The Doctor Dialogue

3.7.25

Happy Friday!

On a different note from last week, here is an article I was attempting to publish in a medical journal but found out you need a terminal degree (MD, MPH, JD) to publish in a medical journal which I do not have. It is a bit more technical but I hope even if you have no background in health care you can still understand the majority of what I am discussing.

Perspectives from a VP of a health insurance company, an emergency medicine physician, a Veterans Affairs (VA) physician, and several premed and medical students are included in this article.

Healthcare: Right or Privilege?

The United States has a unique challenge among developed countries: as of 2023, to take care of just under 335 million people living in a geographically diverse landscape with an array of cultural, physical, and linguistic diversity. Our system of medical care is varied and complex yet there is one unifying thread which unites us, for better or worse: dollar is king.

The US health care system works best for the employed and well-heeled; the more money and better insurance you have, the more access to high quality care you can receive. The central question of whether health care should be a privilege reserved for those with money or a public good is: Is access to healthcare a right for a US citizen? If not, can we ensure Americans receive high quality, easy-to-access care through the marketplace?

The stakes are high: poverty compounds sickness and sickness exacerbates poverty. Howard Thorkelson, a legal aid lawyer, performed one of the first studies merging economic welfare and health care in 1969. He examined disability payments for miners in rural Appalachia, concluding: “In the United States sickness attends poverty, and the inability to work compounds sickness.” The downward spiral of personal economic struggle is only accelerated by lack of access to care in resource impoverished areas.

A helpful framework to examine this question is a spectrum; on one side is health care as a right and on the other side health care as a commodity (i.e. a product that can be bought and sold). The annual conversation in both state and federal legislatures is where to draw the line on the spectrum. Should all healthcare be a commodity? Or should primary care be a right? Should tertiary care, such as trauma surgery or a knee replacement, be included? Cosmetic care? Gender-affirming care? Should people have a right to a minimum decency of care?

Hannah Diaz emphasizes the importance of money in drawing the line, both at an individual and societal level: “the line shifts based on who you are and where you are. I wish it could just be in one place for the whole world, but it can't, and it isn't. I think, unfortunately, that line moves based on the amount of money that you have access to.” Caleb Wataoka, a first-year medical student, explores the downstream consequences in determining where resources are allocated: “if there's no cure to a disease that you might have, is it a human right that research should go into discovering a cure to this disease before you die? Resources are limited, so that will inevitably take away [resources] from the rest of the community.” Caleb highlights the reality of prioritizing certain health care services over others, even in a wealthy country such as the United States: which ones should be more robust and receive more funding?

In the federal legislature under the Trump administration, we expect the line to shift towards commodity, with increased privatization and consolidation of the health care system. Many of the decisions regarding health care will be offloaded to state legislatures across the country, all revolving around the question: if health care remains a commodity, how can we ensure high quality health care for the least amount of money possible?

A Balancing Act

For Dr. Alex Edwards, an emergency medicine physician, health care is a question of balance: “There are three aspects of health care, but you can only prioritize two: cost, access, and quality.” To prioritize high quality and low cost, there will most likely be long lines–increasing the barriers to access. Among young medical professionals, the general consensus is to prioritize accessibility and quality. For example, Tafadzwa Mapiki, a first year DO student, would prioritize “easy access because I really would want everyone to have accessibility…I would go with high quality because I wouldn't want a patient to come to me for help, and then I don't give them the best quality of health care that they deserve. I wouldn't want them to come back and have 6 more surgeries because I didn't do the first one correctly. So I would rather have them come to me, do the surgery once, and they are all set because I have done the best that I could.”

If you were a director for a medical system, which two would you prioritize?

Nerd Out on the Dollar

How can America prioritize easy-to-access, high quality care? The first is through increasing insurance coverage. Refusal of service prevents high quality service. Through legislation such as the Affordable Care Act and the Medicare and Medicaid Act, 7-8% of US citizens are uninsured as of 2023. However, with Medicaid cuts on the table in the federal legislature, this number could increase very soon. The enrollment process for medical insurance is often complicated by confusion, fear, and language and literacy challenges.

Secondly, reimbursement rates for Medicare and Medicaid must snap out of free fall. A reimbursement rate is how much an insurance pays a physician for a certain service (such as a well child check up or an MRI). With the Biden administration finalizing 2025 reimbursement rates, physicians will see their Medicare rates, the federal government insurance for citizens 65 and older, drop by 2.9% next year, resulting in $1.8 billion less in revenue. The cuts in funding will especially affect independent practices, which now are a rarity in a landscape of consolidated medical corporations. Notably, from 2001 to 2024, after adjusting for inflation, Medicare reimbursement rates plummeted 29%. If the US wants to supply high quality care to one of the biggest generations–baby boomers now constitute a large portion of Medicare–reimbursement rates need to keep pace with inflation, if not exceed it to regain lost ground. To achieve this, the American Medical Association (AMA) has lobbied for a permanent, annual inflation-based update to Medicare physician reimbursement.

Importantly, Medicare insurance is administered by the federal government while Medicaid is administered by the state governments; a vital relationship which might change if more health care decisions over the next four years are made at the state level. Medicaid/Medicare parity, or the ratio of reimbursement rates between the two plans, varies from state to state. Further complicating matters, this parity differs between specialties in the same state. For example, in 2023, primary care and pediatrics in Washington had a parity close to 1:1, while for specialists (i.e. neurology) it was 0.57:1.

Moreover, Medicaid/Medicare parity ranges widely between states due to two factors: how many people Medicaid covers and how much money the state legislature can raise through taxes. For example, just over 1.85 million people (21%) in Washington state are covered through Medicaid/CHIP (Children's Health Insurance Program). Despite being close to the national average of percentage of population insured under Medicaid, the reimbursement rate for specialists for Medicaid is among the worst in the nation–only Rhode Island and New Jersey are worse. The paltry rate of reimbursement for doctors is one of the root causes of health care inaccessibility, forcing once abundant independent practices to close doors or consolidate with larger practices; limiting competition between practices, narrowing choices for patients, limiting doctor autonomy, and causing increased physician turnover. To promote accessibility, Washington voters must either be willing to pay more taxes, accept fewer benefits, or insure fewer people through Medicaid.

Universal Health Care

Some physicians believe the best way to ensure quality and accessibility while limiting the cost of care is to switch to universal health care. For Dr. Meredith Mathews, a retired Senior Vice President and Chief Medical Officer of Blue Shield of California, health care as a commodity plays by a separate rule book than other commodities such as lumber, computer processors, or labor:

“[W]hat I find most difficult about the system is that [health care] is not viewed as a public good. It's built and viewed as a commodity subject to microeconomic principles. Unfortunately, [in healthcare] there are a whole bunch of things that violate microeconomic principles. It's not informed buyers and sellers. You don't get to put a product out there and see if people want to buy it because the person that buys it [employers] is different from the person that uses it [employees] and you can offer a product that takes care of the left arm but not the right arm. When there is a problem, people double down on the microeconomic model as opposed to stepping back and still taking care of the whole person.”

However, if you can learn the rules of the health care industry, it is one of the largest markets in the United States. As of 2023, national health expenditures account for 17.6% of the US GDP. Regardless of moral judgments surrounding the supremacy of the dollar in healthcare, health expenditures shape the fortunes of many states and metropolitan areas, create tax revenue, and provide the foundation for many careers.

Central to universal health care is the conviction that health care is a right. Dr. Jan Hirschmann, a retired physician at Veterans Affairs (VA) who spent 1.5 years in the UK National Health Service (NHS), believes “a universal health system is the best system, and that would eliminate a lot of these problems of inequity in receiving care and differences from one area to the next. Costs of care would go down. A lot of the costs in the system now have to do with insurance costs, overlap, things that just don't exist in a universal health system. You don't have to deal with insurance companies.” The VA system is a form of universal health care, but confined to veterans; an existing American model of what a wider US health system could become.

However, for universal health care to become a reality, there are two major hurdles to jump over: US citizens agreeing to pay higher taxes and increasing trust in the federal government, neither of which are likely to happen under the Trump administration. If there is enough political and cultural will to surmount those obstacles, to fundamentally restructure the health care system would cause widespread layoffs and foreclosures of companies. For an emerging system to thrive, the old system must yield and die. However, many people’s livelihoods are heavily invested in the current iteration of the American health care system. Transition is rife with uncertainty, instability, and underperformance; a mythical three-headed monster health care business will not force upon itself.

The World Over

Lastly, if health care is a right for a US citizen, does that mean everyone in the world has a right to healthcare? In Article 25 of the Universal Declaration of Human Rights (UDHR), all humans have “the right to a standard of living adequate for…health and well-being…, including food, clothing, housing and medical care and necessary social services.” Is the UDHR a lofty goal or a set of laws safeguarding human rights? Currently, there is a large gap to bridge for every US citizen to receive medical care adequate for health and well-being; an even larger one when considering the world population.

The best way to start building that bridge in America is to start small: focus on increasing accessibility and financial viability of practicing medicine by increasing reimbursement rates and insurance coverage at a local and state level–then expand from there. However, there remains a fundamental question: is it possible to fulfill everyone’s human right to medical care through treating health care as a commodity?

Next Week: Teamwork in Medicine

Be well!

Your friend,

Ian Scott

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