The concept of universal healthcare in the United States raises, in many, their hackles. However, it really need not do so. The most important part of this article to remember is that in the US, we already have universal healthcare. Yes, you read that right, the US already has universal healthcare. As will be explained shortly, it is already in place but implemented in as inefficient, costly, and patient unfriendly way as one could imagine. Let me explain.
The emergency room in the United States is the medical venue of last resort, especially for those who have been suffering increasingly but do not have the financial means or otherwise access to the medical system. A frequent potential user is someone with pneumonia who increasingly becomes dehydrated, enervated, malnourished, wracked with chest pain, and short of breath. The patient frequently plays medical “Russian roulette” hoping against hope that the illness will remedy itself. If that person has limited financial means and no insurance (and sometimes even with insurance but a high deductible), that person will often wait to seek help until feeling near death or experiencing so much suffering that it is just beyond tolerability. At that point, the person will engage the emergency room for help. Contrary to popular belief, all emergency rooms in the United States by law must accept all patients who request help. The legal basis of this is the Emergency Medical Treatment and Labor Act (EMTALA) of 1986. An emergency room cannot turn away a patient in medical need on the basis of ability to pay. There are a number of points to be made around this issue.
First, this shows that every American and indeed anybody near an American emergency room has access to healthcare, i.e. there is universal healthcare.
Second, it disproves that we can’t afford a universal healthcare system. After a fashion, we can but this universal healthcare threatens to bankrupt us as it gobbles up an increasingly greater part of our income.
Third, as noted in the previous paragraph, the uninsured engage the system at the most expensive and frequently most disastrous point (please see the previous articles, The Markovian Mambo parts I+II). We as a society simply cannot afford to continue a system where insurance is decentralized and unaffordable. This is itself worth developing a bit. Many people think “magically” that by failing to insure certain parts of the population, we somehow are saving money. It is almost as if we close our eyes, the uninsured will have no medical needs. The truth is simply not so. Hospitals, by keeping their ERs open, lose many billions of dollars per year to care for the uninsured. They make up for this loss by shifting expenses to those who have insurance and by charging them more. The insurance companies, to maintain their margins, increase their premiums or reduce services, sometimes both to that part of the population which can afford insurance.
So, in summary of the above, the United States has a form of universal healthcare, it works poorly, and it needs to be fixed before we go bankrupt.
However, there is good news in that we can remedy this, i.e. the problem is tractable.
Most research of which this author is aware affirms that, if artfully implemented, universal healthcare can not only remedy the poor coverage of the current system but also maintain or improve its best parts. We will now review one notable article about this.
In the article Improving the Prognosis of Healthcare in the United States (Lancet-February 15, 2020), Galvani et al. discuss that such a system would save (approximately) $500,000,000,000/year and save 68,000 lives/year. Cost savings and lives saved cannot be overappreciated. One (of many) systemic failures noted in this Lancet article involves women who have health insurance through their job. The article reports that 19% of women, once diagnosed with breast cancer, will be unemployed within 4 months of completing treatment. Once unemployed, healthcare insurance is lost. Because cancer follow-up is a resource intensive (i.e., very expensive) process, the absence of insurance consigns those patients to either suboptimal or no care, allowing for a much higher rate of cancer recurrence. As a physician, let me assert emphatically that recurrent cancer is significantly more difficult to address then cancer at its presentation. As another quick point, just by pursuing universal healthcare, each and every individual of the United States will save approximately $1500/year every year (please note that there are multiple other avenues to be developed in upcoming articles discussing and revealing additional techniques to reduce costliness and inefficiency above and beyond universal healthcare).
Let us make a non-exhaustive list of who wins with universal healthcare:
- The uninsured and underinsured (who number in the tens of millions).
- Those whose insurance is through their employer (see the discussion of breast cancer treatment in the paragraph above).
- Those who wish to maintain continuity with their own physicians (since insurance companies frequently drop physicians from their panels and shift patients to other, unknown physicians in their panels).
- Those who wish to have their blood drawn, mammograms imaged, colonoscopies performed, inpatient hospital care and so on at the same center as they did the last time (barring closure). Continuity of services is no longer at the whim of the insurance.
- Those who wish to have one insurance card from birth onward, not expiring every year or with every job change.
- Every emergency room in the country.
- Every business in the country (whose employees will now be 100% covered without their help).
- Every taxpayer in the country.
- Every patient in the country.
- Let us make a non-exhaustive list of those who lose with universal healthcare:
- Insurance companies who take a large piece of their premiums for profit.
- Hospitals whose business model is highly invested in performing very expensive procedures while poorly invested in preventing the need for such procedures.
Implementing universal healthcare in an efficient, coherent matter is not trivial but is tractable. It is an imperative. Hopefully circumstances will allow this to be discussed at a future point.