Ideas and Questions

Thoughts on Healthcare, Part 3

Welcome to week 3 of the Happy Wanderer healthcare series!

Part 1 discussed the systems in Czechia and Switzerland.

Part 2 argued that rationing is good, actually.

Part 3, this week, offers ideas to improve our system and also poses some questions.

Photo by Toa Heftiba on Unsplash.

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If I Had a Magic Wand

Even if I could, I would not impose Medicare for All. Millions of Americans actually like their insurance and their doctors, and it would be impolitic and unjust to force them to change. In addition, single-payer systems can be corrupted by financial incentives too.¹ There are other ways than single-payer to cover everyone and also save money. Here are some of my ideas, and I hope you’ll share yours in the comments:

• Allow anyone to buy Medicare, with the help of subsidies based on income. This one change would bring so many benefits. People with “pre-existing conditions” could get coverage. Patients could be confident that recommendations for or denials of care would be for their benefit and not that of shareholders. People wouldn’t have to fear losing their healthcare if they lost their job. Doctors would have lower administrative costs. I suspect that Medicare would gradually replace most private insurance, because it would deliver better service to more people for less money.

• Provide free medical training for doctors and nurses who work in primary care (i.e. emergency medicine, family practice, gerontology, gynecology, obstetrics, and pediatrics), as is the norm in the rest of the developed world.

• Investigate malpractice rather than litigating it. In Switzerland, when there is an unexpected death or other serious adverse event in a healthcare setting, the police investigate.² If they find that the doctor was impaired, negligent, or malicious, s/he is criminally prosecuted. But otherwise, people here tend to accept that mistakes can happen, and so malpractice suits are rare.

• Require transparency about conflicts of interest. When patients are offered a test, treatment, or drug, it would help them make an informed choice if the healthcare provider had to disclose, say, that they own the MRI machine and make a profit from each patient who gets an MRI. Similarly, people have a right to know whether a hospital or medical practice is owned by a nonprofit organization, by independent doctors, or by private equity.

• Ban direct-to-consumer advertising of prescription medications, as is the norm in every country except the US and New Zealand.

• Use other models than insurance for delivering basic healthcare. Most primary care—for example checkups, throat cultures, and vaccinations—need not be done by doctors. Physician assistants and nurse practitioners, working either in doctors’ offices or in clinics at stores and pharmacies, are cheaper and more convenient for families.³ Another option is direct primary care, which a reader described in a recent comment: “My mom’s primary care doctor had a sort of subscription model that I found really interesting. She paid a set monthly rate, which allowed the doc to provide better services and coordination.” Doctors who offer direct primary care are free of insurance hassles and can pass the savings along to their patients.

How about you, readers? If you had a magic wand, how would you improve our healthcare system?

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The Case for the Profit Motive

This series has been suspicious of the profit motive in healthcare. And yet it’s not clear how we could have achieved lifesaving medical advances without it. Yes, Big Pharma companies are motivated by money, but they have also developed products that benefit humanity.⁴ Sometimes when companies profit, we do too. Here are a few stories to illustrate this point.

• Cystic fibrosis “once all but guaranteed an early death.” Back in the nineties, I knew a woman who had cystic fibrosis. She had hoped to survive until age thirty, and she did, but she died shortly after her thirtieth birthday. Terrible as her death at such a young age was, she actually lived longer than the vast majority of cystic fibrosis patients at that time. Today, Trifakta, a drug developed by a for-profit corporation, allows people with cystic fibrosis to live a normal lifespan—and a normal life. They can have babies, run marathons, and enjoy life after thirty.

• In 2013, Jimmy Carter, of blessed memory, announced the Carter Center’s plan to eradicate river blindness from the world. When Carter was diagnosed with metastatic cancer in 2015, it looked doubtful that he would live to see his goal realized. But Carter survived almost a decade after his terminal diagnosis, in part because of Keytruda, a drug developed by Merck, which cured his metastatic melanoma. Thanks to the Carter Center and other health organizations—but also to Merck, which donated tens of millions of doses of its drug Mectizan—the incidence of river blindness worldwide has dropped by more than 90 percent.

• So many diagnoses that were a death sentence only a generation ago are now curable or manageable because of public-private partnerships. Gleevec cures leukemia and many other cancers. New gene therapies cure sickle-cell disease. We now have effective and tolerable HIV treatments, as well as a vaccine that protects people for six months at a time.

• I saved the best one for last. Researchers at universities, working together with pharmaceutical companies, have developed malaria vaccines that could save “hundreds of thousands of lives . . . this decade.” Imagine a world without malaria, a disease that kills almost 600,000 people a year, three-quarters of whom are children under age 5. No senseless deaths. No blighted lives. Thanks to academic researchers, but also to Big Pharma, that world is about to be here.

Daniella, right, was the first person in the world to receive the malaria vaccine. Source.

Much as we might wish that all medical research could be publicly funded, the past few days have made it abundantly clear that government funding is subject to politics. We can’t rely on it. In addition, many people don’t realize that public funding contributes only a tiny fraction of the total cost—which is often more than a billion dollars—of bringing a drug to market. Public funding may support initial basic research, but pharmaceutical companies pay an order of magnitude more for the FDA approval process of testing drugs for safety and efficacy. Most of us would not want to dispense with this process in order to fund drug development exclusively through our tax dollars.

So this is a sincere question: If we were to eliminate the profit motive and institute the kind of nonprofit universal healthcare system that is common throughout the developed world, how would we pay for medical advances that save the lives of so many people?

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Two Ankles, Both Alike in Dignity

A friend, whom I’ll call Paul, grew up poor. He broke his ankle when he was a little boy, but his parents had neither health insurance nor the money for a doctor. So Paul had to limp around until his ankle (sort of) healed on its own. Because his ankle was never properly set, it bothers him to this day.

When she was five, our daughter, Casey, broke her ankle. We had good health insurance, so we took her straight to the emergency room. After x-raying her ankle, the doctor set it and put it in a cast. Three weeks later, Casey’s pediatrician took the cast off, and she was totally fine. She has never had any trouble with the ankle—to the extent that none of us, including Casey, can remember which ankle it was that she broke.

Let’s step behind the Veil of Ignorance. Imagine that you don’t know what kind of health insurance you and your family have, or whether you have insurance at all. Now take a moment to think about a recent time you or a loved one needed healthcare, even for just an ordinary accident like breaking your ankle. What kind of healthcare system would you devise so that your outcome would be like Casey’s, and not like Paul’s?

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What We Can Do Right Now

I am not optimistic that revolutionary change to improve our healthcare system is possible—or rather, I fear that revolutionary change will happen, but in the opposite direction. Last week Mike Johnson and House Republicans announced a plan to make significant cuts to Medicaid to pay for tax cuts for the rich.

If you think that what happened to Paul’s ankle was not only morally wrong but also wasteful and stupid; if you believe that it is neither Christian nor pro-life to deny healthcare to low-income pregnant women and their children (Medicaid pays for 42 percent of all births in the US, and 39 percent of all children in the US are on Medicaid); if you acknowledge that you or someone you care for might need to go into a nursing home one day (Medicaid pays for almost two-thirds of nursing home patients); or if you fear that a car crash or bad diagnosis could bankrupt you or someone you love, then please call your elected representatives to make your voice heard. Next year, please consider voting for leaders who care about our health, and not just the wealth of the one percent.

One final recommendation: If we are able, we can donate to Undue Medical Debt. This organization buys up medical debt for pennies on the dollar, relieving the financial burden so many Americans carry, simply because they needed healthcare.

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How about you, readers? What do you think of these ideas? Please share your thoughts—and ideas of your own—in the comments!

The Tidbit

It’s week three of Bee Gees appreciation! Most of us associate the Bee Gees with disco, but they started out as a critically-acclaimed soul group. Below is a 1967 performance of their first big hit, “To Love Somebody.” Barry Gibb was only twenty, and Robin and Maurice were only seventeen, when they recorded this song!

1. This issue is beyond the scope of this essay, but it is disturbing to me that Medical Assistance in Dying has been used in single-payer systems not just to end the suffering of terminal patients, but also, apparently, to save money. In Canada, for example, “people were euthanized based on other factors [than terminal illness] including an ‘unmet social need’.”

2. I know this for a sad reason. A few years ago, our sweet elderly neighbor Eugene died suddenly in the hospital. The police came to investigate as a matter of routine.

3. Case in point, New Jersey, where our family used to live, requires by law that flu shots for patients under age eighteen must be given by a doctor. Every fall, New Jersey parents spend hours online refreshing their pediatricians’ websites, waiting for them to post available slots. The moment the appointment site goes live, we pounce. It’s like trying to buy Taylor Swift tickets! Then, on the appointed day, we pull our kids out of school early and race over to the doctor’s office, only to encounter a line that stretches around the block and two-hour wait times.

By contrast, one year we were in Minnesota during flu-shot time. It took about fifteen minutes total for us to get our flu shots as walk-ins at the MinuteClinic at our local Target.

4. In the interest of transparency, I’ll disclose here that after a five-year postdoc at the NIH, my husband has spent his career working as a data scientist for Big Pharma companies. Our personal experience with these companies may bias me in their favor, but it may also offset the bias against Big Pharma that I, as a liberal Democrat, might otherwise have.