Dr. Patty Gabow shared a letter with me that she is sending to Senator Lamar Alexander, the chairman of the Senate’s Health, Education, Labor and Pensions Committee. I think several of her points deserve extra emphasis and I have bolded them.
Dear Senator Alexander,
I am a physician who was the CEO of a large, integrated public safety net health care system for 20 years, so I am deeply committed to the care of all the population. Over my 40 years in healthcare I have gained a broad understanding of the strength and weaknesses of American healthcare. As you are part of the Senate’s working group to develop a health reform plan, I thought it would be worth sharing some important facts with you. I have included a series of slides that illustrate the issues we must address to achieve health for every American.
- We spend almost twice as much as every other developed nation. Currently we are spending over $3 trillion/year and almost 18% of GDP. Yet despite much lower expenditures, these other countries provide health care to all their residents.
- In America health care coverage matters. Those who are uninsured are almost five times more likely than Medicaid or privately insured patients to have no usual source of care, they are more likely to postpone seeking care, go without needed care, or be unable to purchase a needed prescription. Without a usual source of care, or going without needed care, prevention and early intervention cannot occur, and patients develop chronic diseases and/or utilize emergency departments for care. This slide also demonstrates the value of Medicaid in enabling Americans to get needed care. Cutting Medicaid will make this worse.
- While we often think, we get high value for the healthcare dollars that we spend, Americans have the lowest life expectancy of all 17 peer countries and it is decreasing. We have the highest infant mortality of all 17 peer countries and during a person’s most productive years we rank 17th out of 17. We never get above 15th out of 17 until age 75 and only become number 1 at age 95. We also spend more at the end of life than many other developed countries. Therefore, for our expenditure we achieve much less than all the other OECD countries.
- One of the reasons for this higher expenditure which achieves less value is the inefficiency our system. The Bloomberg Healthcare Efficiency Index ranks us 50th out of 55 countries -near Columbia. The Institute of Medicine study estimated that 30- 40% of health care expenditures are waste, largely due to administrative and delivery inefficiencies and provision of unnecessary care. In fact, 30% of all care provided to Americans is either not valuable or even harmful. At the current rate of expenditure, this waste is over $1 trillion dollars. Much of this inefficiency stems from the myriad of delivery and payment models and the fee for service system we have adopted. Health reform should increase efficiency, eliminate unnecessary care, and abandon fee for service payment.
- Moreover, where you live in America determines your health and even your life expectancy. Examining the performance on over 40 variables, there is marked geographic variability. This is due in part to the huge variability in Medicaid coverage. In Minnesota, the threshold for coverage for an adult is 215% of FPL are whereas in Texas and Alabama it is 20% of FPL. Block grants or per capita caps will make this geographic disparity worse. In contrast, this disparity does not exist for Medicare since the coverage is not dependent on where a person lives.
- While health care coverage is critical in health, our over expenditure in health care and our under expenditure on the other major determinants of health, have resulted in our shorter lives and poorer health than other developed countries. The health care system determines about 15% of health while the other determinants of health, except for genetics, determine over fifty percent. Eleven other OECD countries spend more in total on social care and healthcare than we do, but no other country, spends more on health care than social care.
- Income may be the most important determinant of health. Although we are the richest country, we have the highest percentage of poverty and the greatest income inequality (Slide 10,11) and this has been worsening in recent decades. Life expectancy rises with income with greater effects at the lower end of income.
- Behaviors are major determinant of health. Among these tobacco, diet, physical activity, alcohol and drug use, sexual practices and injurious behaviors play an important role.
We have the highest level of obesity and disorders related to drug use compared to other countries. Importantly, Medicaid is a major source of funding for treatment for drug use. Shockingly, we have almost 20 times the incidence of years of life lost to disability and death due to gun violence of other developed countries.
Therefore, it should be clear that we are not providing the path to health and well-being that other developed countries are. This is robbing our citizens and negatively impacting competitiveness in our global economy. Fixing this is no simple matter:
It cannot be addressed by cutting Medicaid or turning it over to states.
It cannot be addressed by simply addressing pre-existing conditions.
It cannot be addressed by cutting social care programs.
Fixing this will require a thoughtful approach that examines what works and doesn’t work here and in other countries. It will require input from many people including those without direct financial interest. A small group of Senators, no matter how committed, cannot accomplish this enormous task. This will require time. The solution must include developing a unified health care system that reduces inefficiencies, duplication, overuse and geographic disparity. One easy first step toward reducing inefficiencies and duplicative efforts would be to put Medicare premiums and copayments on a sliding fee scale with the poorest having no payment, thereby eliminating the need for poor Medicare patients to sign up for Medicaid only to pay premiums and copayments. Reform also must address in a meaningful way the social determinants of health. In the meantime, we must maintain and expand those programs which have a demonstrated return on investment: Medicaid, CHIP, Earned Income Tax Credit, SNAP, Healthy Hunger Free Kids, Comprehensive School Physical Activity Model, Home Visitation Program, Tobacco Cessation, and Universal Pre-school.
Thank you for your service to the country and for allowing me to provide input to your process.
Patricia Gabow, M.D., MACP
Arlie Russell Hochschild, a professor of sociology at UC Berkeley, has written Strangers In Their Own Land: Anger and Mourning on the American Right that adds insight to some of Dr. Gabow’s points. Hochschild spent five years in Louisiana interviewing conservative white voters researching why there was “…an increasingly hostile split in our nation between two political camps.” Patty Gabow implied the same thing to me before the election when she observed that our biggest problem was our lack of “social solidarity.”
Hochschild is a left leaning intellectual and many on the right will be distrustful of her observations. Many scratch their heads in confusion wondering just how blue collar workers can vote against their best interests and against politicians and programs designed to assist them and their families. In a wonderful review of Hochschild’s book Jason DeParle writes:
…What unites her subjects is the powerful feeling that others are “cutting in line” and that the federal government is supporting people on the dole — “taking money from the workers and giving it to the idle.” Income is flowing up, but the anger points down.
The people who feel this are white. The usurpers they picture are blacks and immigrants. Hochschild takes care not to call anyone racist but concludes that “race is an essential part of this story…”
Whether or not you accept Hochschild’s formulation or “deep story” as the explanation for Patty Gabow’s observation that there is a lack of “social solidarity,” we must begin to look for ways to communicate across the divide that exists if we are to find solutions to our healthcare problems and get beyond knee jerk resistance to the ACA and improve on the absurd bill that emerged from House as a challenge for the Senate. Patty’s letter is a request that the Senate develop its own deep understanding as it searches for answers to a problem that most people, including many very smart senators and their staffs, only partially understand.
We must find a “set of reasons” to “fix healthcare” that contains enough common ground to allow our leaders to negotiate an outcome that helps everyone. The bill the House sent to the Senate suggests that many in Congress are less interested in a real solution than they are in finding some “faux solution” that can fool enough people on both sides of the question to avoid political losses in 2018.
Hochschild wanted to understand why poor white people on the right who were the logical beneficiaries of social programs were opposed to them and were aligned with the rich against their own best interests. She evolved a “deep story” hypothesis built on empathetic understanding of those people that Hillary Clinton unwisely called a “basket of deplorables.” Hochschild’s efforts and Patty Gabow’s outreach to Lamar Alexander may be the sort of small steps necessary to begin to rebuild enough social solidarity to solve our healthcare problems.
Dr. Gabow’s facts show America to be far from great. In part we are as bad as we are because of the devastating impact of pollution on the people, land and water of Louisiana. Hochschild looks at the same information and uses inquiry as a diagnostic tool. She “walks a mile” in their shoes and realizes that those shoes really hurt. She provides us with insight, but unfortunately, understanding does not guarantee resolution. Nevertheless, understanding born of empathy is essential as a foundational step.
More than twenty years ago, as the Clintons were failing to achieve any substantive changes to healthcare, I chirped that we would not have better access to care or control costs, what we now call the Triple Aim or describe as:
…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness..
…until Republicans and the rest of the political right became convinced that it would be good for business to have a healthy nation. Dr. Gabow suggests the same idea near the end of her letter. Back in 1993, as we listened to the industry backed domestic drone of Harry and Louise, my comment about getting business onboard through the Republicans was facetious. I was mocking the self interest of the wealthy. I was not thinking of the marginalized and suffering angry white Americans who feel their “fair share” is threatened by the changes that government driven universal entitlement would bring.
We need the whole Triple Aim especially the “…cost we can afford” and “… for every person…” parts. Understanding that our current dysfunctional state of healthcare is a threat to business may create some social solidarity around a bipartisan attempt to develop workable answers.
The dual concepts of healthcare as an entitlement and affordable universal coverage as necessary for business success might foster the mindset and motivation to do something to correct the issues of “ the business of healthcare” gone wrong that are described by Elisabeth Rosenthal in An American Sickness: How Healthcare Became Big Business and How You Can Take It Back and Robert Pearl in Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong. Nixon dropped his concerns about Communism when he decided it was good for business to open relations with China. Why can’t all of our senators come together and agree we need to help America be healthy, if we are to remain great or, if you prefer, become great again. I hope that you follow Dr. Gabow’s example and write somebody a letter.