By Nan Victoria Munger
Consuming 17% of the U.S. Gross Domestic Product (GDP), “medical costs are the tapeworm of American economic competitiveness,” says billionaire Warren Buffett. The U.S. spends more on health care than any other country. However, a 2014 report by The Commonwealth Fund compared the health care performance of the U.S. to that of 11 other developed countries and found that it ranked last. The Health Affairs journal reports that national health care expenditures are currently over $10,000 per person annually, and health care spending is outpacing GDP growth. The high costs of care are problematic for many Americans: 37% of those surveyed said that they had avoided recommended care or medication due to cost.
With the passage of the Affordable Care Act, or “Obamacare,” in 2010, all Americans became required to purchase health insurance or pay a tax penalty. Under Obamacare, an estimated 20 million people became insured by 2016, and increases in health care expenditure slowed. Many people complained that, under Obamacare, premiums and deductibles increased. Some Democrats, including Buffett, advocate switching to a single-payer system, in which the government is responsible for all health insurance. This is the system most other developed countries use.
The Republican efforts to repeal and replace Obamacare would cut Medicaid by $761 billion over the next 10 years, according to the Congressional Budget Office. As a result of these cuts, an estimated 22 million Americans would lose their health care coverage. The bill aims to decrease government health care expenditure by forcing higher-risk Americans out of the health care market and increasing market competition.
While the government is focusing on the insurance side of health care, some people believe that there are other ways of reigning in health care costs. Jamie Koufman’s New York Times op-ed, “The Specialists Stranglehold on Medicine,” published on June 3, 2017, puts the blame on specialist doctors. She notes that physician specialty groups use lobbying to influence the pricing decisions of Medicare and Medicaid. Seeking larger incomes, the specialists push for higher prices. The prices set by Medicare and Medicaid are then followed by private health insurance companies.
Koufman argues that many visits to specialists relate to issues that could actually be addressed by primary care practitioners, and that specialists often prescribe unnecessary tests and procedures simply to generate more income. She advocates a ‘Healthcare Accountability Act’ to shift care back to primary care practitioners and separate specialists from pricing.
Under Koufman’s proposed plan, more health care decisions would be executed by primary care practitioners, all of whom would receive more training and higher salaries. Primary care practitioners would have to approve specialist referrals, preventing specialists from passing patients along to each other. Her proposal would also mandate the preemptive disclosure of procedures’ costs and strengthen the Independent Payment Advisory Board, which Obamacare created to provide oversight on price determinations.
Koufman’s commentary is part of the nationwide discussion on how to “fix” our broken system. Although she is correct in stating that specialists receive very high salaries and that drug costs are exorbitant, a large portion of health care expenditure is in hospital care. In 2015, hospital care comprised 32% of health care expenditures—more than physician and clinical services and prescription drugs combined (20% and 10%, respectively).
Rather than prescribing drugs and surgical procedures for health issues, perhaps we should focus on keeping people healthy in the first place. At present, many people go to the doctor only when something is seriously wrong with them. This behavior leads to more hospitalization and far higher health care expenditures. Furthermore, when physicians treat patients, they are much more likely to prescribe medical treatment than lifestyle changes. Koufman specializes in acid reflux, and says that she sees many cases in which specialists have prescribed endoscopies, CT scans, and other procedures. However, the acid reflux could have been handled by primary care practitioners advocating “basic changes in diet, lifestyle, and sleep.” Primary care practitioners are in a position to encourage lifestyle changes not only to address patients’ existing problems, but to decrease the likelihood of future issues developing.
The problem is that lifestyle medicine and preventative care are not profitable. In his article, “Why I Had to Close My Preventative Healthcare Clinic,” published in The Atlantic on January 13, 2014, Steven Charlap recounts the story of MDPrevent, a health care clinic he created to help patients “identify their risk factors” for serious diseases and “help them make lifestyle changes to prevent these factors from evolving to illness.” The clinic succeeded in helping many patients lose weight without drugs or procedures, and “discontinued…patients’ statins [and] lowered or discontinued blood pressure and blood sugar medications.” Only one insurance company contracted with them, and “not a single one of their patients needed a hospital visit after seeing us all year.”
Unfortunately, MDPrevent was unable to continue despite promising results. “For every dollar we collected, our expenses equaled three dollars,” wrote Charlap. Few doctors referred patients to them, and most insurance companies refused to cover their services. Patients, accustomed to receiving panacea prescriptions or supplements, were also skeptical of MDPrevent’s approach. The clinic closed in December of 2013.
The cost structure of our current health care system is built around treating disease, not preventing it. Preventative care could save money on hospitalizations, prescriptions, emergency care, and specialist doctor visits, but only if the public and insurance companies are willing to give it a chance.