is it the only change required. We also must curb rising costs through an array of means -- and universal coverage, research shows, could play a role in this.

Ideally, this would be an extension of a Medicare or Medicaid type of program to every American without any age or income requirement, providing cradle-to-grave coverage. To maintain equity of care and benefits, as well as the economic savings that would come with a single infrastructure and the purchasing power that a large program would enjoy, I feel that a federally run, single-payer system for basic care would be best. Expecting the government to provide for our health and well-being is no more of a socialist concept than our expectations that government should provide universal protection from fire and crime and be responsible for our national security.

I also believe that the system should be financed through taxes and that there should be a means test -- those who make more should pay more for this coverage.

And because we're an outstanding example of a capitalist democracy, we need to accept a two-tier health system with everybody receiving basic coverage, while those who can afford it can use their own money or buy more insurance to pay for levels of service that may not be included in the basics. And by additional levels of service, I don't just mean medical luxuries like facelifts, tummy tucks and vision-correcting laser surgery. Those who can afford it, may be able to fly around to find top experts in the country or speed up the timing of an elective surgery. It's fair that they can choose such options, and it's also fair that they're on their own in paying for the upgrades.

In the next few months, I'll offer some additional prescriptions for how all of us, including physicians like me and other caregivers, might improve our health care system. In this great country of ours, we may face fiscal shortfalls, but the disparities we face in getting and keeping folks well cannot be tolerated. As Americans we've never had a deficit in our ideas, aspirations and our will to see all our friends and neighbors live healthier, better and longer. Our health care system is sick and we must attend to it before it collapses.